The introduction of the R21 vaccine marks a significant milestone in the fight against malaria.
Côte d'Ivoire became the first country to include the R21 malaria vaccine in its routine immunization program through support from Gavi, a global vaccine alliance helping developing countries get vaccines.
"Malaria represents a significant public health challenge in Côte d'Ivoire," said Thabani Maphosa, the Managing Director of Country Programmes Delivery at Gavi, who was involved in the introduction of the R21 malaria vaccine into Côte d'Ivoire's routine immunization program.
"From 2018 to 2021, the incidence rate in the general population rose from 155 per 1,000 to about 300 per 1,000. For children under five, the situation is even more dire... Over 1,000 children under five die from malaria each year in Côte d'Ivoire, which equates to around three child deaths per day," he said.
These figures underscore the critical nature of the malaria problem and its devastating impact on public health.
"Until now, the prevention strategies have included the use of insecticide-treated mosquito nets, chemoprevention with sulfadoxine-pyrimethamine for pregnant women, and environmental sanitation efforts to control malaria vectors. However, the effectiveness of these measures is increasingly compromised by the growing resistance of malaria vectors to insecticides, which has escalated from 25% to 80%," he said.
Maphosa said the severity of malaria in Côte d'Ivoire, including high incidence and mortality rates among children, and the broader socio-economic impacts. "Malaria affects education and economic productivity. School and work absenteeism due to malaria-related illness results in significant loss of earnings, with households estimated to lose about 43% of their monthly income because of the disease," he said.
He expressed optimism about the vaccine, saying, "The introduction of the malaria vaccine is a development we are very excited about. It will be a crucial complementary measure to enhance existing prevention efforts and aims to significantly reduce the incidence and prevalence of malaria."
Malaria vaccines offer hope for millions
"A new milestone in malaria prevention was reached when Côte d'Ivoire and South Sudan introduced the R21/Matrix-M malaria vaccine into their routine immunization programmes," said Maphosa. He elaborated on the anticipated benefits, saying that the RTS, S vaccine has already been deployed in other African countries, Kenya, Ghana, Malawi, Cameroon, Burkina Faso, Sierra Leone, Benin, and Liberia, and is expected to greatly impact child health. The first routine malaria vaccinations outside of pilot countries took place in January 2024 in Cameroon. WHO expert reviews of RTS, S, and R21 data show that both vaccines are expected to have a high public health impact.
"Both vaccines are projected to save tens of thousands of young lives annually," Maphosa said. He added that the successful results from the RTS, S pilot programs in Ghana, Kenya, and Malawi, where the vaccine reduced deaths by 13%, demonstrated that it did not adversely affect other preventive measures or childhood vaccinations.
Maphosa said that the vaccines will also reduce severe cases among children that require hospitalizations, which will be transformative for health systems and healthcare workers. He said that the impact of these vaccines will be maximized when combined with existing prevention strategies like insecticide-treated nets.
"With two vaccines, there is now enough supply to meet the current demand. The pace of rollout is dependent on country preparation and readiness - introducing new vaccines, particularly in lower-income countries, takes time and planning to ensure optimal outcomes," he explained. "With the support of Gavi, 15 African countries are set to introduce malaria vaccines in 2024, to protect at least 50 million children across the continent by the end of the decade."
Reaching the most vulnerable
"Malaria is a serious and well-known disease and building trust in the vaccine is essential for its success," said Maphosa. "It is essential to inform parents that the vaccine has been successfully used in several other African countries, showcasing its safety, effectiveness, and transformative impact."
"Côte d'Ivoire's comprehensive communication strategy, combining mass media with community outreach, is key to ensuring widespread uptake of the malaria vaccine among vulnerable populations." He explained that alongside strategic planning for vaccine introduction in high-prevalence areas, "effective communication and community engagement are crucial for successful immunization activities, especially when introducing a new vaccine."
Maphosa said that Côte d'Ivoire developed a multifaceted communication approach to raise awareness about the new malaria vaccine. "At the central level, they are using mass communication methods, while locally, each health district is engaging in targeted outreach." He pointed out the proactive approach taken before the vaccine launch, saying that local media presenters, bloggers, online press, and community leaders were briefed to ensure accurate information dissemination. "As the vaccination campaign unfolds, their communication efforts will include interpersonal engagement at health centers, where more personalized information will be provided to parents as the vaccination campaign progresses."
Why is Malaria still a threat?
Malaria kills over 608,000 people worldwide every year, and Africa accounts for 94% of these cases. Malaria kills children under 5 and pregnant women the most.
Maphosa identified several significant obstacles to eradicating malaria in Africa, saying, "One primary challenge is programmatic. Côte d'Ivoire, for example, is starting the vaccination roll-out in 38 districts out of 113, which means that 75 districts will not have immediate access to the vaccine." "This approach allows for sustainable implementation of other essential immunization services and provides opportunities to learn and improve. However, there is a risk that neighboring districts may feel neglected, complicating efforts to combat malaria."
"To address this, the government and partners are focusing on raising awareness and ensuring that these districts understand that they will be included in future phases of the roll-out," he said.
Maphosa also pointed out funding as another significant challenge.
"While the vaccine is provided free of charge, the development and distribution costs are substantial. Currently, Gavi covers most of these expenses, but Côte d'Ivoire also contributes. As part of Gavi's sustainability model, the country is preparing to transition out of Gavi support and is actively working on plans to secure state funding for ongoing costs," he said.
He added that coordination and monitoring are always another challenge, especially for malaria, both to deliver four doses of the vaccine to the same child and also to ensure that the vaccine is given as part of the broader malaria control and prevention strategy. Côte d'Ivoire established an Interagency Coordination Committee to oversee the expanded vaccination program, including the new malaria vaccine. Maphosa said that "this committee will closely monitor the performance of the vaccine roll-out and, if issues arise, it will provide recommendations to enhance the program's effectiveness. The Expanded Programme for Immunization also coordinates closely with the National Malaria Control Programme. This structured approach ensures that the country can address challenges promptly and maintain the overall success of the vaccination initiative."
Maphosa explained Gavi's comprehensive approach to tackling the challenges of malaria eradication, emphasizing the importance of partnership and innovative strategies.
"As a public-private partnership, Gavi's unique model was always designed to unlock the comparative advantages of its broad array of stakeholders. We work alongside new partners in ways that strengthen health systems, create efficiencies, and open up entry points for other vital programmes, such as nutrition to reduce food insecurity," he said.
He outlined Gavi's financing strategy saying that "Gavi funds the malaria vaccination programme by paying for doses, with a portion of the cost shared by countries, as well as funding for transport and vaccination activities, including the introduction of new vaccines. Sovereignty and country ownership are key parts of Gavi's approach, and countries show a strong commitment to co-finance and set priorities for their own immunization programmes."
"Currently we are asking donors to match that commitment and fund our strategy for the period 2026-2030, with a total ask of at least US$9 billion," he said. "This financing will ensure we can continue to support countries with access to more than 20 vaccines, help respond to outbreaks, and build stronger and more resilient systems and infrastructure."
"We are focused on partnerships for impact, both with local actors and through a gender-focused approach to immunization to target the hardest-to-reach communities. Between 2026-2030, Gavi will facilitate hundreds of millions of contacts between families and health services through routine vaccination, and we want that to serve as an entry point to deliver other essential services."
We have also set up partnerships with NGOs and humanitarian actors to reach un- and under-immunized children in fragile and conflict zones, and want to leverage every innovation we have to ensure no one is left behind," he said. "An example specifically for malaria is how Gavi and the Global Fund work together closely to enhance malaria prevention in Sub-Saharan Africa, by ensuring access to all tools and interventions and aligned approaches to financing and supporting health systems."
U.S.$1 billion boost for African Vaccine Production
Through the African Vaccine Manufacturing Accelerator (AVMA), up to U.S.$1 billion will be available over ten years to support the sustainable growth of Africa's manufacturing base, contributing not only to the healthy growth of vaccine markets globally, but also to the prevention, preparedness, response, and resilience from outbreaks and pandemics.
"This initiative has the potential to contribute not only to healthy global vaccine markets but also to outbreak and pandemic prevention, preparedness, response, and resilience," said Maphosa.
"AVMA aims to ensure supplies of vaccines for countries that need them the most and to boost the supply of vaccines for which there are currently critical shortages, such as cholera, yellow fever, Ebola, and meningitis. Malaria is a priority antigen for AVMA. The idea is to create a thriving routine vaccine manufacturing ecosystem that can produce many of the vaccines the continent needs while also filling gaps in the global market."
The AVMA was launched by the French government, the African Union, and Gavi in Paris on 20 June 2024. This initiative will provide financial incentives to help vaccine manufacturers in Africa scale up production and become sustainable on a long-term basis.
Maphosa emphasized the initiative's long-term goals saying "Given that Gavi set up this initiative in collaboration with the African Union as a learning from the COVID-19 pandemic, these facilities can be ready to shift gears in a future global emergency to produce vaccines that the continent needs. This will not only contribute to health security and vaccine sovereignty but also provide a buffer for the region against vaccine nationalism."
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Vision for a healthier Africa
Maphosa discussed the role of strategic partnerships and innovations in bolstering disease prevention and health security in Africa, saying, "AVMA is the latest example of how Gavi has used financial innovation and private sector innovation to address vaccine supply constraints, unlock new sources of funding for immunization, and deliver vaccines more effectively."
He elaborated on Gavi's approach, saying, "By partnering with innovators, Gavi has made breakthroughs in the use of drones and biometrics to improve last-mile delivery of vaccines. Here, investments in health systems are critical - not only from the perspective of resilience but also in how countries can rapidly detect and respond to health security threats. The broader the reach of the health system, the safer it is for everyone."
Looking ahead, Gavi's priorities for driving sustainable impact in Africa's immunization programs and disease prevention are multifaceted.
"Countries will make their largest ever investment in immunization over the next five years, covering over 40% of the costs of their routine vaccines," he said. He highlighted that Gavi's support has helped 19 countries transition as their national income levels have grown, with one-third of the original 73 supported countries expected to transition by 2030.
He also pointed out that Gavi's portfolio now includes vaccines against more than 20 infectious diseases, stressing the importance of listening to countries to prioritize and determine the most feasible vaccines. A key focus is on reaching missed communities, which often lack access to basic services. "Vaccines are the widest-reaching health intervention we have, so by reaching them with immunization, we can open the door to other services," he said.
Gavi is also addressing the impacts of climate change on disease spread, maintaining global vaccine stockpiles like cholera and yellow fever, funding outbreak response, and supporting local vaccine manufacturing through initiatives like the AVMA.
"This will be a critical part of our focus for the next five years," he said. "And of course, we hope that as the latest innovative financing mechanism to be designed by Gavi, AVMA will play a formative role in helping build a high-quality, sustainable manufacturing sector."
"We are hopeful that this over U.S.$1 billion investment from us - as one of the largest buyers of vaccines in the world - sends a strong signal to others who must invest in infrastructure, capacity building, regulatory environments, and other aspects to concretely support the African Union's goal for the region to produce 60% of the vaccines it uses by 2040," he concluded.
