The Brazilian Experience with Mass Vaccination Efforts

The below summarizes an October 22, 2021 meeting of the Global Mass Vaccination Collaborative, led by Ariadne Labs. For information on previous meetings of the Global Mass Vaccination Collaborative, read our past blog posts.

The joyous dance of samba plays a prominent role in Brazilian culture. Now samba schools are playing a vital role in ensuring Brazilians are protected against the COVID-19 virus. Rio de Janeiro samba schools have been used as walk-up vaccination sites by Community Organized Relief Effort (CORE) and its Brazilian partners as part of a broad-based vaccination strategy for a huge, sprawling city of 6.5 million people.

It’s an example of how a country’s culture can be incorporated to fight the COVID-19 pandemic.

Rio’s vaccination effort has been successful in many ways but fraught with challenges, Matt McCoy, a program manager for CORE, told members of Ariadne Lab’s Global Mass Vaccination Site Collaborative, during an Oct. 22, 2021 meeting that focused on CORE’s COVID-19 vaccination efforts in Brazil. The collaborative, launched by Ariadne Labs in April 2021 to facilitate a rapid information exchange about COVID-19 vaccines, meets weekly to discuss a range of issues related to vaccine delivery.

Demand for the vaccine is high in Brazil, but supplies are often low, McCoy said. As of now, about 80 percent of Rio’s adult population has been vaccinated with two doses. This was no small feat, given Brazil’s slow initial response.

“Brazil is by definition a middle-income country, but they didn’t prepare themselves well for the rollout of the COVID-19 vaccine,” McCoy explained to the collaborative, many of whom had organized and promoted mass vaccination initiatives almost immediately after vaccines were available. “President Jair Bolsonaro did not take COVID-19 very seriously. … He was a proponent of herd immunity: let the virus do what it needs to do and don’t really intervene. By the time the vaccine was ready to roll out, the country was not very well prepared.”

When CORE began its vaccination efforts in Rio in April 2021, about 70,000 COVID-19 cases were being reported daily. Five hundred thousand deaths were reported. Only health workers and the elderly were getting vaccinated. CORE, an emergency response nonprofit launched in 2010 had first tackled the pandemic with support for COVID-19 testing, initially in Los Angeles and then in New Orleans, New York City, Atlanta, Chicago, Washington D.C. It was natural for the organization to transition into vaccinations.

Establishing Mass Vaccination Sites

Working closely with Rio partners such as the RIO Prefeitura, Saude, and SUS, CORE began to provide support in capacity building, operations flow, technology integration, and help with data management. For example, CORE helped health workers transition from paper to tablets so that information was immediate, and there was no data loss or backlog; this was a challenge as many health workers were wedded to the tried-and-true paper system.

To date, CORE has helped administer 300,000 vaccines in Rio.

Four mass vaccination sites were initially set up in Rio. Sites were situated throughout the city, close to vulnerable and low-income communities, including a large drive-through site in Olympic Park, where the 2016 Olympics were held. With six lanes, it can vaccinate 1,500 people a day. CORE had helped run a drive-through site at Dodger Stadium in Los Angeles and thus was able to advise on how to make traffic flow more efficient. Three more sites were established by October.

“We have put sites right next to clinics facing a huge demand, making it easy on the population,” McCoy said. “We have a couple of walk-ups in samba schools, which can do 1,000 a day.” Sometimes the atmosphere is festive, creating a guest experience. “We have big samba fans, who come up dressed completely in their favorite gear and they help at the door. They are proud for us to be in that space and help out,” he said.

Building Trust

“In the beginning of the rollout in Brazil there was a lot of mistrust about the COVID-19 vaccine; there were reports of people getting saline shots, reports of people not getting the correct vaccine. So that created a lot of mistrust. But that hasn’t stopped the Brazilian population from wanting to get vaccinated,” said McCoy.

To combat mistrust, vaccinators showed the entire process of drawing the vaccine out of the vials in front of patients “It created trust in the entire process,” McCoy said. Margaret Ben-Or, MPH, Assistant Director of Strategic Projects at Ariadne Labs, noted that this method may not be as efficient but was a “really important tradeoff” to build confidence.

“The patient gets to see the entire process,” McCoy noted. “But in Brazil there’s no monitoring time after vaccination, so once you get the shot, you can walk away. That’s the tradeoff in efficiency.”

Supply Challenges

Another challenge has been getting enough vaccines. The Brazilian federal government lagged in ordering vaccines for municipalities. “As a consequence, the vaccine roll out has been very slow,” McCoy said. “There are times when there are no vaccines in a day and all vaccination operations have to wait until the federal government provides municipalities with more vaccinations.”

Ben-Or was curious about the cause behind insufficient vaccine supply; was it a supply chain issue or lack of understanding of the need for vaccines?

“A little of both,” McCoy said. “The initial response was political; the federal government truly did not want to prepare for this vaccination. But then as time went on, the vaccine supplies came and then it became an issue of the federal government supplying the municipalities with the vaccines. That’s the issue we’re having today. Even just last week, Rio had to suspend vaccination for a day or close early. The country has the vaccines now, it’s a matter of being supplied at the municipal level…There was a day at the drive through site, they were only able to give out six shots.”

CORE’s Impact

CORE has worked with Rio health officials in two crucial vaccine campaigns; one on the Ilha de Paquetá, an island off the coast of Rio with a 55,000 population and the other in the Maré favela, a large complex of slums with a population of 30,000. In two intense weekends, 90 percent of the adult population in each location were vaccinated. “These were big events, planned with the community,” McCoy said. “People were excited about it.”

Julie Rosenberg, MPH, Ariadne Labs’ Assistant Director of Project Management for Better Evidence, was impressed by CORE’s efforts: “An amazing effort, and the numbers are pretty astounding. What a difference you are making,” she said. She asked about what data CORE used to place their vaccination sites.

McCoy explained that with a federal data management base, CORE could see in real time where vaccinations were being done and where the demand was. For example, data showed a small clinic near the municipal border of Rio was being overwhelmed and CORE was able to intervene.

Rosenberg followed up. “Should you go where the demand is or where the (vulnerable) people are?”

“In Rio, thankfully, demand is high across all demographics,” McCoy responded. The only area where there was doubt was among the street or homeless population and efforts were made to reach this population.

Collaborative Principal Investigator Eric Goralnick, MD, MS, Associate Faculty at Ariadne Labs, asked McCoy about what CORE has learned from other vaccination efforts and employed in Brazil.

McCoy considered the question carefully. “I think there are a lot of similarities across the board but you can’t forget that even though CORE has a wealth of knowledge from the United States, ultimately, when you’re operating in another country, you have to be willing to accept that not everything you bring will manifest.”

Most importantly, “I would always keep culture in mind,” he said.

Key Takeaways

Vaccination organizations should stay flexible for the demands of a region and adapt as needs change.

They should form collaborative partnerships with local institutions.

Take note of local culture which plays a big role in acceptance and success. For example:

• Privacy screens were not deemed essential in Brazil but were vital in Haiti and India.
• Cleaners, who moved constantly throughout the site for sanitation, were essential in Brazil.
• Electronic record keeping was adopted more readily in India than Brazil
• Paid scribes, as well as nurses, were used in Brazilian sites.