The Most Vaccinated Country In The World

Alfama neighborhood in Lisbon, Portugal (2020). Photo by Veronika Jorjobert on Unplash.

As of September 4th, Portugal became the country with the highest share of people fully vaccinated against COVID-19 in the world.

Back in the winter of 2020, Portugal faced the first wave of the COVID-19 pandemic surprisingly well. Despite having the second highest percentage of citizens aged over 65 in Europe, following Italy, and a public health system crippled by the Economic Debt Crisis of 2008, Portugal managed to consistently keep its case fatality rate below 5% throughout 2020. The same could be said for Germany, Finland, Norway and Denmark — all European nations which were praised for their response against the pandemic.

It can’t be denied that luck played an important role in this success. Portugal was one of the last countries in southwestern Europe to be hit by the pandemic. It registered its first two cases on the 2nd of March, almost a month after the disease had spread in Spain, France and Italy. This delay allowed the Portuguese people to witness the downfall of more economically stable nations and brace for impact.

Portuguese citizens soon began social distancing, way before any guidelines had been put in place. “If Germany is struggling, imagine what will happen to us” was a common sentiment. The government soon declared a state of emergency and consequent lockdown on March 18th, two days after the first recorded death and with a total of 448 COVID-19 cases. Italy and Spain, by comparison, declared their states of emergency respectively on March 10th and 15th once they had gone way beyond a thousand reported cases. This quick action by the Portuguese government, which was also successfully employed by Greece, showed a strong success in limiting the initial spread.

The lockdown imposed in March wasn’t particularly restrictive. Although only essential businesses remained open, citizens could still commute to work, go out for individual outdoor exercises and grocery shopping. Only people who tested positive for the novel coronavirus (SARS-CoV-2) were obliged to stay home and could be charged with crime of disobedience if they failed to do so. The Portuguese people were overall responsible and respected the restrictions imposed, even during Easter celebration where travel between municipalities was temporarily restricted.

The fact that Portugal is a small nation with a centralized government allowed for a fast and relatively coordinated response, but it is safe to say that government action was made easy by a cooperative political opposition. The leader of the center-right Social Democratic Party (PSD) — Rui Rio — which represents the main opposition to the current government led by the center-left Socialist Party (PS), made it clear early on that he would cooperate with the government in the fight against the pandemic.

At the start of the new year, however, things took a turn for the worst. Over the month of January, Portugal become the country with the highest number of daily new confirmed COVID-19 cases per million people. The record was held for over half a month, and for a few days the same could be said for the number of daily deaths per million. Restriction’s fatigue had begun to settle among the public, but government complacency was the main reason behind the surge in cases.

One year into the pandemic, the Portuguese government had failed to fortify the health care system which began to collapse with the rise in cases. Over twenty thousand doctors and nurses had contracted COVID-19 by the end of January, and intensive care unit bed were running short. Case tracking systems were severely impaired, and the state-issued tracing mobile app was a failure. The government remains until today without a proper scientific advisory board, and as a consequence it took several decisions which predictably led to an increase in cases. Namely, it eased travel restrictions over the Christmas holidays and was reluctant to close schools until late January of 2021.

The winter was not particularly kind either. The Iberian Peninsula was strongly affected by storm Filomena in January, which brought heavy rain and snowfall to Portugal and Spain. Additionally, the SARS-CoV-2 alpha (B117) variant, which emerged in the United Kingdom, began to spread in Portugal. The Portuguese Prime-minister — António Costa — was quick to blame the new variant for the spike in cases, but the government was obviously to blame. With a second more restrictive lockdown in place and the people’s reluctant compliance, daily cases were forced down by the end of February. Meanwhile, vaccination against COVID-19 had begun across the globe.

Portuguese tram in Lisbon, Portugal (2020). Photo by Portuguese Gravity on Unsplashed.

In the European Union, the vaccine rollout was off to a slow start, when compared to that of the UK. The Union had been slower to both approve vaccines and establish purchasing contracts with pharmaceutical. To make matters worse, it had bet on some unsuccessful vaccines. Its Joint Procurement Program, which guaranteed that vaccines would be equally distributed across the twenty-seven nations, was now falling apart with Germany making bilateral deals and Hungary purchasing Russian and Chinese vaccines — not approved in the EU. It soon became clear though that the main problem with the European vaccine rollout was short supply.

By April 2021, AstraZeneca’s vaccine plant in Belgium had only delivered one quarter of the expected doses to the EU, due to production issues. At the same time, the company refused to divert doses made in the UK toward the EU to compensate for the delays — claiming they had a contractual obligation to provide the UK first. This led to a court battle between the EU and AstraZeneca which has recently been settled. Most important though, it prompted the EU’s decision to restrict vaccine exports and to increase vaccine production sites within the bloc. Once vaccine supplies were no longer a limiting factor, vaccination all over Europe began to ramp up and nowhere was this more evident than Portugal.

In less than one year, Portugal has fully vaccinated 85% of its population against COVID-19, making it the country with the highest share of fully vaccinated people in the world. The United Arab Emirates coming at a close second, still holds the title for the highest share of people having been given a first dose. Therefore, it will likely surpass Portugal in the upcoming weeks in the percentage off fully vaccinated people, but it nevertheless stands that Portugal has vaccinated practically every eligible citizen. Meanwhile, countries initially praised for their expedience are now lagging behind. With a population of barely over ten million people, it would be easy to dismiss Portugal’s achievement by arguing that it is faster to vaccinate a small population, but that would be a rash judgement.

The success of Portugal has been largely attributed to Vice-Admiral Henrique Gouveia e Melo, who has led the vaccination task force since February of 2021. Under his command the task force quickly expanded and standardized vaccination sites, forgoing traditional vaccination strategies used during flu-season. It automated vaccination scheduling by adopting text messages, online auto-scheduling and open-house venues. But most importantly perhaps was the decision to simplify the vaccination strategy by establishing only one priority group comprised of medical professionals, first aid responders and vulnerable elderly people. The remaining public was segregated by age groups, thus avoiding the prioritization of any district despite population density or case incidence. This ultimately allowed for the process to be as automatic and as fast as possible.

There were challenges of course: vaccine supplies remained irregular throughout the year, the new Delta variant, originally identified in India, spread easily in the country and there were constant changes to the guidelines regarding the AstraZeneca and Janssen vaccines. Small-scale protests against vaccines and the European Vaccination Certificate also erupted in Lisbon and Porto. However, Gouveia e Melo remained unfazed by these events providing an image of efficiency and stability.

Equally important to Portugal’s achievement was the public adherence to the vaccination program, including among younger people — despite being less vulnerable to the negative effects of COVID-19 themselves. Portugal is the country with the highest rate of vaccine confidence within the EU, according to the European Commission. It has also consistently reported one of the highest vaccination coverages for measles-containing vaccines within the EU. The public’s trust in vaccines, made stronger by the task force’s leadership was ultimately responsible for the continuing success of the vaccination program.

Other factors also played a role. Namely the adoption of the European Vaccination Certificate, which allows vaccinated EU citizens to easily travel within the bloc without having to show a negative COVID-19 test. The certificates contributed as a vaccination incentive all over the EU, even in countries where confidence is remarkably low such as France. But in the end, once vaccine supplies are no longer an issue, hesitancy becomes the bottleneck.

In Portugal vaccine hesitancy is low and, as a result, the vast majority of the population eligible to be vaccinated against COVID-19 has done so. The country is now able to send vaccines to Portuguese-speaking African countries, having donated already over four-hundred thousand doses. Restrictive measures are gradually being lifted as of October 1st and life is slowly going back to normal.

PS: All data regarding COVID-19 case fatality rates, daily new confirmed cases/deaths and vaccination rates is available at:

https://ourworldindata.org/coronavirus/country/portugal

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Gil Pires

Gil Pires

Junior Consultant | MSc in Biotechnology