Even as the health sector in Malawi faces competing priorities and some resource limitations, the country is implementing time-proven and innovative approaches to improve child health, with support from WHO. The results of the collaboration are generating progress to reduce suffering, illness and deaths among vulnerable children. Two activities stand out as milestones in Malawi’s public health: mass drug administration to combat neglected tropical diseases and the landmark pilot implementation of the world’s first malaria vaccine in childhood vaccination.[1]

Towards the elimination of neglected tropical diseases

Neglected tropical diseases affect the most vulnerable people and have historically received less attention than other diseases. Yet, they can lead to severe health outcomes such as blindness, disfigurement, cancer or death. By mass drug administration, a number of these diseases could be eliminated or controlled so that they no longer present a public health concern. In Malawi, there are eight widespread tropical diseases and five of them could be eliminated via mass drug administration: Trachoma; Schistosomiasis, also known as snail fever; Soil-transmitted helminths, commonly known as intestinal worms; Onchocerciasis, also known as river blindness and Lymphatic filariasis.

With WHO’s support in providing medicines and technical guidance, Malawi administered treatment against these five diseases to children across ages and across stages. The coverage of above 80% has been achieved for snail fever and intestinal worms. As a result, the five tropical diseases are now on the verge of elimination. To verify this status, WHO supported Malawi to develop dossiers and apply to be certified free of Lymphatic filariasis and Trachoma. The successful verification would mark a milestone in Malawi’s public health and make it one of few countries in Africa that is free from these diseases.

A potential new tool: RTS,S malaria vaccine for added malaria protection

Malawi has been taking historic steps to deliver added malaria protection to children through pilot implementation of the RTS,S malaria vaccine. The national immunization programme was the first in the world to launch the country-led malaria vaccine pilotin2019, followed by Ghana and then Kenya. From pilot initiation through 2020, nearly half a million(490 000)doses of RTS,S malaria vaccine have been administered to children by the Ministry of Health in select areas of 11 districts, and about 184000 children received their first vaccine dose and should benefit from the additional malaria prevention.Malawi has managed to reach and provide added protection against malaria to around 90% of children in the vaccinating districts. The number of children reached with malaria vaccine indicates good community acceptance of the vaccine.The vaccine provides considerable added protection against malaria to children when used with other WHO-recommended malaria control measures,building on the successful child vaccination platform.From 2010 to 2017, use of insecticide-treated nets(ITNs or bed nets), indoor residual spraying and antimalarial medicines nearly halved malaria prevalence (from 43% to 24%)among children in Malawi.1Yet, malaria remains the leading cause of death among children under the age of five in the country, and new tools and approaches are needed to add to those currently recommended, to further drive down illness and death in this high-risk group.

The WHO-coordinated malaria vaccine implementation programme (MVIP) was designed to answer several outstanding questions related to the public health use of the vaccine. The pilot evaluation is assessing the feasibility of delivering the recommended4 doses of the vaccine, the impact of the vaccine in reducing childhood deaths,and the safety of the vaccine when provided through the routine childhood vaccination programme.Accrued safety data from the evaluation are reassuring.Results of the evaluation will inform a potential WHO recommendation for wider use of the vaccine across sub-Saharan Africa.

In addition to the feasibility, safety and health impact of the vaccine, the MVIP includes a qualitative research component that is looking into social determinants of vaccine acceptance.

Two years on, as of April 2021, the pilot programme is progressing well across the three pilot countries, despite the COVID-19 pandemic –more than 1.7 million doses of the malaria vaccine have been administered and more than 600 000 children have received at least one dose of vaccine. (In Malawi, about 220 000 children have been vaccinated with their first dose.) This level of coverage shows the strong capacity of the routine childhood immunization programme to deliver this vaccine with a novel schedule.

The malaria vaccine pilots are now approaching a major milestone: a review of data on the routine use of the RTS,S vaccine by WHO global advisory bodies for immunization and malaria, and a potential WHO recommendation for wider usein 2021. Should there be a positive recommendation for broader use, Malawi will have made a substantial contribution to the MVIP and, potentially, made it possible for children in other areas with high malaria burden to benefit from an entirely novel approach to malaria prevention.

[1]. Malawi brochure: First malaria vaccine: A potential new tool for child health and improved malaria control in children https://www.who.int/publications/m/item/malawi-brochure-first-malaria-vaccine-a-potential-new-tool-for-child-health-and-improved-malaria-control-in-children(assessed 13 March)

Photo caption: Grace Butawo completed her 4th dose  and at home she still sleeps under a net.

Photo credit: WHO