Vaccine Hesitancy is a highly complex phenomenon that benefits from analyses conducted through various lenses and perspectives. We are pleased with the selection of the debaters, each bringing a unique perspective from institutions in different regions of the country and diverse fields of knowledge. We thank Tatiana Minchoni and Lia Schucman¹1 Minchoni T, Schucman LV. “Eu não preciso de vacinas”: raça, classe e território como posições decisórias para saúde coletiva. Interface (Botucatu). 2024; 28. doi: 10.1590/interface.240212.
https://doi.org/10.1590/interface.240212... ; Tatiane Leal²2 Leal T. Saúde e distinção: uma análise interseccional da recusa à vacinação. Interface (Botucatu). 2024; 28. doi: 10.1590/interface.240214.
https://doi.org/10.1590/interface.240214... ; Gustavo Matta, Ester Paiva, and Celita Rosário³3 Matta G, Paiva E, Rosário C. Hesitação vacinal e interseccionalidade: reflexões para contribuir com as práticas e políticas públicas sobre vacinação. Interface (Botucatu). 2024; 28. doi: 10.1590/interface.240226.
https://doi.org/10.1590/interface.240226... ; and Deisy Ventura⁴4 Ventura DFL. A não vacinação infantil no contexto de insurreições extremistas e de redimensionamento da propaganda contra a saúde pública. Interface (Botucatu). 2024; 28. doi: 10.1590/interface.240187.
https://doi.org/10.1590/interface.240187... for their insightful analysis of our article⁵5 Matos CCSA, Tavares JSC, Couto MT. “Eu vivo num mundo muito burguês, não moro na periferia”: não vacinação infantil e a intersecção entre raça, classe e gênero. Interface (Botucatu). 2024; 28. doi: 10.1590/interface.230492.
https://doi.org/10.1590/interface.230492... .

The comments from the debaters all focused on one common theme: the impact of the COVID-19 pandemic and political polarization on perceptions and opinions about vaccines. According to Leal²2 Leal T. Saúde e distinção: uma análise interseccional da recusa à vacinação. Interface (Botucatu). 2024; 28. doi: 10.1590/interface.240214.
https://doi.org/10.1590/interface.240214... , the politicization of vaccines in Brazil during the health crisis exposed pre-existing movements. Studies have also examined the link between political ideology and COVID-19 vaccination in Brazil⁶6 Seara-Morais GJ, Avelino-Silva TJ, Couto M, Avelino-Silva VI. The pervasive association between political ideology and Covid-19 vaccine uptake in Brazil: an ecologic study. BMC Public Health. 2023; 23(1):1606.^,77 Paschoalotto MAC, Cima J, Costa E, Almeida SA, Costa JG, Santos JV, et al. Politics and confidence toward the Covid-19 vaccination: a Brazilian cross-sectional study. Hum Vaccin Immunother. 2024; 20(1):2318139.. A study by Seara-Morais et al.⁶6 Seara-Morais GJ, Avelino-Silva TJ, Couto M, Avelino-Silva VI. The pervasive association between political ideology and Covid-19 vaccine uptake in Brazil: an ecologic study. BMC Public Health. 2023; 23(1):1606. revealed a strong connection between support for President Bolsonaro in the 2018 and 2022 elections and reluctance to get vaccinated against COVID-19, particularly in areas with lower Human Development Index. This indicates that political ideology has influenced vaccine hesitancy, creating new challenges for vaccination programs requiring government and civil society collaborative efforts.

We emphasize the meticulous design of the research project that gave rise to the article under discussion⁵5 Matos CCSA, Tavares JSC, Couto MT. “Eu vivo num mundo muito burguês, não moro na periferia”: não vacinação infantil e a intersecção entre raça, classe e gênero. Interface (Botucatu). 2024; 28. doi: 10.1590/interface.230492.
https://doi.org/10.1590/interface.230492... . Initiated in 2019, before the COVID-19 pandemic, the project was aimed at investigating the movements of (non-)vaccination concerning routine childhood vaccines. The subsequent amendment, submitted to the Research Ethics Committee, allowed us to incorporate questions about the influences of COVID-19 on parents’ perceptions of vaccines and decisions regarding (non-)vaccination, thereby enriching our understanding of this complex issue.

Conducting the research in this context led to the production of rich data on the influence of COVID-19 on childhood vaccination, resulting in an article on this subject⁸8 Matos CCSA, Avelino-Silva VI, Couto MT. The politicisation of vaccines and its influence on Brazilian caregivers’ opinions on childhood routine vaccination. Cienc Saude Colet [Internet]. 2023 [citado 26 Jul 2024]. Disponível em: http://cienciaesaudecoletiva.com.br/artigos/the-politicisation-of-vaccines-and-its-influence-on-brazilian-caregivers-opinions-on-childhood-routine-vaccination/18959?id=18959
http://cienciaesaudecoletiva.com.br/arti... . The findings, based on interviews with parents of young children in Florianópolis (SC) and São Luís (MA), reveal that, regardless of prior positions on vaccines, the political-health event of the COVID-19 pandemic shook beliefs, meanings, and attitudes towards childhood vaccination. There was no single trend in this disruption; on the contrary, among families hesitant about routine childhood vaccines, some had their hesitancy reinforced by controversies surrounding the COVID-19 vaccine, while others reconsidered their hesitant position in light of the importance of vaccines for controlling the pandemic. Similarly, among families who fully vaccinated their children, some remain steadfast in their pro-vaccine stance, while others specifically hesitate regarding the COVID-19 vaccines, which may (or may not) lead these families to question and doubt routine childhood vaccines.

We emphasize that, as the debaters mentioned, the article analyzes narratives from parents in Florianópolis (SC), a fact considered in the analysis. As Ventura⁴4 Ventura DFL. A não vacinação infantil no contexto de insurreições extremistas e de redimensionamento da propaganda contra a saúde pública. Interface (Botucatu). 2024; 28. doi: 10.1590/interface.240187.
https://doi.org/10.1590/interface.240187... pointed out, the state of Santa Catarina is a key Bolsonaro stronghold and stood out in the opposition to mandatory COVID-19 childhood vaccination. However, contrary to what might be expected, vaccine-hesitant parents in Santa Catarina who participated in our research made a point of reaffirming their opposition to the Bolsonaro movement, emphasizing that they are not anti-vaccine or anti-science, even ridiculing conspiracy comments made by then-President Jair Bolsonaro about COVID-19 vaccines⁸8 Matos CCSA, Avelino-Silva VI, Couto MT. The politicisation of vaccines and its influence on Brazilian caregivers’ opinions on childhood routine vaccination. Cienc Saude Colet [Internet]. 2023 [citado 26 Jul 2024]. Disponível em: http://cienciaesaudecoletiva.com.br/artigos/the-politicisation-of-vaccines-and-its-influence-on-brazilian-caregivers-opinions-on-childhood-routine-vaccination/18959?id=18959
http://cienciaesaudecoletiva.com.br/arti... . This is because, as discussed in the article, we deal with families who practice alternative health approaches and lead lifestyles connected to nature—or, as some call themselves, “alternative people”. As presented in a previous study involving high-income, highly educated couples in São Paulo (SP), the emphasis on a more natural and healthy lifestyle, free from excessive biomedical interventions, along with the questioning of the influence of commercial interests from pharmaceutical industries on vaccination policies, highlights the complexity of the motivations and beliefs that lead to non-vaccination in this family segment, reflecting a panorama of alternative health practices in the contemporary context⁹9 Couto MT, Barbieri CLA. Cuidar e (não) vacinar no contexto de famílias de alta renda e escolaridade em São Paulo, SP, Brasil. Cienc Saude Colet. 2015; 20(1):105-14..

Regarding the effects of COVID-19 on routine childhood vaccination, we draw attention to a point raised by Matta, Paiva, and Rosário³3 Matta G, Paiva E, Rosário C. Hesitação vacinal e interseccionalidade: reflexões para contribuir com as práticas e políticas públicas sobre vacinação. Interface (Botucatu). 2024; 28. doi: 10.1590/interface.240226.
https://doi.org/10.1590/interface.240226... : the infodemic. Undoubtedly, the internet and social networks were fundamental in spreading (mis)information about vaccines and play an essential role in the repeated exposure to false information once people encounter it. On the other hand, another article from this research showed that, despite mentioning the internet as a source of information, vaccine-hesitant parents in Florianópolis do not consider the internet a reliable source for acquiring information¹⁰10 Matos CCSA, Couto MT, Oduwole EO, Wiysonge CS. Caregivers' perceptions on routine childhood vaccination: a qualitative study on vaccine hesitancy in a South Brazil state capital. Hum Vaccin Immunother. 2024; 20(1):2298562.. It is the social groups that introduce and keep these parents in the universe of childhood non-vaccination—such as humanized childbirth groups during pregnancy, for example¹⁰10 Matos CCSA, Couto MT, Oduwole EO, Wiysonge CS. Caregivers' perceptions on routine childhood vaccination: a qualitative study on vaccine hesitancy in a South Brazil state capital. Hum Vaccin Immunother. 2024; 20(1):2298562.. Finally, in the article under debate⁵5 Matos CCSA, Tavares JSC, Couto MT. “Eu vivo num mundo muito burguês, não moro na periferia”: não vacinação infantil e a intersecção entre raça, classe e gênero. Interface (Botucatu). 2024; 28. doi: 10.1590/interface.230492.
https://doi.org/10.1590/interface.230492... , it is evident that access to information is understood by the interviewed families as a tool of power and privilege, as they speak other languages and know how to search for articles from renowned universities, almost as if this exempts them from being vulnerable to misinformation. In contrast, “others” do not have the resources to make such distinctions.

Another significant differentiation pointed out by the debaters is the exacerbation of the conflict between the individual and the collective, reflecting the complexity of the individual-society relationship in public health and highlighting the need to understand individual perceptions and decisions within the broader context of social and cultural, and political influences¹¹11 Couto MT, Barbieri CLA, Matos CCSA. Considerações sobre o impacto da Covid-19 na relação indivíduo-sociedade: da hesitação vacinal ao clamor por uma vacina. Saude Soc. 2021; 30(1).. As Minchoni and Schucman¹1 Minchoni T, Schucman LV. “Eu não preciso de vacinas”: raça, classe e território como posições decisórias para saúde coletiva. Interface (Botucatu). 2024; 28. doi: 10.1590/interface.240212.
https://doi.org/10.1590/interface.240212... mention, while vaccination is an act for the collective, the decision not to vaccinate occurs within the private/individual family sphere. Ventura⁴4 Ventura DFL. A não vacinação infantil no contexto de insurreições extremistas e de redimensionamento da propaganda contra a saúde pública. Interface (Botucatu). 2024; 28. doi: 10.1590/interface.240187.
https://doi.org/10.1590/interface.240187... , in her response, offers an interesting reflection on this by stating that the survival of the Brazilian National Health System (SUS) challenges neoliberalism, as its universal propositions contradict the logic of customized healthcare⁵5 Matos CCSA, Tavares JSC, Couto MT. “Eu vivo num mundo muito burguês, não moro na periferia”: não vacinação infantil e a intersecção entre raça, classe e gênero. Interface (Botucatu). 2024; 28. doi: 10.1590/interface.230492.
https://doi.org/10.1590/interface.230492... and compel some families to vaccinate their children. However, as Minchoni and Schucman¹1 Minchoni T, Schucman LV. “Eu não preciso de vacinas”: raça, classe e território como posições decisórias para saúde coletiva. Interface (Botucatu). 2024; 28. doi: 10.1590/interface.240212.
https://doi.org/10.1590/interface.240212... rightly note, which families are constrained? Those not supported by the structure of social inequalities: those who must present a vaccination card to access public daycare, those who fear the Child Protection Council, and those affected by state surveillance. Thus, we can say that the data show that state mechanisms affect families differently depending on markers such as social class, race, and geography.

This is how the act of (non-)vaccination emerges as a device of distinction, as aptly defined by Leal²2 Leal T. Saúde e distinção: uma análise interseccional da recusa à vacinação. Interface (Botucatu). 2024; 28. doi: 10.1590/interface.240214.
https://doi.org/10.1590/interface.240214... in her response. Despite all the inequities highlighted here by Matta, Paiva, and Rosário³3 Matta G, Paiva E, Rosário C. Hesitação vacinal e interseccionalidade: reflexões para contribuir com as práticas e políticas públicas sobre vacinação. Interface (Botucatu). 2024; 28. doi: 10.1590/interface.240226.
https://doi.org/10.1590/interface.240226... concerning vaccine access for vulnerable social groups, such as Black people and LGBTQIA+ individuals, it is among higher-income and more educated groups that we find the lowest vaccination coverage rates. This may be the core of the entire debate being conducted here: the issue of (non-)vaccination goes beyond misinformation or parental negligence, as pointed out by Leal²2 Leal T. Saúde e distinção: uma análise interseccional da recusa à vacinação. Interface (Botucatu). 2024; 28. doi: 10.1590/interface.240214.
https://doi.org/10.1590/interface.240214... and Ventura⁴4 Ventura DFL. A não vacinação infantil no contexto de insurreições extremistas e de redimensionamento da propaganda contra a saúde pública. Interface (Botucatu). 2024; 28. doi: 10.1590/interface.240187.
https://doi.org/10.1590/interface.240187... . The authors remind us that, globally, highly educated parents refuse to vaccinate their children. This prompts us to reflect on how to address the phenomenon of vaccine hesitancy since, as noted by the debaters, health education and scientific dissemination may be insufficient when faced with decision-making shaped by distinct and interconnected social markers.

It is also worth noting that the documents and guidelines developed by international health organizations to address vaccine hesitancy are based on “measuring” the so-called drivers of vaccination, continuously from the perspective of ‘measuring’ something to then ‘acting’ upon it¹²12 World Health Organization. Behavioural and social drivers of vaccination: tools and practical guidance for achieving high uptake [Internet]. Geneva: WHO; 2022 [citado 25 Jul 2024]. Disponível em: https://apps.who.int/iris/handle/10665/354459
https://apps.who.int/iris/handle/10665/3... . We ask: Is it possible to measure social representations based on individuals’ positions in the web of social markers that locate them in the world? How can we measure what is symbolic, for example, whiteness? Further, in unequal, racially and gender-segregated societies like Brazil, can we conceive of health policies appropriate to local realities without considering the sexist, classist, and racist structure that frames human relationships?

The idea that action should be taken on what is potentially modifiable is based on a reductionist understanding that non-vaccination is the result of misinformation. In this logic, vaccine hesitancy must be “combated” with solutions tailored to each group of drivers mapped by available measurement instruments. These interventions consist of ‘educating’, ‘informing’, ‘encouraging’, and ‘advising’, among other verbs that imply a non-dialogical process in which an active and a passive party is transmitting information. The findings of the study under discussion, based on the perspective of intersectionality, reinforce that passive education will not be sufficient to engage with social groups whose resistance to vaccination is embedded in a broader context of distrust in science (and vaccines) and the dissemination of misinformation, associated with the micro and macropolitical axes of racism, sexism, classism, and spatial segregation in an increasingly unequal society.

The Social and Human Sciences in Health allow us to look at the phenomenon of vaccine hesitancy with a different perspective, replacing the paternalistic and condescending approach that international health organizations¹¹11 Couto MT, Barbieri CLA, Matos CCSA. Considerações sobre o impacto da Covid-19 na relação indivíduo-sociedade: da hesitação vacinal ao clamor por uma vacina. Saude Soc. 2021; 30(1). have taken with a deeper and more layered historical, social, political, and cultural analysis as complex as the phenomenon itself. As Matta, Paiva, and Rosário³3 Matta G, Paiva E, Rosário C. Hesitação vacinal e interseccionalidade: reflexões para contribuir com as práticas e políticas públicas sobre vacinação. Interface (Botucatu). 2024; 28. doi: 10.1590/interface.240226.
https://doi.org/10.1590/interface.240226... rightly pointed out, it is essential to “less medicalize” the discussion surrounding (non-)vaccination, understanding it as a socially and historically determined phenomenon. Thus, we understand the decision-making process regarding (non-)vaccination of oneself or those under one’s care as a way of positioning oneself in the world, reflecting much more than mere opinions about vaccines.

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