How Brazil entered ‘high risk’ list back from polio

Brazil, Bolivia, Ecuador, Guatemala, Haiti, Paraguay, Suriname and Venezuela are the countries in the Americas at high risk of a return of polio, according to reports released by PAHO (Pan American Health Organization) throughout the second half of 2021.

According to the organization, the low rate of vaccination in these places represents a danger for the entire continent, which has not registered a single case of the disease for exactly 30 years.

“These countries, which represent 32% of the under-one-year-old population in the Americas, have sustained low vaccination coverage and weak surveillance systems, which pose a threat of virus emergence and subsequent circulation,” alerts Opas.

But how did Brazil, which had one of the most successful polio immunization programs in the region, end up on that list? And what is being done to reverse this scenario?

According to experts interviewed by BBC News Brasil, the Covid-19 pandemic, the lack of communication campaigns, a general mistrust of the authorities and the feeling that this disease is no longer a concern are some of the factors that help explain the current situation. .

A serious and disabling illness

The infectious disease specialist Raquel Stucchi, a professor at Unicamp (State University of Campinas), understands that vaccination against polio is a victim of its own success.

“The vaccines are so good that this disease has disappeared from the country. Currently, my students only see cases of polio in their books”, he says.

The last patient with poliomyelitis in Brazil was identified in 1989. In 1994, our country received from PAHO the certificate of elimination of the transmission of the virus that causes this disease.

The doctor, who is also a member of the Brazilian Society of Infectology, explains that this virus is transmitted from person to person or through the contamination of sewage and water networks.

“The infectious agent, known as poliovirus, stays in the intestine and is eliminated through feces. From there, it can contaminate other people”, he teaches.

Most of the time, the infection does not have major health repercussions. But there is a portion of those affected, especially children under the age of five, who develop very serious forms.

In these cases, the virus affects the nervous system and can cause a kind of muscle weakness—hence the term “infantile paralysis”, one of the popular names for the disease.

“Some patients suffer a paralysis of the legs and can no longer walk. In even more serious conditions, the chest muscles are affected and the ability to breathe is lost”, adds Stucchi.

For much of the 20th century, the only way to keep these individuals alive was “steel lungs,” a large machine that generated pressure in the chest to ensure oxygen ingress and carbon dioxide out of the airways.

Known for thousands of years, polio was a huge public health problem in the 19th and 20th centuries, with outbreaks and epidemics recorded in various parts of the world.

History began to change in the 1950s and 1960s, when the two vaccines used until today were developed.

The first, injectable and made from the inactivated virus, was created by the American physician Jonas Salk (1914-1995). The second, the result of the work of Polish researcher Albert Sabin (1906-1993), is given in droplets and contains the attenuated virus in its formulation.

Since polio eradication efforts have advanced across all continents, polio cases have dropped 99 percent.

Just to give you an idea, in 1988 350,000 polio diagnoses were registered in 125 countries. As of 2021, the wild virus remains endemic in just two places: Pakistan and Afghanistan, which have registered 5 cases in the past 12 months.

It is also necessary to mention here the cases of polio caused by the attenuated virus of the Sabin vaccine, given in droplets: they are very rare and have been observed especially in Africa, in people with compromised immunity and in places with little access to water and sewage treatment.

Let me be clear: having an oral polio vaccine has greatly facilitated the global eradication effort, and this product has been instrumental in controlling the disease on the international stage. After all, droplets are very easy to transport and apply, in addition to not requiring very complicated training.

More recently, however, with a 99% reduction in cases of the disease caused by the wild virus, many countries started to offer, especially in the first doses, only the injectable immunizing agent (Salk), made with the inactivated virus. In this case, the risk of having polio from a vaccine derivative does not exist.

Our country even adopts this strategy, as you can see below.

Brazil, from success to concern

Between 1968 and 1989, Brazil recorded more than 26 thousand cases of polio, according to data from the Ministry of Health.

Although there were municipal and state projects to vaccinate children against this virus, the first national immunization campaign against polio was officially launched in 1980, in line with a worldwide effort to eradicate this disease, which is ongoing to this day.

Our country was even a pioneer in several aspects and launched some strategies that made a big difference in the engagement of the population, according to experts.

The two most successful examples were the creation of the famous “D days” of the campaign, which were widely publicized in the media, and the creation of characters with strong popular appeal, as was the case with Zé Gotinha.

The last case of polio in the country was observed in the city of Sousa, Paraíba, in 1989. The disease is considered officially eliminated from the national territory for 27 years, since 1994.

The vaccine against polio is still indicated for all Brazilian children in a five-dose schedule. The first three are made with the injectable immunizing agent and must be applied at two, four and six months of life. Afterwards, the two boosters (usually given with the drops) are given between 15 and 18 months and at age five.

In recent years, however, vaccination coverage has left something to be desired. According to data from the Ministry of Health, the rate of people immunized against polio has dropped considerably from 2015 until now.

Six years ago, 98.2% of the target audience received the doses. In 2016, this rate dropped to 84.4% and remained at that level until 2019.

In 2020, another important drop was registered: according to preliminary data, which may still undergo some technical review, only 75.9% received doses against the virus that causes infantile paralysis.

In other words, one in four Brazilian children is not sufficiently protected against polio.

“If we consider the number of live births in the country, we are talking about practically one million unprotected individuals”, calculates pediatrician Juarez Cunha, president of SBIm ​ (Brazilian Society of Immunizations).

It is precisely this contingent of non-vaccinated people that alarms the authorities and has placed Brazil on the list of countries at “high risk” for the reintroduction of polio in the Americas.

“This whole situation makes us very worried. We are talking about a disease that paralyzes children”, calls the attention to infectologist and pediatrician Luiza Helena Falleiros Arlant, coordinator of the Technical Chamber of Immunizations (Polio) of the Ministry of Health.

“And the main pillar for not letting this virus reach our country again is to vaccinate the entire target population. Because then, even if someone infected with polio happens to enter airports, ports and land borders, there would be no risk of internal transmission , since the majority of the population would be protected”, adds the specialist, who also coordinates the Department of Children’s Health at the Faculty of Medicine of the Metropolitan University of Santos, on the coast of São Paulo.

In other words: in the current scenario, with about 1 million susceptible children, there is an imminent danger of a person with polio coming from outside and creating internal transmission chains, something that has not been seen here for over three decades.

A similar scenario, in fact, happened recently with another infectious disease that can be prevented with vaccination: measles, which was eliminated from Brazil in 2016.

Low immunization rates, however, made the disease come back with a vengeance two years later, with important outbreaks registered in 2018 and 2019 in several cities.

How did we get here?

Cunha says that the drop in vaccine coverage rates can be explained by three words that start with the letter C: trust, convenience and compliance.

“Let’s start with trust: we live in a time when, because of the spread of false information, people are suspicious not only of the safety and efficacy of vaccines, but also of institutions, governments and health professionals”, observes the pediatrician.

“The second point is precisely the convenience: the functioning scheme of the vaccination posts is out of line with the routine of mothers and fathers, who are unable to take their children to take their doses during business hours. We need to expand the infrastructure and train better the professionals who are on the cutting edge,” he continues.

“And it is worth remembering that the PNI (National Immunization Program) of the Ministry of Health has been without a coordinator since July 2021.”

Finally, complacency has to do with that absolutely misguided feeling that polio is a thing of the past and there’s no reason to worry about it anymore.

According to health professionals consulted by the report, the high number of unvaccinated children against polio in 2020 also has to do with the Covid-19 pandemic, which closed or restricted health services for some time last year and made people look less to health centers to update the vaccination booklet.

To reverse these barriers, the president of SBIm understands that it is necessary to invest in massive communication campaigns.

“One of our strengths was the transmission of information with the support of references in the area of ​​health, artists and politicians”, recalls Cunha.

“Nowadays, this issue is very flawed. Communications seem to be aimed only at managers and health professionals. The population does not even know about D-day or periodic campaigns”, he criticizes.

“It’s no use setting a ‘D-day for vaccination’ and not letting people know through advertisements on radio, television and social media,” agrees Stucchi.

Sought by BBC News Brasil, the Ministry of Health took a stand on the discussion through a note for clarification.

In the text, the press office emphasizes that a National Multivaccination Campaign was carried out this year, with the objective of “promoting social mobilization for the updating of the Child and Adolescent Vaccination Booklet (under 15 years of age), the in order to improve and expand vaccination coverage in the country”.

“The Ministry of Health also informs that it has been developing and intensifying necessary strategies related to childhood vaccination. Among them, the Movimento Vacina Brasil, launched in 2019, with the objective of mobilizing the population about the importance of vaccination and the need to maintain the vaccination situation updated”, follows the note.

Those responsible for the PNI also say that they have reinforced with the States, municipalities and the Federal District “the maintenance of routine vaccination actions, even in times of the Covid-19 pandemic” and that “it acts strongly in the dissemination of information in its means of communication and interaction on social media”.

Finally, the ministry emphasizes that it is adopting a “ten steps strategy” to expand vaccination coverage in the country. Are they:

1. Keep the vaccine room open at all hours of operation of the Health unit;

2. Avoid access barriers;

3. Opportunity for vaccination (in consultations and/or other procedures in the unit);

4. Monitor vaccination coverage;

5. Ensure proper registration of applied doses;

6. Guide the population about vaccination updates;

7. Combat false information;

8. Intensify vaccination actions;

9. Promote availability and quality of vaccines;

10. Ensure trained and qualified professionals in the vaccine rooms.