Despite ongoing efforts, a highly effective vaccine against Plasmodium falciparum remains elusive. Vaccines targeting the pre-erythrocytic stages of the P. falciparum life cycle are the most advanced to date, affording moderate levels of efficacy in field trials. However, the discovery that the members of the merozoite PfRH5-PfCyRPA-PfRipr (RCR) complex are capable of inducing strain-transcendent neutralizing antibodies has renewed enthusiasm for the possibility of preventing disease by targeting the parasite during the blood stage of infection. With Phase I/II clinical trials now underway using firstgeneration vaccines against PfRH5, and more on the horizon for PfCyRPA and PfRipr, this review explores the rationale and future potential of the RCR complex as a P. falciparum vaccine target.
Malaria Vaccine StatusGlobal malaria mortality and morbidity has declined sharply in recent decades. Still, in 2018 there were 228 million infections resulting in 405 000 deaths, disproportionately shouldered by the developing world [1]. Despite progress, malaria continues to be an intractable global health threat. Improved access to insecticide-impregnated bed nets, vector control, and the availability of effective antimalarial medications have been the cornerstones of global malaria control efforts and will continue to play indispensable roles. However, even optimal deployment of current tools will still leave elimination in high-transmission settings unattainable [2].A highly effective malaria vaccine would be one way to achieve further reductions in the global malaria burden. The observation that passive immunoglobulin (Ig) transfer confers immunity against malaria suggests that a malaria vaccine is conceivable [3]. One malaria vaccine candidate from GlaxoSmithKline, RTS,S/AS01, targets the circumsporozoite protein (CSP) and has now progressed beyond Phase III and into pilot implementation trials. This is a milestone for the malaria vaccine field and provides an important proof-of-principle for this approach; however, improvement is still required given that RTS,S/AS01 affords only partial protection of modest duration [4]. Nonetheless, this partial success gives strong impetus for continued effort and investment to develop a more effective next-generation malaria vaccine.Currently, the field awaits proof-of-concept for a substantially improved CSP-based vaccine, while whole-sporozoite strategies still face challenges with regard to scalability, immunogenicity in African infants, and breadth of protection [5,6]. An alternative and complementary approach would be to include a vaccine targeting the subsequent pathogenic blood stage of infection; this would have the potential to protect against malaria death, disease, and transmission. This review focuses on the recently described PfRH5-PfCyRPA-PfRipr (RCR) complex, an elongated protein trimer formed on the P. falciparum merozoite surface that binds to erythrocyte basigin, as a new and highly promising next-generation blood-stage vaccine (see Glossary) candidate (Figure 1A). I...