Sidelining experts, Brazil bungled its immunization plans

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DIANE JEANTET and DÉBORA ÁLVARES
·7 min read
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RIO DE JANEIRO (AP) — Like many Brazilian public health experts, Dr. Regina Flauzino spent most of 2020 watching with horror as COVID-19 devastated Brazil. When the opportunity to join the government’s vaccination effort came, she was thrilled: She would be able to share her decades of on-the-ground experience.

But her excitement quickly faded. Flauzino, an epidemiologist who worked on Brazilian vaccine campaigns for 20 years, became frustrated with what she described as a rushed, chaotic process.

The government has yet to approve a single vaccine, and Health Ministry officials have ignored outside experts’ advice. Shortly after the government presented its vaccination plan, more than a quarter of the roughly 140 experts involved demanded their names be excised.

“We weren’t listened to,” Flauzino told The Associated Press. The plan’s creation “was postponed for too long and now it’s being done in a rush.”

Brazil has suffered more than 200,000 COVID-19 deaths, the second-highest total in the world after the United States, with infections and deaths surging again. Despite a half-century of successful vaccination programs, the federal government is trailing regional and global peers in both approving vaccines and cobbling together an immunization strategy.

The AP interviewed four expert committee members and four former Health Ministry officials. They criticized the government’s unjustifiable delay in formulating a vaccination plan, as well as months spent focused on a single vaccine manufacturer.

They also complained of President Jair Bolsonaro undermining the ministry’s effectiveness, pointing to the removal of highly trained professionals from leadership positions, who were replaced with military appointees with little or no public health experience. Experts also blamed the president, a far-right former army captain, for fueling anti-vaccine sentiment in Brazil, compromising the mass immunization effort.

‘STILL WAITING’

The government’s COVID-19 immunization plan, finally released on Dec. 16, lacked essential details: How many doses would be sent to each state and how would they be refrigerated and delivered? How many professionals would need to be hired and trained — and, above all, how much funding would governors receive to implement the campaign? The plan did not include a start date.

“How is each state going to organize its campaign if it doesn’t know how many doses it is going to receive, and the timeline for delivery?” said Dr. Carla Domingues, an epidemiologist who oversaw the logistics of Brazil's 2009 H1N1 vaccine campaign, and worked on more than a dozen other vaccination efforts.

Bolsonaro’s press office and the Health Ministry did not respond to AP requests for comment about Brazil’s vaccination campaign or why more contracts with vaccine manufacturers were not signed in 2020.

The Health Ministry's National Immunization Program has a long history of success. Created over 40 years ago, it has enabled Brazil to eradicate polio and significantly reduce measles, rubella, tetanus and diphtheria. The effort won recognition from UNICEF for reaching the vast country’s most remote corners and has contributed to extending Brazilians’ life expectancy from 60 to over 75 years.

The program “is the central axis of all vaccination campaigns in the country,” Flauzino said.

That is no small task in a nation of 210 million people, the world’s sixth-largest population. The program provides a complex blueprint for vaccination campaigns across more than 5,500 municipalities in 26 states and the federal district.

In a Dec. 1 Zoom meeting, Health Ministry officials presented the experts with a general overview of the COVID-19 vaccination plan. The consultants the AP interviewed said it became abundantly clear the ministry was incapable of providing many crucial details.

Epidemiologist Dr. Ethel Maciel, who was among those who later demanded her name be removed from the plan, said many of the experts' recommendations weren't implemented, including obtaining vaccines from more than one manufacturer. But neither she nor other consultants could voice their concerns.

“They didn’t let us talk during this meeting, our microphones remained on mute,” Maciel said, adding that officials instructed them to send their comments in writing, and that they would receive a response within a week.

“To this day, we’re still waiting,” she said.

SYRINGE SHORTAGE

Maciel was also shocked to hear that five months after the ministry signed its first contract to obtain vaccine doses in June – up to 210 million of the AstraZeneca and University of Oxford shot — it still hadn’t secured syringes to administer them.

The Health Ministry published its tender for 331 million syringes in mid-December, but received bids for only 8 million by its Dec. 29 deadline. Brazilian syringe manufacturers complained the government’s price limit was below market value.

State health secretaries had for months warned the federal government about the need to buy syringes as soon as possible to avoid excessive pricing, but to no avail, said Carlos Lula, chair of the National Council of Health Secretaries.

“It took too long,” Lula said. Dozens of other countries are already vaccinating, “and we’re falling behind.”

Hamstrung, the government told Brazilian syringe makers in December it would requisition 30 million units, to be delivered by the end of January. A call for an additional 30 million followed.

However, in an injunction issued last week, the Supreme Court prohibited the federal government from requisitioning syringes from state governments like Sao Paulo that had already purchased them.

“The federal government’s negligence cannot penalize the diligence of the state of Sao Paulo, which has been preparing for a long time, with due zeal, to face the current health crisis,” Justice Ricardo Lewandowski wrote in the ruling.

The syringe shortfall has left state governors scouring markets for their own supplies. The Health Ministry said this week that state stocks amounted to just 52 million syringes, plus an additional 71 million acquired by Sao Paulo.

For Domingues the confusion is emblematic of the government’s poor pandemic planning.

“You’d need at least six months to go through all the bureaucratic procedures and make that purchase," she said.

A FAILURE OF LOGISTICS

The Health Ministry’s planning difficulties are all the more glaring considering the background of Health Minister Eduardo Pazuello, an active-duty army general tapped for his expertise in logistics.

The rise of a military man with no experience in public health to the top of the institution in the midst of a pandemic worried experts. “We don’t have a minister who understands the health sector,” Flauzino said.

Since Pazuello took over in May, more than 30 military personnel have been appointed to key ministry positions, including the head of Anvisa, the agency that approves use of vaccines.

Bolsonaro's contentious relationship with Sao Paulo state Gov. João Doria, a likely rival in next year's presidential race, also played a role in Brazil's vaccination debacle.

While Sao Paulo had zeroed in on Chinese pharmaceutical Sinovac Biotech's CoronaVac vaccine with a contract in September for 46 million doses, the Bolsonaro administration delayed signing a contract for months, focusing only on the AstraZeneca shot, ignoring experts and state officials who urged including Sinovac in the national vaccination strategy.

“Neither laboratory has the capacity to supply the entire national territory,” said Luiz Henrique Mandetta, health minister during the first months of the COVID-19 health crisis until he was removed by Bolsonaro. “We will need a lot of vaccines.”

Then last week, even as Bolsonaro continued scoffing at CoronaVac, the Health Ministry announced it was buying up to 100 million doses of the Chinese-made vaccine.

But with the need to provide two doses of vaccine to some 210 million people, Brazil is still far short.

Pazuello this week visited the Amazon city of Manaus that’s suffering a brutal second wave of the virus, with hospitals again pushed beyond capacity. He offered assurance that vaccines would be dispatched to all states within four days of approval by health regulators, which could come as early as Sunday — followed by a 16-month vaccination campaign.

However, Pazuello was was still unable to provide a rollout date.

“The vaccine in Brazil will arrive on D Day and H Hour,” he said cryptically.

___ Álvares reported from Brasilia.