Gavi, the Vaccine Alliance’s Critical Role in the Fight Against Malaria

Last week, U.S. Senators Ben Cardin (D-Md.), Chair of the Senate Foreign Relations Committee, and Roger Wicker (R-Miss.), Ranking Member of the Senate Armed Services Committee, introduced a resolution affirming continued U.S. support for the purchase of life-saving vaccines for lower-income countries through Gavi, the Vaccine Alliance (Gavi), as a cost-effective, efficient means to end preventable child and maternal deaths around the world. Colleagues in the House followed suit with a resolution introduced by Rep. Tom Kean, Jr. (NJ-07), Rep. Sara Jacobs (CA-51), Rep. Gabe Amo (RI-01), and Rep. Maria Salazar (FL-27).

Gavi plays a critical role in procuring malaria vaccines. Funding for Gavi ensures more children have access to malaria and life-saving routine child immunizations. Research and testing for the malaria vaccine has been 30 years in the making. On May 20, United to Beat Malaria hosted an advocacy webinar discussing how vaccines prevent malaria, the demand for the vaccine, and the role of Gavi, the Vaccine Alliance in malaria elimination efforts. Click to view the full recording and slides from the May 20 webinar.  

Unprecedented Demand 

There is great demand for malaria vaccines. There are about 40 million children born every year in malaria-endemic areas in Africa who would benefit from a vaccine. The demand is estimated to be 40 to 60 million doses by 2026 alone. Since July 2022, when Gavi, opened a funding window to support program eligible countries in the vaccine roll out … over 28 countries expressed interest in introducing the vaccine. Fourteen applications, submitted to Gavi by countries in the first two application opportunities were recommended for approval by Gavi’s Independent Review Committee (IRC) following the standard Gavi processes. The available vaccine supply for the period 2023-2025 is currently limited to 18 million doses and falls short of the vaccine dose requirements for the countries recommended by Gavi IRC for approval.  

How Does the Vaccine Work? 

The RTS,S malaria vaccine is designed to target the Plasmodium falciparum parasite that causes malaria, which is spread by anopheles mosquitoes.  The vaccine targets the sporozoite. The Plasmodium sporozoite constitutes the first form of the malaria parasite entering the human body and, hence, provides the first and leading targets to control an infection.  When a person is vaccinated, the immune system is stimulated to produce antibodies against the circumsporozoite protein, which is found on the surface of the sporozoites.  If a vaccinated person is later bitten by a malaria-infected mosquito, the antibodies can neutralise the sporozoites in the bloodstream, preventing the parasite from establishing an infection.   

Effectiveness 

The RTS,S vaccine has been tested in rigorous clinical trials and shown to be safe and effective in children, including in those with HIV and malnutrition. Both the R21 and RTS,S malaria vaccines prevent around 75% of malaria episodes when given seasonally in areas of highly seasonal transmission where malaria chemoprevention is provided.    

Since 2019, nearly 2 million children at risk have been reached with the malaria vaccine across Ghana, Kenya and Malawi. The RTS,S malaria vaccine implementation has resulted in a substantial fall in severe malaria hospitalizations and a significant drop in child deaths — there was a 13% drop in all-cause mortality (i.e. not just from malaria) from use of the vaccine.   

Combination of Tools 

The RTS,S/AS01 vaccine reduces malaria deaths by 30% and is especially important for children, who are most at risk from malaria.  If you had 100 children who would die from severe malaria, you could save 30. The second vaccine, R21/Matrix-M, is highly effective, reducing cases of malaria by 75%. Hundreds of millions of doses of this vaccine can be produced each year.  

The vaccines are new tools, but they have to be used with the other measures we have against malaria. These include bed nets and the administration of antimalarials to children at the highest risk of malaria at specific times throughout the year. This is why we are now advocating in support of Gavi, in addition to PMI, GF + CDC and UNICEF. Because all these programs work collaboratively to tackle the different challenges of malaria elimination. If we add the vaccine on top of these measures effectively, we may move further towards malaria elimination. 

How Are Vaccines Allocated? 

As mentioned, demand for the malaria vaccines is high, and, although there is optimism for the increased supply of vaccines now that two vaccines have been approved, there is a gap between supply and demand.  In order to address this gap, Gavi utilizes a framework shown to prioritize vaccine allocations.   

Source: WHO July 2022

The Framework Allocation Implementation Group, comprised of technical staff from the WHO, UNICEF, Gavi Secretariat, and Africa Centres for Disease Control and Prevention (Africa CDC) was mandated to recommend the malaria vaccine quantities to be allocated to countries by systematically following the principles, considerations and indicators defined in the Framework.  Key Framework considerations include:  

• Ensure continuity of access to vaccine once a programme has started & Honouring commitments to Malaria Vaccine Implementation Programme (MVIP) countries.  

• • A fundamental principle for Gavi is that once a new vaccine is introduced through routine public health services in a certain area, continuous and sustainable access needs to be maintained.   
  • Stopping the provision of a vaccine temporarily or indefinitely while the need is still present has serious ramifications for the immunization programme as a whole, including a potential loss of trust by communities accessing immunization services. 

• First priority allocation principle: Greatest need & Foundational value of solidarity.   

• • The measure for need was defined as a composite index combining measures of malaria burden (either P. falciparum parasite prevalence rates (PfPR) in children or malaria incidence rates) and under-five all-cause mortality rates.   

• Second priority allocation principle: Maximize health impact  

• • The highest health impact will be achieved where vaccines are most needed and where there is capacity to deliver the full course to children living in areas of greatest need.   

• Final priority allocation principle: Fair benefit sharing  

• • The fourth principle is specific to Mozambique and Sudan as both were found to have similar levels of performance in relation to the vaccine drop-out rates. In order to establish the rank order between the two, the Framework’s final priority principle, i.e., fair benefit sharing, was applied. Since Mozambique participated in the clinical development of the RTS,S/AS01 vaccine as a Phase 2 and 3 trial site, Mozambique would therefore be prioritized among the two.  

Gavi Within the Malaria Ecosystem 

Working collaboratively, PMI worked with WHO and Gavi to develop an expedited process for vaccine program design and applications. Gavi, UNICEF and WHO helped to allocate and distribute 18+ million dosed of RTS,S.   

As PMI and GF continue to mobilize preventions tools including mosquito nets, quick-diagnostics tests, as well as reinforce in-country health systems expanding training for community health workers and laboratory capacity, GAVI and UNICEFs efforts to deploy the vaccine creates a backstop of sorts to prevent reinfection. This is especially important in high burden countries where it is not uncommon to be infected with malaria multiple times per year.  

Gavi’s country-ownership model is unique in that it requires eligible countries to contribute a portion of vaccines costs themselves.  Through this mechanism, USG contributions have helped leverage more than $1.5 billion in country contributions to improve immunization campaigns between 2008-2022.  What’s more, Gavi’s sustainability model transitions countries away from Gavi support once the country achieves certain national income and development standards.  By the end of 2022, 19 countries have successfully transitioned away from Gavi support since 2020, and another 10 are expected to transition in the next 20 years.    

For every $1 of taxpayer dollar invested in global vaccines, approximately $54 is returned in economic benefits, decreased health costs, and lives saved.    

Ghana Country Spotlight 

Ghana, along with Malawi and Kenya, was part of the Malaria Vaccine Implementation Programme (MVIP), which kicked off in May 2019. Just one year after the initial rollout, confirmed malaria cases per 1,000 people dropped from 192 in 2019 to 159 in 2020.  

In 2022, Ghana reported only 151 deaths due to malaria. This marks significant progress from 2012 when Ghana recorded 2,799 malaria deaths. Ghana’s countrywide prevalence rate – which measures the total number of cases divided by the total population- also declined from 27.5% in 2011 to 8.6% in 2022. 

Following the successful first year of malaria prevention, Ghana’s ministry of health developed the National Malaria Elimination Programme (NMEP) which aims to reduce malaria mortality by 90% by 2028, and reduce malaria case incidence by 50% by 2028. They plan to eliminate malaria in 21 districts with very low malaria burden by 2028.  

The NMEP strategy involves sub-national elimination, focusing on areas with low and high malaria rates, rather than a nationwide approach. So far, the NMEP has rolled out the RTS,S malaria vaccine in seven regions, reaching over 1 million children. Each child receives four doses of the vaccine, beginning at six months of age.  

In 2023, significant coverage of child malaria vaccination was achieved in Ghana’s Central and Bono East regions, with 87% and 92% coverage rates amongst all children respectively. At a smaller district level, 98% of children were vaccinated in Awutu Senya East, 87% in Gomoa East, and 95% Atebubu-Amanten.  

Progress So Far 

The malaria vaccines have contributed towards the reduction of all-cause mortality among eligible children by 13%, with a 22% reduction in hospitalised severe malaria cases, and 17% reduction in hospitalisation with positive malaria test in the pilot countries (Ghana, Malawi, and Kenya).  

In Ghana, malaria-related mortality among children under five has been declining in vaccination districts since 2019. Similarly, there have been reductions in children under-five malaria-related hospital admissions, particularly in the Bono and Central regions. It is important to note that these improvements are the result of the malaria vaccines in combination with other malaria elimination efforts such as bed-net distribution and seasonal malaria chemoprevention.   

Take Action in Support of Gavi, The Vaccine Alliance! 

United to Beat Malaria Champions contribute to helping to increase access to life saving interventions. The resolution introduced last week by Senators Wicker and Cardin reinforces the importance of the malaria vaccines. The language of the resolution highlights the importance of Incorporating malaria vaccines into routine childhood immunizations, noting that malaria vaccines are expected to make the most impact in terms of lives saved since early studies have already shown a 13% reduction in all-cause mortality associated with the malaria vaccines.   

You can take action TODAY to express your support of the resolution and encourage your senators to do so as well!  Click here to send a letter to each of your senators and HERE to send a letter to your Representative asking them to support the Gavi resolution and click through all the fields to post on X tagging those elected officials for added reinforcement!