The document discusses malaria control and the RTS,S vaccine currently under trial. It provides an overview of the global malaria situation, the situation in sub-Saharan Africa and Nigeria specifically. It outlines the key components of malaria control including case management, vector control methods, and monitoring and evaluation. Progress made in malaria control from 2000-2011 is highlighted, along with current challenges such as funding shortages and insecticide and drug resistance. The development of malaria vaccines including the RTS,S vaccine currently undergoing trials is also discussed.

1. MALARIA CONTROL
& THE RTS,S VACCINE
UNDER TRIAL: Matters Arising.
Dr. Abraham Idokoko
Department of Community Health & Primary Care,
Lagos University Teaching Hospital, Idiaraba
June 14th, 2012 Seminar

2. Outline
1. Seminar objectives
2. Introducing malaria
current global picture
sub-Sahara Africa
outlook
the Nigeria situation
3. Parasitology &
Pathogenesis: in relation to
control
4. Malaria Control:
key components
Progress indicators
2011
what is working ?
current Challenges
current strategies
5. Vaccines: what they are?
6. Malaria Vaccine: the idea
7. Malaria Vaccine
Development: some history
8. RTS,S vaccine
9. RTS,S vaccine trials
The mid study report
Issues arising
10. Conclusions
Bibliography
Remarks & Gratitude
© Dr. Idokoko A. B. (14/06/2012) 2

3. Seminar Objectives:
 To draw attention to the key findings of the 2011
global situation report on malaria
 To highlight the focus of current malaria control
strategies globally and locally
 To emphasise the changing concepts of the "malaria
life cycle" as it relates to control
 To bring to light and underscore various issues,
challenges and prospects of the malaria vaccine
under trial (RTS,S/AS01 -Mosquirix)
 To stimulate a renewed departmental interest in
malaria control that may yield a dedicated
“Malariology unit” with potentials to drive the
discourse on Malaria control locally and in the sub-
Sahara Africa region
© Dr. Idokoko A. B. (14/06/2012) 3

4.  World Malaria
Day –April 25th.
2012 theme:
Sustain gains,
save lives, invest
in Malaria.
Slogan: Let’s
work together
© Dr. Idokoko A. B. (14/06/2012) 4
Picture shows the road show motorcade during
World Malaria Day 2012 Celebration. ©National
Malaria Control Programme, Nigeria,
www.nmcpnigeria.org
 ALMA and the UN SG
2012-2017 target
 65th WHA statements
 World Immunization
Week 2012 –April 21-
28 –protect your
world, get vaccinated
RECENT MALARIA EVENTS

5. Introduction
 Malaria -an ancient disease (documented by the
Chinese as early as 2,700 BC), a perennial tropical
monster that can pass as one of the
greatest scourge of the developing world.
 A parasitic ???-zoonosis-??? transmitted
by culex, aedes, mansonia, culiseta,
theobaldia and anopheline mosquitoes
 Infect birds, reptiles, monkeys,
chimpanzees, rodents and of course,
humans.
Today, human malaria poses an enormous
public health challenge with over half the
World’s 7billion people at risk.© Dr. Idokoko A. B. (14/06/2012) 5

6. Introduction(2)
 Malaria mortality may be heart-breaking but, the
morbidity is most devastating to the poorest of
households & national economies in all the
continents.
Slows economic growth in African countries by
1.3% per year. Literally defines the poorer nations.
 Sachs et al at CID intimately linked malaria with
poverty. As at 1995, the GDP of malaria countries
was 33% lower than that of those without.
Africa lost about $100 billion to malaria over the
period analysed
About $12 billion lost each year to malaria in
AFRO and Sachs estimates that malaria can be
controlled for US$3 billion per year, thus
suggesting that anti-Malaria projects are
economically justified investment.
© Dr. Idokoko A. B. (14/06/2012) 6

7. Malaria: Current global picture
 About 3.3 billion people at risk. All continents affected.
106 endemic nations. 99 countries with on-going
transmission
 216 million cases in 2010 (range 149-274 million)
resulting in 655, 000 deaths (range 537,000 –
907,000) and 86% of those killed were U5 children
and 91% of all malaria deaths occurred in WHO
AFRO.
 Artemisin monotherapy resistance persist in the
Mekong Region while insecticide resistance is
expanding rapidly.
 45 countries around the world have identified
resistance to at least one of the four classes of
insecticides used for malaria vector control and 27 of© Dr. Idokoko A. B. (14/06/2012) 7

8. TABLE 1.0: ESTIMATED MALARIA CASES AND DEATHS BY
WHO REGION, 2010
WHO Regions Estimated cases Estimated deaths
African region 174 million 596, 000
Americas region 1 million 1,000
Eastern Mediterranean
region
10 million 15, 000
European region 200 0
South East Asia 28 million 38, 000
Western Pacific region 2 million 5, 000
Total 216 million 655, 000
© Dr. Idokoko A. B. (14/06/2012) 8

9. Malaria: Current global picture (2)
 Estimated incidence globally dropped by 17% and
mortality fell by 25% in 2010 as compared to 2000.
 Europe (99%), America (55%), Western Pacific (42%)
and African Regions (33%) made the largest
percentage reductions in mortality.
 Also, the malaria map is shrinking progressively. UAE
was out in 2007, Morocco & Turkmenistan in 2010;
while Armenia was certified malaria free in 2011 i.e. 4
countries in 5 years.
 Still, $32billion is needed to achieve zero malaria
death by 2015 according to ALMA & UN (2012)
© Dr. Idokoko A. B. (14/06/2012) 9

10. Malaria: sub-Sahara Africa Outlook
WHO AFRO accounts for 81% of global malaria
cases in 2010 and 91% of malaria deaths.
Six countries in WHO AFRO account for 60%,
or 390,000, of all malaria deaths. -Nigeria, the
Democratic Republic of Congo, Burkina Faso,
Mozambique, Cote d'Ivoire and Mali.
sub-Saharan Africa account for 27 of 45
countries globally that have identified
resistance to at least one of the four classes of
insecticides used for malaria vector control
Between 2008 - 2010, 290 million insecticide-
treated bednets (ITNs) were delivered to Sub-
Saharan Africa
© Dr. Idokoko A. B. (14/06/2012) 10

11. Malaria: sub-Sahara Africa Outlook (2)
The number of long-lasting insecticidal nets
delivered to malaria-endemic countries in sub-
Saharan Africa increased from 88.5 million in
2009 to 145 million in 2010 (63.8%).
An estimated 50% of households in sub-
Saharan Africa now have at least one bed net,
and 96% (???) of persons with access use it.
In 2010, 11% of the population at risk here
were protected through IRS
Diagnostic testing rate in the public sector in
the WHO African Region rose from 20% in
2005 to 45% in 2010
No Artemisin resistance reported yet in this
region
© Dr. Idokoko A. B. (14/06/2012) 11

12. Malaria: The Nigeria Situation
A high transmission zone (>1 case per
1000 population). P. falciparum caused
100% of cases tested in 2010. P. Vivax
infection do occur but, very rarely
Over 80% of global malaria burden is in
sub-Saharan Africa and Nigeria shares
about 1/4 of that
44% (290,000) of all global malaria deaths
in 2010 occurred in Nigeria and Congo
DR.
Accounts for 60% outpatient visits to
health facilities, 30% childhood death,
25% infant death and 11% maternal death.
© Dr. Idokoko A. B. (14/06/2012) 12

13. Malaria: The Nigeria Situation (2)
 2010 NMIS, national prevalence in U5 is 42% -
varies 28% in the 6-8 mths old to 49% in the 48-59
mths olds.
 Overall, it ranges from 28% in South East zone to
56% in North West zone
 No. 1 killer of children U5 (2009) and consistently
rank among the 3 most common cause of death for
all ages.
© Dr. Idokoko A. B. (14/06/2012) 13

14. Malaria: The Nigeria Situation (3)
Malaria-related economic losses has been
estimated to be about 132billion Naira per
annum
46.8million LLINs delivered to Nigeria -
distributed in 30 states –this is the largest in
the world
Almost 30% of U5 children now sleep under
an ITN the night before the 2010 NMIS
survey. (This is almost a five-fold increase since
2008. Still, ownership of ITNs is higher than children’s
use).
© Dr. Idokoko A. B. (14/06/2012) 14

15. Parasitology & Pathogenesis in relation
to control
∆Organism: Plasmodium (phylum–apicomplexa,
class-sporozoa, 16 sub-genera, over 275 species)
 11 species infect man but, only 6 cause significant
disease and are of public health importance viz: P.
falciparum, P. malariae, P. ovale, P. semiovale, P. vivax
and P. knowlesi.
 P. knowlesi and P. semiovale infect primates but,
cause human disease mostly in South East Asia.
∆Transmitted exclusively by the female Anopheles
Mosquito to man.
 Discovered by Charles Louis Alphonse Laveran (Nov. 6,1880) in Constantine, Algeria and
he was awarded the Nobel Prize in 1907.
 Fist described and named by Marchiafava and Celli in 1885. Giovanni Battista Grassi in 1898 isolated and
showed plasmodium could only be transmitted by female anopheline mosquito
 Identified & isolated in the midgut and salivary gland of Culex mosquitoes by Sir Ronald
Ross in 1898 in India and he got the 1902 Nobel prize for medicine. He described the
lifecycle
 Camillo Golgi differentiated malaria parasites & fever. He got the 1906 Nobel Prize in Medicine© Dr. Idokoko A. B. (14/06/2012) 15

16. Parasitology & Pathogenesis (2)
∆Plasmodium falciparum: most deadly of
parasites that infect humans. It is the most
studied. It’s life cycle is typical of others. It is
the focus of vaccine efforts.
∆Transmission route:
∆vector(female anopheles mosquito) –
major route
∆Direct via infected blood transfusion and
∆vertical transmission from mother to child
is possible and do occur
∆The vector typically has a nocturnal feeding
habit (6pm -6am, peaks @ 1am.) habit that for
important to control measures
© Dr. Idokoko A. B. (14/06/2012) 16

17. 17© Dr. Idokoko A. B. (14/06/2012)

18. 18© Dr. Idokoko A. B. (14/06/2012)

19. 19© Dr. Idokoko A. B. (14/06/2012)

20. Malaria Control: Key Components
1. Mortality control: The emphasis is achieving zero mortality which require:
prompt & effective case management via accurate diagnosis and
effective treatment accessed early  T3
2. Morbidity & transmission control: mortality is not the only problem,
economic and social burden takes a big toll as well.
Integrated Vector Management (IVM) by:
ITNs & LLINs
IRS –indoor residual spraying
Larviciding with temephos
Outdoor Spraying
Wearing protective clothing
Environmental management, drainage and application of bye-
laws
Improved housing and screening
Chemoprophylaxis: IPT during pregnancy with SP & Proguanil in
SCDx.
© Dr. Idokoko A. B. (14/06/2012) 20

21. Malaria Control: Key Components (2)
 Principles of IVM –borrowed from IPM
Reduction of breeding sites?
Draining swamps and flooded areas
Use of fish to eat mosquito larvae
Grass cutting and detritus removal
Peridomestic source removal (spade work!)
Solving problem of nuisance mosquitoes
3. Advocacy, Communication and Social
Mobilization.
4. Monitoring and Evaluation along with
Effective Management of Programmes,
Partnership and Collaborations.
© Dr. Idokoko A. B. (14/06/2012) 21

22. Malaria Control: Progress Indicators 2011
The WHO GMP litmus test of progress include:
1. Long lasting insecticidal nets (LLINs) -in
sub-Sahara Africa
Number of LLINs delivered by manufacturers (145 million)
Number of countries that have adopted policy of providing
LLINs to all persons at risk (27)
2. Malaria diagnostics (Worldwide)
Number of countries that have adopted policy of
diagnostic testing for all age group (82)
Number of rapid diagnostic tests (RDTs) supplied by
manufacturers (88 million)
Percentage of suspected malaria cases tested (42%) -
76% AFRO
© Dr. Idokoko A. B. (14/06/2012) 22

23. Malaria Control: Progress Indicators 2011 (2)
3. Use of artemisinin-based combination
therapies (ACTs) –worldwide
Number of ACTs courses procured by public
sector (181 million)
Number of countries having adopted ACTs as
first line treatment out of 80 countries with
falciparum malaria (80)
Number of countries still allowing the marketing
of artemisinin monotherapies (25)
Number of pharmaceutical companies still
marketing monotherapies (39). Now 28 in 2011.
© Dr. Idokoko A. B. (14/06/2012) 23

24. Malaria Control: What is working?
One million lives were saved in 10 years (2000-
2010):
Improved funding –the Global Fund
Increase political commitment and better
coordinated global and local partnership
IVM – LLINs and IRS
ACTs remain highly effective in almost all
settings, so long as the partner drug in the
combination is locally effective
IPT with SP
Increased rapid diagnostic test use & falling
costs(US$ 0.50).
If this efforts are sustained and scaled up,
another 3 million lives could be saved before© Dr. Idokoko A. B. (14/06/2012) 24

25. Malaria Control: Current challenges
 Funding: grossly inadequate. About $32billion is
needed to achieve zero malaria death by 2015
 Insecticide resistance expanding rapidly: 45
countries identified resistance to at least one of the
four classes of insecticides in use. 27 of these are
in sub-Saharan Africa
pyrethroids, organochlorines
(dichlorodiphenyltrichloroethane-DDT),
organophosphates and carbamates}.
 Emerging ACTs drug resistance in the Mekong
region. falciparum resistance to artemisinins
confirmed on the Cambodia-Thailand border in
2009, now suspected in parts of Myanmar and Viet
Nam.
 Over 80% of cases are being treated without
testing in sub-Sahara Africa
© Dr. Idokoko A. B. (14/06/2012) 25

26. Malaria Control: Current Strategy
Target: remains the WHA & MDG goal of
reducing the malaria burden by at least 75%
by 2015
T3 –Test, Treat & Track: newest initiative to scale up
the three fundamental pillars of existing global strategy to fight
malaria.
Test: Every suspected malaria case must be
tested
gold standard remains a thick film with Giemsa stain
showing the signet-ring merozoites, trophozoites, halter-
shaped gametocytes, round-oval schizonts or haemozoin
crystals.
Rapid diagnostic test (RDT) based on ELISA
Treatment based on clinical suspicion alone is no© Dr. Idokoko A. B. (14/06/2012) 26

27. Giemsa Stain shows trophozoites in RBC
27© Dr. Idokoko A. B. (14/06/2012)

28. Macro
Micro
P. falciparum gametocytes
28© Dr. Idokoko A. B. (14/06/2012)

29. Malaria Control: Current Strategy (2)
Treat: ensure every confirmed case is
treated with a quality-assured
antimalarial medicine.
ACTs remain first line for uncomplicated falciparum
malaria
CQ for P. Vivax infection (use ACT if resistance to CQ).
IM / IV Artesunate followed by full course ACTs for
severe Malaria.
Track: ensure the disease is tracked
through timely and accurate surveillance
systems to guide policy and operational
decisions
© Dr. Idokoko A. B. (14/06/2012) 29

30. Malaria Control: Current Strategy (3)
 Malaria Eradication Strategy:
Geographical reconnaissance
 Attack Phase: Vector control until parasite rate is
low.
 Surveillance Phase: Active case detection
programs continue until parasites undetectable. ?
Antigametocyte drugs
 Maintenance Phase: Passive case detection and
effective treatment
 It is vital that malaria remains high on the political
agenda in both malaria-endemic and donor countries,
and that investments are scaled up further to support
prevention, control and elimination efforts.
© Dr. Idokoko A. B. (14/06/2012) 30

31. Vaccines: What they are?
Vaccines are dead or inactivated organisms
or purified products derived from them, that
improves the immunity of recipient to a
particular disease
Edward Jenner in 1796 inoculation of cowpox to prevent smallpox
 Valence: monovalent or multi-/Poly -valent
 Types based on constituents:
Killed organisms e.g. Cholera, pertussis, rabies, HAV,
Influenza
Attenuated -better immune response and longer protection
e.g. YF, Measles, rubella, mumps, BCG
 Toxoids –high efficacy e.g. tetanus, diphtheria
Sub unit e.g. HBV
Conjugate e.g. HiB, meningococcal conjugate vaccine
However, no vaccine guarantee complete
protection from a disease for everyone. Host
immune system role is critical
© Dr. Idokoko A. B. (14/06/2012) 31

32. Malaria Vaccine: The idea
 Why? -Vaccines are one of the most cost-effective public
health intervention
 The strategy: P. Falciparum is the focus
o Type 1 vaccine: for those exposed mostly to P. falciparum malaria
in sub-Saharan Africa -to reduce the number of severe malaria
cases and deaths in infants and children exposed to high
transmission rates.
o Type 2 vaccine: could be thought of as a ‘travellers’ vaccine’,
aiming to prevent all cases of clinical symptoms in individuals with
no previous exposure.
 Challenges:
o Protozoans are more complex organism than viruses and bacteria
o The use of live, inactivated or attenuated whole parasites is not feasible
o The parasites' evolutionary capacity especially P. falciparum
o Intricately complex life cycle of the parasites
 Potential agents: over 30 are being considered out of several
 approaches involve surface expression of the antigen, inhibitory effects of specific
antibodies on the life cycle and the protective effects through immunization or
passive transfer of antibodies between an immune and a non-immune host
© Dr. Idokoko A. B. (14/06/2012) 32

33. Malaria Vaccine Development: prior efforts
 SPf66: tested extensively in the1990s. Was clinically
ineffective.
 CSP: appeared promising the study group used in Kenya
had an 82% incidence of parasitaemia whilst the control
group only had an 89% incidence.
 NYVAC-Pf7 multistage vaccine attempted to use different
technology, incorporating seven P. falciparum antigenic
genes. Trials in humans yielded very poor antibody
responses
 [NANP]19-5.1: proved to be very successful. In the 1995
trial 194 children vaccinated, none developed symptomatic
malaria in a 12 week follow up period. Only 8 failed to have
higher levels of antibody present. Consists of schizont
export protein (5.1) and 19 repeats of the sporozoite
surface protein [NANP]. Had low levels of immunogenicity© Dr. Idokoko A. B. (14/06/2012) 33

34. The RTS,S Vaccine
 RTS,S/AS01“Mosquirix” –recombinant
vaccine
 Developed and manufactured by
GlaxoSmithKline
 Targets pre-erythrocytic stages of P.
falciparum: to prevent hepatocyte invasion
and stimulate cellular response to destroy
infected hepatocytes
 Consists of recombinant antigenic proteins:
 a circumsporozoite protein (CSP) engineered using genes
from the outer protein of P. falciparum sporozoites,
 a surface antigen of hepatitis B virus plus –as an adjuvant
 a chemical adjuvant {monophosphoryl A & QS21 (SBAS2)}.
 Target population: children resident in malaria
endemic areas who suffer the biggest burden© Dr. Idokoko A. B. (14/06/2012) 34

35. RTS,S Vaccine Trials
Phase I trial: 7 out of 8 volunteers (87.5%)
challenged with P. falciparum had protective
immunity.
Phase II trial done in 2007-2008 in Kenya and
Tanzania: 894 children involved with 53%
protection observed after 8-months
RTS,S was found to be safe, well tolerated,
immunogenic and had reasonable efficacy
in both malaria-naive and -experienced
adults and children
Phase III trial started in March 2009, still on-
going, expected to be concluded by 2014.© Dr. Idokoko A. B. (14/06/2012) 35

36. RTS,S Trial: Mid study report 2011
Funded by GSK, Program for Appropriate
Technology in Health (PATH) Malaria Vaccine
Initiative with grant from the Bill and Melinda
Gates Foundation
WHO plan to roll out vaccine by 2015 if end
results are reasonably favourable ( usual
target efficacy is >85-90%)
Interim analysis as at January 2011 report
was published in November 2011 in NEJM.
Trial objective: to study the efficacy, safety,
reactogenicity, and immunogenicity of
RTS,S/AS01 in African children up to 32
months of follow-up
© Dr. Idokoko A. B. (14/06/2012) 36

37. RTS,S Trial: Mid study report 2011 (2)
Study locations: 11 centres in 7 countries
-Gabon, Mozambique, Tanzania, Burkina
Faso, Kenya, Ghana and Malawi
Design: double blinded, randomized,
controlled multi-centre and multinational
trial
Size: Expected to recruit 16,000 children
in 7 sub-Saharan Africa Countries by the
end of trial
Randomization: 15, 460 participants in 2
age group (6-12 weeks olds and 5-17
months olds) were enrolled. Each age
group was randomised into 3 study group© Dr. Idokoko A. B. (14/06/2012) 37

38. RTS,S Trial: Mid study report 2011 (3)
Treatment: Dosage: three I/M doses, one month apart.
one study group got all 3 doses of vaccine
alone
2nd group got all 3 doses plus booster at 18
months
3rd group received a ??placebo (rabies
vaccine for 5-17months olds and meningitis
vaccine for the 6-12 weeks old).
Immunogenicity was tested 1mth after 1st dose
ELISA
Patient were followed up passively for study© Dr. Idokoko A. B. (14/06/2012) 38

39. RTS,S Trial: Mid study report 2011 (4)
Operational definitions of outcomes:
◦ Primary clinical malaria: illness in a child
who had a temperature of 37.5C or more or
more than 5000 P. falciparum parasites per
cubic millimetre of blood or both
◦ Severe malaria: clinical malaria plus one or
more markers of disease severity and
without diagnosis of a co-morbidity
◦ Vaccine’s efficacy: the proportion of new
cases of malaria that were prevented by
vaccinations
◦ Vaccine efficacy against severe malaria,
which was defined as 1 minus the risk ratio
© Dr. Idokoko A. B. (14/06/2012) 39

40. RTS,S Trial: Mid study report 2011 (5)
Findings of mid study analysis as at end of January 2011:
15,460 enrolled (6,537 in age group 1 and 8.923 in the other)
Mean follow-up time: 9mths in group 1 & 18mths in older group
The first 6000 in the age group 5-17mths were analysed 12 months
after the 3rd dose of vaccine. {2,830 children received all three
doses of the malaria vaccine (with or without the booster) and
1,466 received the control vaccine.}
Efficacy against clinical malaria (per protocol & ITT analysis):
Incidence rate: 0.44 first episodes of malaria/person-year in
the group that received the malaria vaccine, and 0.83 first
episodes of malaria/person/year in the control group.
Efficacy against clinical malaria was 55.8% (97.5% CI 50.6-
60.4) as per protocol and 50.4% (95% CI 45.8-54.6) as per
ITT
When all episodes of malaria (including repeat episodes)
were included, the vaccine efficacy was 55.1% (95% CI 50.5
- 59.3) as per protocol
© Dr. Idokoko A. B. (14/06/2012) 40

41. RTS,S Trial: Mid study report 2011 (6)
Efficacy against severe malaria (per protocol & ITT
analysis):
Incidence: 2% in the group that received the
malaria vaccine, and 3.8% cases of severe malaria
in the control group.
Efficacy against severe malaria was 47.3% (95% CI
22.4-64.2) as per protocol and 45.1% (95% CI 23.8-
60.5) as per ITT.
Further analysis of the pooled age groups after a mean
16mths of follow-up in the older & 7mths in the younger
age group shows:
Incidence: 1.7% in the group that received the
malaria vaccine, and 2.7% cases of severe malaria
in the control group
efficacy against severe malaria was 34.8% (95% CI
16.2-49.2) as per protocol and after 11months
© Dr. Idokoko A. B. (14/06/2012) 41

42. RTS,S Trial: Mid study report 2011 (7)
Vaccine’s efficacy was higher at the beginning than at the end of
follow up period. Some tailing off effect
After 15 months, overall efficacy against clinical malaria
is 46% in all age group
Overall efficacy against severe malaria in all age group is
31%.
Serious adverse effects:
Incidence: 17.6% in the group that received the malaria
vaccine and 21.6% in the control group for the older
group
Incidence: 13.1% in the group that received the malaria
vaccine and 13.4% in the control group for the younger
group
Similar side effects profile in those who received the
malaria vaccine as in the control vaccine, but there were
more cases of meningitis (RR of 5.5 & 4.0) and seizure© Dr. Idokoko A. B. (14/06/2012) 42

43. RTS,S Trial: Mid study report 2011 (8)
Side effects included: fever, pains, injection site
reaction, myositis, febrile convulsions, anaphylaxis
and seizures
Mortality profile: total of 151 deaths, 10 due to
clinically diagnosed malaria, 7 confirmed by blood
smears
Same proportion in the RTS,S and control
group for older age category –0.9%
Proportion in the RTS,S group (1.1%) is slightly
higher than that in the control group (0.8%) for
younger age category © Dr. Idokoko A. B. (14/06/2012) 43

44. RTS,S Vaccine: Issues
Arising
Lower efficacy of RTS.S compared to
standard vaccines especially against
severe malaria
Waning efficacy within a relatively short
time
A relatively short follow-up plan -
32months
The operational definition of malaria used
Prior exposure of the participants to
plasmodium
Concurrent use of ITN -75% of enrolees
No reduction in overall mortality in the
vaccine group © Dr. Idokoko A. B. (14/06/2012) 44

45. RTS,S Vaccine: Issues Arising
(2)
Low immunogenic profile of CSP used
Safety of the adjuvants in the long term
Incidence of serious adverse effects
Exclusion of Nigeria and Congo DR
with the highest mortality and morbidity
burden in this study
Cost: though GSK promises a cheap
end user price with no more than 5%
profit margin
© Dr. Idokoko A. B. (14/06/2012) 45

46. In conclusion:
a) Now more than ever, Malaria control,
especially in sub-Sahara Africa is at a crucial
crossroad
b) T3 and IVM strategies are the seemingly
reliable tools at hand towards achieving control
c) The pharmacological and clinical profile of
RTS,S vaccine are remarkable but, a more
efficacious vaccine is required if global
eradication can be a realizable dream
d) However, a more effective, active surveillance
in sub-Sahara Africa, particularly Nigeria &
Congo DR is critical to succeeding with current
or future interventions.
© Dr. Idokoko A. B. (14/06/2012) 46

47. In other words,
© Dr. Idokoko A. B. (14/06/2012) 47
Vector control with LLINs is working,
ACTs are working,
the Malaria map is shrinking
but, funds are depleting, resistance is
rising.
So, support T3,
let's work together and hope for a vaccine!!
.

48. Bibliography
 WHO Global Malaria Programme, World Malaria Report 2011; Geneva:
WHO Press
 Agnandji ST, Lell B, Soulanoudjingar SS, et al. (November 2011). "First
Results of Phase 3 Trial of RTS,S/AS01 Malaria Vaccine in African
Children". New England Journal of Medicine 365 (20): 1863-1875.
 WHO Global Health Observatory. www.who.int/gho. Accessed 10-06-2012
 WHO AFRO & EMRO, Malaria Control in Africa: Progress report on the
implementation of Abuja declaration; 2004: 19 - 26
 National Malaria Control Programme, Federal Ministry of Health, Nigeria.
www.nmcpnigeria.org. accessed 10-10-2012
 Clive Shiff, Malaria Control, The Johns Hopkins University, 2006
 L.H. Miller et al; Malaria pathogenesis; Science, 1994; 264: 1878 – 1883
 Edington G M, Gilles H M (1976) Pathology in the Tropics, 2nd Ed. Edward
Arnold, London. Malaria p17-33John Luke Gallup and Jeffrey D. Sachs,
The Economic Burden Of Malaria; Centre for International Development
at Harvard University Working Paper No. 52, July 2000
 Dr. Wiser. Malaria: Plasmodium lifecycle;
http://www.tulane.edu/~wiser/malaria/
© Dr. Idokoko A. B. (14/06/2012) 48

49. Merci beaucoup.!!
© Dr. Idokoko A. B. (14/06/2012) 49
This tiny insect
transmit a disease
that killed many
valiant warriors
including
Alexandria the
Great and
contributed much
in driving the
colonialist out of
the tropics.
It is a veteran
that has lost no
battle on the
tropical soil.
Be wise! Do not
harbour it in your
neighbourhood!

50. Appendixes:
© Dr. Idokoko A. B. (14/06/2012) 50

51. THE ABSTRACT
"For those of you who watch what you eat, here's the final word on nutrition and health.
It's a relief to know the truth after all those conflicting medical studies.
FINDINGS:
1. The Japanese eat very little fat and suffer fewer heart
attacks than the British or Americans.
2. The Mexicans eat a lot of fat and suffer fewer heart attacks
than the British or Americans.
3. The Japanese drink very little red wine and suffer fewer heart
attacks than the British or Americans
4. The Italians drink excessive amounts of red wine and suffer
fewer heart attacks than the British or Americans.
5. The Germans drink a lot of beers and eat lots of sausages and
fats and suffer fewer heart attacks than the British or Americans.
CONCLUSION:
Eat and drink what you like.
Speaking English is apparently what kills you..“
{NB: This is a joke. Reader discretion is implied. Author: Unknown}