The Silent Backslide of Childhood Vaccination in Latin America

By Grisha Vera with the collaboration of Elizabeth Salazar, Gabriela Verdezoto, Maximiliano Manzoni and Verdad con Tinta.

But by 2022, the region’s coverage was one of the worst and it had fallen five points below the world’s average, according to estimates of the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF).

These organizations estimate that 1.2 million children lack the first dose of the DTP3 (diphtheria-tetanus-pertussis vaccine, the benchmark for vaccination coverage globally) and that approximately 2 million children in the region are susceptible to immunopreventable diseases.

Coverage of the DTP3 and measles vaccines has declined in 23 countries in Latin America and the Caribbean. The level of underperformance is alarming in seven: Bolivia, El Salvador, Ecuador, Honduras, Paraguay, Peru and Venezuela – coverage receded 20 points or more for one of the aforementioned vaccines since 2012.

From a regional perspective, the reasons for this backslide are a response to different causes: the decline in public campaigns to promote the importance and quality of vaccines, the deterioration of health systems, anti-vaccination movements, the health crisis deriving from measures implemented during the pandemic, and the decreased expenditure se in vaccine purchases.

CONNECTAS analyzed the figures of human use vaccine imports (available in the UN’s Comtrade Database, global trade data platform) in the seven countries with the worst drops in coverage. It found that in two (Venezuela and Ecuador) expenditures decreased in the last decade.

Although experts consulted for this feature agree that vaccine purchase is just one element to consider. Success of immunization programs relies on the robustness of health systems. In other words, whether countries have enough trained personnel, attain coverage in remote areas and maintain an adequate cold chain.

Field reporting in Bolivia, Ecuador and Venezuela also evinced that governments are not being transparent in their vaccination status and that there are failures in data systematization – events that complicate addressing the problem even further.

Miriam Alia Prieto, coordinator of ER medicine and vaccination specialist at Doctors Without Borders, explains that anti-vaccination movements are an additional reason for the vaccination drop, albeit to a lesser extent, and that these usually affect developed countries in Europe or the United States. “It is true that they don’t have a very large impact on overall coverage because cases are perhaps not anecdotal but reduced, depending on the country. But for some vaccines, measles in particular, a decline in coverage had been detected even before COVID-19.”

Since the last dose of the vaccine is the only one that guarantees immunization, the WHO and UNICEF have established the third dose of the DTP3 vaccine to monitor immunization programs’ performance. Additionally, Ralph Midy (immunization advisor at UNICEF Latin America and the Caribbean) explains that “attaining the full scope of this indicator involves several factors that are typical of service, such as: at least three visits of the child to the health center, an adequate follow-up of the vaccination goal, as well as sufficient human resources and input.”

Prieto adds that the first dose of the measles vaccine is recommended for children between nine and 12 months of age, therefore “it is regarded in many countries as an indirect indicator of a fully vaccinated child.”

These vaccines do not seek to eradicate the diseases they prevent. The DTP3 does not provide lifelong immunity, and even though the measles vaccine does, the expert underscores that 15% of people don’t get immunity. “Still, in most countries measles epidemics occur when coverage decreases. It is a clear indicator that routine programs are not going well. And this has been happening since 2020. We have seen an increase in cases and outbreaks in every region of the world.” Prieto asserted.

The backslide in the region’s vaccination coverage was alarming by 2019, just before the pandemic. Estimates revealed that Latin America and the Caribbean were 16 points below the year’s recommendation.The situation worsened with the arrival of COVID-19, but there was a slight recovery in 2022: coverage went from 75 to 79% in a single year. In other words, the region matched the year prior to the pandemic.

In February 2023, the Pan American Health Organization (PAHO) issued an alert. It urged countries of the Americas to update its response plans to avoid the endemic transmission of measles in the continent again. Even though in 2016, the region was declared measles-free, since as the virus circulates in places outside of the subcontinent, there was an increase in imported cases between 2017 and 2019. Measles are even considered endemic to Brazil, although overall, cases decreased in 2022 due to social distancing to fight COVID-19. “According to the Organization’s Technical Advisory Group (TAG), the risk of outbreaks of vaccine-preventable diseases in the region is at its highest point in the last 30 years,” warns the PAHO’s press release.

Weak Systems

Vaccine expenditure surged in Peru in the last decade. Despite fluctuations since 2019, it follows an upward trend: in 2023, the Peruvian government spent 108% more than in 2012. Maria Elena Martinez, executive director of immunization at the Ministry of Health of Peru, confirmed that the country has significantly raised its vaccine expenditure.

Nevertheless, that rise does not translate into better childhood vaccination coverage. It has had a downward trend in the last ten years: measles coverage decreased 20 percentage points over that period and the DTP3 coverage went down 13 points. The most important drop occurred in the pandemic, but as of this date, coverage has not bounced back and the recommended coverage levels are still far from being achieved.

Despite the setback in vaccination coverage, the tendency to greater vaccine expenditure is also seen in countries such as El Salvador, Honduras, Bolivia and Paraguay. Prieto, the expert at Doctors Without Borders, expounds that the growth in vaccine purchase is what should normally happen, because there are new vaccines that are added to national vaccination schedules, for instance: pneumococcus, human papillomavirus and rotavirus.

But Midy, the advisor at UNICEF, warns: “Investing in vaccine imports is not the only factor to consider if the intention is to increase vaccination coverage.” The expert adds that in order to guarantee the success of its immunization programs, countries need to have enough health care personnel to reach the target population, the system needs to have the capacity to respond to the increased vaccination demand, raise awareness among the population to accept the vaccine and have an infrastructure (cold chain) in optimum conditions or fit for the requirements of vaccine storage.

The Venezuelan case exemplifies that access to vaccines does not necessarily guarantee suitable coverage. Huniades Urbina, pediatrician, intensivist and vice-president of the National Medicine Academy of Venezuela, comments that in recent years, the Venezuelan state has not purchased vaccines due to its outstanding debt of 10 million dollars with the PAHO. Existing doses have arrived through donations made by international organizations.

That is why, Urbina says, in 2023 the Venezuelan government executed an agreement with Gavi, the Vaccine Alliance, an international mechanism that increases access to vaccination in developing countries. According to the expert, the agreement was devised as follows: Gavi would purchase the vaccines required for the expanded immunization program in 2023, and it would support its implementation. For its part, Venezuela would commit to continue with the program and to purchase the necessary vaccines starting in 2024.

But, so far, progress has not been made public. “The year is almost over and the vaccines haven’t arrived. When they were ready to ship the vaccines, the government said: ‘Well, we don’t have the means to distribute the vaccines to the 3,500 health districts because we don’t have temperature-controlled trucks.’ Then, private companies offered to arrange the transportation. Well, but you see, there is no gasoline. Moreover, UNICEF, as well as the Red Cross are installing refrigerators in hospitals or dispensaries because there are none. Refrigerators, of course, require generators, power shutdowns could render the vaccines useless. Some locations are even installing solar panels to have permanent electricity. It is a tough game.”

Urbina also warns that Venezuela needs more vaccinators to cover for the shortage of 70% of nursing personnel that has left the healthcare system due to the low salaries. “Staff’s salaries are not enough to get to work. This is all adding up to the detriment of the expanded immunization program.”

On November 14th, representatives of the Ministry of Health met in Caracas with members of Gavi, UNICEF and the PAHO with the “aim of strengthening the regular vaccination scheme in the country, including sustainable funding, and reinforcing the National Public Healthcare System.”

CONNECTAS requested the information pertaining to the expanded immunization program, as well as an interview with the Minister of Health. As of the publication date, messages had not been responded to.

Ignorance and Exclusion

Lack of knowledge about the importance of vaccines is one of the causes that has had a bearing on the decline in vaccination coverage. Urbina, the Venezuelan expert, explained that there is more to it than just having the vaccine available. “It has to go hand in hand with an advertising campaign, people need to be told that these are good vaccines and that they are available, so when the patient gets there, the opportunity is not lost.”

Enrique Teran, teacher at Universidad San Francisco de Quito and PhD in pharmacology, mentions more reasons that account for the backslide in vaccination coverage in Ecuador. For instance, he states that the Ministry of Health of that country changed a proactive strategy for a reactive one. Prior, the State continuously motivated families to vaccinate their children but that five years ago, he goes on, the health system waits for them to get to the medical centers. “This could be one of the main reasons for vaccination coverage to plummet.”

For Cristina Jacome, head of the National Directorate of Immunization in Ecuador, a factor that has affected the coverage in that country is that vaccination stopped being compulsory when the new Constitution was adopted in 2008. Children are not required a vaccination card to enroll in schools and that has led to many of them being unvaccinated. “Parents just forget. It’s not that they don’t want to do it, they forget to take them, they don’t have time because they are working parents. When we did the campaign they said: ‘To tell you the truth I forgot, I didn’t have the time. But now that you are here please vaccinate him/her’”.

Nevertheless, Prieto warns that this is not the only element to consider. Segments of the population are usually excluded from these health programs, she highlights the migrant population. “They are left out not because they refuse to get vaccines or because they don’t want to do it, it is because there is no way for them to get included. Bureaucracy throws them into the limbo of health services, and healthcare policies seldom include extensive services for migrant populations.”

By 2021, 14.8 million international migrants lived in Latin America and the Caribbean, according to the International Organization for Migration (IOM). In 2023, UNICEF calculated that 25% of that population is composed of children and teenagers. Moreover, UNICEF has warned that children in poor households are three times less likely to get vaccinated.

Blindfolded

Partly due to the aforementioned reasons, Ecuador plunged 17 points in DTP3 coverage and 22 points in measles coverage from 2012 to 2022, according to data from UNICEF. Yet the fact that there isn’t total certainty of the figures is another issue.

Jacome, the Ecuadorian authority explained to CONNECTAS that in September of this year, precisely as a result of a special vaccination campaign aimed at rising coverage, they realized that the estimates they had reported to the PAHO were incorrect. She stated that the Statistics Institute had overestimated the children’s population, thus, coverage projections were low. They became aware of the mistake this year, after the special vaccination came to an end and when they compared the data with the new 2022 census. Jacome assures that: “We identified 100% of children, out of which 99.4% were vaccinated in the follow-up vaccination campaign.”

Teran, the Ecuadorian expert, mentions that it is impossible to know exactly what is going on with the immunization program because it is not systematized and it lacks transparency. “The Ministry of Public Health has a rather odd system to assess vaccination coverage. If you analyze the data of the last vaccination campaign, the Ministry says that coverage reached 90% of the expected population. This is mathematically impossible because the Ministry of Public Health does not cover all of the remote areas. Unfortunately, and this is an embarrassment to say, they cover up the figures to justify coverage.”

As of the publishing date of this feature, Bolivia hadn’t replied to our requests for information. They argued that the requested data weren’t systematized.  Concurrently, in August 2023, Bolivia confirmed 847 cases of the whooping cough or pertussis. To remedy this situation, the Ministry of Health and the Ministry of Sports activated a vaccination campaign in the most affected areas.

On the other hand, Venezuela has failed to report vaccination data to the UN since 2013, and the budget to execute the National Immunization Scheme has remained a mystery since 2017. However, data available in the National Budget Law and in the 2012-2017 accountability reports evince the decrease in the amount of vaccines applied. For example, in 2014, applied doses went down by 58%. The following year, the figure rose to 2012 values. But in 2016, applied doses decreased again, this time 12%. This trend remained in 2017 – the last year in which official figures were provided.

Official data pertaining to the real impact of the backslide in vaccination coverage in Venezuela are unknown because the Ministry of Health hasn’t published its Epidemiology Newsletter since 2016. However, Urbina recalls the most visible consequences of the failed healthcare policy. “We were diphtheria-free for 24 years. What happened? In 2016, the coverage we were able to trace in the PAHO-UNICEF website revealed that in the state of Bolivar, where the first cases occurred after 24 years, vaccination coverage barely reached 15 to 18%.” And he adds that the MMR vaccine (against measles, mumps and rubella) has a coverage of 68% for the first dose and 37% for the second. “That is why measles was back in 2016 after nine years.”

Another Impact of COVID-19

In 2020, DTP3 coverage went down in 23 of the 33 countries in Latin America and the Caribbean. Likewise, measles coverage went down in 26 countries. By 2022, six of these countries hadn’t shown indications of recovery in DTP3 coverage, and 15 in measles coverage.

The case of Paraguay is noteworthy, not only does it lack improvement, but the post pandemic backslide remains – and it is significant. In the last four years, the country’s vaccine coverage for DTP3 decreased 17% and 33% for measles. However, vaccine expenditure is on the rise, and the budget to execute the expanded immunization program has remained stable.

Prieto, the expert at Doctors Without Borders, comments that starting in 2020 and as a result of the pandemic, very restrictive policies were established with the aim of preventing agglomerations of people in health centers. “Consequently, regular preemptive campaigns in low-income or low-coverage countries had to be suspended. The same happened with reactive campaigns that responded to the epidemic because there was not enough personal protective equipment for the vaccination teams.”

Immunization authorities in Ecuador and Peru also stated the sanitary crisis driven by the pandemic as the main cause for decreased vaccination coverage, despite both countries having a slight drop in vaccination prior to the COVID-19 pandemic. Martinez, the Peruvian authority, explained that a setback in vaccination coverage in rural areas and indigenous communities became evident since 2019. “We assumed it was set off by anti-vaccine activists.” Although she clarified that there was a decrease that year in measles vaccine coverage and that they had recently concluded a vaccination campaign to address an outbreak of the disease that occurred in 2018, the State’s efforts focused on addressing that situation. Subsequently, the pandemic made everything worse: “We were all centered on COVID-19 and, somehow, the remainder of the vaccination calendar got neglected.”

Lost Opportunities

The Pan American region has the PAHO Revolving Fund, a mechanism that allows purchasing doses at affordable prices. “The Revolving Fund clusters the countries’ funds, purchases large lots to the most convenient laboratory, and then sells it to the countries at a lower price. This is because countries mustn’t directly negotiate with the industry,” explains Urbina.

Prieto underscores the region’s advantage in purchasing vaccines. “This system is a pioneer in the world, and other continents should have it too. The PAHO always pays the minimum price. For example, European countries or African countries with middle or high income have to negotiate with the laboratories. These negotiation processes happen behind closed doors and are very opaque. Frequently, countries’ resources are limited to negotiate a good price.”

The lack of transparency of analyzed countries leaves many unanswered questions. For instance, if vaccine expenditure in some countries in the region has so much as doubled, why has vaccination coverage receded?

Zooming in on the causes for the region’s backslide in vaccine coverage leaves us with an outlook of lost opportunities. Arguments such as “low income” and “structural problems”, which are commonly the justification for the most pressing problems in Latin America and the Caribbean, are out the window. A decade back, the region had achieved an almost-perfect outlook, proving that the goal of 95% coverage in childhood vaccination in Latin America was attainable.