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Story Publication logo March 18, 2023

The Battle for Vaccines


Needle extracting solution from a vial, held upside down

Brazil is one of the 10 countries in the world with most children unprotected against measles, and...


Expectations for the coming years are positive, but there are a number of challenges to regaining the enviable vaccine coverage of the past. Image by Jonathan Gelber, Andriy Onufriyenko, and Ewerton Manzotte/Getty Images. Illustration by Rodrigo Damati/SAÚDE é Vital. Brazil, 2023.

A seguir, um resumo em inglês do relatório original "A batalha pela vacinação", escrito em português e publicado na revista Veja Saúde. Para ler a reportagem, clique aqui.

The following is an English summary of the original report "A batalha pela vacinação," written in Portuguese and published in Veja Saúde. To read that report, click here.

We only survive and thrive these days thanks to vaccination. But never before in the history of this country has it been the focus of so much debate, fighting and interaction on social media.

For decades, vaccines were a normal part of the landscape and everyday life: There was a campaign, you read the leaflet, got your shot, and that was it! Nobody argued about efficacy, side effects, conspiracy theories, or plans of world domination.

Without fuss or controversy, billions of vaccines were administered everywhere—before and after the COVID-19 pandemic—saving the lives of children, adolescents, adults, and the elderly. Fewer deaths, fewer after effects, fewer days away from school and work, and a brighter and healthier future ahead.

The infant mortality rate in the country alone dropped from more than 100 deaths per thousand live births to around ten.

In over a few years, however, the once robust National Immunization Plan (PNI) developed in 1973 was in shambles. And through word of mouth and social media, fake news whitewashed the defense of vaccines.

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“There was a downward trend in vaccination coverage in 2016, followed by a reversal in 2018. However, as of 2019, actions were no longer intensified and there was a sudden return to an average coverage similar to that of the 1980s,” contextualizes epidemiologist Carla Domingues, coordinator of the program when it was a global leader.

Yes, “was.”

Today, Brazil is among the ten countries with the most unvaccinated young children according to the World Health Organization (WHO), alongside nations with historical difficulties, such as Congo, India, and Pakistan.

“We went from pride to shame,” laments infectologist Cristiana Toscano from the Federal University of Goiás (UFG), who forms part of the WHO group of immunization experts.

Is there an explanation for this? Structural problems? Yes, and many. Vaccination hesitancy? Undoubtedly, it grew and hitched a ride on the anti-vaccine speech that still hounds COVID-19 vaccination and undermines confidence in immunization as a whole.

It's ironic: The same pandemic that showed, in practice, how this strategy saves lives, also stirred up the denialist movement.

But the change in Brazil’s federal government marks new discourse—and, hopefully, a new course for the PNI. “I want to appeal to everyone to get vaccinated, because it is a guarantee for life,” said President Lula at the launch of the National Vaccination Movement in February, upon receiving the newly arrived bivalent COVID-19 vaccine.

Words help, but a lot more is needed to reverse the situation.

Imminent Danger

Ever since I started working on this story at the end of 2022, the question has been hammering in my head: Am I over worried? After listening to more than 25 people from international authorities on the subject of people who fall prey to fake news, I can say no.

The fall in coverage is a worldwide trend and represents real danger. “Brazil is one of the countries most at risk for the return of already controlled diseases,” says epidemiologist Ana Brito, from the Brazilian Association of Collective Health (Abrasco).

We lost the measles-free country certificate in 2019, and between 2018 and 2021, we reported 40,000 cases. Cases of diphtheria have been reported here and in the surrounding area, and polio could reappear in our territory. Infant mortality has risen again, with around 20,000 preventable deaths per year from conditions such as diarrhea and pneumonia.

Social inequality is clearly to blame, with the worsening of hunger and malnutrition, but the lack or delay in vaccination plays its part too.

Believe it: The administering of all vaccines for children is below the target in Brazil. In the case of COVID-19, according to Fiocruz, coverage for those between 4 and 5 years of age was around 5% until November last year, and adoption for baby doses is crawling.

It doesn't make sense: With the exception of the elderly, they are the group most at risk for infection from an age point of view. COVID-19 killed one Brazilian child a day in 2022.

“Apart from the long-term neurological and cardiovascular effects which are still being studied,” points out immunologist Cristina Bonorino, professor at the Federal University of Health Sciences in Porto Alegre.

Adults do not escape what has become the rule. The flu shot collected dust at health centers last year. And, after an enviable engagement with the first COVID-19 shot, boosters are dragging along.

The latest edition of the vaccination coverage survey, in which the vaccination cards of 38,000 children throughout Brazil were checked, exposes the complexity of it all. Including socioeconomic issues.

Despite having access to a privileged health system, the richest upper class had the biggest drop in immunization: from 76 to 30%.

“But this difference is heterogeneous. In some places, class D has lower levels, and vice versa,” ponders Dr. José Cassio de Moraes, from the Faculty of Medicine of Santa Casa de São Paulo, one of the authors of the survey.

The reasons behind non-vaccination vary across layers of society. But in the past, there was homogeneity in vaccination habits—and it has been eroded in recent years.

The Roots of the Downfall

When vaccine coverage began to fall in 2016, the explanation was clear to experts: Apart from the population’s perception of low risk, the underfinancing of Brazil’s Single Health System (SUS) intensified through Constitutional Amendment 95 approved that same year, established a cap on public spending.

“This weakening affected the functioning of vaccination centers and the supply of vaccines,” says epidemiologist Eliseu Waldman, professor at São Paulo University (USP).

The scarcity of investments has direct and indirect effects. Let's take as an example, BCG vaccines which protect against tuberculosis and hepatitis B, which should be administered in new-born babies.

With the crisis in government accounts, maternity hospitals redirected resources and professionals to maintain assistance and thus stopped offering the service. No wonder the coverage of these vaccines is low, in the region of 60%.

In the vaccination survey, almost 30% of parents replied that they weren’t able to vaccinate their children when they went to the health centers. They do not always come back, and the opportunity, when it arises, is lost.

"We have increased vaccines on the timetable, but we do not offer alternatives to the new social configurations of the population, with fathers and mothers working away from home and being less and less available to bring their children to health centers," says infectologist Julio Coda, professor at Federal University of Mato Grosso do Sul (UFMS).

The vaccination room is the responsibility of the municipalities, but the Ministry of Health can (and should) foster these spaces, providing guidance, training and even financial incentives to cities that meet their targets. Speaking of federal government...

In the Eye of the Storm

The COVID-19 pandemic turned the health system upside down, required more and more funding, directed medical assistance to COVID-19 victims, drained PNI efforts, and drove people away from consultations, tests and, initially, vaccines.

But the pandemic is not entirely to blame for the mess. Countries such as Uruguay, Chile and Costa Rica have managed to maintain immunization levels close to ideal.

In Brazil, however, the federal government scored their own goal, and not only with comments of former President Jair Bolsonaro warning that anyone who got the COVID-19 vaccine would turn into an alligator.

“Despite budget problems, there was initially a team on hand at the Ministry of Health. When the president started changing ministers and other key positions, especially during the pandemic, appointing people unprepared for the basic role of vaccination. Then we came to see the administrative incompetence, with doses passing their expiry dates, distribution problems and absence of communication campaigns,” criticizes Fernando Aith, legal expert and professor at the USP School of Public Health.

Current Secretary of Surveillance and Health (departmental to which PNI was subordinate), epidemiologist Ethel Maciel, says he came across a scene of chaos when taking over the portfolio in January 2023.

We talked in late February after his first 45 days of management trying to clean up. "Billions of Reais were lost to expired vaccines, and we didn’t have enough COVID-19 doses for children, nor the bivalent vaccines for priority groups," she describes.

"In addition, there was a lack of inventory vaccines for tuberculosis, polio, hepatitis B and so many others," she continues.

The lack of communication about the importance of vaccines, one of the most critical points for maintaining the coverage, also begins to be deciphered by opening this black box. “There were no more contracts in place with advertising agencies. We need to redo everything to launch this year's actions,” says Ethel.

During the pandemic, national campaigns to restore levels of protection against polio, measles, and other diseases were few to say the least, and they bordered on non-existent for COVID-19.

Disinformation in Power

Former Health Minister and General Eduardo Pazuello came to fame for the tragedy in Manaus and the chloroquine hype—a drug that did not prove to be effective against COVID-19.

But it was after the arrival of Dr. Marcelo Queiroga in March 2021 that vaccination went haywire, culminating in the extinction of technical and research groups and the absence for almost a semester of a coordinator for the PNI after the departure of nurse Franciele Fantinato in July 2021, at the height of the pandemic.

An employee of the agency who prefers not to be identified reports feeling that their hands were tied at the time: “We prepared recommendations that were not always followed, and the last straw was the issue of childhood Covid vaccinations.”

In January 2022, the government summoned experts to “listen to both sides” on the topic. In favor of vaccination, armed with a pile of studies proving its benefits, were infectologists, pediatricians, and medical societies.

Contrary to the measure, a body of professionals with no experience in the field, relying on distorted information or lies to suggest that vaccines were dangerous.

Anyone can quote a rumor, even surreal ones, about the COVID-19 vaccine, but the rumors did not affect much the adult population who were the most gullible, even though they’re slow in getting their boosters shots.

It is the children who are largely unprotected because of fears instilled in their parents' minds, including by some doctors.

Fact: Vaccines have been tested, are safe, effective, and lower the risk of death and hospitalizations from the disease. There is solid evidence for this, such as a review of 17 studies involving more than 10 million children and adolescents, recently published in the Journal of the American Medical Association (JAMA).

But you still hear that the shots cause myocarditis—inflammation of the heart considered a very rare reaction and most often associated with COVID-19 itself—or even that children are dying “out of the blue” because of the jabs.

“Misinformation and mistrust affect the medical class, leaving families feeling insecure,” says infectologist Renato Kfouri, from the Brazilian Society of Pediatrics (SBP).

And woe betide those who speak in favor of vaccines. Kfouri and other doctors present at the hearing had their personal data leaked by politicians aligned with the anti-vaccine narrative and received a series of threats. Parents who begged for the arrival of pediatric vaccines were also harassed.

In the wake of ideological polarization, vaccines have become ammunition in the trenches of the internet.

A New Stronghold for the Antivax Movement

American pediatrician Peter Hotez, co-director of the vaccine development center at Texas Children's Hospital, has followed the anti-vaccine movement for decades ever since his daughter was diagnosed with autism in the 1990s.

This condition is often associated with immunizations because of a fraudulent study conducted by an ousted doctor who profited from lawsuits and wanted to sell his own measles vaccines—all bankrolled by families seeking compensation from the pharmaceutical industry.

Hotez, who participated in the development and distribution of 100 million vials against COVID-19 for low-income countries without receiving a penny from “big pharma,” sees an unprecedented increase in messages raising doubts and fallacies in this regard.

“Ten years ago, the agenda began being used by extreme right-wing movements, relying on the concept of 'individual freedom' or 'medical freedom,'” commented the expert.

He says that in the United States, more than 200,000 people died even after the COVID-19 vaccines arrived, the majority in states with governments and populations reticent to vaccination.

“The anti-science movement today kills more than guns and car accidents around here, but we still don't see it as a lethal tool. And this has expanded to the rest of the world, including Brazil,” warns Hotez.

I know, we're tired of talking politics, and that's not even the focus of this publication. But it is a necessary sore point to improve Brazilians' confidence in vaccines.

“As a doctor, it is the hardest thing for me to position myself politically, as we are trained to be neutral, but this is a holdover from the mindset that science exists in an ivory tower. We need to demolish this tower in order to save lives,” believes Hotez.

By all indications, national spokespersons for the anti-vaccine movement are few and far between and losing engagement with the end of federal support. But they still make noise and are organized, attest the scientists who research these networks.

“It's easier to fight the problem now, at the root, than to wait for it to grow like in other countries,” says epidemiologist Denise Garrett, vice president of the Sabin Vaccine Institute in the USA.

Misinformation spread around the doses of COVID-19, but the scary and detached narratives of reality spread to other immunizers—sometimes to the entire class. “My concern is that what started with the Coronavirus will contaminate the view of other vaccines,” says Hotez.

In groups that act against vaccination, stories ranging from the relationship with autism to lies about the flu shot are popping up. And, when we no longer see the diseases fought by immunizers, as in the case of polio, the risk of an adverse event from the vaccine outweighs the benefit when taking a child to the health center.

We can say, in this case, that misinformation is a market that follows the law of supply and demand.

“The population has a demand for clarifications that do not always reach them, and there is a systematic offer of false information purposely spread to generate mistrust,” interprets data scientist João Guilherme, researcher at the National Institute of Science & Technology in Digital Democracy, who participated in analyses on the subject.

Messages are transmitted like viruses and are tailor-made. For the religious, the vaccine delivers the “mark of the beast chip;” for the more skeptical, the bait is texts full of technical terms; for those prone to conspiracy theories, there is a plan for world domination.

On the cell phone screen, ordinary people who are not even anti-vaccine are frightened by the imminent danger. Behind all this, there is a hamper of political actors and health professionals selling “courses” and “detox therapies.”

In this parallel universe, there is even a false post-vaccine syndrome, very similar to the post-COVID-19 one—a real and preventable problem with the vaccine.

And these things happen under the eyes of the Federal Council of Medicine (CFM) itself, which, in the middle of 2023, still holds hearings to question the mandatory immunization against COVID-19 and does nothing to punish those who disseminate this type of content. The council made no comment after attempts for clarification.

"Anti-vaccination" Mobilization

The WHO considers vaccine hesitancy, delay, or reluctance to be immunized, as one of the greatest threats to human health and explains it through three C's.

First, Complacency, when there is no perception of the risk of failing to be immunized; then, the Convenience of access; and, finally, Confidence, shaken during the pandemic. “Now we are talking about 2 more Cs, Communication, which needs to be more empathetic, and the Cultural and socioeconomic context in which the hesitation occurs,” reveals Kfouri.

Given the size of the challenge, the actions of the Ministry of Health will not be enough to restore the sense of importance and urgency of vaccines. It will be necessary to better educate and train doctors and other health professionals—who do not always study the subject satisfactorily in colleges or keep up to date with it—and to mobilize the big tech (Google, Facebook, Twitter...) and the press, which has also become the target of a crisis of confidence in recent times.

Restoring Trust

When facts do not change opinions, trust may need to be regained in other ways. For example: What if the journalist wasn't me, a mysterious being, but your grandson, neighbor, or fellow churchgoer?

This is one of the commitments of Fiocruz, a major public institution focused on public health issues, within the project For the Regaining of High Vaccination Coverage (PRCV). Carried out in partnership with the Brazilian Society of Immunizations (SBIM), it involves, firstly, action in vaccination itself, supporting municipalities to solve infrastructural and professional training problems.

The rollout of the project began last year in two pilot states, Amapá and Paraíba, which had worrying levels of coverage. And they managed to raise the level of protection in a few months. “The two were the only states that met their polio target,” celebrates Dr. Lurdinha Maia, coordinator of the Fiocruz project.

Now, the PRCV moves on to another important axis, communication through innovative actions that pierce the “bubble,” a term used to describe the digital and social media channels in which people share information. I went to Paraíba in February to accompany one of these fronts, the Young Reporters action.

The idea is to train teenagers from low-income communities in João Pessoa to produce content about the importance of immunization and disseminate it among their own circles. In other words, breaking the bubble with someone who is already inside it.

“We want to reach families, neighborhoods, churches, and work groups,” envisions Isabel Cristina Alencar de Azevedo, leader of the project's communication and education axis.

In partnership with Central Única das Favelas (CUFA), the team set up a three-day workshop with 30 young people from nine communities in the city. A diverse group: evangelicals, teenage mothers, college freshmen, shy boys, girls with flairs for being digital influencers...

They learned concepts such as collective immunity and social responsibility, the roots of misinformation and how to produce audiovisual content with cell phones. They also talked to health authorities in the city and, after training, will create regular content with the help of a bag and a smartphone.

I closely followed one of these groups from the Muçumagro community, made up of five young, creative, and inspiring people whose story is presented in a video that accompanies this report on the VEJA SAÚDE website.

As soon as I met them, they already wanted to go out on the streets with us to hear the opinion of Muçumagro's neighbors about immunizations.

With camera and recorder in hand, we listened to everything: from the man who had a heart attack and blamed it on the vaccine, to the guy who doesn't need to protect himself because “he has God in his heart,” passing by the mother who can't vaccinate her child because the neighborhood health center is closed after having been repeatedly broken into.

For me—and I imagine for them too—it soon became clear that a project like this, despite being the work of ants, is the type of thing that can facilitate complicated dialogue with those who are afraid of the jab. “These young people have something that we, on the outside, don't: the credibility that is given by the community,” argues Lurdinha.

This doctor from Paraíba was the coordinator of the PNI and was with us there at the end, in the heat of João Pessoa, talking for hours on end with the group.

Her colleague in the creation of the PRCV is physician Akira Homma, a beacon of vaccination in the country, who, even in his 80s, is never out of breath. These two have no need to be involved, but vaccination is something they've fought so hard for that they're still there, rethinking tactics to win on the battlefront.

Today, programs like PRCV are doing everything “on the fly,” with limited resources. However, there is the prospect of improvement with the initiative launched by the federal government and the union between states, municipalities, and civil society.

“We are engaged in a great national movement to attack this wide range of causes that has brought us here,” comments Cipriano Maia, president of the National Council of Health Secretaries (Conass).

He hopes to be able to expand vaccination opportunities, as took place during the pandemic, with stations in malls, pharmacies, and parking lots, in addition to the resumption of administering in schools.

The Ministry of Health, on the other hand, will meet with authors of works such as the vaccine survey and the PRCV to understand and overcome hesitation and access barriers.

The challenge will be twofold, as it is necessary to engage the population and health professionals not only regarding existing vaccines, but also for those to come.

Now, with the advancement of science, it is to be expected that new types of vaccines will arrive quickly, many of them based on messenger RNA, the technology pioneered by Pfizer’s COVID-19 vaccine—and, not by chance, one of the most attacked.

“It is a very promising platform, as it does not involve manipulating the virus itself and triggers a more specific immune response than those of inactivated or attenuated virus vaccines,” says pharmacist Gustavo Mendes, who led the approval of COVID-19 doses at Anvisa, Brazil’s regulatory agency, and today participates in the International Vaccine Institute, the arm of WHO that promotes the development of better and more accessible vaccines around the world.

Vaccination makes a better future possible on a planet where people live longer, chronic diseases do not subside, there is an imminent risk of new epidemics, and social inequality persists.

We will soon see unprecedented vaccines against Chikungunya and respiratory syncytial virus (RSV)—in fact, Anvisa has just approved a vaccine against the four types of dengue virus from the Takeda laboratory.

And anyone who wants to age well should continue (or return) to embrace vaccines. “After mass vaccination, life expectancy in the world increased by an average of 30 years. We can therefore see that the elderly are losing their natural immunity, becoming more susceptible to infections. And that's why they also need to be vaccinated,” says geriatrician Maísa Kairalla, president of the Vaccination Commission of the Brazilian Society of Geriatrics and Gerontology (SBGG).

Stop and reflect: The same public health strategy that saves children is one of the keys to longevity—and, not by chance, products especially produced for the elderly population have been arriving in Brazil, such as new vaccines for herpes zoster and flu vaccines.

The PNI completes 50 years in existence in 2023, victim of its own success, management errors, and denialist attacks. The rescue that is starting to operate is no less important amid so many upheavals in the area of health or the economy.

Just think about the consequences of the lack of vaccination, something we have already experienced with COVID-19: hospitalizations, overcrowded hospitals, lack of medicine, complications and aftereffects, loss of productivity...

“Prevention is always the most cost-effective. With less resources, we have more impact, especially in the segments that, in my view, should be the focus of the health system: child, maternal, and health of the elderly,” analyses Waldman.

But Brazil, which was once a beacon in these seas, is lagging behind while the rest of the world is starting to use the hexavalent vaccine instead of the pentavalent one and is abandoning the polio vaccine drops.

Finally, fighting together for the resumption of vaccination coverage can be a way to rebuild the bridges that have collapsed in recent years. As anthropologist Heidi Larson from The Vaccine Confidence Project says, vaccines act as a kind of window to other issues that are so inherent in our times, such as the erosion of trust in institutions and the loss of the ability to think in groups.

“Vaccinating is both a right and a duty of citizenship and solidarity, part of life in a democratic society. Not only do I protect myself and my family, but I contribute to the whole community being protected,” sums up Aith. We need to regain that sense of community and pride in vaccines. For us. And for the rest of the world.


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