Sarampo e pólio: o perigo real de não ser vacinado

Sarampo e pólio

Sarampo e pólio: Campanha do Ministério da Saúde tenta reduzir uma das mais baixas coberturas vacinais na história do país. Mas adultos ficam de fora

Febre, conjuntivite e pequenas manchas avermelhadas espalhadas pelo corpo. O sarampo, uma das doenças mais contagiosas que se conhece, está de volta. E desta vez não só no Velho Mundo: a tragédia que acometeu a Europa em 2017 ameaça se repetir no Brasil. Em fevereiro deste ano, o caso de um bebê venezuelano com sarampo registrado em Boa Vista, capital de Roraima, preocupou as autoridades. Desde esse mês até agosto, já foram confirmados 1100 casos da doença, considerada erradicada do país desde 2015.

A maioria está concentrada na Região Norte, nos estados do Amazonas (71,6%) e Roraima (25,5%), que enfrentam surto da doença. Mas há casos isolados no Rio de Janeiro, São Paulo, Rio Grande do Sul, Rondônia e Pará. Se a população não se vacinar, o risco de uma epidemia generalizada de sarampo é alto. Pior: a menor cobertura vacinal dos últimos dezesseis anos aumenta o risco do retorno de outras doenças erradicadas, como a poliomielite, a rubéola e a difteria.

Baixa cobertura vacinal

Para uma pessoa ser considerada imunizada contra o sarampo, são necessárias duas doses da vacina. Em 2017, a cobertura vacinal da primeira dose, cujo imunizante aplicado é o tríplice viral, que protege não só contra o sarampo, mas também contra caxumba e rubéola, foi de 85,2%. Já a segunda dose, a tetra viral, que, além da imunização contra as doenças citadas, confere proteção contra a catapora, foi de apenas 69,9%.

Conta a poliomielite, a cobertura vacinal no ano passado foi de apenas 77%. O único estado brasileiro a atingir a meta em 2017 foi o Piauí. O Amapá teve o menor índice, com 60,30%. Ainda mais grave: 312 municípios não vacinaram nem metade das crianças menores de 1 ano.

Essas taxas estão bem abaixo dos 95% recomendados pela Organização Mundial da Saúde (OMS) para manutenção da erradicação, eliminação ou controle de doenças imunopreveníveis, ou seja, que podem ser evitadas com vacinação. Pior ainda: estão abaixo da taxa de países da Europa que viram os casos da doença explodir no ano passado – em 2017 a Europa viu os casos de sarampo aumentarem 400% e contava com quinze países no vergonhoso rol dos que voltaram a sofrer com a enfermidade antiga. Na Itália, o segundo país na liderança dos mais afetados pelo sarampo, a taxa de vacinação era de cerca de 86%.

Graças ao Programa Nacional de Imunização, em vigor desde 1973, o Brasil sempre teve vacinação considerada alta (acima de 90%) e era tido como exemplo na erradicação de doenças. Em 1994, o país recebeu da OMS o certificado de eliminação da poliomielite e em 2016, do sarampo e da rubéola.

No entanto, a queda nos últimos anos ameaça essa realidade. Diz o infectologista Artur Timerman, presidente da  Sociedade Brasileira de Dengue e Arboviroses: “A volta do sarampo é resultado do sucateamento da saúde pública. Qualquer cobertura, de qualquer vacina, tem que ser superior a 90%. Como deixamos chegar a uma cobertura tão baixa? Todos erramos. Governo e sociedade”.

Movimento antivacina

A queda na taxa de vacinação é resultado de uma combinação de fatores, incluindo o aumento do movimento antivacina. Originário dos Estados Unidos, ele se disseminou pela Europa e chegou ao Brasil. Ao menos quatro grupos no Facebook sobre o assunto juntam cerca de 15.000 seguidores. Esses fóruns contribuem para a circulação de notícias falsas na internet e no WhatsApp questionando a segurança e eficácia das vacinas. Os argumentos obscuros de adeptos da causa, que rejeitam se vacinar ou vacinar seus filhos, incluem a crença de que remédios homeopáticos dariam conta do recado e crianças nascidas de parto normal teriam os anticorpos necessários para qualquer tipo de proteção.

O mais estapafúrdio argumento recorre à tese do gastroenterologista inglês Andrew Wakefield. Em 1998, o médico publicou, na prestigiosa revista científica The Lancet, um artigo em que associou a vacina tríplice (contra caxumba, rubéola e sarampo) a um risco aumentado de autismo. No estudo, Wakefield dizia ter acompanhado doze crianças que desenvolveram a doença depois de tomar a tríplice. Sonegou duas informações: já havia indícios de autismo nas crianças e o médico preparava um processo contra um fabricante de vacinas. Desmascarado por uma reportagem do jornal The Sunday Times, Wakefield foi investigado pelo Conselho Médico Geral do Reino Unido. Em 2010, sob acusação de fraude, perdeu o registro profissional. A The Lancet pediu desculpas e retirou a publicação de seus arquivos. Mas o estrago estava feito: muitos acreditaram na lenga-lenga de Wakefield – e os reflexos são sentidos agora.

Entretanto, segundo especialistas, a força do movimento antivacina não é grande o bastante para ter um impacto tão alto na redução da taxa de vacinação. Diz Isabella Ballalai, presidente da Sociedade Brasileira de Imunizações: “O brasileiro não foge de vacina. As imensas filas formadas no verão para se imunizar contra a febre amarela são prova disso. Mas ele não valoriza o perigo”.

Doenças podem voltar

Por mais contraditório que pareça, o sucesso do programa nacional de imunizações é apontado como um dos responsáveis por essa falsa sensação de segurança da população. A erradicação das doenças, alcançada por anos de política de vacinação em massa, fez com que o brasileiro se esquecesse da gravidade dessas doenças e se descuidasse da vacinação. No entanto, a ausência da circulação do vírus no país não significa que não há risco de infecção. Uma determinada vacina só não é mais necessária quando a doença está erradicada no mundo. Até hoje, isso só aconteceu com a varíola.

É preciso lembrar que doenças como sarampo, difteria, coqueluche, tuberculose e poliomielite ainda não foram extintas. Algumas delas são bastante frequentes em determinadas regiões do mundo e o alto fluxo de pessoas aumenta o risco de uma delas viajar de um país a outro na carona de uma pessoa não imunizada. Se as pessoas do local de destino não estiverem devidamente imunizadas, o estrago está feito.

Foi o que aconteceu com o sarampo no Brasil. A doença é tão contagiosa que se dez pessoas tiverem contato com uma pessoa infectada, nove vão adoecer. Outros motivos apontados como responsáveis pela redução da taxa de vacinação são: o desconhecimento individual sobre a importância e benefícios das vacinas e o horário de funcionamento das unidades de saúde, incompatíveis com as novas rotinas da população.

Campanha de vacinação

Com o objetivo de reverter esse cenário e impedir que o sarampo se espalhe pelo país e a volta da pólio, o Ministério da Saúde iniciou nesta semana umacampanha de vacinação em massa. De 1 a 31 de agosto, a meta é imunizar 95% das 11,2 milhões de crianças com idade entre 1 ano e menores que 5 anos, independentemente da situação vacinal. Isso significa que mesmo aquelas crianças que já se vacinaram devem comparecer ao posto de saúde para receber uma dose de reforço.

Nesse caso, o esquema vacinal será um pouco diferente do tradicional. Por exemplo, crianças que nunca foram imunizadas contra a pólio vão receber a vacina inativada poliomielite (VIP), na forma injetável. Crianças que já receberam uma ou mais doses contra a pólio vão receber a vacina oral poliomielite (VOP), a famosa gotinha. Contra o sarampo, todas as crianças na faixa etária estabelecida vão receber uma dose da tríplice viral, independentemente de sua situação vacinal, desde que não tenham sido vacinadas nos últimos trinta dias.

Diz Carla Domingues, coordenadora do Programa Nacional de Imunização: “As crianças, além de mais suscetíveis, são disseminadoras da doença. São elas que geram a capacidade de manter o vírus circulando. Por isso a campanha massiva é feita nessa população”.

A estratégia faz sentido. Uma campanha que abranja toda a população exige uma capacidade de logística e insumos que provavelmente não seria factível em tão pouco tempo. Portanto, é melhor focar em crianças pequenas, que não têm imunidade nenhuma contra o sarampo e a pólio, já que nunca entraram em contato com o vírus, do que em pessoas mais velhas. “A maioria da população dessa faixa etária já tem algum tipo de imunidade, seja por já terem tomado alguma dose da vacina ou por terem sido infectadas pelo vírus”, explica Carla.

Além disso, ao vacinar 95% da população infantil, alcança-se a chamada imunidade de rebanho: pessoas não imunizadas também ficam protegidas devido à redução da circulação do vírus, ao passo que não imunizar as crianças causa o efeito contrário, criando os bolsões suscetíveis – áreas com uma grande parcela da população que não está protegida, aumentando o risco de surto – como aconteceu em Roraima e Amazonas.

Por outro lado, a campanha deixa de fora os adultos, que embora sejam menos suscetíveis a essas doenças, quando infectados, apresentam sintomas mais intensos e têm um risco aumentado de complicações. As possíveis explicações para esse fenômeno incluem questões evolutivas – como essas doenças são típicas da infância, evolutivamente, o organismo infantil estaria mais apto a combatê-las – e imunológicas. Quanto mais jovem é um organismo, mais rapidamente o tecido linfoide, imunologicamente ativo, produz defesas. Além de reagir mais lentamente ao vírus, o sistema imunológico adulto reagiria de forma mais exacerbada. Por isso, os sintomas das doenças infantis costumam ser mais sérios em idade mais avançada.

O sarampo comporta riscos razoáveis, especialmente em adultos. Pode resultar em pneumonia e encefalite, entre outras complicações. A caxumba, a rubéola e a pólio, também começam a assumir características de males da idade adulta. Além disso, muitos adultos com idade entre 18 e 50 anos não tiveram doenças como sarampo ou caxumba, nem tomaram todas as doses necessárias para se proteger delas. Logo, diferentemente dos idosos, que provavelmente estão imunizados por terem sido expostos a essas enfermidades, a população adulta jovem representa uma janela perigosa. Portanto, a recomendação é unânime: adultos precisam atualizar seu calendário vacinal.

Quem já manifestou alguma dessas doenças está protegido porque quando o organismo entra em contato com um dos vírus causadores dessas moléstias, o sistema de defesa deflagra a produção de anticorpos – uma espécie de vacinação natural. “Na dúvida se tomou a vacina ou se teve a doença, o ideal é se vacinar”, ressalta a pediatra Isabella Ballalai.

Adultos também precisam se imunizar

Uma pesquisa conduzida em 2017 pelo instituto Ipsos MORI mostrou que 64% dos adultos não está com a vacinação em dia. Os recentes surtos de caxumba e hepatite A – doenças que podem ser prevenidas por meio de vacinas – em adultos evidenciam esse quadro. A questão é que a vacinação em adultos é um problema mais difícil de solucionar que a imunização de crianças. O calendário de vacinação adulto é mais recente que o infantil e falta conhecimento da população e do profissional de saúde sobre esse assunto. “Falta conscientização. Vacina é um procedimento que deve ser feito por toda a vida da pessoa”, alerta o infectologista Artur Timerman.

O vírus causador do sarampo tem enorme poder de disseminação. É transmitido por meio das vias respiratórias, sobretudo em espirros e tosses. Pode provocar pneumonia, diarreia e, em casos graves, cegueira, surdez e retardo mental. O primeiro passo para a criação da vacina foi dado na década de 50, quando os médicos John Enders e Thomas Peebles isolaram o vírus responsável pela doença e trabalharam com o microrganismo em cultura celular.

Até 1963, quando a imunização teve início, o sarampo era uma das principais causas de morte entre crianças. Hoje, a vacina (aplicada no primeiro ano de vida, com reforço a partir dos 15 meses de idade) salva meio milhão de crianças no planeta, anualmente. Também conhecida como paralisia infantil, a poliomielite é causada por um vírus que vive no intestino (poliovírus), atingindo crianças com menos de 4 anos, mas pode contaminar adultos também.

Polio

A poliomielite pode ser transmitida de uma pessoa para outra por meio de saliva e fezes, assim como água e alimentos contaminados. A maioria das infecções apresenta poucos sintomas, geralmente semelhantes às infecções respiratórias (febre e dor de garganta) e gastrintestinais (náusea, vômito e prisão de ventre). A forma paralítica da doença pode atingir cerca de 1% dos infectados pelo vírus, deixar sequelas permanentes e causar insuficiência respiratória — em alguns casos, levar à morte.

De acordo com o Ministério da Saúde, o último caso de poliomielite registrado no Brasil aconteceu em 1989. No mundo todo, o cenário da doença também melhorou radicalmente. O número de casos de polio em todo o globo caiu 99% desde 1988, passando de 350 000 para 406 notificados em 2013, segundo a OMS.

Embora não haja casos da doença no Brasil há 29 anos, a preocupação do ministério se justifica por alguns motivos. O vírus só é endêmico no Afeganistão, no Paquistão e na Nigéria mas, nos últimos três anos, circulou em 23 países e, em junho foi notificado um caso suspeito na Venezuela. Embora esse caso tenha sido descartado, o susto serviu como um alerta vermelho para o risco de volta da doença, devido à baixa cobertura da vacina.

 

 (Arte/VEJA)

Fronteira

No domingo 5, um juiz federal da 1ª Vara da Federal de Roraima determinou a suspensão do ingresso e a admissão de imigrantes venezuelanos no Brasil através da fronteira roraimense. A decisão previa ainda a vacinação compulsória de venezuelanos que já estejam no país. Na segunda-feira 6 a ministra Rosa Weber, do STF, rejeitou um pedido que havia sido feito em abril pelo governo do estado para fechar a fronteira. Roraima é o principal destino no Brasil de quem foge da crise econômica e política na Venezuela. Nos registros da Polícia Federal, mais de 2 400 pessoas entraram no estado nos dois primeiros meses deste ano. O governo alega que a entrada desordenada facilita o cometimento de crimes e pode representar perigo real à saúde pública. No entanto, em sua decisão, a ministra ressaltou que fechamento de fronteira cabe ao presidente da República. Vale ressaltar que o presidente Michel Temer já se pronunciou contra essa possibilidade.

No entanto, a decisão da ministra não revogou a determinação do juiz Helder Girão Barreto. Na segunda-feira (6), a fronteira foi fechada pela Polícia Federal no fim da tarde e só reabriu na terça (7), após dezessete horas de bloqueio, quando o Tribunal Regional Federal da 1ª Região (TRF1) derrubou a liminar a pedido da Advocacia-Geral da União (AGU). Os demais itens da liminar, como a vacinação obrigatória dos venezuelanos que já vivem em Roraima, continuam valendo.

Fonte: Veja.com

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