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. 2020 Nov 5;54:115. doi: 10.11606/s1518-8787.2020054003142
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Pandemic and vaccine coverage: challenges of returning to schools

Ana Paula Sayuri Sato 1,✉
PMCID: PMC7647469  PMID: 33175029

ABSTRACT

Since March 2020, Brazil has faced the pandemic of the coronavirus disease 2019 (Covid-19), which has severely modified the way in which the population lives and uses health services. As such, face-to-face attendance has dropped dramatically, even for child vaccination, due to measures of social distancing to mitigate the transmission of the virus. Several countries have recorded a substantial drop in vaccination coverage in children, especially of those under two years of age. In Brazil, administrative data indicate the impact of the covid-19 pandemic on this downward trend, which was already an important challenge of the National Immunization Program in recent years. Many children will be susceptible to immunopreventable diseases, which reinforces the need to assess the vaccine status of schoolchildren before returning to face-to-face classes.

DESCRIPTORS: Coronavirus Infections, prevention & control, Vaccine-Preventable Diseases, Immunization Coverage, Immunization Programs

INTRODUCTION

Vaccination (along with other public policies, especially those aimed at expanding sanitation) has made possible to substantially decrease the number of deaths of children under five years of age worldwide1. Widespread vaccination allowed the eradication or control of immunopreventable diseases in several regions of the world, including Brazil, due to successful immunization programs1–3.

In Brazil, since the 1990s, vaccine coverage in children under one year of age had rates above 95%, which indicated the high participation of the population in vaccination and the good performance of the National Immunization Program (NIP)4. The gradual implementation of the Brazilian Unified Health System (SUS) in the late 1980s allowed for a high rate of vaccine coverage through the expansion and decentralization of health services, mainly due to its principle of universal and free access to vaccination5–6.

Throughout its history, the NIP faced several challenges. In the 1980s, the first national surveys of vaccination coverage showed worse coverage in poorer segments of the population; this difference disappeared in the late 1990s, indicating that equity of access to vaccination had been reached in different socioeconomic strata of Brazil2,7,8. However, according to the 2007 national survey, the country now has a lower coverage on both the richer and the extremely poor demographics9. Moreover, from 2016 onwards vaccine coverage rates have declined about 10% to 20%10,11, due to factors not yet understood. The measles epidemic that hit several states in 2018 and 2019 is an immediate consequence of the decrease in vaccine coverage12.

Among the possible explanations for this, we have the decrease in the perception of risk of these diseases and the increased perception of risk of adverse events following immunization (AEFI). This phenomenon was also recorded in other countries, due to the success of immunization programs when disease control or elimination is reached, a result of the prolonged maintenance of high vaccination coverage. Thus, success itself has become a great challenge13.

However, it is accepted that this is not the sole reason: among other factors that influenced the drop in vaccination coverage since 2016, the emergence of vaccine hesitancy is highlighted. This a phenomenon that has gained importance in various parts of the world and is characterized by the delay in accepting or refusal of the vaccine, regardless of its availability and access to health services10,14–16.

The political and economic crisis, the decrease in government support for the SUS17 and the dissemination by social networks of distorted information about vaccines are also worthy of mention, all of which possibly contributed to the sharp drop in vaccine coverage in recent years18–20.

THE GLOBAL IMPACT OF PANDEMIC ON CHILD VACCINATION

In 2020, due to the pandemic of coronavirus disease 2019 (covid-19), face-to-face attendance in health services dropped dramatically in many countries; this included child vaccination, given the measures of social distancing to mitigate viral transmission21–27.

Efforts to contain the pandemic, which involve distant medicine practices and the use of other technologies in order to continue health care at home, have affected vaccination actions, which require travels to the healthcare unit22. Parental concern in exposing children to Sars-CoV-2 when taking them to health services for vaccination also contributed to the decline in vaccination coverage22,24–26,28. A risk-benefit study in African countries showed that avoidable deaths from routine vaccination outweigh the excess risk of death from covid-19 associated with attendance at the healthcare unit, evidencing the need for increasing vaccination coverage at this time21.

Child vaccination coverage has declined sharply during the pandemic in several regions of the world26,28. In the USA, a considerable decline in the vaccine coverage of children was found, starting in the week after the national emergency scenario was declared (March 13, 2020). Higher rates were found among children under two years of age25. In England, three weeks after the introduction of social distancing (March 20, 2020), there was a 19.8% drop in doses of the measles-mumps-rubella vaccine, compared to the same period in 201924. In Michigan (USA), completeness of the vaccination schedule for five-year olds dropped from 67.0% to 49.7% in May 2020. At 16 months, it was found that measles vaccine coverage decreased from 76.1% to 70.9%22. In Indonesia, where immunization occurs in schools, a significant drop in coverage of the basic vaccination schedule was predicted after the closure of schools in March 202027. Moreover, it is known that this impact will be even more important in families with unfavorable socioeconomic conditions26.

The World Health Organization (WHO) estimates that at least 80 million children will be susceptible to immunopreventable diseases such as measles, diphtheria and polio because of the decrease in vaccination coverage during the covid-19 pandemic29. It is worth remembering that outbreaks of measles were attributed to the interruption of vaccination services during the 2013–2016 Ebola epidemic in West Africa, causing a second public health crisis30–31.

The pandemic of the new coronavirus has challenged health systems around the world in providing essential services, including immunization programs, as routine vaccination and mass vaccination campaigns could contribute to the spread of covid-1932.

On March 26, 2020, WHO and the Pan American Health Organization published recommendations on vaccination during the covid-19 pandemic. The measures considered three scenarios of availability of health services and included the temporary suspension of mass vaccination campaigns during this period. It was recommended that routine vaccination be maintained in places where essential health services had operational capacity of human resources and supply of preserved vaccines, respecting social distancing and other measures to control transmission of Sars-CoV-233,34.

In Brazil there was the recommendation of suspending routine immunization during the first 15 days of the influenza vaccination campaign, as this was a period in which older adults and health professionals were supposed to be vaccinated; although this was valid as a safety measure for the older population, it has generated concern among Brazilian medical societies35.

The WHO recognizes this fragility and recommends efforts to ensure high vaccination coverage, seeking herd immunization for preventable diseases, in such way that vaccination programs should adopt innovative measures36,37. Vaccination strategies in vehicles, at home or in specific rooms and well-separated from the locations of other clinical visits could be used, as well as the identification of absentees and recruitment for vaccination with the aid of electronic immunization registries (EIR)22,24–26,28.

EIR allow greater efficiency of health services, because, in addition to providing the evaluation of vaccination coverage, they also help in routine practice and enable the convocation of absentees, thus increasing the scope of immunization38,39. In addition, they are important sources of information, which can be applied in the evaluation of performance indicators and in the development of epidemiological research38,40. In 2020, researchers from countries such as the USA and the United Kingdom evaluated in real time the decline in vaccination coverage and the number of doses applied during the covid-19 pandemic through EIR. With this quick identification, it is possible to quickly adopt strategies in the face of this challenge22,24,25.

With the emergence of many radical groups worldwide that deny the importance of the pandemic and its associated mitigation measures, vaccine hesitancy might acquire more strength, especially considering the availability of vaccines for covid-19 in the near future that will have an important role in dealing with this disease41.

CHALLENGES OF RETURNING TO SCHOOLS

The safe resumption of day care centers and schools should be a national priority. Children have lost fundamental benefits of social, educational and developmental nature. For many parents, it will not be possible to return to work if these institutions remain closed, thus exacerbating social inequities. Several individual practices (use of masks, hygiene, social distancing, temperature measurement etc) as well as environmental ones (maximum capacity and layout of classrooms, cleaning etc) will be necessary to prevent the transmission of Sars-CoV-2 between schoolchildren and staff, including in transportation to schools42,43.

However, in addition to care for covid-1944, the American Academy of Pediatrics recommended that schools, health services, and local health authorities promote child vaccination well before the beginning of the school year. It is important that children receive vaccines at the recommended age and be updated in case of vaccine delay due to the pandemic45. This recommendation should be considered in other countries, including Brazil.

In Brazil, the pandemic was an additional challenge for the return to schools due to the abovementioned immunopreventable diseases, as we recently faced a consistent drop in vaccination coverage and a wide epidemic of measles that reached several states and amounted for thousands of cases. This situation has worsened in 2020, which until August had registered more than 7,000 confirmed cases of measles46.

According to data from the NIP Information System (IS-NIP), when comparing the number of first doses of the pentavalent vaccine applied in March 2020 with March 2019, we found a decrease of 27% (Figure)10–11. These data indicate that the return to classes may increase the risk not only of the expansion of measles epidemics throughout the country, but also of the reemergence of other already controlled diseases, such as diphtheria and the whooping cough. Studies show that outbreaks of diphtheria occur when vaccination coverage drops due to migration and/or political instability, emphasizing that it is a disease of relevant lethality47–49.

Figure. Number of doses applied of the pentavalent vaccine* (first dose) in Brazil, month and year (2015–2020).

Figure

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Source: SI-PNI (http://sipni.datasus.gov.br).

Thus, it is evident that, before the progressive return of face-to-face school activities, intensive actions to assess the vaccine situation of this population will be necessary in order to recover sufficient vaccination coverage to prevent or reduce the spread of immunopreventable diseases45. Innovative instruments, such as EIR, can be useful for real-time assessment of vaccination coverage, as well as to warn about immunization and rescue individuals with vaccine delay22,24,25,38–40.

FINAL REMARKS

To date, there are no studies on the impact of covid-19 on the decline in vaccine coverage. Delays in child vaccination (a demographic that should have been immunized in the most intense moment of social distancing) are also yet to be studied, even in other countries. Moreover, despite the universal access to child vaccination achieved by the NIP in the last decade, this impact will probably be greater in children from families with unfavorable socioeconomic conditions, due to less access to health services and information.

When social distancing measures are loosened, many children will be susceptible to preventable diseases, and there will be a need to assess the vaccine situation of schoolchildren before returning to school22,24–26,28,45.

The covid-19 pandemic recalled the importance of vaccination by showing how fast a disease can spread and cause irreparable harm in societies without this defense. When a safe and effective vaccine for Sars-CoV-2 is available, immunization programs will have an even greater challenge of strengthening and reaching those most vulnerable28.

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Rev Saude Publica. 2020 Nov 5;54:115. [Article in Portuguese]

Pandemia e coberturas vacinais: desafios para o retorno às escolas

Ana Paula Sayuri Sato 1,✉

RESUMO

Desde março de 2020, o Brasil enfrenta a pandemia da doença do coronavírus 2019 (covid-19), que modificou intensamente o modo de viver da população e o uso dos serviços de saúde, nos quais o comparecimento presencial caiu drasticamente, inclusive para a vacinação infantil, devido às medidas de distanciamento social para mitigar a transmissão do vírus. Diversos países registraram queda substancial das coberturas vacinais em crianças, especialmente nas menores de dois anos de idade. No Brasil, dados administrativos apontam o impacto da pandemia de covid-19 no agravamento dessa queda, que já constituía um desafio importante do Programa Nacional de Imunizações nos últimos anos. Muitas crianças estarão suscetíveis a doenças imunopreveníveis, o que reforça a necessidade de avaliar a situação vacinal dos escolares antes do retorno às aulas presenciais.

DESCRITORES: Infecções por Coronavirus, prevenção & controle, Doenças Preveníveis por Vacina, Cobertura Vacinal, Programas de Imunização

INTRODUÇÃO

A vacinação, junto com outras políticas públicas, especialmente as voltadas à ampliação do saneamento, tornou possível o declínio substancial das mortes de crianças menores de cinco anos de idade em todo o globo1. O amplo uso da vacinação possibilitou erradicar, eliminar ou controlar doenças imunopreveníveis em diversas regiões do mundo, inclusive no Brasil, refletindo programas de imunização bem-sucedidos1–3.

No Brasil, desde a década de 1990, as coberturas vacinais em menores de um ano estiveram acima de 95%, o que indicava a elevada adesão da população brasileira à vacinação e o bom desempenho do Programa Nacional de Imunização (PNI)4. Vale destacar o papel da progressiva implantação do Sistema Único de Saúde (SUS), a partir do final da década de 1980, para o alcance das altas coberturas vacinais, por meio da expansão e descentralização dos serviços de saúde, mas principalmente pelo princípio do acesso universal e gratuito à vacinação5–6.

Em sua trajetória, o PNI enfrentou vários desafios. Nos anos 1980, os primeiros inquéritos nacionais de cobertura vacinal apontavam piores coberturas em segmentos mais pobres da população, diferença que desapareceu no final dos anos 1990, indicando que se havia atingido a equidade de acesso à vacinação em diferentes estratos socioeconômicos do Brasil2,7,8. No entanto, conforme o inquérito nacional de 2007, passamos a ter menores coberturas nos segmentos mais ricos e nos extremamente pobres da população9 e, a partir de 2016, por fatores ainda não perfeitamente compreendidos, as coberturas vacinais declinaram cerca de 10 a 20 pontos percentuais10,11. As epidemias de sarampo que atingiram vários estados em 2018 e 2019 são consequência imediata da diminuição das coberturas vacinais12.

Entre as possíveis explicações para isso, temos a diminuição da percepção de risco dessas doenças e o aumento da percepção de risco de eventos adversos pós-vacina (EAPV). Esse fenômeno também foi registrado em outros países, em decorrência do sucesso dos programas de imunização ao atingirem o controle ou a eliminação de doenças, como resultado da manutenção por tempo prolongado de elevadas coberturas vacinais. Ou seja, o sucesso passou a ser o seu grande desafio13.

No entanto, aceita-se que essa não seja a única razão: entre outros fatores que influenciaram a queda das coberturas vacinais a partir de 2016, é apontado o surgimento da hesitação vacinal, fenômeno que tem ganhado importância em várias partes do globo e se caracteriza pelo atraso em aceitar ou pela recusa da vacina, independentemente de sua disponibilidade e do acesso aos serviços de saúde10,14–16.

São citadas também a crise político-econômica, a diminuição do apoio governamental ao SUS17 e a difusão por redes sociais de informações distorcidas sobre vacinas, que possivelmente contribuíram para a acentuada queda das coberturas nos últimos anos18–20.

O IMPACTO GLOBAL DA PANDEMIA NA VACINAÇÃO INFANTIL

Em 2020, com a pandemia da doença do coronavírus 2019 (covid-19), o comparecimento presencial nos serviços de saúde caiu drasticamente em muitos países, inclusive para a vacinação infantil, devido às medidas de distanciamento social para mitigar a transmissão do vírus21–27.

Os esforços para conter a pandemia, que envolvem práticas de telemedicina e o uso de outras tecnologias a fim de dar continuidade aos cuidados de saúde em domicílio, afetaram as ações de vacinação, que necessitam o deslocamento ao serviço de saúde22. A preocupação dos pais de expor as crianças ao Sars-CoV-2 ao levá-las aos serviços de saúde para a vacinação também contribuiu para o declínio das coberturas vacinais22,24–26,28. Estudo de risco-benefício em países africanos mostrou que as mortes evitáveis pela vacinação de rotina superam o excesso de risco de morte por covid-19 associado ao comparecimento no serviço de saúde para a vacinação, evidenciando a necessidade de esforços voltados a aumentar as coberturas vacinais neste momento21.

As coberturas vacinais infantis caíram acentuadamente durante a pandemia em diversas regiões do mundo26,28. Nos EUA foi encontrado um declínio considerável das coberturas vacinais de crianças, com início na semana após a declaração de emergência nacional (13 de março de 2020), sendo maior entre os menores de dois anos de idade25. Na Inglaterra, três semanas após a introdução do distanciamento social (20 de março de 2020), houve queda de 19,8% das doses aplicadas da vacina de sarampo-caxumba-rubéola, comparando-se com o mesmo período em 201924. Em Michigan (EUA), a completude do esquema vacinal de crianças aos cinco meses de idade caiu de 67,0% para 49,7% em maio de 2020. Aos 16 meses, verificou-se que a cobertura da vacina de sarampo caiu de 76,1% para 70,9%22. Na Indonésia, onde a imunização ocorre nas escolas, estimou-se uma queda importante da cobertura do esquema básico vacinal após o fechamento das escolas, em março de 202027. Ademais, sabe-se que esse impacto será ainda mais importante em famílias de condições socioeconômicas desfavoráveis26.

A Organização Mundial da Saúde (OMS) estima que pelo menos 80 milhões de crianças estarão suscetíveis a doenças imunopreveníveis como sarampo, difteria e poliomielite por conta da queda das coberturas vacinais durante a pandemia de covid-1929. Vale lembrar que surtos de sarampo foram atribuídos à interrupção de serviços de vacinação durante a epidemia de ebola de 2013–2016 na África Ocidental, ocasionando uma segunda crise de saúde pública30–31.

A pandemia no novo coronavírus desafiou os sistemas de saúde do mundo todo na prestação de serviços essenciais, incluindo os programas de imunização, pois a vacinação de rotina e as campanhas de vacinação em massa poderiam contribuir para a disseminação da covid-1932.

Em 26 de março de 2020, a OMS e a Organização Pan-Americana da Saúde publicaram recomendações sobre a vacinação durante a pandemia de covid-19. As medidas consideravam três cenários de disponibilidade dos serviços de saúde e incluíam a suspensão temporária das campanhas de vacinação em massa durante esse período. Recomendou-se que a vacinação de rotina fosse mantida em locais onde os serviços essenciais de saúde tivessem capacidade operacional de recursos humanos e fornecimento de vacinas preservados, respeitando-se o distanciamento físico e outras medidas de controle da transmissão do Sars-CoV-233,34.

No Brasil, houve a recomendação de suspender a imunização de rotina nos primeiros 15 dias após o início da campanha de vacinação de influenza, período destinado aos grupos de idosos e profissionais da saúde, o que, apesar de válido para a proteção de idosos, gerou preocupação por parte de sociedades médicas brasileiras35.

A OMS reconhece essa fragilidade e recomenda esforços para garantir altas coberturas vacinais, buscando-se a proteção de rebanho para doenças imunopreveníveis, de forma que os programas de imunização devem adotar medidas inovadoras36,37. Estratégias de vacinação em veículos, em casa ou em salas específicas e bem separadas dos locais dos demais atendimentos clínicos poderiam ser utilizadas, bem como a identificação de faltosos e o recrutamento para a vacinação com o auxílio de registros informatizados de imunização (RII)22,24–26,28.

Os RII permitem maior eficiência dos serviços de saúde, pois, além de proporcionarem a avaliação de coberturas vacinais, também auxiliam na prática rotineira e viabilizam a convocação de faltosos, aumentando assim a abrangência da imunização38,39. Além disso, constituem importantes fontes de informação, que podem ser aplicadas na avaliação de indicadores de desempenho e no desenvolvimento de pesquisas epidemiológicas38,40. Em 2020, pesquisadores de países como EUA e Reino Unido avaliaram em tempo real a queda das coberturas vacinais e do número de doses aplicadas durante a pandemia da covid-19 por meio de RII. Com essa ágil identificação é possível adotar rapidamente estratégias ante esse desafio22,24,25.

Com o surgimento, em muitos países, de movimentos radicais negando a importância conferida à pandemia e contrários às medidas de mitigação do evento, a importância da hesitação vacinal pode ser ampliada, tendo em vista a possível disponibilidade, num futuro próximo, de novas vacinas para a prevenção da covid-19, que terão papel importante no enfrentamento dessa doença41.

DESAFIOS DO RETORNO ÀS ESCOLAS

A retomada segura das creches e escolas deve ser uma prioridade nacional. As crianças perderam benefícios sociais, educacionais e de desenvolvimento elementares, e para muitos pais não será possível o retorno ao trabalho caso essas instituições permaneçam fechadas, exacerbando as iniquidades sociais. Diversas medidas individuais (uso de máscara, higiene, distanciamento social, medição de temperatura, entre outras) e ambientais (capacidade e disposição das salas de aula, limpeza, entre outras) serão necessárias para prevenir a transmissão do Sars-CoV-2 entre escolares e funcionários, inclusive no transporte até as escolas42,43.

Entretanto, além dos cuidados em relação a própria covid-1944, a American Academy of Pediatrics recomendou que escolas, serviços de saúde e autoridades sanitárias locais promovam a vacinação infantil bem antes do início do ano letivo. Ressalta-se a importância de que as crianças recebam as vacinas na idade preconizada e sejam atualizadas em caso de atraso vacinal devido à pandemia45. Tal recomendação deveria ser considerada em outros países, inclusive no Brasil.

No país, a pandemia constituiu um desafio adicional para o retorno às escolas devido às doenças imunopreveníveis, pois, conforme já exposto, há alguns anos enfrentávamos uma queda consistente das coberturas vacinais e uma ampla epidemia de sarampo, atingindo vários estados e totalizando milhares de casos. Esta situação piora em 2020, que até agosto havia registrado mais de 7 mil casos confirmados de sarampo46.

Segundo dados do Sistema de Informação do PNI (SI-PNI), ao compararmos o número de primeiras doses aplicadas da vacina pentavalente em março de 2020 com o mesmo mês do ano anterior, verificamos uma queda de 27% (Figura)10–11. Tais dados apontam que o retorno às aulas poderá ampliar o risco não só de expansão das epidemias de sarampo em todo o país, mas também de reemergência de outras já controladas, das quais vale salientar a difteria e a coqueluche. Estudos mostram que surtos de difteria ocorrem quando há queda das coberturas vacinais devido a migrações e/ou instabilidade política, ressaltando ser uma doença de letalidade importante47–49.

Figura. Número de doses aplicadas da vacina pentavalente* (primeira dose) no Brasil, segundo mês e ano (2015–2020).

Figura

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Fonte: SI-PNI (http://sipni.datasus.gov.br).

Assim, fica evidente que, antes do retorno progressivo das atividades escolares presenciais, serão necessárias ações intensivas de avaliação da situação vacinal dessa população com o intuito de recuperar coberturas vacinais suficientes para impedir ou reduzir a disseminação de doenças imunopreveníveis45. Instrumentos inovadores, como os RII, podem ser úteis para a avaliação em tempo real das coberturas vacinais, bem como para alertar sobre a imunização e resgatar indivíduos com atraso vacinal22,24,25,38–40.

CONSIDERAÇÕES FINAIS

No Brasil, até o momento não há estudos sobre o impacto da covid-19 na queda das coberturas vacinais. Também não foi investigado, mesmo em outros países, o atraso vacinal de crianças que deveriam ter sido imunizadas no momento mais intenso do distanciamento social. Além disso, apesar da universalidade do acesso à vacinação infantil alcançada pelo PNI na última década, provavelmente esse impacto será maior em crianças de famílias com condições socioeconômicas desfavoráveis, devido ao menor acesso aos serviços e às informações de saúde.

Quando as medidas de distanciamento social forem afrouxadas, muitas crianças estarão suscetíveis a doenças imunopreveníveis, e haverá a necessidade de avaliar a situação vacinal dos escolares antes da volta às aulas22,24–26,28,45.

A pandemia de covid-19 relembrou a importância da vacinação ao mostrar o quão rápido uma doença pode se espalhar e causar danos irreparáveis na sociedade sem essa defesa. No momento em que uma vacina segura e eficaz para o Sars-CoV-2 estiver disponível, os programas de imunização terão um desafio ainda maior de se fortalecer e alcançar os mais vulneráveis28.

Articles from Revista de Saúde Pública are provided here courtesy of Universidade de São Paulo. Faculdade de Saúde Pública.

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