ORIGINAL ARTICLE
158 A q B as O almol. 2022;85(2):158-65 h p://dx.doi.o g/10.5935/0004-2749.20220071 ■
A q u i o s B a s i l e i o s d e
This con en is licensed unde a C ea i e Commons A ibu ions 4.0 In e na ional License.
Vascula e inal indings a e COVID-19 accina ion in 11
cases: a coincidence o consequence?
Achados ascula es e inianos pós acinação con a COVID-19 em uma
sé ie de 11 casos: coincidência ou consequência?
Le ícia S. C. da Sil a1 , Luciana P. S. Finamo 1, Gab iel C. And ade1 , Luiz H. Lima1 , Claudio Ze 2, C is ina Muccioli1,
Edua do P. Sa a 1, Paula M. Ma inho1,3, Julia Pe uchi4, Raiza D. de L. Oli ei a5, Lena Gi al 6, I onne Cha can6,
Alex Fonollosa6 , Jose D. Diaz7, Jane L. Da is7, Heloisa Nascimen o1,3,8 , Rubens Bel o J 1,3
1. Depa men o Oph halmology, Uni e sidade Fede al de São Paulo, São Paulo, SP, B azil.
2. Pon i icia Uni e sidad Ca ólica de Valpa aíso, Valpa aíso, Chile.
3. Ins i u o Paulis a de Es udos e Pesquisa em O almologia, Ins i u o da Visão, São Paulo, SP, B azil.
4. Visão Cen e , São Ma eus, ES, B azil.
5. Depa men o Oph halmology, Uni e sidade de São Paulo, São Paulo, SP, B azil.
6. Depa men o Oph halmology, BioC uces Bizkaia Heal h Resea ch Ins i u e, C uces Uni e si y Hospi al, Uni e si y o he Basque Coun y,
Ba akaldo, Spain.
7. Bascom Palme Eye Ins i u e, Uni e si y o Miami Mille School o Medicine, Miami, FL, USA.
8. Hospi al Municipal de Ba ue i, Ba ue i, SP, B azil.
Submi ed o publica ion: Oc obe 22, 2021
Accep ed o publica ion: Oc obe 28, 2021
Disclosu e o po en ial con lic s o in e es : None o he au ho s ha e any po en ial
con lic s o in e es o disclose.
Co esponding au ho : Heloisa Nascimen o.
E-mail: [email p o ec ed]om
App o ed by he ollowing esea ch e hics commi ee: In i a e Pesquisa Clínica
(# 3.975.953).
ABSTRACT | Pu pose: The p ima y pu pose o his s udy
was o assess ascula e inal indings empo ally ela ed o
COVID-19 accina ion. Wi h g ea e in o ma ion ega ding all
possible u u e ad e se e en s, we hope o unde s and he eal
dimension and ele ance o wha was p esen ed. Me hods: Ele-
en pa ien s wi h isual complain s a e COVID-19 accina ion
we e en olled. Da a on he ollowing we e included: age, sex,
accine, ime o symp om onse , sys emic indings, medical
his o y, bes -co ec ed isual acui y, and ocula indings by
sli -lamp biomic oscopy as well as mul imodal e inal imaging
(colo undus, ed- ee pho og aphy, spec al-domain op ical
cohe ence omog aphy, op ical cohe ence omog aphy angio-
g aphy, and luo escein-angiog aphy). Inclusion c i e ia we e
he p esence o oph halmologic signs wi hin 30 days a e he
i s o second dose o any COVID-19 accine. Resul s: O 11
pa ien s, i e had a e ial occlusion (45.4%), ou had enous
occlusion (36.4%), and wo (18.2%) had nonspeci ic ascula
al e a ions sugges i e o e inal ischemia such as co on-wool
spo s. The mean age was 57 (SD = 16; ange: 27-84) yea s.
The mean ime o symp oms onse was 10 (SD = 5.4; ange:
3-16) days. Nine pa ien s we e emale (81.8%). Sys emic isk
ac o s we e obse ed in 36.4% o pa ien s. Two pa ien s had
bo h neu ological and isual symp oms, wi h a e ial occlusion.
O e all, 36.4% pa ien s had COVID-19 in he p e ious yea . Se en
pa ien s (63.6%) ecei ed ChAdOx1 nCoV-19 (AZD1222) accine.
Conclusions: Ou da a sugges ha e inal e en s empo ally
ela ed o COVID-19 accina ion a e possible bu a e e y a e.
The ela ionship o hese e en s wi h pos -COVID-19 accina ion
wa an s u he a en ion o de i e a meaning ul conclusion.
Keywo ds: COVID-19; Co ona i us in ec ion; Vaccine; A e ial
occlusion; Venous occlusion; Susac synd ome
RESUMO | Obje i os: o p incipal obje i o des e es udo
oi desc e e pacien es com achados ascula es e inianos
empo almen e elacionados à acinação con a COVID-19.
Com maio no i icação de possí eis e en os ad e sos simila es,
espe amos comp eende a eal dimensão e ele ância do que
oi ap esen ado. Mé odos: Onze pacien es com queixas isuais
após acinação con a COVID-19 o am es udados. Os dados
analisados o am: idade, gêne o, ipo de acinação, empo de
apa ecimen o de sin omas, achados sis êmicos, an eceden es
pessoais, acuidade isual com melho co eção, biomic oscopia
e imagem e iniana mul imodal ( e inog a ia colo ida, ed- ee,
SD-OCT, OCTA e angio luo esceinog a ia). Os c i é ios de inclusão
o am a p esença de al e ações o almológicas oco idas den o
de 30 dias após a p imei a ou segunda dose de qualque acina
con a COVID-19. Resul ados: Onze pacien es o am incluídos:
5 com oclusão a e ial (45,4%), 4 com oclusão enosa (36,4%) e
2 (18,2%) com al e ações não especí icas ascula es suges i as de
Sil a LSC, e al.
159
A q B as O almol. 2022;85(2):158-65
isquemia e iniana como exsuda os algodonosos. A idade média
dos pacien es oi de 57 anos (DP=16; com in e alo de 27 a 84
anos). A média de empo de apa ecimen o de sin omas após a
acinação oi de 10 dias (DP=5,4; com in e alo de 3 a 16 dias).
No e dos onze pacien es e am do sexo eminino (81,8%). Fa o es
de isco sis êmicos o am obse ados em 36,4% dos pacien es.
Dois pacien es i e am sin omas neu ológicos e isuais, com
oclusão a e ial. 36,4% dos pacien es i e am in ecção p é ia
po COVID-19 no úl imo ano. Se e pacien es (63,6%) ecebe am
a acina ChAdOx1 nCoV-19 (AZD1222). Conclusões: nossos
dados suge em que e en os e inianos empo almen e ela-
cionados à acinação con a COVID-19 são possí eis, po ém
a os. A elação en e es es e en os pós- acinais exigem u u a
a enção an es de maio es conclusões.
Desc i o es: COVID-19; In ecções po co ona í us; Vacina;
Oclusão a e ial; Oclusão enosa; Sínd ome de Susac
INTRODUCTION
Se e e acu e espi a o y synd ome co ona i us-2
(SARS-CoV-2) has in ec ed millions o people globally,
causing he co ona i us disease 2019 (COVID-19) pan-
demic. This has esul ed in an unp eceden ed e o
o de elop accines agains his i us. As accines a e
now being in oduced globally, we ace he p ospec o
millions o people being accina ed wi h mul iple accine
ypes, many o which use new pla o ms.
Al hough highly e ec i e and well- ole a ed in mos
pa ien s, immuniza ion is no wi hou side e ec s. The
a es o mild acu e ad e se e en s epo ed in accine
egis a ion ials ypically ange om 10% o 30%(1).
Few s udies ha e epo ed ein and a e y e inal
occlusion, u ei is, acu e idiopa hic maculopa hy, acu e
macula neu o e inopa hy, Vog -Koyanagi-Ha ada dise-
ase, and mul iple e anescen whi e do synd ome a e
adminis a ion o di e en accines, such as hose o B
hepa i is, yellow e e , smallpox, In luenza, Neisse ia
meningi idis, and He pes Zos e (2-13).
Recen ly, Fowle e . al. epo ed a case o a 33-yea -old
male who p esen ed wi h unila e al cen al se ous
e inopa hy 3 days a e mRNA BNT162b2 accine
adminis a ion (P ize /BioNTech)(14). Mudie e al. epo -
ed a case o a 43-yea -old emale wi h asymp oma ic
COVID-19 in ec ion who de eloped panu ei is 3 days
a e he second dose o mRNA BNT162b2 accine
(P ize /BioNTech)(15). In addi ion, Book a al. epo -
ed bila e al pa acen al sco omas in a 21-yea -old
woman 3 days a e ecei ing he i s ChAdOx1 nCoV-19
(AZD1222) accine (Ox o d/As aZeneca)(16).
This s udy desc ibes a se ies o pa ien s wi h ascula
e inal indings, empo ally associa ed wi h COVID-19
accines, including inac i a ed SARS-CoV-2 accine
(Co onaVac), mRNA-1273 accine (Mode na), mRNA
BNT162b2 (P ize /BioNTech), and ChAdOx1 nCoV-19
(AZD1222) accine (Ox o d/As aZeneca).
METHODS
In Ma ch 2021, a s udy g oup o ocula ad e se
e en s a e SARS-CoV-2 accina ion was c ea ed in São
Paulo, B azil, ollowing su eillance and exchange o
in o ma ion. Ele en pa ien s wi h isual complain s a e
COVID-19 accine we e s udied. Inclusion c i e ia we e
as ollows: p esence o oph halmologic signs wi hin 30
days a e he i s o second dose o any COVID-19
accine.
Da a on he ollowing we e collec ed: age, sex,
ype o accine ecei ed, ime o symp om onse a e
accina ion, p esence o absence o sys emic indings,
medical his o y (including p e ious COVID-19 in ec-
ion), bes -co ec ed isual acui y, and ocula indings
by sli -lamp biomic oscopy as well as mul imodal e inal
imaging (colo undus, ed- ee pho og aphy, SD-OCT,
OCTA, and luo escein-angiog aphy). We analyzed ca-
ses om Ma ch o Augus 2021 ha we e epo ed by
specialis s om B azil, USA, and Spain.
The s udy was app o ed by he Heal h E hics Commi ee,
and pa ien s ag eed o pa icipa e.
RESULTS
The mean age o pa ien s was 57 (SD = 16; ange:
27-84) yea s. The mean ime o symp om onse a e
accina ion was 10 (SD = 5.4, ange: 3-16) days. Nine
o ele en pa ien s we e emale (81.8%).
Sys emic isk ac o s we e obse ed in 36.4% o pa-
ien s. In addi ion, 36.4% pa ien s had COVID-19 in ec-
ion in he p e ious yea . Two pa ien s had bo h neu o-
logical and isual symp oms wi h a e ial occlusion, and
de ails on one o hem a e p esen ed in igu e 1.
Among he 11 desc ibed cases, i e had a e ial
occlusion (45.4%) (Figu es 1, 2, and 3), ou had enous
occlusion (36.4%), and wo (18.2%) had nonspeci ic
ascula al e a ions, sugges i e o e inal ischemia such as
co on-wool spo s (Figu e 4). The mos equen ly admi-
nis e ed accine was ChAdOx1 nCoV-19 (AZD1222),
wi h 7 o 11 o 63.6% o pa ien s ecei ing i . The
collec ed da a a e summa ized in able 1.
Vascula e inal indings a e COVID-19 accina ion in 11 cases: a coincidence o consequence?
160 A q B as O almol. 2022;85(2):158-65
DISCUSSION
Al hough i may seem in ui i e ha agen s in ended
o ac i a e he immune sys em may lead o he de e-
lopmen o unin ended immune ac i a ion and in lam-
ma o y ad e se e en s in some pa ien s, he p ecise
mechanisms unde lying such e en s is s ill unclea (17).
Acu e e inal ascula occlusions a e common causes
o isual impai men . Re inal a e y and ein occlusions
a e associa ed wi h inc eased age and ca dio ascula
isk ac o s(18). The p esence o co on-wool spo s e-
p esen s ne e ibe laye in a c ions ha esul om
inne e inal ischemia, seconda y o he occlusion o
p ecapilla y a e ioles, and can occu in se e al sys emic
diseases(19).
In his s udy, we ound e inal ascula indings in 11
pa ien s a e COVID-19 accina ion, o which 7 (63.6%)
had no p e ious ascula isk ac o s. The p e alence o
e inal ein occlusions in p edominan ly whi e popula-
ions is 0.6%-1.2% (BRVO) and 0.1%-0.4% (CRVO), wi h
an incidence o 0.12% (BRVO) and 0.03% (CRVO) pe
Figu e 1. (A-E) Case 1. Mul imodal imaging o s udy pa ien ’s le eye a p esen a ion. A. Colo pho og aph o he
le eye demons a es in e io pe i o eal pallo o he macula egion, co esponding o ocal e inal a e y occlu-
sion. (B) Angiog aphy o he le eye demons a es widening o he o eal a ascula zone. (C and D) Swep -Sou ce
op ical cohe ence omog aphy o he le eye shows a hype e lec i e band a he le el o he inne nuclea laye
and ou e plexi o m laye wi h a enua ion o he unde lying inne segmen / ou e segmen (IS/OS), and OS/
e inal pigmen epi helium laye s (C) and hickening o he inne e inal laye s wi h shadow e ec on he ou e -
mos e inal laye (D), co esponding wi h pe icen al acu e middle maculopa hy associa ed wi h cen al e inal
a e y occlusion. (E) OCT angiog aphy e eals dec eased capilla y densi y in he macula egion, co esponding
o p e iously desc ibed indings.
A
D
C E
B
Sil a LSC, e al.
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A q B as O almol. 2022;85(2):158-65
yea . The es ima ed incidence o acu e CRAO is 1-2 pe
100,000 people pe yea o 0.001%(18).
Al hough a e, e inal asculi is has also been epo -
ed as an ad e se e en ollowing In luenza accina ion,
mainly in elde ly and emale pa ien s. This ad e se e en
is p obably associa ed wi h an inc ease in pos - accine
p oin lamma o y cy okines(7).
In he p esen s udy, wo women wi h a e ial
occlusion had neu ological symp oms, hea ing diso -
de s, and magne ic esonance imaging indings sugges-
i e o Susac synd ome; one had bila e al e inal occlu-
sion. Bo h had ecei ed he second dose o inac i a ed
SARS-CoV-2 accine (Co onaVac) jus 7 and 15 days
p io o isual symp oms, and bo h had a his o y o
COVID-19 in ec ion. I is unknown i COVID-19 his o y
inc eases he isk o side e ec s om he accine.
Vaccina ion as a igge o immunologically ela ed
ascula in lamma ion has been p e iously desc ibed.
Landa e al. desc ibed a case o an adul male who de e-
loped mul iple b anch e inal a e iola occlusions and
encephalopa hy ha occu ed 10 days a e smallpox
accina ion. This was hypo hesized o be Susac syn-
d ome induced by accina ion(2).
Figu e 2. (A-H) Case 4. Mul imodal imaging o pa ien ’s bo h eyes a p esen a ion. (A and B) Colo pho og aph o bo h
eyes demons a es di use pallo o he macula egion, co esponding o cen al e inal a e y occlusion. (C and D) Angio-
g aphy o bo h eyes demons a es hype luo escence due o papilla y leakage associa ed wi h he a eas o asculi is and
widening o he o eal a ascula zone. (E and F) Spec al-domain op ical cohe ence omog aphy o he igh eye (E) shows
he epi e inal memb ane associa ed wi h he diso ganiza ion o in a e inal s uc u es. Le eye (F) e ealed hickening o
he inne e inal laye s wi h shadow e ec on he ou e mos e inal laye s. (G and H) OCT angiog aphy e eals dec eased
capilla y densi y in he macula egion, co esponding o p e iously desc ibed indings.
A
C
E
B
D
F
Vascula e inal indings a e COVID-19 accina ion in 11 cases: a coincidence o consequence?
162 A q B as O almol. 2022;85(2):158-65
Figu e 3. (A and B) Case 2. Mul imodal imaging o pa ien ’s le eye a p esen a ion. (A). Colo pho og aph o he le eye demons a es
pe i o eal pallo o he macula egion, co esponding o he ocal e inal a e y occlusion. (B) Spec al-domain op ical cohe ence omo-
g aphy o he le eye e ealed a hype e lec i e band a he le el o he inne nuclea laye and ou e plexi o m laye wi h a enua ion o
he unde lying inne segmen /ou e segmen (IS/OS), and OS/ e inal pigmen epi helium laye s. (C and D) Case 3. Mul imodal imaging
o he pa ien ’s le eye a p esen a ion. (C) Colo pho og aph o he le eye demons a es di use pallo o he macula egion wi h a
“che y macula” appea ance, co esponding o cen al e inal a e y occlusion. (D) Spec al-domain op ical cohe ence omog aphy o
he le eye shows hickening o he inne e inal laye s wi h shadow e ec on he ou e mos e inal laye s. (E and F) Case 5. Mul imodal
imaging o he pa ien ’s le eye a p esen a ion. (E) Colo pho og aph o he le eye demons a es bo h enous and a e ial macula
b anch occlusions wi h macula edema. (F) Spec al-domain op ical cohe ence omog aphy o he le eye shows hype e lec i i y in
e inal ne e ibe laye , co esponding o in a e inal hemo hages and cys s in he inne nuclea laye as well as smalle pe i o eal cys s
associa ed wi h sub- e inal luid.
A
C
E
B
D
F
Sil a LSC, e al.
163
A q B as O almol. 2022;85(2):158-65
Figu e 4. (A and B) Case 6. Mul imodal imaging o he pa ien ’s igh eye a p esen a ion. (A) Colo pho og aph
o he igh eye demons a es supe o empo al in a e inal hemo hages wi h macula edema, co esponding
o b anch e inal ein occlusion. (B) Swep -sou ce op ical cohe ence omog aphy o he igh eye shows la ge
cen al cys s in he inne nuclea laye and smalle pe i o eal cys s associa ed wi h sub- e inal luid. (C and
D) Case 7. Mul imodal imaging o he pa ien ’s le eye a p esen a ion. (C) Colo pho og aph o he le eye
demons a es di use in a e inal hemo hages eme ging om he op ic disc wi h macula edema co espon-
ding o cen al e inal ein occlusion. (D) Swep -sou ce op ical cohe ence omog aphy o he le eye shows
la ge cen al cys s in he inne nuclea laye and smalle pe i o eal cys s associa ed wi h sub- e inal luid. (E
and F) Case 10. Mul imodal imaging o he pa ien ’s le eye a p esen a ion. (E) Colo pho og aph o he le
eye demons a es in a e inal hemo hages. (G and H) Case 11. Mul imodal imaging o he pa ien ’s le eye a
p esen a ion. (G) Colo pho og aph o he le eye demons a es in a e inal hemo hages wi hin he pos e io
pole and a co on-wool spo in e io o he op ic disc. (H) Spec al-domain op ical cohe ence omog aphy o
he le eye shows hype e lec i i y in he e inal ne e ibe laye , co esponding o in a e inal hemo hages
and sub- e inal luid.
A
C
E
G
B
D
F
H
Vascula e inal indings a e COVID-19 accina ion in 11 cases: a coincidence o consequence?
164 A q B as O almol. 2022;85(2):158-65
Table 1. Summa y o demog aphic, epidemiological, and clinical cha ac e is ics o all pa ien s
Case Sex Age Ci y/coun y
Vaccine
adminis e ed
Symp oms onse a e
accina ion (days) Sys emic indings
Type o e inal
mani es a ion
Sys emic
isk ac o s
P e ious
COVID-19
1Female 27 São Paulo,
B azil
Co ona ac,
Sino ac
14 Men al con usion,
amnesia, pa es hesia,
inni us, c anial RMI
wi h hype signal in
whi e ma e
A e ial None Yes (COVID-19
1 yea ago)
2Female 57 São Paulo,
B azil
Co ona ac,
Sino ac
15 Hea loss, headache,
lep omeningi is,
bila e al cochlea
hea ing loss
A e ial None Yes
(COVID-193
mon hs ago)
3Female 84 Espí i o San o,
B azil
Ox o d/
As aZeneca
16 None A e ial Sys emic
a e ial
hype ension
and bila e al
ca o id
a he oscle osis
No
4Female 74 Miami, Flo ida,
USA
Mode na 3 None A e ial None No
5Female 39 São Paulo,
B azil
Ox o d/
As aZeneca
3 None A e ial Pso iasis
wi h p e ious
use o
me ho exa e
Yes (COVID-19
1 yea be o e)
6Female 66 São Paulo,
B azil
Ox o d/
As aZeneca
16 Headache Venous Hys e ec omy
4 mon hs
ago due o
endome ial
hype ophy,
inc eased
BMI, and
inc eased
apolip o ein a
No
7Male 51 Bilbao, Spain P ize 6 None Venous None Yes
(COVID-19 10
mon hs ago)
8Male 66 São Paulo,
B azil
Ox o d/
As aZeneca
4 None Venous Sys emic
a e ial
hype ension
No
9Female 54 São Paulo,
B azil
Ox o d/
As aZeneca
10 None Venous None No
10 Female 56 São Paulo,
B azil
Ox o d/
As aZeneca
10 None Non-pe usion None No
11 Female 50 São Paulo,
B azil
Ox o d/
As aZeneca
15 None Non-pe usion None No
This case se ies has some limi a ions. We desc ibed
pa ien s om di e en coun ies (B azil, USA, and Spain)
who ecei ed di e en accines. The mRNA-1273 (Mo-
de na) and mRNA BNT162b2 (P ize /BioNTech) accines
a e based on mRNA ha encodes a SARS-CoV-2 spike
p o ein, whe eas he Co onaVac (Sino ac Li e Sciences,
Beijing, China) comp ises inac i a ed SARS-CoV-2 i us.
In con as , he ChAdOx1 nCoV-19 (AZD1222) accine
(Ox o d/As aZeneca) uses a chimpanzee adeno i-
us-based ec o . The mos common accine among
he pa ien s was ChAdOx1 nCoV-19 (AZD1222) accine
(Ox o d/As aZeneca), bu he small sample size and
a ailabili y o di e en accines among cen e s limi ed
ou abili y o link he e inal e en s o a speci ic accine.
An igenic c oss- eac ions, immedia e hype sensi i i y,
and deposi ion o immune complexes di ec ly ela ed
o he accine a e hypo hesized as explana ions o
he pa hophysiology o e inal ascula occlusions a e
COVID-19 accina ion; howe e , he e is no con i med
mechanism(3). Ano he heo y implica es adju an s ha
enhance he immunogenici y o accine an igens and
may inc ease he isk o au oimmune side e ec s(20). The
mRNA-1273 (Mode na) and mRNA BNT162b2 (P ize /
BioNTech) accines use lipid nanopa icles, whe eas he
inac i a ed SARS-CoV-2 accine (Co onaVac) uses alu-
minum as adju an s. The ChAdOx1 nCoV-19 (AZD1222)
accine (Ox o d/As aZeneca), which was mo e common
among ou pa ien s, does no comp ise adju an s.
Sil a LSC, e al.
165
A q B as O almol. 2022;85(2):158-65
The e we e wo cases o e inal hemo hages and
co on-wool spo s, occu ing 10 and 15 days, espec i-
ely, a e he i s dose o Ox o d-As aZeneca accine,
bo h in women. Repo edly, e inal hemo hages occu
in child en a e ou ine accina ions(21), and co on-wool
spo s occu a e smallpox accina ion(2). Na u al
COVID-19 in ec ion has also been epo ed o be asso-
cia ed wi h e inal and i eous abno mali ies, such as
co on-wool spo s, ou e e ina changes, and i i is(22,23).
Al hough we canno exclude he ac ha he e inal
e en s we e coinciden al and ela ed o sys emic isk
ac o s in 4 o 11 (36.4%) pa ien s, he e was a e y
s ong ela ionship be ween accina ion and e inal
ascula e en s a a mean o 10 days a e accina ion.
The COVID-19 pandemic is p opelling he global accine
numbe o an unp eceden ed le el. I is possible ha we
will ha e an inc easing numbe o ocula e en s, which
may o may no be caused o no by accina ion, and i is
o g ea impo ance o desc ibe new indings. To he bes
o ou knowledge, no o he s udy has desc ibed cases
o such e inal mani es a ions ollowing COVID-19 ac-
cina ion in he li e a u e. Only u u e obse a ion o an
inc ease in he incidence o hese e en s, h ough obus
epidemiological su eys, will help be e elucida e he
causali y o hese indings wi h COVID-19 accina ion.
The speed o global accina ion agains COVID-19
is unp eceden ed. Ou da a sugges ha e inal e en s
wi h a empo al associa ion a e COVID-19 accina ion
a e possible bu e y a e. We ale oph halmologis s
and clinicians abou he need o in es iga e suspec ed
cases and ca e ully sea ch o p eexis ing condi ions
ha migh explain he e inal ascula e en s, so ha
ea men can be a anged i needed. In addi ion, epo -
ing a e e en s o cen al agencies such as he Vaccine
Ad e se E en Repo ing Sys em in he Uni ed S a es and
B azilian Heal h Regula o y Agency can help supply e-
qui ed epidemiologic e idence ega ding whe he hese
ascula e en s a e mo e common a e COVID-19. The
immunologic basis o accine- ela ed e inal ascula
e en s dese es u he explo a ion.
ACKNOWLEDGMENTS
This s udy was suppo ed by CNPq ede i us MCT
and CAPES.
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