How São Paulo Became ‘The World’s Vaccine Capital’

Many non-Brazilians, even epidemiologists, were astonished by the announcement in November 2021 that São Paulo had achieved universal full vaccination of adults against Covid-19. After all, São Paulo is one of the five largest cities in the world, creating potential logistical challenges to getting to 100%.

Across the country, there have been political obstacles to overcome as well. President Jair Bolsonaro has been spouting ludicrous misinformation throughout the pandemic, as well as delaying vaccination. (More recently, he’s fiercely opposed the vaccination of children aged 5 to 11, which began in January 2022.) Yet most Bolsonaro supporters have ignored his vaccine-related rantings.

Overall, Brazil’s high vaccination coverage shouldn’t come as a surprise.

Although there are of course pockets of vaccine hesitancy, as well as deep health disparities, Brazil has had a strong culture of vaccination for years. This is linked to the strength of government institutions. The campaigns and requirements of the public health system, public schools and public assistance programs have contributed to the utter normalization of vaccination.

“Brazil and São Paulo have always been a model of excellent vaccination campaigns through the universal health coverage system, low vaccination hesitancy and great uptake,” according to Otavio T. Ranzani, an epidemiology researcher at the University of São Paulo (as well as an assistant professor at the Barcelona Institute for Global Health). And, “unfortunately, the COVID-19 pandemic has affected the São Paulo population to a great extent, which is a factor to motivate the vaccination rate.”

Brazil, like some other countries, even has a vaccine mascot. Since 1985, the character Zé Gotinha (Droplet Joe) has helped overcome suspicion of publication vaccination programs – although Bolsonaro’s administration has limited his role during the pandemic.

Vaccine acceptance is high across Brazil. According to the US-based Institute for Health Metrics and Evaluation (IHME), as of December 23, 2021, 92% of people aged 12 and up in Brazil said that they would accept or probably accept a Covid-19 vaccine. In no state was the percentage lower than 80%. (Some other Latin American countries also have high vaccine acceptance rates – reaching 100% in Brazil’s neighbors Colombia and Argentina.)

Eagerness to be vaccinated has been high throughout the pandemic. In January 2021, 89.5% of Brazilians surveyed online said they intended to be vaccinated against Covid-19.

This doesn’t necessarily translate into high actual vaccination, partly due to supply issues. As of December 13, according to IHME data, 62% of people in Brazil were fully vaccinated, while 72% had received only one dose.

To some extent Brazilians have been hitting the road to obtain access. In fact, São Paulo’s vaccination rate exceeds 101% because of non-residents traveling there to get jabbed. The city has long been a magnet for migrants and visitors.

The Covid-19 vaccines used in Brazil haven’t always been the ones with the highest effectiveness. Yet even the lower-efficacy vaccines have helped to bring caseloads down, for instance in Serrana in São Paulo State. In in São Paulo, the distribution of higher-efficacy vaccines have helped to dramatically bring down coronavirus infections and hospitalizations.

According to Ranzani, “The vaccination success was able to decrease the burden of the Gamma wave in São Paulo, which was massive. Another remarkable success that occurred in São Paulo and other places was the containment of the Delta spread, resulting in a much lower number of cases, hospitalizations and deaths than expected.”

The speed and breadth of the vaccine rollout boosted São Paulo’s vaccination rate. “There was a rapid and coordinated allocation of doses,” Ranzani comments. Vaccination was made broadly accessible, in terms of time (weekends, holidays, sometimes 24 hours a day); location (mobile units); and outreach to vulnerable populations (homeless, those with overdue second doses).

Still, extremely high vaccination isn’t a panacea. In a press briefing on January 12, Carissa F. Etienne, the director of the Pan American Health Organization, stated that Omicron “has led to a rise in re-infections, even among those who are fully vaccinated. This new wave of infections, it won’t be ‘mild’ for our health systems as the Omicron variant is already challenging our health workforce and limiting care for other diseases.”

And Ranzani notes, “I don’t think we should consider the concept of ‘herd immunity’ as a public health goal at this moment. The arrival and spread of Omicron has shown it clearly again.” Across Brazil, booster shot coverage is currently low.

Yet as it moves into new phases of the pandemic, São Paulo is demonstrating that a strong public health service and legacy of vaccination can supersede politics to protect as many people as possible.