Mal-aria

Ok, I know a few interesting facts about malaria, I’d call them fun facts but it doesn’t seem very appropriate..

• The word malaria literally means Bad Air – Mal meaning bad, Aria meaning air – harking back to the miasma theory, which said that diseases travelled around in a kind of invisible cloud of bad air
• Oliver Cromwell, he who banned Christmas, died of malaria in England in the 17th century – he lived in the marshy Fens where it was endemic
• A particularly severe complication of malaria used to be called Blackwater Fever, because of the dark, bloody urine it caused when red blood cells were destroyed en masse.
• The mosquitos harbour a parasite called plasmodium, which they transmit into the person. The parasites get passed back and forth between mosquito and person, via mosquito bites, as they go through their life cycle. (Click here if you want to see a vivid animation of the process)
• In the human body, these little parasites invade the liver cells and then the red blood cells, and cause a cyclical fever and atrocious headaches, according to one of my patients.

And I know a few facts which are, in fact, extremely serious and sad. I learnt these courtesy of Doctor Mehreen Datoo, at Oxford’s annual Meeting Minds Conference 2025. She is a clinical lecturer in Infectious Diseases and is of Tanzanian heritage. It was a fascinating, informative and inspiring talk.

The grim reality:

• over 260 million people a year contract malaria (according to the WHO)
• there are approximately 600 000 deaths a year from malaria (also WHO)
• 2/3 of those deaths are in children under 5
• many of these are in Africa, where some children can get malaria several times a year
• pregnant women are also a highly vulnerable group, as malaria can cause anaemia, foetal death and newborn complications

If you want a quick peek at where malaria is most prevalent – mostly sub-Saharan African countries, but also Papua New Guinea, Pakistan, Afghanistan and a few others – take a look at this map – https://ourworldindata.org/grapher/incidence-of-malaria

Adults do also get it, but typically it is less severe.

So what do we do about it?

Well, there is a goal to eliminate malaria by 2030. This is unlikely to happen, still, it’s good to have hope..

At the moment, prevention consists of

• bednets, provided annually, although some get converted into fishing nets, and the white bednets can look too much like ghosts. There has been a move to introduce coloured nets to remedy this problem. They are impregnated with long lasting insecticide.
• various prophylactic medicines for travellers, which have problems with side effects and compliance
  • Malarone – you have to take it before you go, all the time during your stay and for a week after, and it might give you nasty tummy aches, nausea and headaches.
  • Doxycycline, you also have to take before and during travels, and for a whole month after. You are likely to get very sunburnt, as it causes photosensitivity. Oh, and there is also tummy ache and nausea with this one.
• different prophylactics in endemic areas for vulnerable groups,
• rapid diagnostics to give some medical treatment in good time.

However even with these measures, a child still dies every one to two minutes.

What about modified mosquitoes?

You might have also heard about genetically modified mosquitos. Well, Bill Gates, of course, is involved in the funding. Dr Datoo did say that it is very exciting science, and there are pilot schemes running, but it has not been licensed for use by the WHO to combat the disease. It goes without saying that there are clearly significant concerns about releasing something into the wild that you cannot control.

Enter the R21 vaccine

People have been working on a malaria vaccine for at least 100 years. Over 140 candidates have gone into trials. But two have finally been licensed – the first vaccines ever against parasites – and Dr Datoo, along with her colleagues at the Jenner Institute in Oxford, and a cast of thousands out in the field, is responsible for the successful R21/Matrix-M (R21 for short). This particular vaccine has been about 14 years in development, and works by stopping the parasite even getting into the liver cells. This is way before the symptomatic blood stage.

Is it safe and effective

It has been tested for safety and efficacy, starting with adults. As part of this process, the team conducted an interesting challenge trial. The subjects had to pass a quiz, which I would have flunked, specifically at a question such as “Are you prepared to be injected with a potentially fatal illness just to see if a brand new vaccine works?” However, enough braver souls than me, with higher risk tolerance, altruism and possibly a more desperate desire for ready cash were willing. They were given the vaccine, then 5 infected mosquito bites were flown under lock and key to Imperial College via Heathrow Airport. The subjects were then infected a month after being given the vaccine.

The safety profile was fine, and the efficacy of R21 was found to be between 65 and 75%. If this seems low, we were told that it’s pretty normal. The BCG is only thought to be 70-80% effective against TB and cholera vaccines are around 50-80%.

How does it work?

Well, this science is too deep for me, but it is something to do with virus-like particles being assembled with Hep B. Honestly, how do they do this stuff? Next generation vaccines (such as those used for covid) are anticipated to target a protein which will look at the blood stage.

How will it be administered?

It was first rolled out in 3 countries –

• Burkina Faso
• Ghana
• Nigeria

Now, along with the one other similar vaccine, RTS,S, they have been rolled out in 23 countries in total. 4 doses are given, from the age of 5 months, over a year. It is not given in sync with the current vaccine schedule, so while the first 2 doses have had good uptake, anecdotal evidence from those in the field think it might be down to 50% by the third.

It was difficult to find somewhere which could produce as many jabs as are required – something like 100 million a year. But the Serum Institute in India has come through.

Any potential issues?

Well, people still need to take other measures, and not have a false sense of security. The bed nets should stay. Along with seasonal chemoprevention and accessing healthcare early for diagnosis and treatment.

There is also some skepticism. Following covid and its controversial vax rollout, vaccination rates have dropped. But it’s not just that. In Tanzania, we were told, due to the late introduction of the genuine covid vaccine, people were selling fakes (saline shots, in fact) for hundreds of dollars. Public confidence in general has been dented, there is suspicions of the West in some quarters, and Dr Datoo spends a lot of time in advocacy with local and national leaders.

There have also been budget cuts to GAVI, and because there is no pan-African licensing agreement, the vaccine has to be approved country by country, which slows everything down.

It is not known if boosters will be needed. It is also not known if vaccinating young children will lead to more prevalent and more serious disease in older children or adults (this is called ‘shifting the disease burden’).

It is still not licensed for travellers, so you’ll have to keep taking your meds!

A hopeful note

So there is real hope that soon we could be seeing a drop in the heartbreaking statistics of this most persistent infectious disease.

Many thanks to Dr Datoo for kindly checking through this post and making any necessary changes