RTS,S/AS01 (RTS,S) is the first vaccine recommended by WHO for use against a human parasitic disease of any kind. If introduced widely, it could save tens of thousands of lives each year. The Government of Malawi was the first to launch the vaccine in a landmark pilot programme in April 2019. In this Q&A, Dr Mike Chisema, Malawi Ministry of Health, reflects on the pilot experience and how coordination with the national malaria programme was a key factor for success.

Q: On 6 October 2021, WHO recommended the first malaria vaccine for children at risk. What were some of your first reactions?

This was an important decision, a time to celebrate and appreciate Malawi’s role in reaching this point, and what we’ve achieved as a country. The reaction in Malawi was very positive, and people welcomed the inclusion of the malaria vaccine as an additional instrument that can support progress toward malaria elimination, as it reduces illness and child deaths from malaria in endemic countries, including in high-burden ones like Malawi.

Q: What’s been most notable about Malawi’s experience with the RTS,S malaria vaccine to date?

The collaboration between the Expanded Programme on Immunization (EPI) and the National Malaria Control Programme (NMCP) during the pilot was a success, and that of the evaluation partners (led by the University of Malawi College of Medicine). Normally, as the EPI, we meet quarterly with technical working groups, bi-annually with the Malawi Immunization Technical Advisory Group (MITAG), and then we have some meetings with committees aligned to different vaccines. For the malaria vaccine, we were constantly in touch with the NMCP and other stakeholders and this helped us remain vibrant in our implementation.  

The introduction of the malaria vaccine provided an opportunity to expand and diversify our approach to immunization delivery more broadly, as other routine immunization services were able to benefit from whatever was being done for the malaria vaccine pilot. Even the roll-out of COVID-19 vaccines benefited from these synergies.

Q: How did the routine immunization programme benefit from the pilot?

First, we were able to expand the country’s entire immunization supply chain. Sometimes you find that you can hardly get the vaccines to the people, perhaps due to lack of resources, but here we had an opportunity to improve our systems, and to make sure districts were not stocked out of any vaccines. We never had any stock outs of the malaria vaccine because there was massive communication with cluster facilities and districts. Second, regarding vaccine safety, the reporting of adverse events following immunization improved quite a lot, not just for the malaria vaccine but also for routine immunizations.

The pilots had an impact on the delivery of immunization trainings. We learned so much about how to provide education tools to health care workers, improve information, education and communication activities, as well as about risk communications and community engagement—and we’ve been able to apply all of these lessons learned to other routine immunizations.

Q: We hear about COVID-19 impeding progress against other diseases. How did the malaria vaccine experience support the roll-out of COVID-19 vaccines? 

Overall, it’s about the support and knowledge we gained. WHO provided both technical and financial support, and in the course of doing that for the malaria vaccine, they also supported the COVID-19 vaccine roll-out, which was very powerful. We are very lean when it comes to human resources, and now we had this extra support for the delivery of the malaria vaccine pilot, as well as other vaccines.

The malaria vaccine pilot offered an opportunity to find new ways and means to get into the communities and mobilize them to demand the vaccine. That made it easier when COVID-19 vaccines were introduced.

Q: What lessons from the pilot would you share with other countries interested in the vaccine?

 The burden of malaria is not just felt by health care providers, it’s also felt by communities. We have a role to play in providing communities with the information they need to make informed decisions about the vaccine. Countries should also recognize that there is likely to be high demand for this vaccine. In Malawi, we saw communities demanding the vaccine both where it was being provided, and in neighboring clusters, which was very good in terms of demonstrating the vaccine’s acceptability.

Countries will still need to go through the normal process of introducing a vaccine, and they should not take any shortcuts. Good ground preparation is very important: to make sure the vaccinators are informed, well trained and oriented. Countries need to make sure their supply chains and data systems are robust and in place, and that they are coordinating with relevant stakeholders – including the malaria control programme, the health education sector, people managing community engagement, influential and political leaders, and chiefs and traditional authorities. Countries should maximize every opportunity to provide the beneficiaries of the vaccine with details about the malaria vaccine and engage them in the process.

Q: What is level of interest in the vaccine and what are you hearing from national and local leaders and communities?

The reaction has been overwhelmingly positive, even before the WHO recommendation. If anything, people would have loved for this to happen earlier. When the recommendation was announced, for most leaders this is what they had been looking for. The big question now is how to manage the cost of the vaccine, how to secure funding, and how soon the vaccine can be available, knowing the anticipated global supply challenges.

Q: With the WHO recommendation and also Gavi funding for broader deployment, what happens next in Malawi?

We now have direction from the senior management at the Ministry of Health to expand introduction of the vaccine as financing for procurement of doses of vaccine becomes available. Next we will need to write proposals to Gavi and demonstrate how we will roll-out the vaccine. These are all questions we’re still trying to address.

We understand that the RTS, S supply will likely be constrained for some years. WHO is coordinating the development of a framework by expert advisers that will guide allocation of the limited vaccine doses. We appreciate the efforts of global and African partners to look for means to increase access, so we may reap the benefits of this life-saving vaccine.

Q: What additional support might Malawi need to integrate this vaccine into the national malaria control plan?

We still need strategies to target immunizations between 5, 6 and 7 months of age, knowing that most children will have received most other vaccines by then, and mothers might not have a reason to come back to the health facility. We need those strategies in place until mothers get used to it and it becomes routine. We will also need strategies to maximize and optimize vaccine uptake in the second year of life.

Q: Is there anything else you would like to add?

It’s not always easy to introduce a vaccine, but we must do our best, especially considering the public health impact of this malaria vaccine. It’s important to acknowledge the support we received from the senior leadership of the Ministry of Health and from international partners, at all levels. Solutions to challenges we faced along the way were not just coming from within the country, they were coming from across the region and the globe. That was very helpful.