The politicisation of vaccines and its influence on Brazilian caregivers’ opinions on childhood routine vaccination

La politización de las vacunas y su influencia en las opiniones de los cuidadores brasileños sobre la vacunación infantil rutinaria

Abstract

Progressive declines in vaccination coverage have been recorded in Brazil in recent years. The COVID-19 pandemic has introduced even more challenges to this scenario. Considering the pandemic as an event, the scope of this article was to analyze the politicization of vaccines from the perspective of caregivers of young children. This qualitative research was conducted in two Brazilian state capitals, namely São Luís (Maranhão) and Florianópolis (Santa Catarina). The study included families with children up to 6 years of age who were fully or partially vaccinated, as well as children who had never been vaccinated. Snowball sampling was used and in-depth interviews were conducted between March 2021 and April 2022. Forty-eight caregivers, most of them mothers, were interviewed. The study revealed that, regardless of their previous stance regarding vaccines, the health-political event of the COVID-19 pandemic shook beliefs and attitudes about childhood vaccination. The results also showed that the pandemic led to delays in routine childhood immunization and caused caregivers to seek private health services. Finally, the results reveal the politicization of vaccines as a new phenomenon to be addressed in the Brazilian context.

Key words:
Vaccination; Vaccine hesitancy; COVID-19; Qualitative research; Politics; Ideology

Resumo

Declínios progressivos nas coberturas vacinais vêm sendo registrados no Brasil nos últimos anos. A pandemia de COVID-19 trouxe ainda mais desafios para esse cenário. Considerando a pandemia como um acontecimento, objetivou-se analisar a politização das vacinas sob a perspectiva de cuidadores de crianças pequenas. Esta pesquisa qualitativa foi conduzida em duas capitais brasileiras: São Luís (Maranhão) e Florianópolis (Santa Catarina). O estudo incluiu famílias com crianças de até 6 anos de idade que fossem total ou parcialmente vacinadas, bem como crianças completamente não vacinadas. Utilizou-se amostragem por bola de neve. Entrevistas em profundidade foram conduzidas entre março de 2021 e abril de 2022. Foram entrevistados 48 cuidadores, em sua maioria mães. O estudo revelou que, independentemente da posição prévia em relação às vacinas, o acontecimento sanitário-político da pandemia de COVID-19 abalou crenças e atitudes acerca da vacinação infantil. Os resultados demonstraram, ainda, que a pandemia levou a atrasos na imunização infantil de rotina e fez com que cuidadores buscassem por serviços privados de saúde. Por fim, os resultados revelam a politização das vacinas como um novo fenômeno a ser enfrentado no contexto brasileiro.

Resumen

En los últimos años se han registrado descensos progresivos en la cobertura de vacunación en Brasil. La pandemia de COVID-19 trajo aún más desafíos a este escenario. Considerando la pandemia como un evento, este artículo tuvo como objetivo analizar la politización de las vacunas desde la perspectiva de los cuidadores de niños pequeños. Esta investigación cualitativa se realizó en dos capitales brasileñas São Luís (Maranhão) y Florianópolis (Santa Catarina). El estudio incluyó familias con niños de hasta 6 años que estaban total o parcialmente vacunados, así como niños completamente no vacunados. Se utilizó el muestreo de bola de nieve. Se realizaron entrevistas en profundidad entre marzo de 2021 y abril de 2022 con 48 cuidadores, en su mayoría madres. El estudio reveló que, independientemente de la postura previa en relación a las vacunas, el acontecimiento político-sanitario de la pandemia de COVID-19 sacudió creencias y actitudes sobre la vacunación infantil. Los resultados también demostraron que la pandemia provocó retrasos en la vacunación infantil de rutina y provocó que los cuidadores buscaran servicios de salud privados. Finalmente, los resultados revelan la politización de las vacunas como un fenómeno nuevo a enfrentar en el contexto brasileño.

Palabras clave:
Vacunación; Vacilación ante las vacunas; COVID-19; Investigación cualitativa; Política; Ideología

Introduction

Brazil is internationally acknowledged for its National Immunisation Program (PNI), implemented since the 1970s. Its successful implementation resulted in the establishment of a consistent “culture of immunisation” in Brazil¹.

Despite these achievements, vaccination coverage has been falling in Brazil in recent years. Studies also suggest a change in the socioeconomic profile of Brazilian vaccination coverage: while in 1982 vaccination coverage was higher among children in wealthy families, in 2015 this pattern changed, with higher coverage among poorer children².

While management and logistical issues in the supply of vaccines, opening hours of vaccination rooms, and underfunding of SUS are relevant determinants of noncompliance³, it is noteworthy that vaccine refusal motivated by personal fears and beliefs is an additional important reason for the recent decline in vaccine coverage in Brazil⁴.

Vaccine hesitancy is a term established by the World Health Organisation (WHO) to standardise the way of referring to all these forms of non-vaccination. WHO first defined vaccine hesitancy, in 2012, as the delay in acceptance or the refusal of vaccination despite availability of vaccination services⁵. In 2022, the concept has been rethought an and defined as “a motivational state of being conflicted about, or opposed to, getting vaccinated; this includes intentions and willingness”⁶.

Some of the vaccine hesitancy drivers found in Brazil are the same as those found globally, such as: doubts about the real efficacy/effectiveness and safety of vaccines; questioning the financial gain and commercial interest of the pharmaceutical industry; criticism of the composition of vaccines and their mechanism of action; fear of adverse events; the belief that immunity acquired through infection is better than that generated by the vaccine; and the belief that lifestyle habits (such as healthy eating) are protective against disease^7,8. Furthermore, vaccines are victims of their own success: thanks to the control or eradication of various vaccine-preventable diseases (VPD), vaccine adverse effects are now perceived as greater than the harm of the diseases⁴.

All the challenges mentioned so far were already a concern for immunisation policies before the COVID-19 pandemic. After it, and especially after its mismanagement by the then Brazilian federal government, the challenges became even greater⁹.

A few days after SARS-CoV-2 transmission started in the country, President Jair Bolsonaro made his first public statement. During his tenure, contrary to current health recommendations, he repeatedly dismantled declarations supporting COVID-19 prevention strategies⁹. The implementation of COVID-19 vaccines faced additional challenges. The former Brazilian president issued several statements of disbelief and distrust regarding COVID-19 vaccines¹⁰. Operational aspects were also hindered with the federal government’s delay in purchasing vaccines, leading to shortages of vaccines and supplies⁹.

From the context presented above, in this research’s analysis the COVID-19 pandemic will be interpreted as an event, that is, an experience linked to the social and political fields that threatens dominant certainties¹¹. While the pandemic and its vaccines centralized attentions globally, a fertile ground for the politicisation of vaccines emerged; vaccines changed from ‘an issue from health’ to ‘a political issue’^10,12. The discursive disputes around the pandemic highlights disputes between worldviews about human relations, the organization of society, the role of governments, and the economy¹¹.

By science politicisation, we refer to situations when ‘political interests shape the presentation of scientific facts to fit distinct models of “reality” for self-interested reasons’¹³.

Discussions about interactions between vaccines and politics are supported by Moulin¹⁴, who highlighted that the complexity of vaccination must be interpreted within its scientific, political, and social contexts. According to Moulin, (non)vaccination confronts individuals with conflicting themes such as the marking of bodies, collective memory, and the individual-group-State relationship.

Considering the historical and cultural dynamics around vaccination in Brazil, and the exacerbation of vaccine hesitancy in the context of the event represented by the COVID-19 pandemic¹¹, this article explores the politicisation of vaccines from the point of view and narratives of caregivers of young children in different Brazilian sociocultural contexts.

Methods

We used a qualitative approach to explore the opinions and understandings of Brazilian caregivers of young children about routine childhood vaccines and the COVID-19 vaccine.

The fieldwork took place in two Brazilian capitals: Sao Luis (State of Maranhao, in the northeastern region of Brazil) and Florianopolis (State of Santa Catarina, in the southern region of Brazil). Among the five capitals with the lowest vaccination coverage recorded in Brazil in 2019, Sao Luis ranked first and Florianopolis fourth¹⁵. These two cities were also chosen because they are in different regions and have the greatest diversity in social, cultural, geographical and economic terms: Florianopolis has a high Human Development Index (HDI; 0,847), a low infant mortality rate, and high percentage of proper water sanitation. Contrastingly, Sao Luis has a lower HDI (0,768), a higher infant mortality rate, a lower rate of adequate water sanitation¹⁶. Also, in Florianopolis, childhood vaccination rates registered in socioeconomic stratum A was significantly lower than in stratum E. Sao Luis registered overall low vaccination coverage, with no statistically significant differences according to socioeconomic strata¹⁷.

Families invited to participate in the study were those who had child(ren) up to six years old. We selected families with distinct opinions regarding childhood routine immunisation: families with fully or partially vaccinated child(ren), the latter comprising the group that selected some vaccines, as well as with unvaccinated child(ren). We separately interviewed two family members identified as the principal caregivers of the child. In some families, it was only possible to interview one of the principal caregivers (usually the mother), either because we failed in contacting the other caregiver or because this caregiver (usually the father) was not available.

Regarding the composition of families included in the study, we favored the diversity of characteristics, seeking to contemplate upper, middle, and lower socioeconomic levels; different racial groups; participants with high and low schooling; and participants residing in different neighborhoods.

Participants were recruited using snowball sampling¹⁸, a strategy that facilitates inclusion of hard-to-reach populations. Starting from initial sources, each family indicated others to participate in the study. Figures 1 and 2 detail the steps undertaken to reach the final sample.

Figure 1
Flowchart of snowball sampling in Florianópolis (SC).

Figure 2
Flowchart of snowball sampling in São Luís (MA).

We extracted empirical data from in-depth interviews. A trained, experienced researcher conducted the interviews in Portuguese, using a pre-established and tested script. Due to the COVID-19 pandemic, only one interview occurred in person at the interviewee’s home; all others took place in a virtual environment using the Zoom platform.

We interviewed 48 caregivers in 33 families, 15 of whom residing in Sao Luis and 18 in Florianopolis (19 caregivers in Sao Luis and 29 in Florianopolis) (Charts 1 and 2). These caregivers were: mothers (30), fathers (16), aunt (1) and grandmother (1). The average interview time was 48.1 minutes. All interviews were fully audio-recorded and transcribed and the names of all interviewees were replaced by codes to protect participants’ anonymity.

Chart 1
Participants’ sociodemographic characteristics in Florianópolis (SC).

	Identification	Age	Skin collor	Occupation	Social class	Children’s age**	Position on vaccines
Fully vaccinated children	F-V-01.Mother	40	White	Professor	Middle/B2	4y3m 6y11m	-
	F-V-01.Father	45	Black	Teacher	Middle/B1
	F-V-02.Mother	35	White	Teacher	Middle/C1	1y7m 14y7m	-
	F-V-02.Father	34	White	Lighting technician	Middle/B2
	F-V-03.Mother	26	Black	Software vendor	Lower/C2	6y, 5y, 4y	-
	F-V-04.Mother	32	Black	Professor	Middle/A	1y2m	-
	F-V-04.Father	37	Black	Engineer	Middle/C1
	F-V-05.Mother	40	White	Tourismologist	Middle/B1	11m	-
	F-V-06.Father	37	White	Data analyst	Middle/B2	2y7m 16y9m	-
	F-V-06.Mother	39	White	Historian	Middle/B2
Delay or refusal of vaccines despite availability	F-H-01.Mother	31	White	Doula	Middle/B2	2y10m 13y11m	Unvaccinated for HPV (oldest child) and rotavirus (youngest one).
	F-H-01.Father	36	White	Civil police	Middle/A
	F-H-02.Mother	43	White	Engineer	Middle/B2	4y2m	Selected or postponed some vaccines.
	F-H-02.Father	37	Brown	Professor	Middle/B1
	F-H-03.Mother	42	White	Researcher	Middle/A	5y	Selected or postponed some vaccines.
	F-H-03.Father	43	N/D	Administrator	Middle/A
	F-H-04.Mother	34	White	Cultural producer	Middle/B2	1y, 3y3m, 12y11m	Youngest child: unvaccinated; 3y child: unvaccinated up to 1 year old (vaccines fully postponed).
	F-H-05.Mother	42	White	Architect	Middle/B2	4y5m	Selected or postponed some vaccines.
	F-H-05.Father	39	White	Trade representative	Middle/C1
	F-H-06.Mother	38	White	Teacher	Middle/B1	5y6m	Unvaccinated up to 3 years old. After this age, selected or postponed some vaccines.
	F-H-06.Father	43	White	Writer	Middle/B1
	F-H-07.Mother	30	White	Student	Middle/C2	6y	Unvaccinated.
	F-H-08.Mother	24	White	Autonomous	Middle/C2	2y5m	Selected some vaccines. Do not vaccinate on mass vaccination campaigns.
	F-H-08.Father	26	White	Craftsman	Middle/C2
	F-H-09.Mother	43	White	Autonomous	Middle/B2	4y11m	Unvaccinated.
	F-H-09.Father	53	White	Therapist	Middle/B2
	F-H-10.Father	33	White	Doctor	Middle/B2	3y11m 5y9m	Selected or postponed some vaccines.
	F-H-11.Mother	37	White	Housewife	Lower/C2	4y6m	Vaccinated exclusively BCG due to maternity hospital’s obligation.
	F-H-12.Mother	34	Yellow	Autonomous / Therapist	Middle/B2	3y9m	Unvaccinated.

• N/D = not declared. * Social class self-declared by the interviewee (upper, middle or lower class)/social stratum defined by the ABEP score (“Brazil economic classification criterion”). ** Children’s age at time of interview, in years (y) and months (m).
• Source: Authors.

Chart 2
Participants’ sociodemographic characteristics in São Luís (MA).

	Identification	Age	Skin collor	Occupation	Social class	Children’s age**	Position on vaccines
Fully vaccinated children	S-V-01.Mother	25	Black	Student	Lower/C2	1y9m	-
	S-V-02.Mother	29	Brown	Economist	Middle/B2	1y25d	-
	S-V-03.Mother	27	Brown	Housewife	Middle/C2	4y11m 2y1m	-
	S-V-04.Mother	38	White	Pedagogue	Middle/B1	4y5m	-
	S-V-04.Father	34	White	Businessperson	Middle/B1
	S-V-05.Aunt	42	Black	Public worker	Lower/B2	4y9m	-
	S-V-05.Grandmother	65	Black	Housewife	Lower/B2
	S-V-06.Mother	29	White	Administrator	Middle/B2	3y3m	-
	S-V-06.Father	25	Brown	Sales executive	Middle/B2
	S-V-07.Mother	43	Brown	Teacher	Middle/A	1y5m	-
Delay or refusal of vaccines despite availability	S-H-01.Mother	27	Brown	Social worker	Middle/B1	1y2m 3a	Youngest child: delaying vaccines due to COVID-19 pandemic.
	S-H-02.Mother	35	Brown	Biologist	Middle/B2	1y3m 6y10m	Youngest child: after BCG, vaccines were postponed due to COVID-19 pandemic.
	S-H-03.Mother	33	Brown	Autonomous	Lower/B2	5m 8y	Hesitation only to vaccines against COVID-19.
	S-H-04.Mother	45	White	Pedagogue	Middle/B2	3y11m 8y	Hesitation only to vaccines against COVID-19.
	S-H-05.Mother	36	Brown	Student	Middle/B2	5y3m	Hesitation only to vaccines against COVID-19.
	S-H-06.Mother	26	Brown	Service consultant	Lower/C2	1y7m	Hesitation only to vaccines against COVID-19. Some regular vaccines are overdue.
	S-H-07.Mother	32	Brown	Accountant	Lower/C2	4y2m	Hesitation only to vaccines against COVID-19. Some regular vaccines are overdue.
	S-H-08.Mother	39	Black	Entrepreneur	Middle/B2	4m 10y	Hesitation only to vaccines against COVID-19.
	S-H-08.Father	37	White	Port operator	Lower/B2

• * Social class self-declared by the interviewee (upper, middle or lower class)/social stratum. defined by the ABEP score (“Brazil economic classification criterion”). ** Children’s age at time of interview, in years (y) and months (m).
• Source: Authors.

The fieldwork started in March 2021 in both cities; we finalized data collection in June 2021 in Florianopolis, and in April 2022 in Sao Luis. The difference in time needed for data collection was due to a much higher adherence to the snowball recruitment among participants in Florianopolis. The final definition of the number of interviews in both cities was based on the information produced during the data collection, according with the saturation criterion ¹⁹.

We analyzed empirical data using the step-by-step theme development proposed by Vaismoradi and team²⁰, focusing on the content of caregivers’ narratives’, as well as contextual meaning. After an immersive reading of the transcriptions, highlighting the meaning units, we listed the codes. A spreadsheet was used both to list the codes, after abstracting participants’ accounts, and for grouping codes into categories, from which the themes emerged. We carried out the final synthesis of relating themes to established knowledge.

The fifteen categories found were grouped into three themes. The theme ‘Impacts of COVID-19 pandemic on parental meanings and representations about childhood vaccination and COVID-19 vaccines’ encompasses the following six categories: Vaccines as a collective pact; The pandemic reinforces the importance of vaccines; The rapid development of vaccines against COVID-19; COVID-19 vaccines: uncertainty about safety; Fear of COVID vaccines side effects; COVID-19 vaccines polemic reaffirm previous anti-vaccines beliefs. The theme ‘The concrete impacts of the COVID-19 pandemic on routine childhood immunisation’ encompasses four categories: Access to routine services in health facilities during the pandemic; Fear of exposure to SARS-Cov-2 leads to avoiding health facilities; Children are less exposed to vaccine-preventable diseases because of social distancing; Private health facilities as a better option than public ones. And the theme ‘Political ideology, government, and governance as drivers of (non)vaccination’ comprises five categories: Vaccination as a political position/decision; COVID-19 vaccine hesitancy associated to supporters of Jair Bolsonaro; Distrust of the mainstream media; Vaccines choice depends on the manufacturer country; The SARS-Cov-2 was purposely created by scientists and the vaccines were ready beforehand. The first two themes were analyzed based on national and international literature on childhood vaccine hesitancy in COVID-19. The last theme was analyzed according to the politicization of science and the critical and anthropological approach to the vaccine phenomenon^10,11,13,14.

The Ethics Review Board of University of Sao Paulo revised and approved this study (CAAE nº 37536320.2.0000.0068). All participants signed an informed consent form.

Results

Impacts of COVID-19 pandemic on parental meanings and representations about childhood vaccination and COVID-19 vaccines

The COVID-19 pandemic has had mixed effects on caregivers’ views about routine vaccination. We categorized these caregivers into two large groups: one including caregivers claiming that their previous opinion about routine vaccines was reinforced by the pandemic - either highlighting their belief on the importance of vaccines, or their refusal/hesitation; and another including caregivers who modified their previous opinions - either moving from a previously hesitant position and pondering on the importance of vaccination, or hesitating/refusing routinely recommended vaccines in which they previously trusted following to the controversies surrounding vaccines against COVID-19.

In both cities, we found caregivers who regularly vaccinate their children, acknowledge the importance of vaccination, and consider that the COVID-19 pandemic only reinforced the meaning of vaccines as a responsibility that must be accomplished to protect the child and honor a collective pact.

From my point of view, not much has changed. I’ve always had a settled position regarding vaccines. I know it’s a very important thing, it helps us, and, of course, as a mother, I will always want to protect my daughter (S-V-01, mother).

We found families who were hesitant to follow the routine childhood immunisation schedule only in Florianopolis. These families had their hesitancies about vaccines maintained or reinforced after the onset of the COVID-19 pandemic. In Sao Luis, specific hesitant perceptions towards COVID-19 vaccines included their fast pace of production and fear of adverse events. In addition, for some families, hesitations towards COVID-19 vaccines were accompanied by reluctancies about routine vaccines that, until then, had never been questioned.

It is like a little light turns on at the back, ‘Wow, now what? What will happen? Do these other vaccines also have sequelae for us?’ (S-H-08, mother).

Contrastingly, for other families with hesitant opinions about the COVID-19 vaccine, routine vaccines remained unquestioned, because unlike vaccines against COVID-19, these “older” vaccines were accurately assessed before being implemented.

Because the other vaccines are already so established, right? And this one was a new thing that happened and as I told you, short production time, I don’t know. And not the others, they were already in our culture, right? (S-H-08, father).

Among families from Florianopolis with previously hesitant beliefs concerning routine vaccination, we observed three types of effects after the pandemic: one, more often observed in families that do not fully vaccinate, was the posture of reaffirming fears, reservations, and criticisms of vaccines; another, more often seen among hesitant caregivers who select some vaccines, was the attitude of understanding the importance of vaccines against COVID-19, without changing attitudes or previous opinions, reinforcing that the child’s context must be considered in the decision to vaccinate; and, finally, a less expressive stance was the reflection on previous decisions about the routine vaccination calendar, with a possible change in conduct.

I think it ends up going back a little bit to that old story, huh? Is this vaccine not a form of control? (F-H-08, father).

[...] reinforced the importance of both vaccination and the Unified Health System, etc. But I honestly don’t think I would make a different decision than we did, I think if I had another child I would have the same attitude of not giving all vaccines in the first year (F-H-02, father).

I agreed at the time because the arguments convinced me, right? [...] But currently, I would research more and be much more resistant to not vaccinating because, for me, the need for the vaccine became more explicit (F-H-01, father).

The concrete impacts of the COVID-19 pandemic on routine childhood immunization

The COVID-19 pandemic had two concrete effects on the pediatric routine immunisation in both cities: delays in administration of vaccines and an increase in vaccines administered in private facilities.

Delays in routine vaccination occurred due to difficulties in accessing primary healthcare units for eligible procedures, or due to intentional deferral as caregivers feared exposing the child to SARS-CoV-2 in health services. Furthermore, parents emphasized the perception that social distancing, imposed by the pandemic, also reduced the child’s exposure to other vaccine-preventable illness.

So now in the pandemic I didn’t vaccinate, I didn’t take her to the doctor, nothing. [...] Because she’s at home, she’s not being exposed to anything, so I didn’t think it was necessary (F-H-08, mother).

Issues related to lower access to health facilities as drivers of delays in vaccination were more pronounced in Sao Luis. Caregivers reported facing mandatory restrictive measures to prevent the spread of SARS-CoV-2 (such as the lockdown enacted in Sao Luis); and difficulties related to the new organization of vaccination services in health units (for example, the need for a prior online registration in Florianopolis and the centralization of immunisation services in a few health units).

The use of private facilities to avoid higher exposure to SARS-CoV-2 in public services was quite pronounced among families that vaccinate, especially the ones from Sao Luis.

[...] at the height of the pandemic, and I was too afraid to go out, so I went to see [the public health unit] because he [the child’s father] kept insisting we should have [the vaccines] in the SUS; then I got scared. Then I saw this huge line, went back, and called the [private] clinic, and the girl came to apply it the next day (S-V-07, mother).

Political ideology, government, and governance as drivers of (non)vaccination

The associations between vaccination, political ideology, and political management were significant aspects that emerged spontaneously from caregivers’ narratives. Statements on politics were mostly associated with a negative assessment of President Jair Bolsonaro and the anti-vaccine position of his supporters. Even the caregivers who were hesitant about routine vaccines often underpinned that their opinions were distinguishable from that of the former president’s supporters, reaffirming that they are neither anti-science nor anti-vaccine.

Today it is a political decision more than ever, right? It shows a lot about political side the person is on, right? If the person doesn’t want to be vaccinated, they don’t need to say anything else, you can already tell who they voted for, at least in the last election (F-H-02, father).

Only the families from Sao Luis who were hesitant about COVID-19 vaccines made the inverse association: they related COVID-19 vaccines to a political opposition to the former President and reproduced some of his anti-science arguments (i.e., the virus was created, as it was a planned pandemic). These families reported some common attitudes, such distrust of the press and other media resources that they considered hegemonic; the differential (dis)trust of vaccines depending on the manufacturer and country of origin; the belief that SARS-CoV-2 had been created purposefully, and that vaccines serve an ulterior purpose (either profit for laboratories or harm to the population).

Because today the press is publishing more things that negatively affect the current government. [...] As the government has always been against the vaccine, then it’s clear that if the vaccine has the opposite effect on some people, of course, the media will not disclose this because they will not want to give this advantage to the government (S-H-07, mother).

Discussion

We found that the event of COVID-19 pandemic has influenced beliefs, meanings, and attitudes on childhood vaccination. Moreover, our results uncover the influence of vaccine politicisation on vaccine hesitancy, in the extent that (dis)trust in vaccines is sometimes connected to ideologies and opinions of political leaders.

Several epidemiological studies have pointed to a significant drop in vaccine coverage in the routine childhood calendar during the pandemic period^21,22. Added to the difficulties in accessing immunisation services during the pandemic²³, beliefs and behaviours supporting vaccine hesitancy are a significant problem, amplified in the pandemic context²⁴.

Over the last four decades, Brazil has developed and mostly sustained a robust culture of immunisation, with a national vaccination schedule that is universally available and free of charge^1,3. Nevertheless, the downward trend in vaccine coverage registered since 2000 is a multicausal phenomenon^4,17. Following the COVID-19 pandemic, studies suggest that this scenario can become even more delicate²³.

The PNI has broad credibility and adherence among Brazilians in all socioeconomic conditions¹. Some vaccines are only available in the PNI, and their incorporation in the national vaccination schedule drastically reduces commercialization in the private network²⁵. Accordingly, we found that even families with high income and schooling primarily use vaccines that are available free of charge within the PNI. However, one of the unexpected findings of this study was the migration from public units to private immunisation services during the pandemic. This finding deserves attention since Brazilian children vaccinated in the public network are more likely to be fully vaccinated at 18 months old than those vaccinated in private clinics¹⁷.

The health crisis surrounding the COVID-19 turned the eyes of all social actors to science, putting all its nuances, contradictions, procedures, and methods under the spotlight²⁶. Although none of the questions in the script pointed directly to the politicisation of health and science, this theme emerged and marked the empirical field.

Overall, families with hesitant beliefs concerning the routine vaccination schedule maintained their opinions despite acknowledging the importance of COVID-19 vaccines. These caregivers, who do not define themselves ‘anti-science’ or ‘anti-vaccine’, believe that vaccines should be selected according to the child’s socio-environmental context, contrasting the perceived risk of exposure to the disease and the potential risks associated with vaccination. Advocacy for adapted vaccination schedules tailored to the needs of each child has already been documented in previous Brazilian studies with hesitant families⁷. Similarly, studies have shown that caregivers weight the perceived potential severity of COVID-19 and the perceived risk associated with the vaccine before deciding on their child’s vaccination^24,27. Moulin emphasized that this tailored vaccination, often desired by the modern citizen, “leads to flirt with the idea, epidemiologically valid but morally unsustainable, that the ideal would be for everyone to be vaccinated, except me”¹⁴.

On the other hand, we observed a concerning phenomenon in some families that fully complied with routine vaccination schedules: controversies surrounding COVID-19 vaccines instigated uncertainties concerning the safety and efficacy of other childhood vaccines. A cross-sectional population-based study conducted in Sao Luis found a 20.7% prevalence of hesitancy regarding vaccines against COVID-19. In this scenario, the distrust of regular vaccines caused by skepticisms about the COVID-19 vaccine could significantly impact on routine vaccination coverage²⁸. A study conducted in India with mothers of children up to six years old showed an increase in vaccine hesitancy from 5% before the pandemic to 38% during the pandemic²⁹.

A remarkable finding of our study is the characterization of the politicisation of vaccines, a new phenomenon with unforeseen challenges for public health stakeholders, including the PNI. Until very recently, reductions in vaccine coverage seemed to be independent of political affiliations and ideologies ³⁰. Several studies have shown that vaccine hesitancy is often justified by ideological motivations that existed long before COVID-19, including skepticism about the medical-pharmaceutical industry, adherence to a more ‘natural´ lifestyle, affiliation to principles such as anthroposophy and homoeopathy, among others^7,31,32. What COVID-19 inaugurated in Brazil was the attribution of vaccines (dis)thrust to statements issued by political leaders - President Jair Bolsonaro in particular. In this context, one’s opinion on the COVID-19 vaccine can also very accurately inform his/her political position^10,12,33.

We propose the notion of ‘vaccine politicisation’, from the spatio-temporal location of the event¹¹ - the COVID-19 pandemic in Brazil. We define it as the influence of political interests and ideologies over technical or scientifical evaluations on vaccine policies, aiming to define or modify public opinions in favor of a political interest.

In line with a far-right wing denialist discourse, Jair Bolsonaro underestimated the severity of the pandemic, discredited prevention and mitigation measures recommended by health organizations, disallowed his first minister of health (who tried to issue official acts following scientific recommendations), and also made several statements against COVID-19 vaccines, particularly for children^9,34.

As a populist leader, Bolsonaro ascended the Brazilian political scene at a time of crisis and popular discontent, creating the false dichotomy between “us” (the people, the dominated) and “them” (the dominant, the elite, in the form of institutions)^10,11,35. Based on this populist logic, he built the narrative that individuals should be free to choose whether or not to be vaccinated¹⁰. Previous researches have shown that the support for populist parties could be used as a proxy for vaccine hesitancy³⁶.

Institutions such traditional media, universities, and scientific organizations were subsequently labeled as discordant entities which should be viewed as mistrustful or ill-intentioned^11,35. This atmosphere of distrust leads to the growth of conspiracy theories and authoritarian speeches, raising up the State Denialism³⁷.

In this same context, the opposition to China, as well as the ideological and political dispute between Bolsonaro and the governor of the state of Sao Paulo, fueled the distrust towards CoronaVac^10,12. Accordingly, the country of origin of a COVID-19 vaccine became a distinctive reason to reject vaccination reported by hesitant Brazilians³⁴. The “ranking” of vaccines according to their country of origin and the specific distrust of the Chinese vaccines were recurrent among hesitant respondents in our study as well as in previously published manuscripts^24,27.

Nuances of this scenario emerged in the narratives of some participants in our study, who were reluctant regarding recommendations of institutions such as WHO and Anvisa; distrusted traditional media; and refused to believe that universities and laboratories could produce a safe and effective vaccine in such a rapid pace. It is known that vaccine trust is associated with high trust in these institutions (Universities, health departments and mainstream news sources, for instance)³⁸.

Reasons for COVID-19 vaccines hesitancy identified in our study were similar to those reported in other national and international studies. The main reasons for vaccine rejection were the rapid production and testing time, distrust of their efficacy, and fear of side effects^27,36,38. Another finding of this study that confirms national and international results is the so-called “wait-and-see” attitude, i.e., the decision to wait for the progression of vaccination and only then decide whether or not to vaccinate one’s children^24,27. The belief in conspiracy theories, such as that China created the virus and that the vaccine was part of an alleged Chinese war, has also been demonstrated previously^12,24. In Ireland and the United Kingdom, COVID-19 vaccines hesitant persons were more distrusting of authorities and institutions and more likely to hold conspiratorial beliefs³⁹.

These findings suggest a general distrust of institutions, and a shift to decisions based on emotions, beliefs, and experiences ¹⁰. While science offers a concrete and probabilistic approach, human experience builds unique perceptions that may influence behaviors and attitudes²⁷. Also, risk perception is a great factor in the decision making process³⁶.

Our finding resemble those reported in the United States, where increasingly conservative political ideology was association with low vaccine trust³⁸. COVID-19 vaccines have produced a similar phenomenon in Brazil: endorsement of far-right ideologies was strongly associated with hesitancy towards COVID-19 vaccination³³. Furthermore, another study revealed that self-declared right-wing or center-right people were more likely to answer that they would only take the COVID-19 vaccine “depending on the vaccine”⁴⁰.

The percentage of votes for Jair Bolsonaro, for both the elections of 2018 and 2022, was inversely associated with COVID-19 vaccine uptake after adjustment for the sociodemographic characteristics, showing significant association³⁰.

It’s important to point out that the two cities where the fieldwork was carried out have very different political scenarios: while Maranhao was the third state with the highest voting rate for then-candidate Lula da Silva, Santa Catarina was the fourth state with the highest voting rate for Jair Bolsonaro. Despite this, the families interviewed don’t necessarily fit into the hegemonic group in each city: in Florianopolis, as previously mentioned, hesitant families to childhood vaccines were rigidly against then-president Jair Bolsonaro. In line with global literature, these families are characterised by a naturalistic worldview, use alternative medicines and pedagogies and position themselves as anti-system, criticising the pharmaceutical industry^7,41,42. These families, although hesitant about childhood vaccines, emphasise that they don’t want to be compared to Bolsonaro’s supporters, whom they describe as “anti-vaccine” or “anti-science”. In Sao Luis, the families that reproduced hesitant narratives also escape the municipal hegemony and are those who supported then-president Bolsonaro. This fact can be supported by Seara-Morais et al.³⁰ and Murphy et al.³⁹ studies, that show that the more socioeconomic vulnerable municipalities (less HDI) are more susceptible to the pervasive influence of political ideologies on COVID-19 vaccination in Brazil and that income level is associated with COVID-19 vaccine hesitancy.

Our study had a few limitations. The protocol was designed before the onset of COVID-19. The pandemic scenario had to be adapted into the initial design and most interviews were conducted remotely, which may have interfered with the quality of interviewer-interviewee interaction. In some cases, the second caregiver was not available to participate in the study. However, this limitation is unlikely to impact our main results, as in most families we found no major disagreements between the main caregivers. The study was conducted by researchers from academic institutions, which may have inhibited more radical anti-science manifestations.

Conclusion

The COVID-19 pandemic prompted a scenario of general distrust of institutions (both scientific ones and the traditional media) and a strong influence of political ideologies on the decision to vaccinate. Jointly, these factors are threats to the culture of immunisation that prevailed in Brazil until recent years.

The politicisation of medical issues can reduce the credibility of official sources of scientific information²⁶, directly affecting people’s attitudes towards health⁴³. In order to formulate immunisation policies that are appropriate to the local reality, it is important to understand the profound impact that the social and political landscape has on health decision-making. As the findings of this study reveal, the COVID-19 pandemic and its political management in Brazil have led to an unprecedented scenario of attributing the decision to (not) vaccinate to one’s political affiliation. This scenario is a warning for the development of future vaccination policies in Brazil. On the other hand, a government policy to encourage vaccination can positively affect the decision to get vaccinated. We therefore emphasize that all government decision-making is political: what defines whether the consequences of the politicisation of vaccines are positive or negative is the management of these decisions.

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• Chief editors:
  Maria Cecília de Souza Minayo, Romeu Gomes, Antônio Augusto Moura da Silva

Publication Dates

• Publication in this collection
  27 Jan 2025
• Date of issue
  Jan 2025

History

• Received
  13 June 2023
• Accepted
  26 Oct 2023
• Published
  28 Oct 2023