Covid-19: disease causes more deaths in Brazilian children among those with available immunizations

Although children are less affected by Covid-19, the number of hospitalizations in this age group has increased

Until the beginning of November last year, at least 39 countries had already authorized or started the use of vaccines against Covid-19 in children under 12 years old. The Pfizer/BioNTech immunizer is the most used. In addition to this vaccine, Sinopharm, Sinovac (CoronaVac) and Soberana 02 were also adopted for this audience around the world. In Brazil, the immunization of children with the Pfizer vaccine was authorized on December 16 by the National Health Surveillance Agency (Anvisa), but vaccination began on January 14 with the application of the Pfizer immunizer, which has a pediatric formula, with an interval of eight weeks.

On January 20 the agency approved the use of CoronaVac for the age group between 6 and 17 years old, with no problems to the immune system. Inactivated virus vaccine, a widely known technology, used in the immunizing agent against influenza, for example, usually provides a good immune reaction in younger organisms. According to Butantan, data show that two doses are more than 96% effective against hospitalizations and deaths in children and adolescents. In Chile, where it is already being used in children from 3 years of age, data show that the immunizer was significantly effective in preventing hospitalizations and ICU admissions and deaths in the pediatric population (from 6 to 16 years). The effectiveness of the vaccine for the prevention of Covid-19 was 74.12% for Coronavac and 84.94% for the Cominarty vaccine (Pfizer). Regarding the prevention of hospitalizations, the effectiveness in Chile was 90.24% for Coronavac and 92.23% for Cominarty. The pediatrician and vice president of the Brazilian Society of Immunizations (SBIm), Isabella Ballalai emphasizes that both the Pfizer and CoronaVac vaccines are two excellent options for children and adolescents. “But both vaccines are important and recommended for this age group”, she emphasizes.

Dr. Ana Frota, an infectious disease specialist at the Pediatric Institute at (UFRJ) Federal University of Rio de Janeiro warns that Covid-19 is the disease that causes the most deaths in Brazilian children among those with available immunizations. She points out that the analysis of mortality rates (deaths per million) attributed to Covid-19, until November 2021, shows values of approximately 41 deaths per million among children and adolescents in Brazil. This is four times the same rate in the United States (11 deaths per million) and 10 times higher than in the United Kingdom (4.5 deaths per million in the United Kingdom), with the burden of disease being most severe in this age group in the United Kingdom. Brazil. “The most striking data is the confirmation of more than 2.500 deaths attributed to Covid-19 in this age group by December 2021, with 50% occurring in children over five years of age and adolescents. If we add up all the deaths caused in a year by diseases whose vaccines are incorporated into the National Immunization Plan (PNI) in the pre-pandemic period, no disease led to so many deaths in the same period of one year”, she points out.

Brazil completes one year of vaccination

The vaccination campaign against Covid-19 in Brazil completed one year on January 17th and despite the late start, a lot has changed since then and the country has shown that it knows how to vaccinate. Praised worldwide, the PNI has carried out numerous successful vaccination campaigns. The campaign against polio, for example, considered one of the most effective, came to vaccinate more than 10 million children in a single day. Although Brazil occupies the 12th place, according to Our World in Data, a project created in partnership with the University of Oxford to keep up with the pace of vaccination against Covid-19 19 in the world, Dr. Marta Heloísa Lopes, professor at the Faculty of Medicine of the University of São Paulo (FMUSP), regrets that the current Brazilian policy to encourage the Covid-19 childhood vaccine is very different from those adopted in past vaccination campaigns.

For Dr. Lopes, who is also responsible for the Immunization Center at the Hospital das Clínicas at FMUSP, adherence to vaccination fundamentally depends on the populations confidence in the benefits of vaccination as an effective means of preventing diseases. “When incorrect information is passed on to the population, both about the efficacy and safety of vaccines, the degree of confidence decreases and the hesitation in relation to vaccination increases. Ambiguous attitudes, on the part of some Brazilian authorities, of making Covid-19 vaccines available to the child population, but disseminating negative messages almost daily, not based on scientific evidence, can undermine the confidence of parents and guardians and contribute to hesitation in relation to the vaccination”, she points out.

Asked whether childhood vaccination should be mandatory, Dr. Lopes recalls that PNI vaccines are mandatory and that childhood vaccination against Covid-19 should be incorporated into the PNI immunization schedule and follow the same rules. For the researcher, more important than the simple obligation are: the need for broad campaigns to educate the population; need to train health professionals on the importance of vaccination, making them able to clarify doubts and convince parents and guardians; strengthening of PNI actions. “The importance of vaccinating children is not limited to preventing serious disease in the child population. The greater the number of people vaccinated, the lower the probability of circulation of Sars-Cov-2”, she adds.

Dr. Ballalai complements by saying that the issue of obligatoriness is a great strategy to undermine the confidence of the population and cites the example of the Vaccine Revolt, which took place in 1904. “When mandatory vaccination is imposed, even people in favor end up calling for freedom of decision. Vaccination in Brazil has always been and continues to be mandatory. What we see, unfortunately, is the attempt to change the focus when public authorities state that there is no obligation. The important thing is not to be mandatory or not. At this moment, for children and adolescents, it is important to inform the population about the need, the impact of the disease on the child – minor but not small –, in addition to the safety and efficacy of vaccines”, she adds.

Dr. Frota praises the Brazilian success in the field of childhood immunization, but recognizes that there is a coordinated movement of discredit of scientific measures and, consequently, in relation to vaccines, which have contributed so much to the health and development of the human species. “If we had a good campaign of correct information and debunking of fake news, I believe it would be a complete success. Within this scenario of erroneous information, I believe that measures such as a sanitary pass to attend schools could be welcome as a way of encouraging the vaccination of this group”, she evaluates, emphasizing that children are infected at least in the same proportion as adults. “With fewer sick children, we will certainly reduce one of the important sources of transmission in the general population”, she assures.

The pediatric infectious disease specialist also expresses concern about the unpredictable behavior of the virus and the possibility of it becoming more aggressive in this public. “Keeping it in circulation in communities favors the emergence of variants and, in the same way that an extremely transmissible variant such as Omicron emerged, more virulent strains are possible, including for the child population. That is why it is important to vaccinate the entire population in general and, in particular, the pediatric population”, justifies Dr. Frota.

Fiocruz investigates parents hesitation in vaccinating children

Although children are less affected by Covid-19, the number of hospitalizations in this age group has increased Even so, hesitation in vaccinating children still exists. According to a Datafolha survey released on January 17, 17% of respondents reject the vaccination of children aged 5 to 11 against Covid-19. For Dr. Ballalai, the Brazilian population has a perception of trust, understands its importance and seeks the vaccine whenever they understand the risk of the disease in question. “But there are factors that make 17% of these families still have doubts. There is a lot of fake news and opinionated messages that do not bring true scientific data – and worse, manipulate this data. There is a great wave of information that seeks to neglect the importance of vaccinating children. More than talking bad, anti-vaccine groups spread that there is no need to vaccinate this public because children are not at risk of Covid-19. Thats not true”, says the pediatrician.

A study by the Oswaldo Cruz Foundation (Fiocruz) with the participation of 15.297 fathers, mothers or guardians of children and adolescents revealed that the main reasons associated with vaccine hesitancy were fear of adverse reactions and supposed long-term effects, minimizing the severity of the pandemic and the false idea that those who already had Covid-19 do not need to be vaccinated. Parents also frequently stated that they disagreed that the vaccine would make returning to school safer and that they believe that natural immunity is a better protection option than the vaccine. Other responses mentioned were that the vaccine needs more time to be considered safe and that children and adolescents have no chance of getting serious if they contract the disease. There were also responses in the sense of preferring natural products to vaccination. Hesitation was greater in the age group from zero to 4 years, not yet covered by vaccination. Among the parents of this group, the percentage that did not intend to vaccinate was 16.4%. Vaccination hesitancy was lower among parents of children aged between 5 and 11 years (12.8%). Among those responsible for adolescents, it reached 14.9%.

Last year, almost 20 thousand children and adolescents were hospitalized for Severe Acute Respiratory Syndrome (SARS) associated with Covid-19. According to a survey carried out by Fiocruz, 1.422 children and adolescents under the age of 18 died from Covid-19 as of December 4 of last year, 418 of which were under 1 year of age; 208 were between 1 and 5 years; and 796 between 6 and 19 years old. Data released by the Butantan Institute on January 7 show that 1.449 boys and girls up to 11 years of age have died in Brazil since the beginning of the pandemic.

Main complications of Covid-19 in children

Dr. Frota details that Covid-19 in the pediatric range, as in adults, can cause acute complications such as infections of the upper airways (otitis) and lower airways (pneumonia), viral or bacterial, myocarditis (7.4x higher incidence between 16-24 years and 36.8x higher in <16 years), arrhythmia, hepatitis, parotitis and pancreatitis, among others. Late complications also occur and the main one is the so-called Pediatric Multisystem Inflammatory Syndrome (P-SIM), a disease with multisystem inflammatory involvement, which usually starts with fever and abdominal pain and mainly affects the cardiovascular system with shock. “This is another potentially serious clinical presentation of the disease, described in children and adolescents. In Brazil, until the 27th of November, 2,435 suspected cases of this Syndrome were reported. Of this total, 1,412 (58%) were confirmed, resulting in 85 deaths, which shows the severity of this condition, which usually occurs 4 to 6 weeks after SARS-CoV-2 infection. Other complications, such as the so-called long Covid, were also described in this group, but more studies are still needed to assess their impact on this population”, she observes.

Unequal vaccination in the world

The World Health Organization (WHO), while recognizing the benefits of vaccination in children, has already stated that it would not be a priority given the need to vaccinate or reinforce immunization of other groups more likely to develop severe forms of Covid-19. Dr. Lopes explains that in regions where there are not enough vaccines, the most vulnerable groups are undoubtedly the priority, a strategy adopted in many countries, including Brazil. According to her, since the priority groups are already covered, we can and should expand vaccination for the child population.

However, the researcher draws attention to the worrying situation in many African countries, in which not even the most vulnerable groups have been vaccinated. “All countries in the world should understand and contribute to effective measures in relation to what is happening in these African countries. When an individual is not vaccinated, in addition to the individual risk of becoming ill, he can be a source of infection for many other individuals. The act of vaccinating is individual, but the benefit is collective”, says Dr. Lopes. Dr. Ballalai agrees with her colleague. “We have countries where they have not managed to vaccinate even 10% of people. As long as we have countries without a good vaccine coverage, we will have a greater chance of the emergence of new variants again and again”, she concludes.