“None of us are immune to the health effects of climate change. That’s why we are working so hard to combine weather and health data,” Harnisch explained at Climate and Health: challenges and possibilities of scientific diplomacy, an event hosted by Science Arena in August.

In his presentation (see the video below), Harnisch spoke about how Mayo Clinic Platform, an initiative led by the US-based Mayo Clinic, is tackling this challenge by establishing an extensive global data network.

Through Mayo Clinic Platform_Connect, the project connects healthcare institutions from all over the world to accelerate innovation by analyzing qualified, secure, and anonymized clinical data.

According to Harnisch, sharing data from geographically and ethnically diverse patient populations is fundamental to developing more personalized medicines, products, services, and healthcare solutions.

Large-scale datasets can also provide scientists with a wealth of information for research, including studies on rare infectious diseases or health risks related to extreme weather events, such as heatwaves.

Read some of the key takeaways from Eric Harnisch’s presentation below.

The urgency of the climate crisis

Harnisch illustrated the severity of the problem by pointing out that Minneapolis, Minnesota—his hometown, known for its lakes and natural beauty—was recently ranked fifth worst city in the world for air quality.

Its level of pollution was comparable to places such as the Democratic Republic of the Congo, parts of India, Baghdad (Iraq), and Dubai. The cause, Harnisch explained, was Canadian wildfires, which have grown longer and more intense due to changes in temperature and precipitation. The phenomenon, he noted, significantly raises the risk of cardiovascular and chronic disease.

He also emphasized that rising temperatures and changing precipitation patterns have dramatically impacted vulnerable populations, especially in emerging markets and the Global South.

Mayo Clinic Platform’s Strategy

The Mayo Clinic, a nonprofit organization renowned for its integrated approach to health research, practice, and education, launched Mayo Clinic Platform six years ago.

The objective, explained Harnisch, was to use data as a way of generating a greater global health impact.

The first step was to analyze its 10 million unique patient records, including social determinants of health. But the organization soon realized the value of joining forces with other global leaders with similar research interests to visualize data from across the world.

The vital connection between health and climate

One of the central focuses of this collaborative effort is the need to combine health data and meteorological data. Examples of these collaborations include helping farmers adapt to changing conditions or adopt new farming techniques, demonstrating the tangible effects of the climate crisis.

Security and global regulations

A crucial issue when working with clinical data is ensuring patient privacy and security. Sensitive data must be anonymized to minimize the risk of patients being re-identified.

He explained that the Mayo Clinic’s role will be to facilitate these connections and advance industry standards that allow people to more easily collaborate and share knowledge.

The goal is to ensure continuous, effective cooperation through a standardized data framework and tools capable of generating important insights.

Call to coordinated action

Harnisch later reiterated the clear need for unified action, requiring a coordinated global research effort. The Mayo Clinic holds a strong interest in partnering with anyone who shares this goal.

International research networks must be organized to focus on key challenges, such as monitoring infectious diseases driven by climate change, assessing the health impacts of heat, and exploring ways to make healthcare systems more sustainable.

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It is, however, a hopeful appeal for vaccination programs and studies into new vaccines to be protected against pressure from denial movements and geopolitical clashes that pervade scientific research.

“As scientists we need to be able to consider how we talk about science to the public, and how we convince populations that vaccination is something beneficial, even in the setting of climate change,” said Kim at the event Climate and Health: challenges and possibilities of scientific diplomacy, held by Science Arena in August in partnership with the São Paulo Innovation and Science Diplomacy School (InnSciD SP) of the University of São Paulo (USP).

The South Korean warned that there is no unique, universal vaccine capable of containing the effects of the climate crisis on global health. The “harsh reality” is that humanity depends on multiple vaccines to tackle a number of illnesses worsened by extreme climate events that favor the migration of pathogen vectors and the advent of new viruses and bacteria.

Climate change, says Kim, is one of society’s biggest challenges alongside population growth, the scarcity of natural resources (water and clean air), and social conflicts. “In this sense, global health interacts with all these challenges, and a partial solution that does not take this interconnectivity into account will be ineffective.”

Read on for key excerpts from Jerome Kim’s presentation.

1. The relationship between climate change and health

Phenomena such as deforestation, interaction between human and wild populations (zoonoses), scarcity of water, droughts, and floods can cause outbreaks of diseases such as cholera and measles, leading to mass migration.

Warming, precipitation, and storms influence the spread of waterborne, airborne, and foodborne vector-transmitted diseases.

2. The reality of current vaccines

Approved vaccines for cholera, typhoid fever, dengue, chikungunya, and malaria exist, but the use of these vaccines has not been optimized for climate change or for the population generally. Currently we tend to respond to outbreaks, but they are just the “tip of the iceberg” of endemic diseases that could be controlled proactively.

3. Demand for new vaccines

There is an urgent need for new vaccines against bacteria such as Shigella—strains of E. Coli that cause diarrhea—invasive non-typhoid salmonella, or even viruses, such as that which causes Congo-Crimea hemorrhagic fever, which is spreading.

Innovation is paramount, including the development of new platforms (e.g., vaccines in patches to reduce hesitation); new vaccine combinations (e.g., a vaccine that covers cholera, typhoid fever, and Shigella); new methods of administration (intranasal, oral), and new adjuvants to render immune responses stronger and longer-lasting, perhaps even in a single dose.

4. Financial challenges

The majority of these vaccines do not turn a profit (estimated at US$1–US$2 per dose), which discourages industry from investing billions in their development, in contrast with high-return vaccines such as mRNA for COVID-19.

5. Denial and the scientific community

Denial of the reality of climate change and the efficacy of vaccination is an underlying issue. Scientists could engage more in the task of clearly communicating information about research and innovation, helping to convince citizens and decision-makers of the benefits of vaccination in the context of climate change.

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At the same time, controversial measures adopted by the Trump administration, such as the decision to withdraw the US from the World Health Organization (WHO), have upset the diplomatic balance, directly impacting international scientific cooperation. The uncertainty sparked by such decisions is still being felt on the global stage, making it essential to strengthen ties between nations to ensure a more efficient and effective response to future health emergencies.

Thus, the second Global Pandemic Preparedness Summit (GPPS), held in Rio de Janeiro, was of great importance. In July 2024, representatives of ten organizations signed a letter calling for sovereignty in health, innovation, and the development of diagnostic methods, vaccines, and medicines to address international public health emergencies in the Global South.

The document, titled the “Rio de Janeiro Declaration,” proposes guidelines for a new relationship between rich and poor countries with the aim of creating stronger and more equitable partnerships to tackle future health crises.

The COVID-19 pandemic was marked by countries frantically racing to obtain masks, personal protective equipment, and respirators. Public agencies in developed nations even diverted supplies during transit through airports, redirecting essential products away from their intended destinations.

In early 2020, for example, the US intercepted a shipment of 200,000 artificial respirators manufactured by China and purchased by Germany, by offering to pay more for the products.

The problem continued into 2021, when many rich countries purchased vaccines that were still in production, sparking a process of unequal distribution—at the peak of the pandemic, 25% of the world’s population had purchased more than 75% of the vaccines.

Pharmaceutical monopolies were also allowed to retain intellectual property rights, leading to vaccines being sold for up to 10 times their production cost.

“A lack of solidarity left poor countries in a delicate situation, which compromised global strategies for combating the novel coronavirus,” says Mario Moreira, president of the Oswaldo Cruz Foundation (FIOCRUZ), one of the organizers of the GPPS alongside Brazil’s Ministry of Health and the Coalition for Epidemic Preparedness Innovations (CEPI).

To overcome these disparities, the Rio de Janeiro Declaration urges countries and institutions to increase international cooperation in science and technology, accelerating research, technology transfers, and innovations linked to the production of vaccines, medicines, diagnostic tools, and other health technologies that could be useful against future pandemics. 

The document also calls for academic and research institutions in developing countries to work together to increase their knowledge-production efforts, forging strategic alliances to develop policies capable of addressing current and future challenges.

The document is based on the observation that the climate crisis and environmental degradation have changed the way infectious diseases are spread, increasing the risk of humans coming into contact with pathogens that could cause new health crises, and that the world remains ill-prepared for another pandemic, with a scarcity of collaborative surveillance, diagnostic tools, and funding.

A 2023 study by researchers from the Center for Global Development, USA, estimated that there is a 19% chance of a new pandemic occurring in the next five years. In the next 10 years, the likelihood is 35%.

Strengthening global research

For some time, the World Health Organization (WHO) has been highlighting the need for scientists and governments to strengthen and accelerate global research in preparation for new pandemics, emphasizing the importance of expanding investigations to include entire families of pathogens that could infect humans.

Thousands of known viruses and bacteria can infect humans, but a relatively small number have ever caused pandemics or epidemics.

Much of the information needed to make decisions about these pathogens is unavailable, not documented in the literature, or not adequate for systematic review.

The specific number of pathogens to be considered could change over time as we improve our understanding of infectious diseases and new pathogens emerge or known ones evolve.

During the Global Pandemic Preparedness Summit, the WHO released the findings of a global pathogen prioritization process that was started in 2020 and involves more than 200 scientists from over 50 countries, who evaluated evidence related to 28 viral families and a core group of bacteria, covering 1,652 pathogens.

According to the nonprofit organization FIND, which connects countries, communities, funders, decision-makers, healthcare providers, and developers, the novel coronavirus is the only pathogen with outbreak potential for which there is adequate diagnostic readiness.

“It is important for countries to have well-established communication channels that can be quickly activated in the event of a health crisis,” stresses Amâncio Jorge Silva Nunes de Oliveira, executive coordinator of the Advanced School of Scientific Diplomacy and Innovation (InnScid) and a professor at the Center for Studies of International Negotiations at the University of São Paulo (USP).

One recent such initiative was the Global Health Security Strategy, launched by the US in April to provide public health support to more than 50 countries, aiming to help them more effectively prevent, detect, and manage outbreaks.

The program is also designed to strengthen global health security through bilateral partnerships.

“This strategy lies at the intersection of health security and scientific diplomacy, based on the US government’s conclusion that future global health crises cannot be tackled without international partnerships,” says Oliviera.

The American approach comes at a time when the WHO’s 194 member states are struggling to ratify a global agreement on how to deal with new pandemics. Although the US participates in these negotiations, the country has historically preferred bilateral agreements as a more efficient way of improving global health security.

Talks have been taking place since 2021, with Brazil representing the Americas region on the steering committee.

At the 77^th World Health Assembly, held in Geneva, Switzerland, in May, the nations met again to discuss international guidelines for preparing for, preventing, and responding to future pandemics, but disagreements between the participants prevented any progress from being made on the agreement.

The aim was for the treaty to establish legally binding policies for WHO member countries on pathogen surveillance, rapid sharing of outbreak data, and local production and supply chains for vaccines and medicines, among other commitments.

The Intergovernmental Negotiating Body (INB), responsible for coordinating the talks, plans to ask for more time to continue discussions.

Igor Barbosa, head of the global health division at Brazil’s Ministry of External Relations, says the main difficulty has been access to the drugs and medical supplies needed to deal with new pandemics, which involves transfer technology agreements for local production, price transparency, and regulatory issues.

“The central countries, especially those in the G7, are not willing to give up their prerogatives and privileges,” says Barbosa.

Another sensitive issue is funding for the creation of a multilateral system, led by the WHO, to grant access to pathogens with pandemic potential from around the world and to the inputs needed to combat them.

“Rich countries, meanwhile, claim they already offer various financial support mechanisms to the developing world in this regard.”

One is the Pandemic Fund, created in September 2022 to provide multiyear grants to help low- and middle-income countries prepare for future pandemics.

Hosted by the World Bank and led by the US, the fund received 179 applications from 133 countries after its first call for proposals and awarded US$338 million in July 2023 to help 37 countries strengthen their capacity to prevent, prepare for, and respond to pandemics.

The US pledged an additional US$667 million to the fund in July 2024, while Germany committed US$54 million.

Efforts in Brazil

Brazil has also been working with the Pan American Health Organization (PAHO), a branch of the WHO, to strengthen existing mechanisms for acquiring vaccines, medicines, and diagnostic tools.

“Our strategy has been to foster debate, explore opportunities, identify challenges and innovative solutions, and promote connections between the various stakeholders in the innovation and production ecosystem of vaccines and other health technologies, with the objective of strengthening value chains for local production of these supplies in Latin America,” explains Barbosa.

An important step was taken in this direction with the Brazilian government’s launch of a plan to support construction of a Health and Innovation Economic-Industrial Complex for the country’s public health system (SUS), with public and private investment of between R$42 billion and R$60 billion until 2026.

The aim is to stimulate the development of chemical, biotechnological, mechanical, electronic, and materials-based industries in Brazil, as well as health services. The move is expected to increase domestic production of supplies and equipment for SUS by 42% to 70% within ten years, reducing dependence on foreign countries.

Another important change occurred at FIOCRUZ’s Institute of Immunobiological Technology (Bio-Manguinhos), which in August joined the CEPI network of vaccine manufacturers in the Global South.

“The initiative will support us in studying molecules with potential for rapid development of medicines and vaccines for infectious diseases that could cause epidemics or pandemics, ensuring supply to less privileged countries, so that what happened during the COVID-19 pandemic does not happen again,” explains Maurício Zuma Medeiros, director of Bio-Manguinhos.

The partnership includes an investment of US$17.9 million by CEPI to diversify Bio-Manguinhos/FIOCRUZ’s vaccine-manufacturing capabilities, expanding new rapid response mRNA and viral vector immunization technology platforms for infectious diseases.

There is a long and far-reaching tradition of health diplomacy at FIOCRUZ, heavily focused on structural cooperation, helping countries develop their own health and health research systems.

One successful example is Mozambique, where FIOCRUZ opened its first international office in 2008.

“We helped create the Mozambican Medicine Society, a factory that today supplies the country’s health system,” says Moreira.

At the regional level, FIOCRUZ works with PAHO to reinforce multilateralism in Latin America and the Caribbean, through projects designed to help countries improve in the areas of diagnosis and medicine and vaccine development and production.

The aim, says Moreira, is to create a well-coordinated regional network capable of responding to future pandemics and ensuring continuous preparedness.

“History has shown us that it is a question of ‘when’ the next pandemic will occur, not ‘if,’” says Moreira.

“Multilateral collaborations involving scientists and institutions from various countries are needed to advance our knowledge about the pathogens around us.”

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Aimed at healthcare professionals and researchers from the fields of biotechnology, pharmaceuticals, regulation, communication, and quality control, the course builds upon the Italian university’s master’s program in vaccinology.

The classes include specialized training in biotechnological applications for vaccine development.

The course will be divided into three modules, covering the following:

• Preclinical development and laboratory analysis
• Clinical development
• Manufacturing and quality control

The modules will be led by Teresa Lambe (University of Oxford), Sue Ann Clemens (University of Siena, University of Oxford, and Science Arena columnist), and Sarah Gilbert (University of Oxford) respectively.

The course also includes a series of lectures to be held in Rio de Janeiro between March 17 and 24, details of which will be shared with candidates after enrollment.

More information about applying can be found on the Institute for Global Health website.

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One was immunologist Ricardo Gazzinelli, head of the Vaccine Technology Center (CTVacinas) at the Federal University of Minas Gerais (UFMG), which went on to develop the SpiN-Tec-MCTI-UFMG COVID-19 vaccine candidate.

The other, also an immunologist, was Jorge Kalil of the University of São Paulo (USP), who chose to create a vaccine applied in the form of a nasal spray.

In an interview with Science Arena, Kalil—who was director of the Butantan Institute between 2011 and 2017—described the development process of the nasal vaccine, explaining the reasons and highlighting the difficulties of doing science in Brazil. One of the challenges is the “brain drain” phenomena, which he classified as “a great shame.”

“We need scientists and technologists capable of working along the entire production chain, from the discovery of the molecule to the development of the product,” says Kalil, who is a professor at USP’s School of Medicine and director of the immunology lab at the university’s Heart Institute (InCor).

Science Arena – In May, you took part in the TEDxUSP event, where you highlighted the challenges of creating a nasal vaccine for COVID-19. How did the process begin?

Jorge Kalil – At the beginning of the COVID-19 pandemic, the MCTI chose me and Ricardo Gazzinelli, head of CTVacinas, to develop SARS-CoV-2 vaccines. Gazzinelli was in charge of the SpiN-TEC studies, while my group chose to try to develop a nasal vaccine. I assembled a team of people I had worked with at InCor and USP’s School of Medicine, as well as people from the Institute of Biomedical Sciences at USP and the Federal University of São Paulo [UNIFESP], who I felt could help achieve this objective.

Why did your group choose this path, to develop a nasal vaccine?

The starting point was our prior knowledge of the SARS-CoV-1 virus, which emerged in 2002 and also causes Severe Acute Respiratory Syndrome [SARS], and which despite being highly lethal, was successfully controlled in China.

There was an important immune response called neutralizing antibodies, which prevented the virus from entering the cell to multiply. We knew that these antibodies acted against the spike protein used by the virus to invade cells.

We therefore already knew that most studies would be directly focused on a vaccine that would inhibit this protein. Then the virus began to mutate and variants emerged. It is also important to note that CoronaVac [produced by the Chinese company Sinovac and bottled by the Butantan Institute], a complete vaccine that uses an inactivated form of the virus, was a poor immunizer with an efficacy of around 50% that hadn’t been tested on older individuals, who are the most susceptible to the disease.

We then moved on to the RNA vaccines, which were much better. Armed with all this knowledge, even at the beginning of the pandemic, we thought about developing an intranasal vaccine, because the virus enters through the nose.

So was the fact that the virus entered through the nose the biggest motivator?

Yes. Our vaccine induces a response in the mucosal cells, something that does not occur with intramuscular vaccines. The trick is to inactivate the virus as it enters, before it multiplies in the mucosa, which is something that facilitates transmission to other people. Intramuscular vaccines do not prevent infection and mild illness because the virus still has a chance to multiply.

How has the development process gone so far? And at what preclinical or clinical stage is the nasal vaccine now?

During the preclinical phase, we injected the virus into the nostrils of animal models and the virus quickly disappeared due to the secretory IgA immunoglobulin (a type of antibody) in the nose. Now, we are preparing the antigen.

In Brazil, there are not yet any companies with an industrial development capacity. But we invested US$4 million in a contract with a foreign company to take the antigen and place it in cells. We will be able to begin the clinical phase, with human trials, by the end of 2024.

In the preclinical phase, you observed a 100% response rate. Is there any guarantee that the result will be the same in humans?

In mice, the response rate was 100%, but even though they are genetically very similar to humans, there is still genetic, social, economic, and hygienic heterogeneity. There are many factors that can alter the response we will obtain in clinical human trials.

In addition to this heterogeneity, what other obstacles are there?

The challenges we have faced so far are often related to underfunding. The research grants on offer are very small.

Another aggravating factor was that because of the pandemic, countries did not want to export laboratory supplies. The supplies and inputs we needed are not produced in Brazil and they were taking a long time to arrive from abroad, with many suppliers facing rules that they must prioritize local laboratories in their own countries.

In total, including industrial scale production, we received R$40 million, which is around US$8 million. Meanwhile, in the USA, a call for research proposals was issued worth approximately US$500 million for each research group seeking to develop a vaccine. It’s like David versus Goliath.

If the next steps are successful and the nasal vaccine proves to be effective, what can we expect?

Our vaccine will be a game changer because it is extremely easy to administer, people are not resistant to it, and it protects against both infection and transmission. That means we will be able to control the disease. To do that, we need to convince politicians to invest in it.

In Brazil, we don’t have a culture of belief that we can solve our own problems. We always think that we need someone from the outside to do this for us.

We have a dengue vaccine, which I started working on when I was director of the Butantan Institute in São Paulo. We’ve done all the industrial development, the phase 2 clinical trials, and we started phase 3 trials in 2016.

But it wasn’t given enough impetus. This vaccine should have been ready by now. Dimas Covas, who was the director of Butantan, did not make testing this [dengue] vaccine enough of a priority.

The Butantan vaccine should already be protecting the millions of Brazilians who continue to contract dengue fever, including a significant number who die.

How is Brazil’s performance in vaccine production compared to the rest of the world? What are our strengths and weaknesses?

We still do not have the capacity to develop and produce vaccines for viruses that pose major threats. Until this happens, we remain extremely reliant on other countries. Brazil does not invest enough to be technologically independent.

We do very few phase 1 and 2 clinical trials. All developed countries have this capability. China doesn’t develop new technologies just because labor is cheap. That’s a common misconception. What China has is an efficient education and training system for technical and scientific workers. They do everything in China, and they can do it cheaply because they know how to make the best use of the materials.

Brazil needs to learn that a large country—and one that intends to be a great nation—must prioritize science and technological development.

Unfortunately, what we have seen in recent times is that the best brains in Brazil usually get tired of things here and leave. I have a huge number of former students who mostly live in three places: around New York, in the Boston region, and in the state of California, especially in San Francisco and Los Angeles. It’s a great shame that we lost these people.

Were the preliminary results of the nasal vaccine trials published in a scientific journal? If not, when will this happen?

We have not yet published the results, because we want the vaccine to remain Brazilian. If it were crucial data that would allow us to contain the disease, we would have disclosed it. But because other vaccines already existed, it was not essential for us to share our preliminary results. We are now finalizing the patent so that we can publish a scientific article, which is currently being written.

What perspective does the world need to take in order to immunize the entire population?

There is a huge global effort for places in Africa and Asia to be able to produce vaccines. What we saw during the pandemic was that after the vaccines were developed, rich countries quickly immunized 90% of their populations with two doses, while poorer nations were only able to achieve 2% coverage. And they were the richest 2% of that population.

We want equity in healthcare. It is essential to have multiple vaccine platforms that can be used against different antigens. The antigen is super important, as it is the target of the vaccine. And this can only be achieved by doing basic research with viruses and understanding the immune response. We need continued investment in science and technology, so that we do not keep falling at the same hurdle.

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The Pan American Health Organization (PAHO) Guide to aid healthcare professionals in addressing the main messages and responses regarding vaccine safety. The document references questions about vaccine development, clinical trials, and approval, as well as the importance of high vaccine coverage and adverse event monitoring.

WHY IT IS WORTH READING:

With the growing wave of misinformation about vaccines, one of the major shortcomings reported by healthcare professionals is the lack of reference materials to quickly answer questions, mainly those regarding vaccine efficacy and safety.

Since 2019, the World Health Organization (WHO) has been warning that vaccine hesitancy will be one of the decade’s ten biggest public health issues, and Brazilians, who were so certain of the effectiveness of our National Immunization Program (PNI), thought we were immune to it all.

The COVID-19 pandemic arrived and, along with it, the politicization of healthcare and vaccines. Defenders and critics, supporters and detractors, a veritable debate featuring “opinions” from all sides.

All of this has shaken one of the main pillars of a successful PNI. The distrust is not limited to the vaccine itself, but also to the public system of the state and government that runs it.

The effects were and are still being felt today, not only in relation to COVID-19, but also other vaccinations.

This PAHO guide, published in 2021, is an extremely useful tool to help all healthcare workers have a clearer and more informed discourse. It is an excellent piece of support material.

The content addresses these vaccine development questions, their clinical trials, and approval processes, as well as the importance of high vaccination coverage and adverse event monitoring.

Questions and answers, myths and truths, key messages, all communicated in a light and intuitive manner, with the main goal of dissipating doubts, changing opinions, and validating knowledge, through trustworthy and safe information, based on scientific proof, reducing vaccine reluctancy and increasing adhesion to the vaccination programs.

Several studies show that healthcare workers are the most reliable sources of information about vaccines and immunizations for the entire population and for healthcare service users.

It is essential that everyone is prepared to answer questions and clarify doubts, avoiding confrontation in an empathetic way, providing clear and accurate information.

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The situation, however, has changed greatly over recent years. Vaccination coverage in Brazil and worldwide has suffered a significant drop. A study published in the journal Ciência & Saúde Coletiva by scientists from several Brazilian universities warned about the seriousness of the decline in childhood polio vaccination, emphasizing the imminent risk of the virus being reintroduced and once again circulating in Brazil if the rise in vaccination uptake observed at the end of 2023 does not continue.

The authors analyzed official PNI data from 2011 to 2021, finding that the drop in vaccination coverage was greatest in the North and Northeast of Brazil—two of the country’s poorest and most unequal regions.

According to the study, almost half of Brazil’s states had an estimated polio vaccination rate of 100% in 2011. Ten years later, however, this feat was not achieved by a single state.

According to the Ministry of Health, 74% of Brazilians were inoculated against polio in 2023, up from 67.1% in 2022. Although there are signs that the country has begun to reverse its downward trend, the recovery is still not as pronounced as has been observed with other vaccines, such as the BCG (for tuberculosis), which is the only vaccine that has reached the target set by the government.

“The figures released by the Ministry of Health are excellent news,” said epidemiologist Maria Rita Donalisio, a professor at the School of Medical Sciences of the University of Campinas (FCM-UNICAMP) and lead author of the article published in Ciência & Saúde Coletiva.

She stresses, however, that there is still a real risk of polio reemerging in Brazil. “We have not reached the ideal polio vaccination rate of 95%. There is a lot to be done, especially because we still have to contend with people visiting from other countries where the virus is circulating, and visiting areas where the population is unprotected.”

The study led by Donalisio and her team shows that Amapá, Roraima, Acre, Rondônia, Ceará, Paraíba, and Pernambuco are the states with the biggest drops in vaccination coverage in the analyzed period of 2011 to 2021 (see graph). Of these, the biggest decline was observed in Roraima (almost 15%).

The polio vaccination decline in the North and Northeast was more pronounced from 2020 onwards due to the COVID-19 pandemic. One after another, states began falling short of the 95% vaccination rate previously achieved in much of the country. “The 95% target reached in most regions in 2011 was largely missed in 2021.”

With a slight recovery in 2022 and 2023, the Northeast recorded the largest increase in coverage for all three doses of the polio vaccine, reaching almost 68%, as reported by the Child Health Observatory.

“We can see that the Ministry of Health is currently very committed to increasing polio vaccine coverage. That does not mean, however, that epidemiological surveillance agencies or the public should let their guard down,” says Donalisio.

Health regions

The researchers used interrupted time series analysis with immunization data from the PNI Information System (SI-PNI/DataSUS) to analyze the downward trend in vaccination between 2011 and 2021. They also investigated the impact on the PNI of the restrictions implemented during the pandemic.

The group then used the Brazilian Deprivation Index (IBP)—created by the Oswaldo Cruz Foundation (FIOCRUZ) and the University of Glasgow, Scotland—to measure the socioeconomic conditions of different municipalities, establishing a relationship between economic and social vulnerability and the decline in vaccination coverage.

This comprehensive data set was used to perform a spatial analysis of polio vaccination in Brazil’s 450 so-called health regions, formed by groups of neighboring municipalities that share cultural, economic, and social identities, communication networks, and transport infrastructure. The purpose of these regions is to facilitate the planning and implementation of health measures and services.

Health regions that once achieved vaccination rate targets of 95% gradually failed to do so over the years studied (2011, 2015, 2019, and 2021). In the North and Northeast, the majority of health regions had coverages of below 70% in 2019 and 2021.

Clusters of health regions with low coverage were mostly concentrated in the North of Brazil (see maps).

“It is extremely worrying that the polio virus is still endemic in Asian and African countries, such as Afghanistan and Nigeria, and that vaccination coverage has fallen in Brazil and worldwide in recent times,” says Donalisio.

As long as the virus is circulating in the population, she says, there will always be a chance of polio being reintroduced in places previously considered safe.

Donalisio also draws attention to the fact that immunosuppressed patients (with low natural defenses against pathogens) find it more difficult to resist infection. “The virus thus circulates quickly and can develop variants, although it is more stable than some viruses, like SARS-CoV-2, for example.”

Socioeconomic characteristics

The study identified the issue of socioeconomic inequality as one of the main factors behind the decline in vaccination coverage in Brazil and around the world. Donalisio names some of the factors behind the falling immunization rates in the country.

“To make matters worse, the spaces used to administer vaccines are often structurally inadequate, leaving health professionals overworked.” Donalisio points out that problems with SUS funding and governance also present obstacles. “There is no drive to train more staff to apply vaccines or to intensify immunization campaigns in the interior of the country.”

Another challenge is improving communication about the importance and complexity of vaccination. “Vaccination schedules have become more robust and complicated in recent years,” says the UNICAMP researcher.

“It includes various doses for vaccines such as the pentavalent vaccine [for diphtheria, tetanus, whooping cough, hepatitis B, and hemophilia B, which causes meningitis and other diseases], the BCG [for tuberculosis] and the MMR [for measles, mumps, and rubella],” she explains.

“This is great, but at the same time it requires assertive and effective dissemination of vaccine schedules for children, adolescents, adults, and pregnant women,” says Donalisio.

It is also necessary to ensure proper management of immunobiologicals in the cold-chain during vaccine distribution. “Some products must be kept refrigerated, while others need to be kept frozen.”

When it comes to polio, the public seems to believe that the disease is no longer a threat, since its elimination from the country was announced such a long time ago.

Measles is another disease that had been eradicated, but has now returned with force. “In 2016, Brazil was internationally certified as a measles-free nation. But since then, there have been outbreaks of this viral infection, which affects the immune system and can be fatal.”

A look at the past

With the threat of the wild poliovirus being reintroduced in Brazil looming, a look at the past may provide valuable insight into the crucial role public health efforts played in combating the disease throughout the twentieth century.

After first being recorded in the country at the end of the nineteenth century, polio caused numerous outbreaks before being classified as a major public health issue by the authorities.

“Polio was considered a mysterious disease that challenged doctors and scientists,” says Dilene Raimundo do Nascimento, a doctor and historian at FIOCRUZ in Rio de Janeiro. “Until the mid-twentieth century, scientists and medical professionals were unable to explain how the disease was transmitted.”

It was in the 1950s that polio caught the public’s attention, as outbreaks spread through several Brazilian cities. The largest epidemic ever recorded in the country occurred in Rio de Janeiro in 1953, resulting in major press coverage and public concern, which increased the pressure on doctors and the authorities to find a solution.

“At the same time, the quest to create a polio vaccine was making good progress, especially in the US,” says Nascimento, editor of História da poliomielite (The history of polio; Garamond, 2010), a book about the scientific, social, and political trajectory of the disease in Brazil and worldwide.

The efforts of the international scientific community in the 1950s resulted in the development of the two polio vaccines still in use today.

The first, which uses an inactivated version of the virus and is administered intravenously, was created by American epidemiologist Dr. Jonas Salk (1914–1995). The second, produced with a live but attenuated virus and given orally, was developed by Polish medical researcher Dr. Albert Sabin (1906–1993).

Thanks to these vaccinations, the disease disappeared in many countries by the early 1960s. In Brazil, however, much of the population remained unprotected due to difficulties accessing medical services and vaccines.

“For health managers and professionals, the biggest challenge was to establish partnerships between multiple institutional and social stakeholders,” says Nascimento.

First nationwide campaign

Mass immunization drives were implemented in the 1960s and 1970s, but without the scope and longevity needed to contain the spread of polio. It was only in the 1980s that Brazil established its first nationwide immunization campaign.

“The outbreak of a major polio epidemic in Paraná and Santa Catarina drew national attention to the issue in late 1979 and early 1980. The political and social landscape at that time were also favorable to fighting polio in the country,” says Nascimento, referring to the fact that the military regime in charge at the time (1964–1985) was facing a serious political and economic crisis that began during the General Ernesto Geisel administration (1974–1978).

‘National Vaccination Day’ was established, with the aim of vaccinating all children aged five and under across the country in a single day. There followed a sharp reduction in the number of cases of the disease, from 1,290 in 1980 to 122 in 1981. The following year, the lowest ever number of annual nationwide cases was recorded: 45.

According to Nascimento, these “national vaccination days” were warmly welcomed by the public, and they continue to be systematically implemented in Brazil to this day.

“The policy even went international, being recommended by the Pan American Health Organization [PAHO] as a model for interrupting the transmission of wild poliovirus in the Americas.”

Vaccination communication and culture

Both researchers report that there were serious shortfalls in communicating the importance of vaccines to the public. For FIOCRUZ’s Dilene do Nascimento, the success of the polio immunization campaign in the 1980s created a “culture of vaccination” among the public, with parents aware of the importance of taking their children to be vaccinated and keeping their vaccine records up to date.

However, she emphasizes that government campaigns are still needed to highlight the importance of immunization and inform people of when they can get vaccinated against different diseases—this is more important now than ever, with the rise of antivaccine groups and fake news on the subject.

The paper cited at the beginning of this article, which compared vaccination coverage in 2011 and 2021, noted that the fourteenth meeting of the Regional Certification Commission for Polio Eradication in the Region of the Americas classified the region as a high risk for the reintroduction of polio.

Against this backdrop, the government launched the National Response Plan for Poliovirus Detection and Polio Outbreaks in November 2022, with the objective of establishing guidelines on how to swiftly respond to cases of wild poliovirus or poliovirus derived from the disease, in addition to creating communication and surveillance strategies for types 1, 2, and 3 of the virus.

“The plan is greatly welcomed. We hope it will help restructure the vaccination program and reinforce health messaging and communication about vaccination campaigns for polio and other diseases,” says UNICAMP’s Maria Rita Donalisio.

“This could give us the boost we need to become a model of free and universal vaccination campaigns once again.”

Re-achieving high vaccination coverage

Nascimento cites a recent project by FIOCRUZ’s Institute of Immunobiological Technology (Bio-Manguinhos), the Brazilian Society of Immunizations (SBim), and Brazil’s National Immunization Program (PNI).

The Reattainment of High Vaccination Coverage (PRCV) initiative aims to reverse the decline in vaccination rates in Brazil.

It was started in 2021 in the state of Amapá and 25 municipalities in Paraíba (covering 11% of the state’s municipalities and 37% of its total population) due to low vaccination rates in the region, especially for diseases such as polio, measles, and rubella.

The results in these locations were encouraging. Between 2020 and 2021, both Paraíba and Amapá placed last in polio vaccination rates among children—in December 2022, after the vaccination campaign and other measures implemented by the project, they were the only two states in Brazil to hit the target of 95% vaccination coverage.

The aim is to increase vaccination coverage nationwide by 2025.

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