Real reasons Nigeria still missing out on malaria vaccine rollout

On 25 April, three West African countries = Liberia, Sierra Leone, and Benin – rolled out, in thousands, doses of an anti-malaria vaccine for infants between 5 and 17 months old.

The rollout began five months after the World Health Organisation (WHO) endorsed two anti-malaria vaccines for children: RTS, S, and R21.

The vaccines were described as a certified tool for improving child health and malaria control in Africa.

Since the rollout, countries such as Benin added the vaccine to their routine immunisation programme after receiving 215,900 doses.

But Nigeria, where malaria is responsible for 11 per cent of maternal deaths and 25 per cent of deaths among infants, and despite carrying the highest global burden of the disease, has yet to receive or commence administration of the vaccine.

However, PREMIUM TIMES has found that Nigeria missed out on the rollout because the malaria vaccine designated for deployment in Nigeria by GAVI was not ready for distribution.

The GAVI Head of Malaria Vaccine, Scott Gordon, told PREMIUM TIMES that the three countries which began deployment of doses of malaria vaccine to their children were those who received RTS,S- the vaccine that was ready for distribution at the time.

He said countries were matched with the vaccines based on cost alongside their level of demand, and that Nigeria, among other countries, was matched with the R21 vaccine.

Mr Scott noted that GAVI considered the R21 vaccine best suited for Nigeria based on the country’s needs and plans, as presented in its proposal to GAVI.

“The match is based in part on the cost of the vaccine as well as the available supply. It is to make sure there’s enough of the vaccine to scale up according to Nigeria’s needs and plans,” Mr Scott told PREMIUM TIMES.

Initial rollout for Bayelsa, Kebbi

Both the RTS,S and R21 are intended to protect against Plasmodium falciparum, the most deadly malaria parasite globally.

The RTS,S is the first malaria vaccine, which was piloted in Ghana, Malawi, and Kenya in 2019. R21, on the other hand, is a newer vaccine developed by the University of Oxford and its spin-out company, Vaccitech. The latter requires a lower dose and is easier to manufacture compared to the former.

According to WHO, these vaccines have similar effectiveness in clinical trials, preventing around 75 per cent of malaria episodes in areas with a high burden of the disease. Also, there’s no evidence showing that one vaccine performs better as they have not been tested in a head-to-head trial

Nigeria matched with the R21 vaccine, intends to roll out its first doses to two states where seasonal transmission of the disease is high- Bayelsa and Kebbi states.

The National Coordinator, National Malaria Elimination Plan (NMEP), Godwin Ntadom, said the vaccine’s launch in the country will only involve the two states because of the limited number of doses.

He said more high-burden states will receive the vaccine when the country is able to secure more doses.

The prevalence of the disease varies at the state level. It is often higher in rural communities situated by the banks of major rivers, water bodies, or irrigation dams.

Currently, Kebbi, Sokoto and Zamfara states have the highest burden, while Lagos and Kwara states have the lowest.

Also, according to NMEP, states in the North-west region have the highest prevalence, with 33.8 per cent, followed by the North-east with 19.9 per cent, North-central with 21.2 per cent, South-west with 18.4 per cent, and South East with 15.7 per cent. States in the South-south have the lowest prevalence, at 15.6 per cent.

The 2022 World Malaria Report showed that Nigeria contributes about 27 per cent of the global burden of the disease.

Rollout date uncertain

Mr Scott predicted that the R21 vaccine should be out to countries by the end of May or the first weeks of June.

He said the vaccine is almost ready, and that the next phase of the process would be rolling to countries listed to receive the vaccine.

“GAVI will be able to supply the vaccine by the end of May or early June, depending on the arrangement to ship it.

“The vaccine is imminent and it’s been a question of working with the country to make sure they have time to do all the preparation that they need,” he noted.

Nigeria, he said, plans to start rolling out the vaccine later in the year, but “the exact timing is up to the health ministry.”

When asked if Nigeria had sent a late application for the vaccine, as health professionals who spoke with PREMIUM TIMES speculated, Mr Scott explained that Nigeria, indeed, failed to send an early application when the window first opened.

However, he noted that given the selection process, this delay could not have interfered with the time of allocation to Nigeria.

WHO comments

Also, WHO, in an email correspondence to PREMIUM TIMES, said it is working with the GAVI Alliance to support Nigeria’s application to secure vaccine doses needed for this introduction.

According to the WHO Country Representative and Head of Mission to Nigeria, Walter Mulombo, Nigeria is currently trying to secure malaria vaccines and will roll them out as soon as it is successful.

When PREMIUM TIMES contacted the NMEP coordinator, Mr Ntadom, to ask when the country is likely to roll out, he said, “ I cannot say anything is certain about it, the process is still ongoing. When we are done, there’ll be an announcement to that effect.”

Combining tools in portfolio

By 2025, Nigeria aims to reduce malaria prevalence to less than 10 per cent and infant mortality to less than 50 deaths per 1,000 live births.

In the 2016-2020 malaria elimination plan, Nigeria aimed to reduce the disease to pre-elimination levels and deaths to zero. However, instead, it achieved a decline from 42 per cent to 23 per cent. The country only achieved 53 per cent of its goals.

According to Mr Scott, Nigeria needs to accelerate its efforts to meet its target against malaria. The country needs to combine all the anti-malaria tools that have been endorsed for use, such as Insecticide-Treated Nets (ITN) and Chemoprevention.

“Nigeria should use all the tools available in the portfolio to accelerate its effort against malaria. Each tool is important, and the efforts should be at both the national and subnational levels.

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“It is not just about the supply of these tools to the country but the distribution to key areas as well,” he said.

Other counsel

Other experts and stakeholders have also advised that Nigeria should reappraise its efforts. Some urged the federal government to increase internal financing for addressing the epidemic.

They also suggested an increased investment in data, leadership, coordination and the local production of anti-malaria drugs.

This way, transmission of the disease is likely to reduce significantly, especially among the most vulnerable populations, pregnant women and children, who reside in remote parts of the country.