University of São Paulo: Barriers to the vaccination of children close a year of struggle for health and foreshadow challenges in 2022

The release by the National Health Surveillance Agency (Anvisa) of the Pfizer vaccine against covid in younger children marks the last weeks of a year of high expectations for immunization to advance. With the obstacles imposed by the federal government, similarly to what happened with the vaccine for adults before, the promise is of new moments of uncertainty.

Furthermore, although we have reached the end of 2021 with a situation of progressive control of the pandemic in Brazil, in terms of hospitalizations and deaths, another factor of concern arises: the omicron variant, which spreads at frightening speeds around the world. Vaccination is able to prevent severe symptoms in the vast majority of people, and protects more those who took the booster dose. But what about the minority? What about the most vulnerable groups, such as the elderly, and even children, who will remain unvaccinated while adults go to the third dose?

All of this indicates that both due to virus factors and socio-political ones (and it is difficult to separate which is which), insecurity about sanitary issues must be part of the climate in the beginning of 2022. Even because some errors were not corrected. after two years of pandemic.

The difficult path from pandemic to endemic
For the infectologist at the University Hospital of USP Gerson Salvador, sars-cov-2 is here to stay. “This is practically a consensus in the scientific community. We are not going to be able to completely remove it from circulation, also because it is a highly transmissible virus that makes many people lightly or asymptomatically infected, facilitating its spread. Other coronaviruses, such as sars and mers, caused severe disease to a greater extent and were less easy to circulate. They weren’t as well adapted to the human species as the current one. But most likely, when we have a large number of people immunized, sars-cov-2 can circulate as a seasonal respiratory disease,” he predicts.

The problem is that we are not going to magically get to this stage: coordinated actions are needed. For the year 2022, the doctor believes that we will continue to need a global response to a challenge that is global, “but there is no space for this decision to be taken in a shared and definitive way”, he says. And exemplifies: only 8% of people living in low-income countries have taken at least one dose of vaccine for covid, compared to 57% of the world population – even considering that low-income countries are pulling this average down. So there is a very large disproportion, with pockets of non-immunized people where there are more chances of appearing variants.

Salvador recalls that, so far, we have not had any high-impact variant, as the one that manages to escape the immune response caused by both the vaccine and previous infections is called (the omicron escapes from neutralizing antibodies, but this is reestablished with a third dose) . Within a scenario with part of the immunized people and pockets of non-immunized people, however, a strain of this type may appear. “For one variant to replace another, it has to have some adaptive advantage. If one appears with this trait, it will thrive. That’s a possible scenario, and it could throw our efforts back – but I hope it doesn’t. Mass vaccination does not eliminate this risk in 100%, but it reduces it a lot”, he ponders.

In addition to vaccines, and the good news of new drugs, such as antivirals and monoclonal antibodies , he recalls that some countries have managed to better control the pandemic in their territories through coordinated non-pharmacological measures: China, New Zealand, Australia and Vietnam, at least for a while. “Places where the collectivity was placed ahead of the individual managed to give more adequate answers. Where the individual spoke louder, ‘I and my right to go wherever I want’; ‘me and my right not to wear a mask’, with emphasis on the United States, there were bad responses”.

The same mistakes
Brazil was also not exemplary in terms of collective strategies. “This year, even with vaccines, we had a very high cost in deaths. We did something very wrong to have many more deaths in 2021 than in 2020. We were unable to implement policies on several fronts, to act in a stronger and more agile way”, says Lorena Barberia, professor at FFLCH and coordinator of the Solidarity Research Network .

For her, it can also be considered a type of denial to think “ah, this wave was the worst, we won’t have another”, and not resolve structural issues. This may continue to cost us dearly in 2022. “Here comes the next wave and we are back to discovering the problems we haven’t solved since the first year of the pandemic,” he says. For example, if it was difficult to test a lot in times of intense outbreaks, then when the cases dwindled it would be time to act and start testing. “There was difficulty in replacing strategies in different moments of the pandemic. We have to have a more coherent strategy, ready to be used when we have an interval between the peaks”, defends Lorena.

In the researcher’s opinion, in 2021 we placed a lot of emphasis on vaccination, ignoring other measures that had to be part of the answer. “We didn’t lose many lives just because the vaccine arrived late, but because we made the measures more flexible at a time of still very high risk, we dismantled the scientific committees and the monitoring programs. The data became more fragmented, outdated, and we couldn’t understand what was happening.” For a smoother 2022, she believes we have to have an early warning system and a defined strategy to react to an emergency. “Many governments simply decided that the worst was over and that the answer would be focused only on vaccination”, he criticizes.

Another neglected area, in the teacher’s view, was vulnerable groups, such as children and the elderly. “Children were very exposed to the risk in 2021, either of death or of having long-term problems from being infected. There is almost no talk of long covid in Brazil, for example. And we underestimated these risks, always saying they weren’t that big.”

For her, the fact that we have not communicated the need to protect children to parents and society is also reflected in the current difficulty in demanding more emphasis on a vaccination campaign for them. “Butantan himself waited a long time to make the request to Anvisa for children’s use of CoronaVac, even though there was already data on this group”, he laments.

Denial rhetoric was constant throughout the pandemic, “floating to a lesser or greater degree depending on how bellicose the government has positioned itself”, says José Gallucci Neto, from the Institute of Psychiatry (IPq) of the Hospital das Clínicas, Faculty of Medicine, USP . On critical issues, such as vaccines, and the adoption of non-pharmacological measures, this was a denial orchestrated by the federal government’s followers, which, for him, had two main impacts. “First in public health itself, which is having people contaminating themselves unnecessarily, by disobeying minimum sanitary rules, as if there wasn’t a problem happening. This increases mortality and reduces vaccine coverage, not just covid. Another impact that I consider equally important, but not so talked about, is to undermine the credibility of the great institutional references in science. Suddenly the WHO guidance[World Health Organization] has no value anymore because someone said it has ideological influence or there is some commercial interest involved. Or Anvisa no longer has the final word on a given matter because someone would have infiltrated there.”

Thus, argues Gallucci, there is a loss of trust in large healthcare institutions. “We can put the major scientific journals there, the universities… The word that comes from the University does not convey as much security to the population as that of a guy who has a YouTube channel and says that the pandemic is a fraud, for example ”, he assesses, reporting having received many phone calls this week from people close to him questioning whether it is possible to trust Anvisa’s decision on the childhood vaccine. “People who have never questioned this before, literate people, but who receive information from denial groups questioning the suitability of these institutions”, he laments.

For him, the silence of the Regional and Federal Councils of Medicine and even the University regarding the behavior of some of its members ends up giving strength to the denial movement. “The University can no longer be passive either, it needs to express itself in some way, take a stand on its professionals. It is not wanting to forbid people to speak, but to make it very clear that this does not represent the University’s vision. I think this has to be done more often, you know? This signaling is still very pressure dependent, and needs to be more spontaneous. It is no longer possible to wait for tragedy to happen. The result of all this that we are seeing is wide open in the number of deaths, in the fall in vaccination coverage… We will reap the fruits of these two years of denial for the next five to ten years.”

Saúde leaves 2021 with partial victory and concerns about the still uncertain end of the war against covid
As a positive highlight, the researcher cites science communicators, who did “a Herculean and very impacting work”. “In my view, they even influenced great political managers. Omar Aziz made it very clear that, during the CPI, many questions he raised and information he received came from serious communicators connected with science. All the pro-vaccination work, supporting CoronaVac there at the beginning, demystifying the story that it was a bad vaccine, maintained the population’s adherence to vaccination, which is already high in Brazil. This had a huge impact on public health, actively questioning false information and bringing true information, demystifying people’s fears”, he concludes.

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