key: cord-0842791-4bbgnuxu authors: Fernandez, Michelle; Matta, Gustavo; Paiva, Ester title: COVID-19, vaccine hesitancy and child vaccination: Challenges from Brazil date: 2022-04-01 journal: Lancet Reg Health Am DOI: 10.1016/j.lana.2022.100246 sha: 8f6de1aaafd11a077585af3124b175a28d990648 doc_id: 842791 cord_uid: 4bbgnuxu nan In the world, the governments' policy decisions in response to COVID-19 were very different. 1 Many countries, including in the Americas, 2,3 political polarisation in health policies has been used as a tool for ideological dispute, draining out the debate around the right to social protection and health. During 2021, these strategies were used in vaccination policies. The consequences of the dissemination of misinformation about COVID-19 vaccines overflows distrust and hesitation into an entire public health project. Since the beginning of 2020, Brazilians have witnessed several mistakes and omissions by the Federal Government, guided by denialism and controversies, creating conflicts and a false opposition between health protection and economic recovery. 4 The consequences of the State's failure in its constitutional duty to defend public health are felt beyond the countless deaths. The Federal Government's position that began with attitudes contrary to non-pharmacological measures, 4 through recommendations without scientific evidence, 4 has impacted the vaccination process against COVID-19. Brazil has one of the most extensive immunisation policies worldwide, the National Immunisation Program (Programa Nacional de Imunizações − PNI), integrated into the National Health System (Sistema Unico de Sa ude − SUS). However, recently, we have observed a drop in confidence and overall vaccination coverage in children 5 (Figure 1) . Historically, the anti-vaccine discourse has had a minimal political impact in Brazil, because the PNI was developed with the support of democratic political leadership, although created during the military dictatorship period. 6 However, the anti-vaccine movement has received considerable input through the President's posture of discouragement and distrust towards COVID-19 vaccines. 7 The way the Federal Government has conducted the vaccination of the paediatric population has been marked by speeches and behaviours that encourage hesitation. On 16th December 2021, the Health Surveillance National Agency (Agência Nacional de Vigilância Sanit aria − Anvisa) approved the vaccination against COVID-19 to the 5 to 11 age group. Since then, instead of a prompt mobilisation to immediately incorporate the vaccine to the PNI − following the scientific evidence 8− several strategies were used by the Federal Government to postpone, discredit and incite doubts in its importance. The Brazilian government threatened Anvisa officials, 9 strongly questioned the vaccine's safety, created a public consultation with poorly formulated and biased questions, and only on 5th January 2022 the final government's approval was granted. Contrary to the decision, the presidential rhetoric continued to instil fear, widely publicising that he will not vaccinate his 11-year-old daughter. The vaccination of children in the age group of 5 to 11 against COVID-19 started on 14th January 2022 by priority groups such as indigenous people, quilombolas and children with disabilities and comorbidities. As per the Ministry of Health's (MoH) guidelines, only those legally responsible can take the child for vaccination, and written authorisation term must be presented in the absence of those responsible, severely restricting access of children living with reduced access to healthcare services and in multigenerational houses under informal supervision of family and community members. In addition, the MoH recommends that children remain at the vaccination place for 20 min to observe possible side effects, which anticipates the fear of adverse reactions, disrupts the flow in vaccination places and incites crowds. These requirements constitute a clear message of distrust never before seen in vaccination campaigns in Brazil. Taking childhood vaccination through the rhetorical argument based on parental responsibility and the image of the unprotected child, the Bolsonaro government wants to capture family morality against all previous immunisation campaigns in Brazil, in which it was up to parents to protect their children by vaccinating them. Bolsonaro's presidency, since 2019, has attacked health policies with budget cuts and science denialism. 10 During the COVID-19 pandemic in Brazil, the Federal Government adopted an anti-science trajectory. 11 Interests of economic and political groups aligned to the current government and ideological [1] First dose of measles, mumps and rubella vaccine. Comment positions seem to constitute a project that alienates fundamental rights and risks the lives of millions of people by disseminating misinformation and fallacies. The manufactured atmosphere of distrust and uncertainty encourages authoritarian actions and conspiracy theories, threatening the democratic rule of law. This is being called State Denialism. The State denialism deceives the logic of vaccination as a human right through scientific disinformation and imposes a conservative liberalism as an "individual choice" against a collective perspective based on solidarity and the common good. This atmosphere of distrust and uncertainty can fuel a movement of vaccine hesitation, capable of reducing the reach of childhood vaccination. Thus, given the importance of vaccination of children in the context of the COVID-19 pandemic and future health emergencies to come, what should be done for a successful reach of childhood vaccination? It is necessary to launch a media campaign to increase awareness and encourage vaccination to fight hesitancy. Besides, it is important to have a strategy to encourage parents to take their children to be vaccinated when they use primary health care and specialised care. And, finally, it is crucial to establish national coordination for the implementation of childhood vaccination in the municipalities, defining minimum parameters for its execution. Vaccination is not only a public health issue, but it is also essential to bring into the debate the health, social, political and communication sciences, as well as civil society representatives to create broad response strategies. Understanding and addressing this situation is urgent and a priority. Children's immunisation is a key action to control the pandemic, but vaccine hesitancy will delay successful vaccination strategies. The vaccination must be implemented by the government and supported by scientists, committed citizens, and parents as a collective endeavour. Coronavirus Politics: The Comparative Politics and Policy of COVID-19 Covid-19: how denialism led Mexico's disastrous pandemic control effort Science denial and COVID conspiracy theories: potential neurological mechanisms and possible responses The Brazilian Government's mistakes in responding to the COVID-19 pandemic Pandemic and vaccine coverage: challenges of returning to schools. Rev Sa ude P ublica Domingues RAS. 46 anos do Programa Nacional de imunizações: uma hist oria repleta de conquistas e desafios a serem superados. Cad Sa ude P ublica The politics of COVID-19 vaccination in middle-income countries: lessons from Brazil Evaluation of the BNT162b2 Covid-19 vaccine in children 5 to 11 years of age The unjustified and politicized battle against vaccination of children and adolescents in Brazil Lancet Global Health. Brazil enters the Bolsonaro zone All authors contributed to the drafting and editing of the manuscript. The vaccination data presented in this comment are made available by the Brazilian MoH through its open data repository (https://datasus.saude.gov.br/). The authors declare no conflict of interest. This study was partially supported by the project "Vaccine Hesitancy and online misinformation consumption and distribution among frontline healthcare workers" funded by the John Fell Fund.