Following years of decline, Brazil’s childhood vaccination rates are on the rise again. The country—once a global leader in immunization—saw a steady drop in vaccination coverage starting in 2016, putting it at risk for the resurgence of diseases, such as measles, which had been previously controlled or eradicated.
After reaching record lows in 2021, coverage for 9 of the 13 vaccines included in the national schedule for children under 2—offered free through the public healthcare system—has improved by at least 10 percentage points (see chart below).
While the rebound is encouraging, vaccination rates still fall short of their 2015 levels, when most vaccines met international coverage standards. The term “vaccination coverage” refers to the percentage of children who receive vaccines at the recommended age. The World Health Organization (WHO) recommends a minimum of 90% coverage for the BCG vaccine (against severe tuberculosis), the vaccine against rotavirus (which causes severe diarrhea), and the COVID-19 vaccine. The target coverage for other vaccines is 95%.
Although Brazil has yet to fully meet these targets, the recent improvements have been enough to remove the country from the list of 20 countries with the highest percentage of unvaccinated children, according to a joint statement by the WHO and the United Nations Children’s Fund (UNICEF) on July 15. In 2021, Brazil ranked seventh on the list.
Researchers from Pesquisa FAPESP, in collaboration with former coordinators of Brazil’s National Immunization Program (PNI), assessed the coverage recovery by analyzing data from both the DATASUS database, which includes records up to 2022, and the Ministry of Health’s Vaccination Coverage website, which provides information starting from 2023. In December last year, the Ministry of Health announced a modest recovery in coverage for eight vaccines. This, however, was based on partial data from 2023, compared to full-year data from 2022. A more comprehensive analysis showed that the recovery trend had already started the previous year.
The researchers analyzed data for 11 of the 13 vaccines recommended for children under 2. All showed some level of recovery compared to 2021—including booster doses listed in the basic vaccination schedule—with 7 vaccines seeing an increase of over 13 percentage points. Among the vaccines with the largest gains were those protecting against hepatitis A and polio, each showing an increase of 14.9 percentage points. In 2021, these vaccines were administered to 67.5% and 71% of the target population, respectively. By 2023, coverage had increased to 82.5% and 86%.
Vaccines with more modest improvements included the varicella (chickenpox) and BCG vaccines. The chickenpox vaccine saw an increase of 3.7 percentage points. It was administered to 67% of the eligible population in 2021, rising to 70.8% in 2023. Coverage of the BCG vaccine, typically given at birth in maternity wards, improved by 5.8 percentage points: 75% of newborns received it in 2021, then 80.8% in 2023.
Experts interviewed by Pesquisa FAPESP attribute the recovery in vaccination coverage primarily to the resumption of regular healthcare services after the disruptions of the pandemic, alongside coordinated government efforts at all levels to reverse the decline in childhood immunization.
“Post-pandemic, many municipalities started actively seeking out children for vaccination,” explains social scientist and epidemiologist Carla Domingues. Domingues, who headed the PNI from 2011 to 2019, is cautiously optimistic about the progress. “It’s encouraging to see coverage improve from 70% to 85%, but for most vaccines, the target is really 95%,” she notes. “When vaccination rates remain below target for years, pockets of unprotected children can form, which raises the risk of outbreaks.”
This concern is especially acute for polio. In 2022, Brazil was classified by the Ministry of Health as being at very high risk for reintroduction of wild poliovirus, which attacks the nervous system and can lead to irreversible paralysis or death. The last case of polio in Brazil was reported in 1989, and since 1994, the country has been certified as free of wild poliovirus transmission by the Pan American Health Organization (PAHO). However, declining vaccination rates since 2016 have put Brazil at risk of new cases and potential loss of PAHO certification. Following a 14.9 percentage-point increase since 2021, polio vaccine coverage reached 86% of the target population last year. As of August this year, coverage was at 82.5%.
Another major concern is the resurgence of measles, a highly contagious viral disease. Brazil lost its measles-free status after a case of domestic transmission occurred in Amapá in 2022. Vaccination coverage for the MMR vaccine—which protects against measles, mumps, and rubella—had plummeted since 2016, hitting a low of 74% in 2021 (see Pesquisa FAPESP issues 270, 313, and 331). This year, first-dose coverage has rebounded to nearly 90%, but second-dose coverage remains just over 70%.
According to experts interviewed by Pesquisa FAPESP, part of the vaccination recovery is attributed not only to locally-led efforts but also to the Ministry of Health’s implementation of a management strategy known as microplanning in 2023. Microplanning provides a framework of guidelines that assist municipalities in developing budgets, organizing logistics, and setting strategies to meet National Immunization Program (PNI) targets.
However, as the interviewed experts point out, microplanning is effective only when applied first on the ground, where vaccinations take place, in upward coordination with state and national strategies. “The method incorporates management tools to help municipalities plan more effectively,” explains Dr. Eder Gatti, director of the Ministry of Health’s PNI Department. “We held several workshops with primary care and health surveillance teams to teach the method and improve routine vaccinations,” he adds.
Léo Ramos Chaves / Pesquisa FAPESPAn SUS healthcare professional administering a vaccine at a health clinic during a measles immunization campaignLéo Ramos Chaves / Pesquisa FAPESP
In 2023, the Ministry of Health allocated R$151 million to states and municipalities to implement microplanning for vaccination initiatives targeting children and adolescents up to 15 years old. A similar amount has been earmarked this year for school-based vaccination campaigns, polio immunization, and tracking strategy implementation in 2023. Maria de Lourdes Maia, who heads the Department of Medical Affairs at Bio-Manguinhos (FIOCRUZ) and formerly served as coordinator at PNI from 1995 to 2005, highlights that microplanning has improved coordination and communication between the Ministry of Health and municipal governments—an aspect that had weakened in recent years. “In the past, the PNI engaged more regularly and actively with healthcare professionals,” she recalls.
Alongside efforts to strengthen the relationship between PNI staff and healthcare workers on the ground, policymakers are also seeking to understand the factors behind the decline in vaccination rates. A wide range of reasons have been identified, from the mistaken perception that certain diseases no longer pose a threat to the limited operating hours of vaccination centers (see Pesquisa FAPESP issue n° 270).
A growing global concern is vaccine hesitancy, which the World Health Organization (WHO) identified as one of the top 10 global health threats in 2019. Vaccine hesitancy—defined as delaying or refusing vaccines despite their availability—is a complex issue influenced by various factors, including public confidence in vaccine safety, accessibility, and concerns over potential side effects.
“Brazil’s immunization schedule is one of the most comprehensive in the world, and as it has grown more complex, it’s only natural that people start to ask questions,” explains pediatrician Juarez Cunha, director of the Brazilian Society of Immunizations (SBIm). For example, parents must bring their children to health clinics a total of nine times between one month and two years of age to complete the full vaccination schedule. “To fight vaccine hesitancy, communication needs to be ongoing. There’s a lot of misinformation making rounds on social media. Healthcare professionals also require regular training,” explains Cunha.
To understand the extent and underlying factors of vaccine hesitancy in Brazil, physicians José Cassio de Moraes and Rita Barradas Barata from the Santa Casa de São Paulo School of Medical Sciences (FCM-SCSP) conducted a nation-wide survey in 2020 and 2021, in collaboration with Carla Domingues and other researchers. The study assessed coverage for key childhood vaccines given up to the age of 2 and investigated the reasons behind non-vaccination. Funded by the Ministry of Health and the National Council for Scientific and Technological Development (CNPq), the study collected immunization data and interviewed parents of 37,800 children from all Brazilian state capitals, the Federal District, and 12 municipalities with over 100,000 residents.
The results were published in 2023 in a comprehensive report, with key findings featured in the Brazilian Journal of Epidemiology. The data showed that coverage for the 13 vaccines ranged from 76.4% (for yellow fever) to 93.6% (for the first dose of the pneumococcal vaccine) in state capitals, and from 83% (for the second dose of the rotavirus vaccine) to 93.6% (for the first doses of the pentavalent and polio vaccines) in other cities.
Despite high coverage for some vaccines, only 60% of children in state capitals and 61% in other areas completed the full vaccination schedule of 23 doses. Curitiba, Teresina, and Brasília had the highest completion rates, with over 70% of children fully vaccinated, while Florianópolis, João Pessoa, Natal, and Macapá had the lowest, at less than 50%.
Vaccine hesitancy rates were relatively low: 2.6% in state capitals and 1.2% in non-capital cities—far below the 20% projected by an international study. The researchers also investigated the reasons behind these decisions in state capitals: 24.5% of parents cited the pandemic as a factor; 24% expressed concerns over side effects; 9% were advised by a healthcare provider not to vaccinate; 8.9% feared the act of vaccination itself; and 8.4% did not believe in vaccines.
“Vaccine hesitancy is certainly a concern, but the logistical hurdles parents face in the vaccination process pose an even bigger challenge,” Moraes explains.
A large number of parents, representing 22,000 children, reported attempting to complete their children’s vaccination schedules but facing barriers: 44% reported that the vaccine was unavailable at the clinic at least once; 10.8% found the vaccination room closed; and 8% were advised by a healthcare professional not to vaccinate. Another group of parents, representing 4,900 children, reported being unable to bring their children to the clinic due to distance (21%); lack of time (16.6%); the child being sick (14.8%); inconvenient clinic hours (14.1%); or lack of transportation (12%).
According to Barata, reversing the decline in vaccination rates requires improving access to healthcare services, enhancing technical training for healthcare professionals, and restructuring the health system.
The survey revealed significant regional disparities in vaccination coverage. “The North has the lowest vaccination coverage, making microplanning even more critical there,” says Dr. Consuelo de Oliveira, from the Evandro Chagas Institute and the State University of Pará (UEPA), one of the survey’s coordinators for the North.
“Another key takeaway from the survey was the need for consistent, ongoing communication with the public to stress the importance of maintaining high coverage for all vaccines,” Domingues emphasizes.
Pediatrician Melissa Palmieri, from the Brazilian Society of Pediatrics’ (SBP) Immunizations Department, views microplanning as a positive development because it provides municipalities with a more accurate, real-time assessment of their vaccination status. “It gives a current and localized snapshot of conditions,” she notes. She also stresses that government strategies must accommodate families’ day-to-day routines. “Parents who are unable to bring their children for vaccinations need access to extended clinic hours and school-based vaccination programs.”
The story above was published with the title “Catching up on childhood vaccination” in issue 343 of September/2024.
Scientific article
BARATA, R. B. et al. Inquérito nacional de cobertura vacinal 2020: Métodos e aspectos operacionais. Revista Brasileira de Epidemiologia. 2023.
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