Fear of reaction and lack of access hinder vaccination – 03/11/2023 – Health

The Venezuelan Kleiveliz Barreto, 18, from Pacaraima, in Roraima, has three children aged between seven months and three years and none of them have their vaccination card up to date. Missing doses against polio, rotavirus, triple viral (against measles, mumps and rubella), pentavalent, among others.

“Why this delay?” Nurse José Luís Gutierrez asks his mother during a home visit. “Because I go to the health center and there’s never a vacancy. We get there, wait, wait, and they send me back the next day. When I was pregnant, it was the same thing.”

To get to UBS da Pedra, Kleiveliz walks for almost an hour holding seven-month-old Nayara in her arms. Hand in hand, Mateus, 3, and Nixany, 1 year and 7 months old, try to keep up with her, but they soon get tired and start crying. “It’s a sacrifice to get there and not have service.”

At UBS, the report found Janima Peres, 22, an indigenous woman from the Taurepanã ethnic group. Alone in the waiting room, she had been waiting for two hours to vaccinate her three-year-old son, after three days of trying to get immunized.

“We come, we wait three, four hours and then they say there’s no more vacancy, that we need to come back another day. I only insisted because I’m at my sister’s house, which is close to here”, he says.

The reports explain some of the reasons for the delay in the vaccination schedule of the child population, a problem faced by 85% of Brazilian municipalities in a survey by UFMG (Federal University of Minas Gerais) in partnership with Conasems (National Council of Municipal Health Secretariats).

Since 2016, the country has had a drop in vaccination coverage and, today, all immunizations are below the target, which increases the risk of reintroduction of diseases that have already been eliminated, such as polio.

On the 27th, the Ministry of Health started the 2023 National Vaccination Program campaign. As of May, the focus will be on updating the children’s immunization schedule, with actions in schools.

The resumption of large immunization campaigns, which were not encouraged during the Jair Bolsonaro (PL) administration, is considered very important for rescuing the population’s confidence in vaccines, but health managers point out that it is also necessary to tackle other, even more complex bottlenecks.

In the UFMG survey, with 4,674 municipalities, among the reasons given for vaccine delay or refusal are from fear of immunization side effects (84%) to difficulty in accessing health services (40%).

“The percentage of municipalities that report delays both in relation to the first dose and the others is very high. We need to look at these territories because there are different causes and that involve different strategies to face them”, says researcher Jackson Freire, from UFMG.

Another survey coordinated by Santa Casa de São Paulo, which investigated the reasons for vaccine hesitancy in Brazilian capitals, shows that in 28% of cases the child was taken to the clinic, but did not receive the vaccine. Among the reasons are lack of vaccine (44%), the vaccine room was closed (11%) and there was no one to administer the vaccine (8%).

According to researcher José Cássio de Moraes, professor at the Faculty of Medical Sciences at Santa Casa, there are also frequent cases in which the population has access to the vaccination room, but the child is not vaccinated with all immunizers at once.

At two months, children need to receive polio, rotavirus and tetravalent vaccines (against diphtheria, tetanus, whooping cough, meningitis and other infections). There is no contraindication to applying them on the same day. However, 40% fail to do so, according to the survey.

“Is it fear of vaccine reaction on the part of parents? Or is it the vaccinator who does not want to apply the vaccine? We need to understand what happens because there is a lot of variation according to each region”, says Moraes.

In Pacaraima, for example, mothers report the fear that, with several vaccines at the same time, their children will have side effects and not find medical care at the UBS. The municipality, which is on the country’s border with Venezuela, has already spent four weeks without a doctor in primary care.

According to Dayane Nascimento, coordinator of the area, in recent years, the city has tripled the demand for health care with the immigration crisis in the neighboring country. It also faces difficulty in hiring doctors.

Often, however, it is the health professional who decides not to vaccinate the child, according to Moraes. There are cases, for example, in which the health unit only has bottles with several doses of vaccine and, if there is not enough public to exhaust them that day, what is left has to be discarded.

“Then they ask the mother to come back another day. In the past, the vaccine was lost and not the child, today this has been reversed”, says the professor. For him, the ideal would be to have different sizes of flasks. “It is not possible to have a single standard. It could even be individual flasks for small municipalities.”

When the subject is the problems related to the application of the vaccine, the work overload of the nursing team (80%) and the lack of personnel for this function (67%) appear as the most cited in the UFMG survey.

“Often, the vaccinator even vaccinates. But he does everything, bandages, takes care of the chronically ill. It is also very common for us to see the vaccination room with limited opening hours”, says Moraes.

Municipalities also face several obstacles to recording vaccination data in the Ministry of Health’s information systems, such as unstable internet or lack of network, insufficient number of computers and municipal system incompatible with the ministry’s.

According to Wilames Freire Bezerra, president of Conasems, these barriers and ways to overcome them have been discussed, but there is an even more urgent issue: the current statistics on vaccination coverage.

“They do not represent the reality of the municipalities. We are working on top of estimates made by the IBGE Census (Brazilian Institute of Geography and Statistics) 11 years ago, of a children’s audience that does not correspond to the reality of what we see in the territory.”

The new edition of the Census was scheduled for 2020, but it was postponed to the following year due to the Covid pandemic and, later, due to the budget cut for research in the Bolsonaro government. On the last 1st, the IBGE announced the end of the household collection of the 2022 Demographic Census.

Another problem is information systems that do not communicate. “We have primary care with e-SUS and sisPNI [sistema do programa nacional de imunização]. If I report data to one system, the other cannot see it. There are situations where systems crash. The municipality promotes vaccinations, but when typing, the system does not receive them”, says Bezerra.

Misinformation is also an important factor for vaccine hesitancy and its impact has increased in recent years, according to Ricardo Fabrino, a researcher at the Nucleus of Education in Collective Health at UFMG. The dissemination of false news is cited by 75% of managers and health professionals as a factor that leads to vaccine delay or refusal.

Eder Gatti, director of the Department of Immunizations at the Ministry of Health, says that the problems are complex and that they will require several action fronts in the short, medium and long term.

The most urgent thing, according to him, is to regularize vaccine stocks and invest in training programs for primary care professionals to improve care.

Gatti says that the folder has also been extracting the municipalities according to the risks, for example, those with lower vaccination coverage against poliomyelitis or measles, and preparing differentiated actions for the most vulnerable.

“Everything we are going to do has to be discussed with Conass [Conselho Nacional de Secretários de Saúde] and Conasems and will depend on resources and adjustments in the supply of labor in primary care.”

Regarding the imbroglios involving information systems, he says that the problems have worsened since 2017, with the creation of a system in primary care that fragmented the records of applied doses. “We do have data quality issues and we’re working to fix all of those.”

In relation to the vaccination targets, delayed due to the delay of the Census, Gatti agrees with the criticism of the municipalities. “We had a pandemic, with a probable decrease in live births. The adjustment in the denominator [que virá com o Censo] will have an impact on vaccine coverage data.”