Why vaccinations for several diseases are falling sharply in Brazil

The country had been a champion of immunization. But the pandemic has now amplified declining rates, and experts warn that diseases once eradicated are re-emerging.

The more than half a million lives lost to COVID-19 in Brazil, ranked seventh in the world in deaths per capita, has underscored the need to amp up vaccination against the coronavirus—and indeed most Brazilians are eager to get the COVID-19 shot.

A May poll showed that 91 percent already had been or planned to be immunized against SARS-CoV-2, which causes COVID-19. But an increasing number have decided that both they and their children can hold off on getting routine vaccines that keep diseases like polio, tuberculosis, measles, mumps, rubella, and flu at bay. That's in line with the World Health Organization and UNICEF's concerns that the pandemic could endanger gains made against a slew of childhood diseases.

It’s not just a pandemic phenomenon: Vaccine coverage in Brazil had been slipping for several years. In 2015 a goal of vaccinating 90 to 95 percent of the population against communicable diseases was easily reached, but by 2019 a significant drop—10 to 20 percent—left the country vulnerable to a slew of preventable diseases it had long eradicated, even causing an ongoing outbreak of measles that started in 2018.

For Renato Kfouri, a pediatrician specializing in infectious disease and president of the Brazilian Society of Pediatrics’ Scientific Department of Immunizations, the COVID-19 vaccine campaign shifted focus from other vaccines, despite “the risk of children getting seriously ill or dying from these other diseases is at least 80 times higher than with COVID-19.”

In 2020 fewer than half the municipalities in Brazil reached or surpassed the coverage goals established by the country’s immunization plan for nine vaccines, among them the MMR (measles, mumps, and rubella), BCG (tuberculosis) and polio, according to a study from the Institute of Health Policy Studies that reviews government data from the Ministry of Health. While vaccine coverage was already on the decline due to complacency, it was fear of COVID-19 that brought it to a new low.

“The present context is alarming not only because of the greater distrust of the population with vaccines in general,” says Letícia Nunes, a health economics researcher and author of the report, “but also because many children will be susceptible to preventable diseases and their complications with the end of social distancing and return to in-person classes.”

In Brazil, the Ministry of Health often runs far-reaching campaigns for vaccination, reaching out to the population through TV ads, social media, billboards, posters, and flyers.

National Geographic’s several interview requests to the ministry to discuss what is being done to improve vaccine coverage went unanswered.

From disease eradication to outbreaks

In 2015 the MMR vaccine had 96.1 percent coverage, just above the required 95 to keep the three diseases at arm’s length. That same year, Brazil was awarded a World Health Organization (WHO) certification for the eradication of rubella, and then another in 2016 for the elimination of measles. The last time it registered cases of measles was in 2015, with just 214.

But in 2017, coverage of the MMR vaccine dipped to 86.2 percent. The following year, when it still was well below the required target, an outbreak occurred when thousands of Venezuelan migrants crossed Brazil’s northern border, bringing measles with them. The low percentage of vaccinated Brazilians—particularly in the north, where the rate in 2017 was 76.2 percent—enabled the disease to spread.

In 2018, 10,330 cases were registered, and in 2019, despite a slight uptick in vaccine coverage, 20,901 cases were logged in several regions.

That year, Brazil lost its WHO certification for eradication of the disease. In 2020, coverage of the MMR vaccine was just 79.5 percent. Despite social distancing and the use of masks because of the COVID-19 pandemic, another 8,419 cases of measles were registered.

With coverage so far this year sitting at just 62.1 percent, experts are concerned—and not just about the MMR vaccine.

The only vaccine to suffer a more significant drop in coverage is the first dose against hepatitis B, given to infants under 30 days old, which plunged from 90.9 percent in 2015, to 78.6 percent in 2019, to 62.8 percent last year. The BCG vaccine, which protects against tuberculosis, went from 100 percent coverage in 2015, to 86.7 percent four years later, and 73.3 percent in 2020.

Young people don’t know the risks of eradicated diseases

While there is a growing anti-vaccine movement in the country, doctors don’t see it as the main reason Brazil’s previously excellent vaccine coverage nosedived.

Other factors have influenced the declining rate—including difficulties reaching health centers for multi-dose shots. But one of the most significant, especially among young people, is a growing perception of low risk surrounding these diseases.

“They wonder, Do I really need to vaccinate my child?” says Zeliete Zambon, president of the Brazilian Society of Family and Community Medicine (SBMFC). “This is a huge mistake, because there’s a good chance more of these diseases will return.”

Precisely because widespread vaccination has worked so well, several diseases have been controlled or eradicated for years and Brazilians haven’t witnessed their ramifications. The desire to be vaccinated against the coronavirus is so high, Zambon notes, because everyone has seen the repercussions of COVID-19. But with polio, for instance, a viral disease that can affect the spinal cord, people forget that it can be deadly or cause life-altering complications, including muscle paralysis.

“We have the experience of dealing with patients who still live with the effects of polio that they contracted in the ’60s and ’70s,” says Fabiano Guimarães, director of the SBMFC and a former primary care manager of the Municipal Health Department of Belo Horizonte who continues to practice family and community medicine in the city. “They say it makes them sad to know that today we have a vaccine that, at that time, wasn’t a preventative measure that was available.”

And with the arrival of the pandemic, parents the world over have become even more leery of getting their children vaccinated, a situation the WHO has warned could lead to the loss of global public health achievements reached through vaccines.

In Brazil, fear of contracting the coronavirus has led parents to delay routine vaccinations for their children. A survey conducted by the Brazilian Institute of Public Opinion and Statistics (IBOPE Inteligência) for the Brazilian Society of Pediatrics and Pfizer showed that 29 percent of parents postponed vaccinations after the arrival of the pandemic, and 9 percent of those parents said they would have them vaccinated only once the pandemic came to an end.

“COVID dominated the news, dominated all communications, because people were afraid, and with good reason,” Kfouri says. “We need to do a better job communicating now that you can see your doctor, you can get preventative medical exams, and you need to be vaccinated. All of this can be done safely.”

In the pandemic, medical care became emergency focused, leaving primary care—regular checkups and routine vaccinations—behind. Plus, with many family medical professionals shifting to work in COVID-19 vaccine centers, Zambon says, the chain of communication about maintaining vaccine coverage was disrupted.

The IBOPE Inteligência survey found that 44 percent of parents stopped taking their children to the pediatrician during the pandemic. That rate increases to 50 percent among parents of children between the ages of three and five.

To get back on track, experts urge a return to focus on primary care and a solid communication plan about vaccines, including showing the effects of diseases like polio and hearing from people who have had them.

“We need to bring people back to a time when there was polio, show them what it’s like to have tetanus,” Zambon says. “We need them to understand how these diseases affect people’s day-to-day lives, the long-term effects they can have, and the deaths they can cause if people aren’t vaccinated.”

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