In 2019, 400,000 people around the world died of malaria. But it may never reach that high a number again.
Early trials of a new vaccine have been shown to be 77 percent effective. This is not the first vaccine that has attempted to fight the deadly mosquito-transmitted disease. But it is the only one that has had this level of efficacy.
This news comes when COVID-19 vaccines dominate the international discussion. Some wealthier nations, most notably the United States, have prioritized vaccinating their own people first. This week, however, the Biden administration did announce it would be sharing its enormous stockpile of Astrazenca doses. Other countries, like China and Russia, have been shipping their vaccines around the world, though some have questioned their efficacy.
Many poorer countries have worried that they might wait years for their people to be vaccinated and be left with other countries’ lower-quality leftovers.
It also comes as scientists have begun thinking through the ways MRNA technology, which was used to develop the Pfizer and Moderna vaccines, might be used to combat other diseases.
This week on Quick to Listen, we wanted to discuss the good news about the malaria vaccine, how this will affect Christian humanitarian work around the world, and what it looks like to be a good neighbor when it comes to vaccine distribution.
Our guest this week is Dan Irvine, the senior director of health and nutrition at World Vision International.
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Highlights from Quick to Listen #262
What do we know about the malaria vaccine R21?
Dan Irvine: We're celebrating the latest research coming out around this vaccine. After one year of implementation, it’s showing 77% effectiveness in protecting the sample group from infection of malaria. That's a relatively small sample group of about 450 children.
R21 is building on top of a previous vaccine platform, the RTS, which had demonstrated less effectiveness at about 56% over one year and 36% over four years. This represents an evolution of malaria vaccine science going forward. The World Health Organization had set a threshold of 75% effectiveness for a malaria vaccine.
This is the first time we're crossing that threshold. It's significant that this trial now needs to be expanded to a much greater trial group. Plans are in place for it to do that in three countries to concretely establish with authority that level of effectiveness.
What are the symptoms of malaria?
Dan Irvine: I've had it myself in both Congo and Zambia. The classic symptom is fever and a lot of the associated malaise that goes along with fever, like headache, nausea, vomiting, sweating, fatigue, and muscular ache across the body. You might experience cold and shivering as well. Small children often will suffer seizures in the first or second stages of those symptoms.
Back in the 1960s, contracting malaria for a second time was often fatal. Have the treatment or outcomes changed over time?
Dan Irvine: I’m not sure that that assumption of fatality due to a second infection is accurate. Generally, the greatest susceptibility to malaria in terms of fatalities is amongst children, whose immune systems are not as well developed as adults. In developing and poor contexts, they are also suffering other issues like malnutrition and other co-infections. Adults can have repeated episodes of malaria and not necessarily have fatal outcomes.
How have we treated malaria up to this point?
Dan Irvine: In recent years, the prevailing recommendation is a treatment of artemisinin-based combination therapy: a combination of one of the artemisinin-based treatments with another treatment; for example, quinine. The high efficacy of that treatment is in the quick action that it takes and also the reduced likelihood of antimicrobial resistance when we use combined therapy versus a single therapy.
What has caused the decline in deaths due to malaria?
Dan Irvine: The latest figure on malaria mortality globally is slightly topping 400,000 people a year. The majority are infants and children under the age of five.
95% of the malaria cases globally are occurring in 29 countries. 51% of them are occurring in five countries in Africa. It's becoming more and more localized.
Malaria has been eliminated in many countries today. It was eliminated in the United States in 1970. This elimination and the decreases in numbers over the years are not due to vaccines, because we haven't been able to employ an effective vaccine, but rather several preventative control methods, as well as rapid diagnostic tools and treatment that have brought down fatality significantly.
There has been significant global investment in eliminating malaria. Billions of dollars go into this effort over the years.
Has there been a specific focus on malaria as opposed to other mosquito diseases?
Dan Irvine: The biggest killer is the falciparum. That's where the majority of this investment has gone specifically. Zika and dengue are also mosquito-transmitted. There are different mosquitos. They have different behaviors that need to be dealt with differently.
Interventions include controlling the mosquito population: indoor residual spraying in households and the use of insecticide-treated bed nets for people to sleep under at night when they’re most active. Also importantly, education: making sure that people are aware of the problem, that they act quickly when they identify symptoms within their households That's critical in this equation.
Are mosquitoes the only way that malaria is transmitted? It isn’t contagious in the same way that COVID-19 is.
Dan Irvine: Malaria and coronavirus is not an apples-to-apples comparison in any sense. Malaria is a parasitical infection and COVID is a viral infection. They're not similar. The transmissions are nothing alike. However, with malaria, people are not protected and remain vulnerable to infection. As long as you have that mosquito population, it means that in the transmission cycle, a mosquito bites an infected person receives those parasites, and can then transmit it to another person. It's not direct person-to-person, but it is person-to-mosquito-to-person.
The United States eliminated malaria in 1970. Has that in some ways been a negative outcome on the disease overall and in terms of global health, for people who live in countries that don’t have the same amount of resources?
Dan Irvine: When a disease is not prevalent in wealthy countries, it's not going to receive as much attention. We see now with the coronavirus; it's a different scenario not only between countries but even within populations in countries. In the 1980s and 1990s in the United States, during the end of the HIV epidemic, less investment went into the HIV issue because it was located primarily in a small subpopulation.
Even within a wealthy country, we have this similar effect. Internationally, there are other factors in the acceleration of vaccine development or a disease approach. One is the market-driven aspect in terms of medicines and vaccines. They’re prioritized according to their profitability in the private sector. A lot of the research and development is driven by the private sector and their fundamental driver is profit. If they don't see relative profitability for their investment, they're not going to accelerate their investment.
There are places where malaria has been eliminated without a vaccine. Does that result in less urgency around the need to create a vaccine?
Dan Irvine: We have historically and contemporarily seen a high level of effectiveness of other malaria control and treatment mechanisms. Unless a vaccine for malaria is highly effective in relation to the other ongoing interventions, it's not deemed as being the top priority.
This is partially the reason why the World Health Organization has established a relatively high benchmark of effectiveness for the malaria vaccine at 75%, in contrast to the generally accepted 60% effectiveness for influenza vaccines. We have these other mechanisms in place that are working quite well.
How is effectiveness measured in relation to cost?
Dan Irvine: In public health, we are focused on impact. We're dealing with hundreds of diseases. Ultimately, we have to prioritize investments and apply these cost-effectiveness lenses to our prioritization processes. Unfortunately, there's a limited amount of resources that can be applied to the issues that we face globally.
Is the global response to COVID going to make people more likely to address some of these other global health issues, like malaria? Or will people have disease fatigue?
Dan Irvine: This global pandemic, which is our generation's first pandemic of this magnitude, affects how we will address global pandemics in the future. A lot of technology and innovation can be leveraged for even non-pandemic purposes as well.
We are seeing a modern miracle in the development of the COVID vaccine, especially based on the mRNA. A culmination of decades of research has now blossomed and gotten the financial push across the line into an effective application.
We're also seeing similar innovations all across the supply chain for vaccines: research, manufacturer to distribution, public-private partnerships, multilateral platforms, new international health regulations, and a pandemic treaty on the table.
The COVID pandemic has equally shown us that a global event like this is interrupting every aspect of our lives: social, economic, and certainly, public health. Whereas we have had decreases in malaria in recent years, unfortunately, we're currently projecting increases in malaria cases again because the COVID pandemic has interrupted public health service provisions on the ground. We're seeing lots of effects like this as well as interrupted routine childhood immunizations, which is going to create problems around the world as well.
What are some of the costs of malaria?
Dan Irvine: There's a loss of human development happening right now. A lot of the developmental progress that we've made over the last years is being eroded. We're seeing significant increases in malnutrition and hunger. Globally, hunger is essentially doubling as an effect of the pandemic. Severe acute malnutrition is increasing significantly. We've got significant increases in mental health problems.
How has COVID interrupted the work to eliminate hunger?
Dan Irvine: Global supply chains: the ability to move food around the world. The cessation of supply chains for farm inputs: seeds, fertilizers, tools, the shutdown of markets. People are unable to even go to a local market to procure food, but also facing the financial impact where their assets have been eroded and significantly limited their ability to buy food.
On the health side, people are unable to access health services either because they've been shut down in lockdown situations, or they're afraid to go because they're afraid to contract the disease in a public place.
What makes the process of developing the COVID vaccine unique?
Dan Irvine: If we look at mRNA technologies, the great success of Moderna and Pfizer with the very high level of effectiveness, it's not that technology was innovated immediately in the last year or two.
It's been an evolving technology over the last couple of decades. Take that historic evolution of that innovation over time. With the COVID pandemic, there was an incredible injection of financial resources--billions of dollars--into those developers to get that technology to cross the line into an effective vaccine for COVID.
What role have Christian humanitarian and medical organizations played in the development of vaccines?
Dan Irvine: Faith representatives, faith institutions, and people of faith, including faith leaders, play an extremely important role in the social uptake and acceptance of the vaccines. They play a role in helping communities to address their hesitancies and their trust issues. It’s not only religious issues but socio-cultural and socioeconomic issues where faith leaders play an extremely important role.
My organization works with over 450,000 faith leaders. We immediately reached out to this network at the front end of the pandemic through a WhatsApp platform to discuss with them what COVID-19 is and what its ramifications are, to make sure that they were getting good information and being directed to good sources.
We've developed a tried-and-true platform that we refer to as “channels of hope” to engage a deeper discussion, workshopping with faith leaders to explore the theological foundations of their approaches to vaccines, as well as the public health science.
We try to bring those things together to empower them, to engage their communities positively concerning the issues that are going on. Faith leaders and people of faith are significant stakeholders in any public health issue, and certainly in relation to vaccines.
Have you seen Christian ideas, either theological or spiritual, that inform how people are addressing diseases?
Dan Irvine: Oftentimes, you might see conservative political issues tied to people of faith. Those issues are not actually religious in nature. They're philosophical, political, or socio-cultural. It’s important to distinguish between vaccine hesitancy issues that are directly tied to faith tenants, versus those broader political and cultural issues.
Faith leaders are critical stakeholders and champions at a community level who need to bring their influence to bear on vaccine uptake. They're not the only ones. All leaders--political, traditional community leaders, and frankly, your neighbors, your peers, people who you talk to, listen to, and trust--need to be champions of positive health actions.
We've recently been doing assessments around coronavirus vaccine uptake. In Bangladesh, over 60% of the people who said they were willing to take a vaccine, agreed that they believed their faith leaders were supportive of that action.
Can you tell us about the nature of vaccine skepticism in the US and other countries?
Dan Irvine: There are hesitant people all over the world. This is just a part of human nature. It’s universal, but we also know that the reasons for hesitancy are highly contextual.
What we recommend in our practice is that when designing a vaccine rollout, we need to invest in assessing locally what the specific barriers and enablers are for vaccine uptake. We just published a study across six countries in relation to the COVID-19 vaccine using our core assessment methodology, which we refer to as barrier analysis.
Many different kinds of barriers exist across these contexts, including logistical difficulties accessing the vaccine, affordability, time to get it, lack of adequate information about the disease, or vaccine non-belief in the disease.
In some cases, it comes from not seeing disease impact in their community and fear of contracting the disease in public facilities. It’s extremely important to listen to people and try to understand where they're coming from and what their hesitancy is based on. You can't be successful in a top-down approach, trying to push vaccines on people who are resistant. In most cases, you've got to tailor your messaging to their specific barriers while also leveraging what you've identified as being the enablers in their communities.
What are mRNA vaccines and how do they work?
Dan Irvine: This is the messenger ribonucleic acid vaccine. It's synthetic, meaning it can be developed with available materials in a lab rapidly and scaled up. It's giving your cells a blueprint, an instruction on how to build a spike protein on the cell.
Your cell puts that spike protein on top of itself, and that attracts antibodies in your system to attack it. Consequently, it develops a blueprint for your body to address this specific disease. It is not introducing any part of the actual virus, either live or attenuated.
What would you say about powerful countries like the US and China wielding their influence by sending or withholding vaccines?
Dan Irvine: There's been a vibrant and important global discourse about equitable distribution of the vaccines and fair allocation and consequently, the discussion about vaccine nationalism.
There's no surprise that first of all, wealthy countries are choosing to prioritize effective coverage of their own populations with vaccination before sharing resources to other countries. It’s not a good thing from a public health epidemiological perspective, but it is a political reality that we live in.
Not only are wealthy countries’ political leaders prioritizing coverage of their own populations, but the electorates in those countries would not accept any other decision. It's not as if in the United States, Joe Biden would be able to say, Rather than vaccinate the majority of our American population, I'm going to suggest that we ship these vaccines to other countries for equity purposes.
How does the mentality “Put on your oxygen mask before assisting another person” apply to this situation?
Dan Irvine: If it were possible to vaccinate the global population in a day, a week, or a month, that's the ideal scenario. But that is not possible. We work with finite resources.
There will not be enough vaccines manufactured in 2021 to vaccinate the entire global population. The next consideration becomes, given limited resources, who should be prioritized for vaccination. The global consensus there is the most vulnerable people at risk of infection, and the severe impact of the infection.
One group that's been identified globally is the elderly. Other highly vulnerable groups are disproportionately at risk of infection and severe adverse effects of the infection. Those populations need to be identified and prioritized as well.
We know that the COVID vaccines are being produced by pharmaceutical companies and manufacturers who are found in a small number of countries, and by and large, wealthier countries. These companies influence where the first wave vaccines go. The majority of the first wave vaccines have gone to wealthy countries and a small proportion goes to low- and middle-income countries. The US was not well-invested in the international mechanisms for ensuring an equitable vaccine distribution around the world.
The Johnson & Johnson vaccine was briefly suspended. Does that leave the rest of the world feeling like they were getting leftovers or inferior products?
Dan Irvine: I always worry about inferior products for several reasons. However, what is important for people to remain focused on in this vaccine equation is that there are very standardized and responsible parameters for developing and trialing vaccines. Those trials typically require population samplings of over 30,000 people. The parameters include a diversity of people and usually require monitoring within that population over time. One, to ascertain effectiveness. Secondly, to ensure safety in the absence of adverse effects to the vaccines.
The leading vaccines that are being deployed today have mostly gone through these standardized trial practices and have submitted their documentation to stringent regulatory authorities.
Those authorities, such as the USFDA, have provided emergency use categorization for their scale-up. Emergency use is a little different than normal authorizations because of this compressed timeframe, but these are the responsible ways for ensuring the safety of these vaccines for public consumption.
Even with the emergency approval, I have full confidence that these are effective and safe tools for us to control the epidemic. However, the administrative authorities in countries around the world have weighed their options and have determined whether or not to use vaccines within their contexts. That is their responsibility as well.
We saw a similar case with AstraZeneca in Europe, where there was a question of whether the vaccines had been associated with adverse effects, generally being blood clotting and thrombosis effects. We have noted that people with certain health dispositions and conditions may react like that. But this is such a statistically insignificant number of unique cases. It does not merit a non-deployment of those vaccines. You're seeing authorities in Europe, the US, and other countries around the world moving forward with those vaccines, as I believe they should.
What should people be praying for in terms of how we address infectious disease?
Dan Irvine: Within World Vision, we've been praying hard. Our CEO and President, the Reverend Andrew Morley, began convening global town hall meetings across our organization. It had such a deep impact because we're humanitarian workers. We come under enormous stress in a situation like this, where every part of our work and everything we've invested in through our careers has been affected negatively. The challenges are enormous. We see the incredible effect on the children that we've been serving for so long and in all the places that we work.
In my prayers, I always like to first thank the Lord for the resources that He's provided us. We have what is a modern miracle in the form of the current vaccines that are becoming available and the rapid scale-up of their availability. We should be thankful for that.
First of all, we should pray that the most vulnerable people in the world get equitable access to those vaccines and the resources and as fast as possible. Through vaccination, in combination with the other pandemic control measures, because they all remain equally important, we can restore the normalcy of our lives and begin our recovery.
Hopefully, not only recover and get back to where we were but learn a lot of lessons and accelerate our development investments to make us more resilient in the future. I would ask that people pray for the humanitarian and development workers out there, for all of the health and frontline workers providing services. They need to be protected to do their jobs and they need to be appreciated.
Pray also that political leaders make socially responsible decisions and investments; that they have wisdom and discernment in what they say, what they do, and the investment decisions that they make. We always pray with priority for children around the world.
Many of them were in very difficult situations already, now made worse by the pandemic. We hold those children up all over the world every day in our prayers, that they would know God's love, God's protection, and have life in all its fullness.