Brazil’s (Jeopardized) Regional Leadership in the Vaccines Realm
What the country’s positive track record in this public health field could mean for the success of the COVID-19 vaccination campaign
Vaccines have been around since the late 18th century and, throughout time, the efficacy of this public health tool was scientifically certified for preventing a variety of infectious diseases, for generating collective immunity in entire societies, for reducing child mortality rates globally, and thus, for enabling unprecedented longevity to humankind. In many ways, vaccines represent a poetic answer from nature as these biopharmaceutical products are made of the very pathogens that cause harm to human (and animals’) health. Inactivated cells or genetically manipulated fragments of viruses and bacteria are therefore used as “raw materials” to strengthen and protect our own immune systems for long periods of time, if not forever in some cases. What an interesting philosophical plot twist! What a beautiful metaphor for life!
In the late 19th and all of the 20th centuries, vaccines were increasingly seen as the solution for rapidly growing urban populations that were severely impacted by multiple disease outbreaks, epidemics, and pandemics. Being knowledgeable about vaccines research, development and manufacturing and having control over related technologies and resources became more and more crucial for countries not only to overcome these recurrent sanitary crises, but also to ensure social, economic, and political stability. In that sense, vaccines have increasingly been observed and deemed as strategic inputs to any nation, no matter the level of income or hemisphere. Having collective health as a genuine public interest matter, countries deliberately pursued establishing either public or private organizations dedicated to this mission, the best example being perhaps the Institut Pasteur, created in 1888, in Paris, France.
In Brazil, for several decades, two Brazilian public-sector companies stand out when it comes to vaccines: The Butantan Institute, created in 1901, linked to the state government of São Paulo; and Bio-Manguinhos, the Immunobiological Technology Institute within the larger structure of the world-renowned Oswaldo Cruz Foundation (Fiocruz), part of to the federal government’s Ministry of Health organigram, established in 1976, based in the city of Rio de Janeiro. Together, these two organizations are among the largest in Latin America and are responsible for supplying the country’s National Immunizations Program (Programa Nacional de Imunização, PNI, in Portuguese), within Brazil’s Unified Healthcare System (Sistema Único de Saúde, SUS, in Portuguese), with almost the entirety of its needs. Butantan covers around 65% with five products, while Bio-Mangunhos is responsible for seven products. A couple of minor vaccine manufacturers also play an important role in Brazil: FUNED, in the state of Minas Gerais, and the Ataulpho de Paiva Foundation, in Rio, which is responsible for the BCG product provided to the PNI.
It is true that the majority of the vaccines provided to the Brazilian population (free of charge through SUS) is the result of technology transfer agreements with major international pharmaceuticals such as GSK, Sanofi and Merck and that multiple manufacturing inputs still have to be constantly imported from countries such as India and China. However, considering its existing infrastructure, industrial plants, qualified personnel and annually allocated public funding for this purpose, Brazil could be characterized as a self-sufficient nation in terms of vaccines manufacturing. That said, Brazil also has the capacity of surpassing its domestic borders by fulfilling its potential of supplying vaccines for global markets — while Butantan has been pursuing the WHO prequalification of its seasonal influenza vaccine, Bio-Manguinhos already sustains this certification for its yellow fever product for several years.
In the past couple of decades, there have been intentions to expand the country’s portfolio of vaccines that could be exported and/or donated to other middle- and low-income countries. In parallel, there has also been some political will for Brazil to boost its investments in these companies’ R&D capacities (Butantan has been developing a dengue vaccine in partnership with NIH) in order for the country to improve its autonomy and strategic position in the global vaccines stage. Nevertheless, these agendas were notably weakened by the current Jair Bolsonaro administration, which not only is known for its denialist attitude towards vaccines and aversion to science, but also for significant cuts in investments in areas such as health, technology, and innovation.
The fact is that the Covid-19 epidemic poses a whole new challenge for Brazil’s ability to import, distribute and produce vaccine doses for its entire population of 210 million inhabitants, the 6th largest in the world. Brazil’s SUS was created in 1990 as a direct result of the promulgation of the country’s current constitution of 1988, which enshrined health as a right of every citizen and a duty of the State. It established a clear overarching commitment towards ensuring accessible, equitable and universal public health to the Brazilian society. Reflecting this principle, since the PNI was established in the mid-1970’s, Brazil has been quite successful in implementing both routine and campaign vaccinations in all 26 states plus the federal district of Brasília.
Vaccination coverage rates have been historically very high, the nation has slowly built its technical expertise and sustained a very positive tradition when it comes to getting children, adults and the elderly vaccinated. The mascot ‘Zé Gotinha’ was born in 1986 during the polio eradication campaign and is an unquestionable symbol of this longstanding and trustful relationship. Over time, Brazil’s PNI increasingly represented a well-succeeded policy, particularly considering the country’s logistic barriers (e.g. continental dimensions and difficult access to populations residing in remote locations such as the Amazon rainforest). In this sense, Brazil gradually became an international reference and a role model to other countries that started replicating these best practices.
This isn’t, however, a story of pure success. Since 2015, vaccination coverage has been decreasing in the country (table above). Misinformation spread by anti-vaccine movements and the assumption that vaccination works only on an individual basis, not as a collective practice, have been leading Brazil into a sort of crisis of confidence. Persistent omission, lack of transparency, coordination and leadership by the Ministry of Health also do not help. Incompetence while negotiating the acquisition of Covid-19 vaccine doses from multiple suppliers (discussions with Pfizer/BioNTech and the Gamaleya Institute are delayed due to the federal government’s idiosyncrasies) and in the implementation of a yet unclear nationwide immunization plan represent elements the majority of Brazilians are ashamed of.
2021 could become a turning-point in this process though. Effective efforts by the PNI could be reinforcing and invigorating the Brazilian’s confidence and willingness to get vaccinated. Brazil’s National Regulatory Agency (ANVISA) has already granted emergency approval for two products on 17th Jan 2021. While Bio-Manguinhos will be responsible for providing over 210 million Covishield (Oxford/AstraZeneca) vaccine doses this year alone, Butantan is expected to produce and distribute 100 million Coronavac (Sinovac) vaccine doses. The vaccination campaign against Covid-19 in Brazil — which should be lasting all year long — could be interpreted as the beginning of the end of the epidemic and this has the potential of winning hearts and minds in an unprecedented manner.