The cost of a malaria-free world

LONDON, (Reuters) – Joe Cohen, a scientist tantalisingly close to delivering the world’s first malaria  vaccine, is on the stump.  

After 23 years of painstaking laboratory work and a  programme of major trials in seven countries, the 67-year-old  biologist says the clinical case for the vaccine is almost  proved. It’s a breakthrough moment that could save hundreds of  thousands of lives, but when it comes to public health in the  developing world, Cohen knows hard science is only half the job.  That’s why the softly spoken U.S.-Italian researcher found  himself one chilly December evening pitching his life’s work to  rich-world politicians whose voters will have to foot the bill,  and fielding questions over festive mince pies and wine in a  leather and oak-clad room in London’s Houses of Parliament.  

How cost-effective will the vaccine be compared to tried and  tested low-tech approaches like mosquito nets and insecticides,  one inquirer asks. Is there any evidence that it will bring down  the spread of the disease in general, helping those who haven’t  been vaccinated?  How long is a shot likely to stay effective?  Is there a danger it might foster a false sense of security? As  the session goes on, it’s clear that enthusiasm for Cohen’s work  is coupled with wariness among the experts and well-informed  lawmakers. The bottom-line question: is the vaccine — and the  global health community’s aim of completely eradicating a  disease that kills a child every 45 seconds — really worth the  money?  

It may seem an absurd thing to ask. Malaria threatens half  the people on the planet and kills around 800,000 people a year,  many of them too young to have even learned to walk.

The death  rate has come down in the last decade, but full-scale  eradication will cost billions and drag funds away from other  equally, or possibly even more urgent health efforts. As  governments in poor countries and donors from wealthy ones weigh  up where to put their money, experts have begun a quiet but  fundamental debate about whether wiping out malaria is realistic  or even makes economic sense. 
 
“With all of the money and human capacity in the world,  there is very little doubt that we could eliminate malaria. The  question is: What is the best value for our dollar? And this is  an increasingly pressing question as we look at the global  economic climate,” says malaria expert Oliver Sabot, who works  at the Clinton Health Access Initiative in Boston.
  
TARGETING
THE PARASITE
 
What is the best value for our dollar? The answer to that  question seems obvious to someone like Loyce Dama Karisa, a  Kenyan woman who recently gave birth to her seventh child, a  girl called Rehema. Karisa has come in a minibus full of other  mothers and babies to a clinic in the mud-and-thatch village of  Madamani in the Kilifi district on Kenya’s south coast.

LONDON, (Reuters) – Joe Cohen, a scientist tantalisingly close to delivering the world’s first malaria  vaccine, is on the stump.  
After 23 years of painstaking laboratory work and a  programme of major trials in seven countries, the 67-year-old  biologist says the clinical case for the vaccine is almost  proved. It’s a breakthrough moment that could save hundreds of  thousands of lives, but when it comes to public health in the  developing world, Cohen knows hard science is only half the job.  That’s why the softly spoken U.S.-Italian researcher found  himself one chilly December evening pitching his life’s work to  rich-world politicians whose voters will have to foot the bill,  and fielding questions over festive mince pies and wine in a  leather and oak-clad room in London’s Houses of Parliament.  
How cost-effective will the vaccine be compared to tried and  tested low-tech approaches like mosquito nets and insecticides,  one inquirer asks. Is there any evidence that it will bring down  the spread of the disease in general, helping those who haven’t  been vaccinated?  How long is a shot likely to stay effective?  Is there a danger it might foster a false sense of security? As  the session goes on, it’s clear that enthusiasm for Cohen’s work  is coupled with wariness among the experts and well-informed  lawmakers. The bottom-line question: is the vaccine — and the  global health community’s aim of completely eradicating a  disease that kills a child every 45 seconds — really worth the  money?  
It may seem an absurd thing to ask. Malaria threatens half  the people on the planet and kills around 800,000 people a year,  many of them too young to have even learned to walk.
The death  rate has come down in the last decade, but full-scale  eradication will cost billions and drag funds away from other  equally, or possibly even more urgent health efforts. As  governments in poor countries and donors from wealthy ones weigh  up where to put their money, experts have begun a quiet but  fundamental debate about whether wiping out malaria is realistic  or even makes economic sense.  
“With all of the money and human capacity in the world,  there is very little doubt that we could eliminate malaria. The  question is: What is the best value for our dollar? And this is  an increasingly pressing question as we look at the global  economic climate,” says malaria expert Oliver Sabot, who works  at the Clinton Health Access Initiative in Boston.
  
TARGETING
THE PARASITE
 
What is the best value for our dollar? The answer to that  question seems obvious to someone like Loyce Dama Karisa, a  Kenyan woman who recently gave birth to her seventh child, a  girl called Rehema. Karisa has come in a minibus full of other  mothers and babies to a clinic in the mud-and-thatch village of  Madamani in the Kilifi district on Kenya’s south coast.  
GlaxoSmithKline, the British-based drugmaker Cohen works  for, is using the clinic as part of Africa’s biggest ever  medical experiment, giving the vaccine to babies and young  children in a trial designed to assess its efficacy. “I wanted  my child to get this vaccine,” Karisa says. “Malaria is a very  bad disease.”  

In the Kilifi District Hospital, the children’s high-  dependency unit is full of malaria patients. Listless babies and  toddlers lie motionless in adult-sized beds, tangles of tubes  taped to their nostrils, arms and legs.

One boy has his hands  bandaged into stumps to stop him pulling a tube out of his nose.  He screams and thrashes about as a drip is attached to a vein in  his foot. Mothers in mint green hospital gowns watch silently.  One cradles her tiny sleeping baby’s hand in her own while a  ceiling fan chops slowly through the hot air, doing nothing to  reduce the draining heat. 

Families in Kilifi, which despite its lush green vegetation  has poor soil for growing crops and high levels of poverty, are  almost numb to the ravages of malaria. It’s a similar story  across the continent: around 90 percent of malaria’s victims  live in sub-Saharan Africa; most of those are under five.
  
The disease is caused by a parasite carried in the saliva of  mosquitoes. GSK’s vaccine goes to work at the point the parasite  enters the human bloodstream after a mosquito bite.

By  stimulating an immune response, it can prevent the parasite from  maturing and multiplying in the liver. Without that response,  the parasite re-enters the bloodstream and infects red blood  cells, leading to fever, body aches and in some cases death.  

The vaccine Cohen and his colleagues have developed combines  technology from GSK’s hepatitis B shot with pieces of the  malaria parasite, and adds in a chemical known as an adjuvant to  boost the body’s immune response further. The result — the  first ever vaccine against a human parasite, as opposed to  simple bacteria or viruses — is a product that could be given  alongside standard infant vaccines and has been shown in a Phase  II, or mid-stage, clinical trial to reduce the risk of clinical  episodes of malaria in young children by 53 percent over eight  months. The pivotal Phase III programme, the one baby Rehema is  part of, will inject the last of 16,000 African children by  February. If all goes according to plan, the vaccine could be  licensed and rolled out as soon as 2015. 
 
GSK’s chief executive Andrew Witty says the trials are going  well and he’s looking forward to bringing the vaccine to market  — something he says won’t make shareholders in his company any  money, but will make them proud. “This is the first vaccine that  has any effect at all against a parasite-borne infection.

If we  went back 20 or 25 years, people would have said it was  impossible,” he told Reuters.
  
An efficacy rate of around 50 percent means the vaccine will  be no panacea. Scientists and health experts normally like a  success rate of at least 80 percent before a vaccine is accepted  for widespread use. There are concerns that the availability of  shots could instil a false sense of protection, leading people  to neglect other measures like mosquito nets.
  
But added to the already extensive range of nets,  insecticides and anti-malarial drug treatments, the vaccine —  known as RTS,S or Mosquirix — could prove a powerful new tool.
  
“There are not many scientists who have this incredible  opportunity to work on a project and see the realisation of that  work being transformed into a vaccine that could save hundreds  of thousands of lives,” says Cohen, who with his baggy cords,  beard and mop of grey hair strikes a contrast with Witty’s  clean-cut corporate look. “My worst nightmare is that it sits on  the shelf for years.”

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