Tropical Health Matters

The class blog for Social and Behavioral Foundations of PHC features a posting by Alice Calhoun on the importance of pilot implementation of the new malaria vaccine in Kenya. Her comments are found below.

Since 2019, significant improvements in death rates and hospitalizations from malaria in young children have been made in Kenya after initiating the pilot malaria vaccine trial, Malaria Vaccine Implementation Programme (MVIP) involving children under 2 years old. Under the leadership and support from WHO, GAVI, and PATH and many other stakeholders, Kenya was able to benefit from the RTS,S vaccine that was developed for over 35 years by GlaxoSmithKline Pharmaceuticals. As the vaccination program continues in Western Kenya, parents in Vihiga County have noted that their children who have been vaccinated are less sick than their older siblings. The 4 part vaccination series typically begins at age 6 months with its completion at 24 months.

Malaria prevention must have a multi-faceted approach to be successful in eradicating this terrible disease from the community. This includes using insecticide treated bednets, indoor spraying, rapid diagnosis and treatment of active malaria, and malaria prevention during pregnancy. By using education and collaboration with groups such as the Kenya Malaria Youth Army, community health workers (CHW) are the key to disseminating information to the villages and encouraging mothers to complete the series for their children. CHW are also providing catch up vaccinations for other diseases while supporting the malaria campaign in Kenya by handing out bednets.

Now is the time for the Ministry of Health (MOH) to expand the vaccine program to all children under 5 years of age, some of whom missed out on the initial set of vaccines due to vaccine hesitancy during the COVID pandemic. The benefits have been seen by the community in Vihiga County and the attitudes of the mothers are now overwhelmingly positive. Due to the dedication of the CHW and the Immunization Coordinator, nurse Edith Anjere, Vihiga County has the highest rate of childhood immunization coverage in Kenya: up to 96% of children as surveyed in 2022.

Vihiga County is the perfect community to capture more children in the vaccination program since the health infrastructure is already in place as well as an openness in the community to continue vaccinating our children. The MOH can support this nationwide campaign against malaria by allowing other vulnerable children access to RTS,S in Vihiga County, serving as a model program for other counties. Kenya has been at the forefront of the malaria vaccination program and will continue to inspire other countries in Africa to work toward this goal of keeping our most vulnerable citizens healthier.

The term “vaccine hesitancy” is relatively new jargon that is defined in Wikipedia as, “… a delay in acceptance, or refusal, of vaccines despite the availability of vaccine services and supporting evidence.” The World Health Organization considers Vaccine Hesitancy among the top 10 threats to global public health. Vaccine hesitancy is primarily a matter of trust in institutions, technology, government, and health workers among others, according to Unfried and Priebe. Thus, hesitancy has social and political dimensions. This public health concern now extends into the realm of malaria control and elimination.

After many years of testing for efficacy and implementability, we now have two malaria vaccines. Therefore, it is not surprising that the issue of hesitancy has been identified as a potential challenge. Hussein et al. studied parents in Ghana and found that “About one-third (34.5%) of the parents were hesitant to give their children the R21/Matrix-M malaria vaccine,” even though “showed a high safety and efficacy level, and Ghana is the first country to approve this new vaccine.” It seems that parents who had not been getting routine vaccinations for their children were among those who were more hesitant.

The experience with door-to-door oral polio vaccine outreach campaigns from twenty plus years ago, shows that the general problem of avoidance or reluctance is nothing new,  but often rooted in political and cultural factors, according to Jegede. Covid-19 has shed new light on the problem as explained in the Lancet: “COVID-19 vaccines to low-income and middle-income countries (LMICs) is threatened by vaccine hesitancy. In Africa in particular, the low vaccine coverage and the ubiquitous vaccine hesitancy in a concerning proportion of the population undermine efforts to fight the COVID-19 pandemic.”

It should be noted that the term ‘hesitancy’ puts the blame for not vaccinating children and others on community members and health care consumers. When the expanded program on immunization started 50 years ago, there was recognition that reasons for seeking or not obtaining vaccines were multifaceted and included much more than consumer knowledge and attitudes. Health system factors and economic barriers were of equal concern. We need to return to those days when we took a holistic view on how to promote vaccine uptake.

Low levels of vaccine overage go beyond trust. When the Wikipedia definition mentions “despite the availability” there is the assumption that in fact vaccines are available, which is a major logistics, economics, and systems challenge. Fortunately, Mutombo et al. in the Lancet stress the other factors for low vaccine coverage including “historical, structural, and other systemic dynamics that underpin vaccine hesitancy.” They address serious supply problems wherein the global community has not made a “firm commitment to expedite vaccine deployment to the African continent.” It is not surprising that Nigeria has the highest level of unmet demand for COVID-19 vaccines in the world. Wollburg et al. also note that “Many who are willing to get vaccinated are deterred by a lack of easy access to vaccines at the local level.”

Concerning the two malaria vaccines, UNICEF notes that “It is clear that the demand is very high and far surpasses the supply that is expected to become available.” Concerns revolve around production capacity, supply chain management, integration within the health system’s existing immunization programs, pricing, and partnerships. While it is useful to plan ways to counteract hesitancy, such efforts will not be relevant is there is inadequate supply to meet current and projected demand and needs. As Gavi explains, “partners will also work with countries to provide orientation and technical assistance to ensure quality planning and country readiness.”