Alexandre da Costa Linhares, MD, PhD
Brazil, Evandro Chagas Institute
In this spotlight of the ROTA Champion Interview Series, Dr. Linhares shares his experiences in leading the pioneering efforts of testing a rotavirus vaccine. Dr. Linhares is a virologist who worked with the Instituto Evandro Chagas on health surveillance for the Brazilian Ministry of Health and is credited with first detecting rotavirus in Brazil.
“Maintaining high coverages has been particularly challenging because messages highlighting the importance of vaccination at public health units are often lost among the dominant messages to stay at home and avoid overwhelming our public health capacity.”
– Alexandre da Costa Linhares
Introducing rotavirus vaccine in Brazil was critical
Since we first detected rotavirus in 1976, I have been actively involved in researching viral infections in the Amazon region. One of the first reports of rotavirus was actually in Indian communities. The Air Force of Brazil notified us in 1977 about an outbreak of diarrhea in the Tiriyó Indians, an isolated group in the north of Pará state near the border with Suriname, and the Air Force medical relief team flew to the village to respond. The attack rate was very high: 157 of 224 Indians at risk had diarrhea. Of the samples we tested, 76% were positive for rotavirus antibodies. Although all ages were affected, children were particularly prone to severe disease.
Rotavirus was a leading cause of severe gastroenteritis with estimations of more than 800,000 cases and 2,400 deaths annually in Brazilian children under 5. Additionally, studies showed that universal vaccination would result in total medical savings of US$19.3 million.
I led phase 2 and 3 trials of Rotarix in Belém, Brazil. We shared results—the vaccine provided high protection (~85%) against severe rotavirus disease—in interviews with radio, television, and others. In light of these results, Brazil was the first Latin American country to launch rotavirus vaccination into the public sector in March 2006, purchasing the vaccine through PAHO’s Revolving Fund. We sustained high levels (≥80%) of rotavirus vaccine coverage from 2007 to 2018, even though rates have been consistently lower when compared to those of established vaccines (e.g. DTP-Hib). This difference is likely due to insufficient health care worker education and information, supply interruptions, inadequate cold chain capacity in rural/remote areas, and missed immunization opportunities.
During the first years following introduction, a substantial number of children were excluded from rotavirus vaccination due to strict age restrictions that were eventually lifted by the WHO in 2013. The adoption of this new policy by the Brazilian Ministry of Health’s National Immunization Technical Advisory Committee was of great importance programmatically and has helped in successfully integrating rotavirus into NIP.
Vaccine hesitancy threatens program success
In 2019, seven vaccines in Brazil showed a significant reduction in doses applied when compared to 2018, all of which being used for childhood vaccination, including rotavirus vaccine. Leading the charge in this reduction were false “scientific facts” (e.g., that children developed cow’s milk protein allergy after rotavirus vaccination) spreading rapidly through social media. We can educate future generations about scientific methodology and evidence-based medicine and health, leading them to critically evaluate the veracity of the information they get from social media.
Other factors for lower coverage include reductions in funding dedicated to the Brazil’s Unified Health System, Sistema Único de Saúde, as well as political conflicts, socioeconomic collapse, and difficulties in bringing vaccines to remote areas such as Indian and rural communities.
COVID-19 pandemic has further eroded vaccine coverage
It is much more difficult to advocate for rotavirus vaccination and other childhood vaccinations during these challenging times of the rapidly evolving COVID-19 pandemic in Brazil—which is [as of 24 August 2020] causing 1,000 deaths per day.
On average, only ~50% of Brazilian children have received rotavirus vaccine from January – June 2020. Reasons include:
- severe public health system constraints
- physical distance measures to mitigate the spread of the coronavirus pandemic
- community reluctance to visit vaccination health units for fear of contracting SARS-CoV-2 infection
Many people in Brazil were prevented from accessing treatments for non-COVID infectious diseases, including diarrhea, due to strict controls on movements, avoidance of crowded waiting rooms, and other measures to curtail the pandemic. Pediatricians and public health units in Belém where treatment for diarrhea is routinely provided remained closed during the lockdown periods due to new strategies adopted during the pandemic that focused mainly on patients affected by COVID-19.
An additional challenge in Brazil is the current atypical situation at the Ministry of Health, where the most recent Health Minister resigned on 15 May 2020, just four weeks after joining the government administration. Until September 2020, there has been an Interim Minister at Brazil’s Ministry of Health in parallel with the loss of other key team members at the MoH’s headquarters in Brasília.
We need to adopt urgent actions to overcome the challenges posed by the COVID-19 pandemic
Brazil is making efforts to follow the recently issued Pan American Health Organization guidance on the operation of immunization programs. With lockdown restrictions easing, vaccination posts will open for extended hours to avoid crowds. However, these actions mostly target vaccinations against flu, measles, and yellow fever in municipalities where these diseases are circulating. As of now, it is still not clear whether rotavirus vaccination will be included among these urgent actions taken while restrictions to movements persist.
Maintaining high coverages has been particularly challenging because messages highlighting the importance of vaccination at public health units are often lost among the dominant messages to stay at home and avoid overwhelming our public health capacity.
Nonetheless, I think clearer national government messaging in informing the importance of maintaining high uptake of routine vaccinations is needed.