With altered immunization plan, comorbidities can be left behind

With the decision by states and municipalities to prioritize teachers and security forces in vaccination against Covid-19, groups of people with comorbidities may be left behind in the immunization queue.

In the order of the national vaccination plan, diseases that increase the risk of worsening Covid-19, such as diabetes, hypertension, obesity, heart disease, lung and kidney diseases, would be in the third phase of vaccination, ahead of teachers and security forces , for example.

The group with comorbidities is the largest among the priority groups, totaling almost 17.8 million in the country, of which 4.8 million are in the state of São Paulo. Given the number of people, there is already an escalation between them, by the degree of severity, age or vulnerability, for example.

According to Jurandi Frutuoso, executive secretary of Conass (national councils of health secretaries), because it is a large group, it is likely that the staggering will occur by age, but the logistics are still being discussed.

For cardiologist Lília Nidro Maia, director of Sogesp (Society of Cardiology of the State of São Paulo), patients with diabetes, obesity and metabolic syndrome should be prioritized.

“This type of person, with multiple comorbidities, should go ahead because they have more risks. If you are going to prioritize only hypertensive patients, for example, they would be 60% of the Brazilian adult population.”

Maia explains that diabetes increases the risk of the infected person developing the severe form of Covid. Obesity, according to her, is one of the main risk factors for younger patients.

“Sometimes, we see the news: he died at the age of 24, he died at the age of 30. When he sees it, he is obese.”

Chronic kidney patients are also another group that should be given priority in immunization, according to experts. In addition to weak health, these patients need to travel three times a week to hemodialysis clinics, which leaves them more exposed to infection.

According to data from the Brazilian Society of Nephrology, there are more than 140,000 receiving dialysis in about 810 clinics across the country.

Nephrologist Ana Beatriz Barra, medical director of Fresenius Medical Care, says that, either by Covid or by the lack of assistance caused by the pandemic, the mortality rate of these patients is 25%, six percentage points above the historical average.

She says these patients have other comorbidities, such as diabetes and hypertension, which make them even more vulnerable to Covid. The majority (73%) are under 64 years of age and were not covered by vaccination by the age criterion.

And there is the fact that they cannot stay at home, in social isolation. “Most of them need to take public transport and face one, two, three hours of travel to get to the clinic. And they are getting infected and dying. They need to be vaccinated urgently”, says Gilson Silva, director of Abrasrenal, an entity representing patients.

According to him, several kidney patients have already died after contracting Covid. Others, recently transplanted, lost their organs and had to return to the dialysis machine. The entity still computes the numbers.

To get to the dialysis clinic in Vila Mariana (south zone of São Paulo), Carolina dos Santos, 21, takes an hour and takes the bus, train and two subway lines. He lives in Ermelino Matarazzo (east side).

“Driving is always overcrowded. It is insecure, even if I take all the precautions. I got Covid, I healed. But what if I get it again?”, He asks, saying that he has already lost colleagues on dialysis to victims of Covid. The nurses at the clinic where they are treated have not yet been vaccinated.

Cancer patients also ask for priority vaccination. A Brazilian study that followed 198 cancer patients who had Covid showed that 33 of them died, a mortality rate of 16.7%, six times more than the global coronavirus mortality rate of 2.4%.

“They are patients who tend to get more complicated if they acquire Covid, since they are already fighting cancer. They need to be prioritized in vaccination”, says oncologist Bruno Ferrari, founder and chairman of the board of directors of Oncoclínicas.

According to him, these patients are often undergoing cancer treatment, using immunosuppressive drugs, which cannot be stopped. “It is a patient who has to leave, go to the clinic, and is at greater risk of being infected.”

The Brazilian Society of Clinical Oncology sent a letter to the Ministry of Health requesting priority for these patients. It is estimated that 1.5 million Brazilians are undergoing cancer treatment.

For the doctor Rodrigo Olmos, professor of clinical medicine at USP and doctor at the University Hospital, within the comorbidities there are differences in risk for Covid and there should be a classification of their impact in each municipality.

For him, as the most common comorbidities, such as diabetes and hypertension, affect a large part of the adult population, an escalation by social vulnerability would be a good way out.

“Perhaps the risk of a person with a good socioeconomic level is less than someone who lives in the periphery, who lives in a situation of social vulnerability.”

For the epidemiologist Carla Domingues, who was at the head of the PNI (National Immunization Program) for eight years, the change in the order of priority groups is bad not only because it delays the vaccination of those who are more at risk of illness and death by Covid but it also impairs the monitoring of the impact of vaccination on different groups.

“Each hour has a state, a city, making a different policy. Many categories that work with the public should have priority, but we don’t have a vaccine. Our focus has to be to protect the most exposed groups, those that are dying the most.”

In his opinion, teachers who are in the home office and security forces in administrative positions should not be among the priority.

In a note, the Ministry of Health says that the anticipation of part of the priority group of security forces was discussed in the Tripartite Commission of Intergestors and agreed with Conass and Conasems (councils of secretaries of Health).

He also stressed that the national vaccination plan is subject to changes and that the guidance to states, municipalities and the Federal District is for local health managers to follow the established order of priorities.

Jurandi Frutuoso, from Conass, says that a minimum amount of vaccine was aimed at security forces who are on the front lines of the pandemic, such as rescuers, airline pilots and ambulance drivers who are transporting patients with Covid.

He says the decision was made because in April there will be more vaccines on offer.

The shipments, according to him, are around 25.4 million doses, which will be used to start new groups, the 5 million from 65 to 69 years old and the 9.3 million from 60 to 64 years old.

“By vaccinating this group, the group of comorbidities starts,” he says. This is expected to occur later this month, if the rate of vaccination is around 700 thousand doses / day.

For patients aged between 18 and 59 years and who present one or more of the comorbidities listed in the national vaccination plan, it will be necessary to prove the condition at the time of immunization (with exams, prescriptions or medical report, for example).

Comorbidities that qualify for the vaccine

Diabetes mellitus;
Severe chronic lung diseases, such as chronic obstructive pulmonary disease, cystic fibrosis, pulmonary fibrosis, pneumoconiosis, bronchopulmonary dysplasia and severe asthma;
Arterial hypertension;
Cardiac insufficiency;
Pulmonary hypertension;
Hypertensive heart disease;
Chronic coronary syndromes, such as ischemic heart disease;
Cardiomyopathies and pericardiopathies;
Diseases of the aorta, of the great vessels and arteriovenous fistulas, such as aneurysms and hematomas of the aorta;
Cardiac arrhythmias;
Congenital heart disease in adults;
Patients with prosthetic valves and implanted cardiac devices (such as pacemakers and cardiodefibrillators)
Cerebrovascular disease;
Chronic kidney disease;
Immunosuppressed, such as transplanted individuals, who use immunosuppressants or with primary immunodeficiencies;
Sickle cell anemia;
Morbid obesity;
Down syndrome

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