Lessons from Kenya to vaccinate all of Africa against malaria

Margret Ayuma is one and a half years old, wears a blue dress and goes from lethargy in her mother's arms to running around, barefoot and stumbling, around the outside of her home in Musitinyi, a rural town of almost 7,200 people in western Kenya, near from Lake Victoria. She is one of the babies who have been immunized against malaria since the RTS, S or

, which is its commercial name, was introduced in September 2019 in this area of ​​the African country where the disease is endemic.

The girl has received three of the four punctures to complete the pattern, which is partially effective: around 36% in children from five months of age. Julia Kulema, 40, knows firsthand the ravages of malaria. "Your whole body hurts a lot," he describes. She and her three older children have had the disease several times. Therefore, she shows the card that proves how disciplined she has been with her little girl's vaccinations. "I don't want him to go through the same thing."

The fourth dose is still a few months away, since she is inoculated at 24. The mother will have to stay until then in the town, where the dispensary where Margret is immunized is located.

If she goes to the city of Mumbasa, to visit her husband for a while, it is very likely that her daughter will not receive that last puncture.

This is what happens in many cases.

Photogallery

Mosquirix, the new ally against malaria, takes action

The Musitinyi clinic's patient and vaccine record books reveal that, in two years, only 33 babies have completed the regimen. “People move around a lot and we only have the vaccine here. It's a challenge with the third and fourth doses, ”explains Sabina Nyaleso, a nurse at the dispensary. A sign in his office reminds staff that the punctures are at six, seven, nine and 24 months. Periods of time in which mobility, forgetfulness, the remoteness of health centers, the belief that one or two doses are enough, the loss of the card in a country where data is written down in pen in notebooks , make the process difficult.

These are the problems that have already appeared on a small scale. “There are four doses for reasons of efficacy. And the more there are, the greater the challenge in terms of logistics and costs. But it is even possible to integrate inoculation with other interventions, "says Marta Tufet, policy officer for the Global Alliance for Vaccines (GAVI).

“It is important that you stay and get the fourth dose. Children under the age of five have a weaker immune system and are at risk if they contract malaria, ”explains Caroline Ong'ayo Olustili, the community health worker at the Musitinyi clinic, to Kulema. She plays with little Margret, picks her up, talks to the mother ... For a decade, the volunteer has been monitoring this family: she visits them, tests them if they show symptoms of the disease, gives them medications if they test positive or refers them to the doctor if they are serious or do not have the treatment.

With the support of the medical NGO Amref and with funding from the Global Fund for HIV, Tuberculosis and Malaria –which has facilitated the logistics for this report–, it also provides them with insecticide-treated mosquito nets when available and guides them to avoid being bitten. of the mosquito that transmits the parasite that causes malaria.

In 2020 alone, malaria killed more than 274,000 children in Africa

With full confidence in Ong'ayo and his advice, Kulema assures that they sleep under the new network that he gave them a couple of months ago, now that the volunteer has been able to resume her activity, interrupted by the pandemic, and that the country has received supplies. . He also closes doors and windows before sunset and keeps the grounds around his home clear of weeds. And he did not hesitate when Ong'ayo spoke to him about the possibility of immunizing his little girl. Everything possible to prevent malaria, which in 2020 alone killed more than 274,000 children on this continent, which is where 96% of deaths worldwide occur. "I am grateful to have agreed to the vaccine," says the mother shyly, knowing that her daughter has been one of the first on the planet to receive it.

The World Health Organization recommended last October the administration of

on a large scale in African children and the Global Alliance for Vaccines (GAVI) announced an investment of almost 138 million euros to implement it in six countries of the continent between 2022 and 2025 The pilot tests that have been developed since 2019 in endemic areas of three countries - Kenya, Ghana and Malawi - will provide experience to develop a technical guide, avoid errors and achieve the best result: reducing cases and deaths that, after a decade declining, they have rebounded (69,000 additional deaths in 2020) due to the impact of the COVID-19 crisis on other health programs, such as the prevention and treatment of malaria.

More information

Malaria deaths increased to 627,000 in 2020 due to the covid-19 crisis

The case of Margret Ayuma and the vaccination and incidence data in her community exemplify almost all the challenges that the massive malaria vaccination campaign in Africa will face. The abandonment of the pattern is one of them. Not only does it mean that the minor will not enjoy the maximum possible immunity, but that the cost of the first doses will not materialize in the highest yield. But this is not the only stumbling block. Before generalizing the vaccine, the population has to trust its safety and benefit. Voluntary community health agents - almost always women - who receive a small stipend from NGOs or governments for monitoring the health of neighbors in rural areas, are fundamental in this chapter.

These figures are common in sub-Saharan Africa, where much of the population lives far from primary care centers. The volunteers are trained in certain ailments, sexual and reproductive health or nutrition, to do field work. And it will be up to them, as Ong'ayo did, to explain to families with young children why malaria puts them in greater danger, how immunization can help prevent infection and, very importantly, that they maintain habits such as sleeping under mosquito nets. , close the houses before sunset and clear their fields. The abandonment of these practices, due to a feeling of false security due to the vaccine, as well as a lack of promotion and investment in them, is another risk. “The combination increases the effectiveness. It is not a matter of substituting one intervention for another, but rather adding them ”,Tufet underlines.

“All these challenges will be addressed in the technical guide, with the lessons we have learned from the pilots and what those responsible have been telling us in regular meetings. From there, each of the countries will have to make their own national plans ”, explains the GAVI manager. "It's about ensuring that everything necessary is in place to be effective." And they have to do so taking into account the additional difficulty posed by the coronavirus pandemic, which erupted when trial vaccinations had already begun. One more obstacle.

“We had to do awareness work before the campaign. We organize massive informative talks. But during the covid, we faced problems. So last November 1 we began with outdoor immunization to reach the population that does not come to the clinics. Both for malaria and for the rest of vaccines. It's something we do when we have funds, once a month. But with the pandemic, it stopped because we couldn't go, nor did people come. Now we plan to do it in 100 days, we will go out ten times a day every 10 days ”, says nurse Sabina Nyaleso.

Tufet, a British and Spanish biologist with a specialty in malaria, is optimistic.

“In the three pilot countries, more than two million doses have been distributed.

Which means hundreds of thousands of immunized children, ”he says.

According to data from the WHO, which coordinates the program, 2.3 million punctures were administered to 830,000 children until December 2021. “The pilots will continue until 2023 to understand the added value of the fourth dose of vaccine and measure the impact on more long term in infant deaths ”, announces the agency.

In the three pilot countries - Kenya, Ghana and Malawi - 2.3 million doses of Mosquirix have been administered to 830,000 children as of December 2021

The problems have been solved with the experience of two decades deploying vaccination campaigns in the Global South of GAVI, the support of UNICEF, the Global Fund, Unitaid and the pharmaceutical company GSK, which has donated 10 million doses for testing. “Now, we already have evidence that implementation is feasible and that the churn rate is acceptable. The data on the effectiveness will still take a couple of years to arrive ”, explains Tufet. .

The information available so far is encouraging. “The cases of malaria in children under five years of age have been reduced. And complications related to the disease, such as anemia, have also decreased, ”notes Nyaleso. "Since 2019, we have 6% less malaria among that age group in this region," specifies Henry Mukuna, representative for health issues of the Luanda sub-county, where Musitinyi is located. “We want to prevent the incidence of vaccination and to join the immunization line for minors. This is an endemic area and it is one more prevention. Is working. We see signs of improvement ”, he asserts.

The clinic's notebooks provide numbers: in June 2019, before the project began, this area registered 146 cases in children under five years of age.

A year later, when none of the children could have finished the pattern and with fewer prevention interventions (and testing) due to the pandemic, there are 73 confirmed cases recorded.

In June 2021, with information less altered by the effect of covid-19, 86 positives were confirmed in this dispensary.

In Kenya, 70% of the population is at risk of malaria

Another of the observations obtained from the pilot programs is that the introduction of the vaccine has not meant relaxation in the implementation of other preventive, control and treatment tools for the disease, in the words of Tufet.

In fact, immunization has reached a population that no other intervention has reached before.

“Currently, with the existing interventions to prevent malaria, it reaches 70% of those under five years of age.

Which means that 30% do not receive a single tool against this disease.

With the vaccine, that percentage increases to 90%, that is, we are reaching children who have never been reached before with any program, ”says GAVI's policy director.

Disease, poverty and vice versa

In Kenya, where 70% of the population is at risk of malaria, winning the battle against this disease is a priority issue. And the vaccine is one more weapon, but we must continue to strengthen the others. This is contemplated in its strategic plan against this disease 2019-2023, which proposes distributing insecticide-treated mosquito nets to 51% of the population that does not have one, as well as expanding access to intermittent preventive treatment during pregnancy. Although it increased in endemic areas, from 35% in 2015 to 49% in 2020 in the Lake area, and from 43% to 46% in the same period on the coast, the country wants to reach 80% of pregnant women. The ultimate goal, according to the document: "Reduce incidence and mortality by 75% by 2023 compared to 2016 levels."

The development of the new generations of Kenya without the burden of the disease is at stake. The cycle of poverty that worsens health, and vice versa, is what the family of Humphrey Joseck Etosabo, 52, suffers every day. The youngest of his children, eight, often misses his classes at school, either because he is suffering from malaria or because the father has not been able to pay school fees that month due to lack of income from his “little jobs”. The last time the boy fell ill, in November, he recovered in three days thanks to the fact that he had access to treatment and was able to return to school quickly. "I feel bad because I don't want them to be sick, that's why we always sleep under the mosquito net, but you never know," says the father. "He has headaches, back pain and fever," he lists.

“It is difficult to take care of everything because I have little. Sometimes I buy because what the land gives us is insufficient. Sometimes we lack to feed ourselves. Therefore, the priority when I have something is to feed them. School after. Eating well helps you have good health ”, reasons Joseck. The family of seven members, five children and the parents, survives from subsistence farming. Despite the difficulties, the two older girls have completed high school and the second plans to study accounting. "But now she is taking care of her grandmother," clarifies the father. “I am proud, they are my daughters. What they do will be fine with me. If they go to the city or if they stay here. If they leave, I'll go visit them. For the little one, I want to get money to do a complete medical checkup ”, the conversation ends in his adobe house.

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