On April 17, 2023, Nigeria approved a promising new malaria vaccine. It's called R21, and in early trials, up to 80% of kids who were vaccinated did not develop malaria.
Nigeria is a country in need of protection from malaria. Its death toll from the disease makes up nearly a third of the world's 619,000 malaria deaths a year.
But in my view, there's a big stumbling block: Many of the people who need the vaccine the most live in poor and rural areas where malaria is troublesome because of living conditions that favor mosquito breeding – for example, low quality housing with broken window nets that mosquitoes can easily infiltrate, standing pools of water in gutters, and the proximity to swamps. But they'll likely not be able to get it. The reason is simple — Nigeria doesn't have the kind of health-care network that makes it easy for people in remote areas to see a health professional.
This isn't the first vaccine to ward off malaria. There is one already in widespread use called the RTS,S vaccine, which reduces chances of developing malaria in a vaccinated population by up to 44%. But the R21 vaccine, which works by inducing high levels of malaria-specific antibodies that help to protect against malaria, has shown to be safe and more effective than the RTS,S vaccine in preliminary results from a 2-year long trial.
In early trials conducted in 2019 and 2020, children aged 5 to 17 months were given three doses before malaria season and a booster 12 months later. Up to 80% of children vaccinated did not develop clinical malaria during the 2-year period of the trial.
This testing on kids is crucial – they are the most vulnerable to dying from malaria. In Nigeria, more than 95,000 children under age 5 die from malaria every year.
Serum Institute of India, the license holder of the R21 vaccine, has expressed commitment to manufacture more than 200 million doses annually. This is important because GSK, the manufacturers of the RTS,S vaccine only committed to producing 15 million doses annually through 2028, due to limited manufacturing capacity and low funding, falling far behind the current need of the vaccine which WHO estimates to range from about 80-100 million doses annually.
While WHO hasn't yet authorized the R21 vaccine because they are awaiting further data from the latest completed trial phase 3, they hope to act quickly when more data are in. In a statement, they said "the R21 vaccine, if approved, could help close the sizable gap between supply and demand and further reduce child illness and death from malaria."
So even though the R21 vaccine is still undergoing larger-scale human trials, Nigeria has joined Ghana in authorizing it because of its promise to be the most effective in preventing malaria and its potential to be manufactured at large scale due to its low cost of just $3 a dose. This provisional approval allows a phase 4 trial to be carried out in Nigeria and also places Nigeria among the first countries who will receive the vaccines at large scale.
But what good is a miracle vaccine if those who need it the most can't get it?
The Nigerian government typically rolls out vaccines through its 30,000 primary health centers, but only 20% out of them are functional. This means that most of the primary health centers in Nigeria lack the capacity to provide essential health-care services, because of poor staffing, inadequate equipment, poor distribution of health workers, poor quality of health-care services, poor condition of infrastructure, and lack of essential drug supply.
And according to data from Nigerian researchers, 78% of primary health-care centers in Nigeria serve upward of 20,000 people within a 30-mile-plus radius. For those who live a great distance, options to get to a center are limited. In a country where most people live on less than $1 a day, they likely do not own a private car or have access to/can afford bus options. That means many parents may need to walk as far as 30 miles to receive a vaccine and wait long hours to be seen in the often crowded centers – and they will need to make that trip four times over the course of 18 months.
Indeed, "long travel times" was listed by one study in Nigeria as one of the most frequent reasons deterring parents from getting routine immunizations for their children. Another reason was long queues at health centers.
And those obstacles take a toll on vaccination rates. "About 9 in every 10 children who lived in the mostly economically disadvantaged communities and states were not fully immunized," according to another Nigerian study that surveyed 5,754 children between ages 12–23 months. "Children of mothers who experience difficulty in reaching health facilities are more likely to be incompletely immunized," the report notes. "Difficulty in getting to health facilities serves as a major barrier to child immunization uptake. This is typical of those living in remote areas."
The obvious fix is one that will not happen overnight: Public health authorities must make a financial commitment, however costly, to set up new primary health-care centers throughout the country to dramatically reduce travel time to and wait times at health centers.
In the meantime, global health authorities need to make it easier for people to get to the health-care centers that already exist. One stopgap solution is to provide transport vouchers for those in the cities, so that people are able to travel for free using bus services that run on a regular basis to the nearest health center.
The other is to bring the health-care center to the families in remote villages through public-private partnerships to set up vaccine administration centers at pharmacies, local markets or schools and churches.
As the founder of a free health clinic in Lagos, Nigeria, funded by the Samuel Huntington Foundation, we partnered with a church in an impoverished neighborhood, transforming a space into a small-scale free clinic run by a lead nurse. We've been able to provide primary care to over 2,000 patients. This model places primary health services in proximity to the poor and saves on the cost and time of building a new facility.
This partnership model could be replicated rapidly by public health authorities on a larger scale to ensure the vaccines reach the most vulnerable children in Nigeria. This is what the United States did with its Federal Retail Pharmacy Program, which allowed 300 million more COVID-19 vaccines to reach people through their local pharmacies.
The United States government and the Global Fund have been leading funders of global malaria eradication efforts in the last two decades. They have spent more than $20 billion on important global malaria eradication programs like insecticide bed nets and vaccines. But funding urgently needs to be expanded to go toward building a primary health-care system in Nigeria and other countries with similar circumstances – one that might deliver breakthrough vaccines like R21.
"Everything in Nigeria isn't easy," says Sunday Aromolayan, a bricklayer living in Berger, a city at the border of Lagos and Ogun State, Nigeria. "I have a 2-year-old and a 6-year-old, and for past immunizations, we've had to queue at the hospital for 4 hours, sometimes 5 hours. My schedule has prevented me from going to take immunizations many times. If the malaria vaccine is available, of course, I'd want to get it for my child."
Tolani Yesufu is the founder and CEO of The Ameliorating Health in Africa (AHA) Initiative, a nonprofit that works to strengthen access to primary health care across Nigeria and Africa. She is also a graduate with a degree in Media, Medicine and Health at Harvard Medical School, where she studied the social determinants of malaria in Nigeria.
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