May 06, 2017 Volume 389 Number 10081 p1771-1858
The next chapter in malaria eradication
Published: 06 May 2017
The narrative around combating malaria has long been equal parts optimism and pessimism. Remarkably, it was only a decade ago that Bill and Melinda Gates made the game-changing call for the eradication of malaria. Previous control efforts to reduce the burden, particularly in low-resource, malaria-endemic countries in sub-Saharan Africa, were limited by poor access to tools such as insecticide-treated nets, and faced rapidly drug-resistant strains of the highly lethal Plasmodium falciparum parasite requiring treatment with costly artemisinin-combination therapies. The proclamation that eradicating malaria was an achievable goal met with stern criticism at the time, but nevertheless spurred massive increases in international funding commitments and served as a lever to shift the then overarching malaria policy towards a common goal of eradication. It also resulted in the introduction of RTS,S, the first candidate malaria vaccine to yield promising safety and efficacy results and to be recommended by both the Strategic Advisory Group of Experts on Immunization and the Malaria Policy Advisory Committee.
Turning a page in the story of malaria, on April 24, 2017, the WHO Regional Office for Africa (WHO/AFRO) announced a pilot implementation programme beginning in 2018. The RTS,S vaccine will be available in three African countries—Ghana, Kenya, and Malawi—chosen for having mature existing immunisation programmes and high coverage of insecticide-treated nets, yet with persistently high malaria burdens. Although the availability and roll out of the RTS,S vaccine is a remarkable achievement, the decision to implement the pilot programme at this stage is not without controversy. Critics have pointed out several serious shortcomings, including the intensive regimen (three injected doses at months 0, 1, and 2, and a booster dose at month 20), which could be unfeasible outside of rigorously controlled clinical trials, as well as waning efficacy over time.
Cautious optimism is understandable, but it must be emphasised that the vaccine is but one additional tool in the current limited armamentarium for making progress against malaria. Adequate support and scrupulous monitoring will determine whether the pilot programme is a success or a cautionary tale.