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While the images of the elderly receiving an injection raised hopes of progress in the fight against covid-19, the news about missed doses and lack of vaccines highlighted planning errors that would lead to delays in immunization of the Brazilian population.
The first month of vaccination against covid-19 in the country had the distribution of only 12 million doses, enough to serve 6 million people. This represents less than 3% of the Brazilian population.
Several cities, such as Rio de Janeiro, Porto Alegre, Salvador, Cuiabá and Curitiba came to suspend vaccination due to lack of doses.
Experts heard by BBC News Brazil point to three errors by the federal government that may have contributed to the vaccine shortage. And they warn that supply problems must recur throughout the year.
“Brazil would have conditions to have a much greater supply of vaccine if we had done what other countries did, like, for example, Chile. Chile today has three doses of vaccine per inhabitant, only that it started buying vaccine in September,” he added. said Gonzalo Vecina Neto, professor at the School of Public Health of the University of São Paulo and founder of the National Health Surveillance Agency.
“We don’t start buying vaccines early. The federal government made no bets. If it were not for Butatan and Fiocruz (respectively, responsible in the country for the CoronaVac and Oxford-AstraZeneca vaccines) we would not have any vaccine ”, he criticizes.
The government did not buy vaccines in 2020
Both Gonzalo Vecina Neto and epidemiologist Ethel Maciel say that the first and biggest mistake was that the federal government was not buying vaccines in advance, not even in 2020.
In the middle of last year, when the manufacturers announced that they were developing vaccines, several countries such as Chile, Colombia, the United Kingdom and members of the European Union negotiated the purchase of these products still in the testing phase.
It was a gamble. The investigation could go wrong, but closing the contract first meant guaranteeing access to the doses.
One of the strategies to minimize risk, says Ethel Maciel, would be to put together a varied basket of vaccines. For example, buy doses of Oxford-AstraZeneca, CoronaVac, Pfizer, and Moderna.
“Brazil did not do this and still rejected an agreement proposed by Pfizer that would guarantee 70 million vaccines in December,” says the epidemiologist, who is a professor at the Federal University of Espírito Santo.
Speaking of the failure of the negotiations with Pfizer, the Brazilian government argued that the proposed clauses were unfair.
In a note, the Health Ministry cited as an example the fact that Pfizer requires that, in the event of a disagreement with the Brazilian government, arbitration negotiations should be based on New York law, not Brazil’s.
Another point mentioned by the Brazilian government was Pfizer’s requirement to sign a liability waiver to exempt the manufacturer from civil penalties for possible serious side effects of the vaccine.
Pfizer responded, also by releasing a note, saying that the same terms were accepted by other countries that purchased the vaccine, including the United States, Colombia, Chile, the United Kingdom, Japan, Ecuador, and the European Union.
Fiocruz and Butantan took a risk
While the federal government hesitated to negotiate the advance purchase of immunizers, the research institutes Fiocruz and Butantan took this initiative.
Fiocruz began negotiations to buy Oxford-AstraZeneca, while Butantan negotiated with the Chinese Sinovac the transfer of technology to produce CoronaVac.
After reaching agreements with foreign manufacturers, both presented the proposals to the federal government.
Jair Bolsonaro’s government accepted Fiocruz’s proposal, but in October last year it rejected a Butantan proposal that provided for the delivery of 45 million doses of CoronaVac by December 2020 and another 15 million in the first quarter of 2021, which would guarantee at least 60 million doses in the first phase of vaccination.
At that time, Health Minister Eduardo Pazuello defended closing the deal, but President Jair Bolsonaro objected. A political dispute with the governor of São Paulo, João Doria, and pressure from right-wing militants who raised suspicions about a vaccine produced in China weighed on the decision.
“We will not buy from China. It is my decision. I do not believe that it transmits enough security to the population because of its origin. That is our thinking,” Bolsonaro said on October 21, in an interview with Jovem Pan radio.
Then in January, President Jair Bolsonaro returned and signed an agreement to buy vaccines from Butantan. The problem is that this delay in the negotiation also delayed the delivery schedule of the products.
This is due to the fact that Butantan’s production capacity, like that of Fiocruz, collides with the rhythm of imports of inputs from China.
Butatán accepted the proposal and, at first, the Health Ministry said yes, then said no, because Bolsonaro was against buying a Chinese vaccine. And there was all that discussion last year about whether it was the Doria or Bolsonaro vaccine. great wear to Butantan and delay in imports from China ”, recalls the health doctor Gonzalo Vecina Neto.
In the end, only 9.8 million doses of CoronaVac (Sinovac / Instituto Butantan) and 2 million doses of the Oxford-AstraZeneca vaccine were available in January and February.
And why doesn’t the government buy from other manufacturers now?
The problem is that, since Brazil started late in the negotiation, the big manufacturers, such as Pfizer and Moderna, have already sold the vast majority of their batches to other countries.
According to Vecina Neto, Brazil now has to bet on vaccines that still arouse suspicion due to the lack of transparency in the studies or that have not concluded the last stage of research, such as the Russian Sputnik V and the Indian Covaxin.
Sputnik V, in particular, has already come under international criticism for a lack of transparency in the immunizer manufacturing process. Even in Russia, the vaccination rate started slowly, because the population questioned the effectiveness of the vaccine.
Earlier this month, the Gamaleya Research Institute in Russia took a major step in demonstrating the efficacy of the vaccine by publishing a study in the scientific journal Lancet that shows a protection rate of 91%.
However, both this vaccine and Indian Covaxin have not yet released the results of phase 3 of the tests, when the immunizer is applied to a large and heterogeneous group of volunteers, to check for adverse reactions, for example.
Lack of definition of who should be vaccinated first
The second mistake, which could have mitigated the consequences of the vaccine shortage, was the lack of a definition of who should get the vaccine first, within the priority group.
That is, who is the priority of the priorities. The federal government has drawn up a huge list of priority groups, which together number 77.2 million people. They range from seniors over 90 to healthcare professionals, truck drivers, education professionals, and the military.
Who should immunize the 6 million people with the available doses?
“There was no order of who should receive the vaccine first. In the scenario of total scarcity, who would be the priority of priorities? The federal government did not make this decision,” says Ethel Maciel, professor at the Federal University of Espírito Santo.
As there was no federal coordination, each municipality created its own rules and distortions arose. For example, the federal government’s list includes “healthcare workers” but does not specify which ones would be prioritized.
For lack of a definition, estheticians, psychologists, dermatologists, veterinarians, and even Pilates instructors were vaccinated earlier than people over 80 in some cities.
Faced with this situation, Minister Ricardo Lewandowski, of the Federal Supreme Court, determined, on February 8, that the federal government should announce the order of preference within the priority group.
But by then, the doses from the first shipment were running low. “We stopped vaccinating the elderly to vaccinate a very wide range of health professionals who were not even on the front line,” laments Ethel Maciel.
Lack of training led to wasted doses
The third mistake, according to experts heard by BBC News Brazil, was the lack of training and guidance for the teams administering the vaccine.
There was no national vaccination campaign, with information for the population and specific training for health center personnel, according to Ethel Maciel and Gonzalo Vecina Neto.
In some municipalities, health professionals reported missed doses, especially in cities that decided to scale by age.
In Rio de Janeiro, it was widely reported that Oxford-AstraZeneca doses were scrapped due to low participation by older people in some areas of the city.
Once the vial is opened to place the syringes, the content of the Oxford vaccine is only valid for six hours. CoronaVac lasts for eight hours after opening the bottle.
As there was no clear guidance on what to do in the absence of the target group for vaccination, the doses left in the opened containers were no longer valid.
In other words, in addition to having little vaccine, the lack of guidance for professionals caused an even greater reduction in the stock.
According to Ethel Maciel, it would be the case to advise that, in situations like this, it is better to administer the vaccine to those who are there, for example, in the elderly companion, to waste the doses.
“What did we start to see in Brazil? Several wasted doses. We opened a very large space for prosecution, with the lack of clear instructions, and there was no information, training for people in the vaccination room on what to do with open bottles ”, Says the epidemiologist.
Brazil could immunize 60 million a month
According to Gonzalo Vecina Neto, who was the National Secretary of Health Surveillance, if Brazil had a vaccine and minimal prior planning, the Unified Health System could immunize up to 60 million people per month.
As there are 159.1 million Brazilians over 18 years of age, according to the 2019 National Health Survey (PNS), it would be possible to complete both doses, says Vecina Neto, in mid-July. For now, vaccines against COVID-19 are not administered to children and adolescents, so the calculation only considers adults.
“Today we have 38 thousand basic health units with at least one vaccination room with a specialized refrigerator for modules, which can be kept at temperatures between two and eight degrees. In the worst case, 10 people can be vaccinated per hour ”, explains Vecina. Net.
“If we vaccinate 10 people per hour, in an eight-hour shift, it gives 80 vaccinations. So, theoretically I am capable of vaccinating 3 million people per working day. That for 20 working days, I can vaccinate in a month. Without a lot of effort, 60 million people ”, he calculates.
The Health Ministry says it has reserved another 364.9 million doses of vaccines with Butatan, Fiocruz and the international consortium Covax Facility, linked to the World Health Organization, but the distribution of these batches will occur throughout the year.
“Our experience with the influenza vaccine shows that we have the ability to become immunized quickly. Last year, in 2020, we vaccinated 80 million in three months. We can do it. Missing? There are no vaccines, ”laments Gonzalo Vecina Neto.
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