COVID-19 vaccination in Bulgaria

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COVID-19 vaccination campaign in Bulgaria
Native name Национален план за ваксиниране срещу COVID-19 в Република България
Date27 December 2020 (2020-12-27) – present
Locationnationwide
CauseCOVID-19 pandemic
Organised byBulgarian Ministry of Health, National Vaccination Operational Headquarters
Participants458,731 doses administered
(31 March 2021)[a]
Part of a series on the
COVID-19 pandemic
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The COVID-19 vaccination in Bulgaria is an immunization campaign currently taking place against SARS-CoV-2, the virus that is the cause of the COVID-19 disease. It began on 27 December 2020, in line with most other countries in the EU, and is in response to the ongoing pandemic in Bulgaria.

Background[edit]

After being one of the first countries in Europe to enter a lockdown, which came into effect on 13 March 2020, Bulgaria had mostly cluster-based transmission and a relatively low rate of infection compared to many other sovereign states on the continent up until mid June 2020 (when the vast majority of restrictions were lifted),[2] but was heavily hit during the autumn months, with the health system coming under severe strain,[3] resulting in a very high death toll per capita, especially for the month of November.[4] The authorities' handling of the pandemic has been criticized for insufficient levels of testing for the virus,[5] the nature of the policies in relation to the quarantining of foreign arrivals and the lax enforcement,[6][7] especially outside the capital city,[8] an absence of an adequate exit strategy after the first lockdown,[7][9] contributing to rather loose general measures against the spread of the virus during the summer of 2020,[10][11] poor preparedness of the country's health system for the second wave of the pandemic,[12] contradictory and inconsistent messaging,[5][13] downplaying the gravity of the epidemiological situation[14] as well as not following some of the recommendations of health experts[3][9] due to concerns that the imposition of tight measures, purportedly not resonating with the wishes of most of the population,[15] could pile on public pressure on the government,[5] which faced political protests from July 2020 to April 2021. Medical professionals and politicians have expressed the view that the second lockdown that entered into force just before midnight of 28 November 2020 should have come earlier.[16][17] Infection rates soared during March 2021, reaching the autumn levels, which prompted the government to impose a third lockdown from 22 to 31 March,[18] though this once again garnered criticism for being a reactive measure that was long overdue and followed the almost complete reopening of the economy in the previous weeks.[19][20] Prime Minister Boyko Borisov has been accused of prioritizing the interests of lobbies in the entertainment business and hospitality industries over those of health care establishments[21] as well as allowing political considerations relating to the spring elections to influence the nature of the policy decisions.[22] The Lowy Institute ranked Bulgaria 67th out of 98 countries in terms of its performance in tackling COVID-19, awarding it a score of 37.4.[23]

In the early months of the pandemic, there was speculation that the BCG vaccine,[24][25] of which the country is a major producer and which has been part of the mandatory vaccination package for newborns in Bulgaria since 1951,[24] offers some degree of protection against COVID-19,[25] with studies in the Netherlands suggesting that it serves as a powerful immune stimulator.[26] However, this has not been corroborated by most scientific sources[27] and the WHO maintains that there is so far a lack of evidence that the vaccine demonstrates effectiveness against COVID-19.[28]

A Bulgarian official printout given to a person who has received an Oxford–AstraZeneca vaccine.

Vaccines[edit]

Map of Bulgaria showing the vaccination rate as a percentage of each province's population as of 9th of April 2021.

Pre-orders of vaccines and procedural matters[edit]

European Union vaccine negotiations[edit]

Bulgaria eventually agreed to purchase all seven vaccines included in the European portfolio - Moderna, Pfizer-BioNTech, Oxford–AstraZeneca, Sanofi, CureVac, Novavax, and Johnson & Johnson-Janssen,[29] even though it had some reservations regarding its participation in the contract with Janssen Pharmaceutica.[30] On 14 October Bulgaria explicitly refused to pre-order the latter's vaccine candidate as part of the EU-wide deal,[31] but reversed course in November and ratified a separate agreement for 2 million doses in December, aided by Sweden's cooperation,[31] with the change of heart partly attributed to concerns pertaining to the progress made by Oxford-AstraZeneca at the time.[31] Some Bulgarian experts reportedly considered the European vaccine portfolio to be overly diverse.[31][32] After major delays due to trial issues of Sanofi and GlaxoSmithKline's vaccine candidate, for 2021 the country is mostly reliant on the Oxford–AstraZeneca COVID-19 vaccine, expecting to receive enough doses for vaccinating 2.5 million citizens.[33] After at first ordering 1 million doses from Pfizer-BioNTech, on 13 January 2021 when the European Commission announced that it had concluded an agreement for extra 300 million doses with this vaccine producer, Bulgaria requested additional 2.9 million Pfizer-BioNTech vaccines.[34] In total, the amount of vaccine pre-ordered or set to be ordered by the country is expected to be equivalent to 18 million doses, able to cover 9 million citizens.[35][36]

Vaccine availability issues and further deals[edit]

On 25 February 2021, Angelov publicly reproached AstraZeneca after it became clear that the pharmaceutical company will be able to provide 40% of the promised vaccines by August. Bulgaria had also offered to assist with the delivery of the next batch of vaccines by sending its own airplane, but this suggestion had not been accepted.[37] On the next day it was revealed that there is an alternative plan, which will entail receiving an extra 1 million Pfizer-BioNtech and 480 000 Moderna doses between March and June.[38]

On 28 February 2021, Boyko Borisov confirmed that Bulgaria had entered talks to borrow vaccines from EU countries where there is no queuing for them, so that Bulgaria does not have to halt its vaccination process.[39][40] On 1 March 2021, it was disclosed that Bulgaria had arranged for over 450 000 additional doses of the Moderna vaccine, as a result of a direct agreement with Sweden.[41]

In early March 2021, Bulgaria and five other EU countries (Slovenia, Croatia, Austria, Czech Republic, and Latvia) insisted that a new debate is initiated regarding the allocation of the vaccines within the EU bloc, with Boyko Borisov echoing Austrian Chancellor Sebastian Kurz's sentiment[42] that some EU states had received more vaccines than warranted by their population numbers.[43] On 13 March 2021, the European Commission sent out statement clarifying that some member states, with Bulgaria being implied to be among them,[44] had on their own accord deviated from the principle of pro rata allocation during the initial placing of orders for vaccines, freeing up additional doses for other countries.[45] Bulgaria is believed to have refrained from exercising its option of ordering 30 million doses in total.[46] On 26 March 2021, Croatian Prime Minister Andrej Plenković stated that Bulgaria should receive the most relative to the other countries out of the 10 million doses of Pfizer-BioNTech vaccines that will arrive in the second quarter of the year, earlier than scheduled, as a compensation for the production issues faced by AstraZeneca.[47] Even though Austria (that led the redistribution campaign), Slovenia and the Czech Republic rejected the eventual proposal that was arrived at,[48] in early April 2021, it was confirmed that Bulgaria (alongside Croatia, Slovakia, Latvia, and Estonia) will in addition to getting its pro rata allocation, also benefit from the sharing of 2.85 million "solidarity vaccines" (out of the 10 million doses) among these five countries.[49][50]

Other vaccines[edit]

According to Todor Kantardzhiev, one of the members of the National Operational Headquarters for the fight against the coronavirus, Bulgaria has not ruled out the purchase of vaccines from companies with which the European Commission has not negotiated contracts, such as Sputnik and Sinopharm, as long as EU regulations are observed[51] and especially if there is a delay regarding the delivery of the other vaccines.[52] On 26 February 2021, the opposition BSP party demanded that the government begin separate talks with Russia for the importation of the Sputnik vaccine.[53] Microbiologist Andrey Chorbanov has pointed out that the country already imports medications that are not regulated by the EU, so the thinking should not be different when it comes to the Russian vaccine.[54] The importing of vaccines from third countries has also been supported by the RzB party, even if the EU is bypassed.[55]

A COVID-19 vaccine based on nanoparticles is presently under development by the Bulgarian Academy of Sciences,[56][57] with a mostly completed prototype, but despite receiving financial support from the Pasteur Institute, issues related to funding are expected to significantly slow down the progress when it comes to the vaccine trials.[58]

Approved vaccines[edit]

Kostadin Angelov, the Minister of Health, has on a number of occasions reiterated that Bulgarians should be able to have a choice regarding the type of vaccine they are to receive.[59][60]

Three vaccines are currently available for limited use in Bulgaria.

The first to be administered in the country was Pfizer–BioNTech, which was approved by the European Commission on 21 December 2020, on the same day after receiving recommendation for granting conditional marketing authorization by the Committee for Medicinal Products for Human Use (CHMP) of the European Medicines Agency (EMA),[61] with the initial doses delivered to Bulgaria 26 December,[62] arriving from Belgium.[63]

On 6 January 2021, following the same regulatory procedure, the Moderna vaccine was also given the green light by the European Commission,[64] arriving in Bulgaria a week later.[65]

On 29 January 2021, Oxford–AstraZeneca vaccine received conditional authorization by the European Commission, paving the way for its use in EU countries.[66] On the same date, Bulgarian Minister of Health stated in an interview with Boyko Vasilev during the TV show Panorama that Bulgaria will wait for the results of further studies regarding its effectiveness when it comes to people over the age of 65 before administering it to members of this age group.[60] On 4 February 2021, Angelov clarified that there is no medical prohibition to give the vaccine to elderly people and that an additional statement will be made before Oxford-AstraZeneca begins to be administered.[67] The government eventually concluded that the vaccine is useful for elderly citizens as well and did not exclude them from receiving it.[68][69] The first batch of this vaccine reached Bulgaria on 6 February 2021.[70]

On 11 March 2021, the one-shot Johnson & Johnson-Janssen became the fourth vaccine to be conditionally approved on the EU level,[71] arriving in Bulgaria slightly over a month later.[72]

Vaccine Doses ordered[73][b] Approval Deployment
Pfizer–BioNTech 3.9 million Green check.svg 21 December 2020 Green check.svg 27 December 2020
Moderna 0.96 million Green check.svg 6 January 2021 Green check.svg 14 January 2021
Oxford-AstraZeneca 4.5 million Green check.svg 29 January 2021 Green check.svg 7 February 2021
Johnson & Johnson-Janssen 2 million Green check.svg 11 March 2021 Pending
Novavax 1.55 million Pending Pending
CureVac 1 million Pending Pending
Sanofi 4.65 million Pending Pending

Rollout schedule and vaccine priority groups[edit]

The national vaccination plan was unveiled in early December 2020 and includes five phases. For the purpose of the vaccination campaign, the country was subdivided into six regions (Vratsa, Veliko Tarnovo, Varna, Bourgas, Plovdiv, and Sofia).[74][75] Kostadin Angelov, the Health Minister, characterized it as a "dynamic plan" that could render itself to change in accordance with the situation and stated that Bulgaria drew on WHO guidance as well as the vaccination plans of Germany, France, Italy, Britain, and a number of US states, while also taking into account the specific conditions pertaining to Bulgarian health care, territory and infrastructure.[74] A National Vaccination Operational Headquarters, chaired by Krasimir Gigov, the general director of the Bulgarian Red Cross, was also established.[74] In January 2021, National Operational Headquarters for the fight against the coronavirus chairman Ventsislav Mutafchiyski specified that election commission members for the upcoming elections will also be considered priority groups for vaccinations.[76] In February 2021, it was confirmed that prosecutors, legal investigators and their staff fall within Phase 3 of the vaccination plan.[77] In the same month the national vaccination plan was further amended to allow for non-priority individuals to receive vaccines even prior to all the priority targets being covered, as long as certain conditions are observed.[78][79] The issue of vaccine hesitancy in Bulgaria is believed to have played a part in the structuring of the plan.[80]

Order Priority group Number eligible (estimated)[74]
1 medical personnel, pharmacists, dentists as well as members of staff in these fields who have assistant functions 243 600
2 staff and customers of social institutions, pedagogical specialists, people working on mink farms 112 080
3 people who are in charge of guaranteeing that activities essential for public life are able to take place not specified, will be based on lists compiled in advance
4 all those 65 years of age and over, and clinically vulnerable individuals due to underlying conditions, including immunocompromised and with reduced immunity 1.8 million
5 vulnerable groups from the population due to high epidemiological risk of infection attributable to their way of life not specified, will be based on lists compiled in advance

Challenges and logistics[edit]

On 5 December 2020, the first two ultracold freezers suitable for the storage of the Pfizer–BioNTech COVID-19 vaccine in accordance with the temperature requirements were installed at the Center for Infectious and Parasitic Diseases in the capital.[81] On 7 December, Bourgas became the second city in the country equipped with such a refrigerator,[82] followed by Plovdiv on 9 December[83] and Varna on the 18th.[84] Each freezer can hold more than 100 000 vaccine doses.[85]

A COVID-19 vaccination point at the University Hospital St. Ivan Rilski in Sofia, the first place in the country to offer 24 hour vaccinations.

The first vaccination site in the country was opened on 15 December 2020, being located in Sofia.[86] On 5 January 2021, four mobile units were set up, so that elderly people living in care homes in Sofia could be vaccinated in their places of residence.[87] Over 40 such vaccination units are expected to cover the whole country.[86][88] As of 18 February, 5 vaccination sites are available at Pirogov Hospital in the capital, with the medical facility also being in a position to provide 2 additional mobile units.[89] The total number of such vaccination points for the whole country had reached 352 by 23 February.[90] The first 24 hour vaccination center in the country began operating in Sofia on 21 February 2021, just outside the University Hospital St. Ivan Rilski,[91] followed by one in Plovdiv on 23 February.[92]

The Military Medical Academy in Sofia where former head of the National Operational Headquarters for the Fight against COVID-19 in Bulgaria Ventsislav Mutafchiyski has personally administered vaccines.

Chronology and vaccination process[edit]

Bulgaria was allocated 9750 doses of the Pfizer–BioNTech vaccine (sufficient for more than 4000 people) for December 2020 and they arrived in the country on the 26th of the month.[62] Just over 60 000 doses of this vaccine were expected to be available in January 2021.[62][93]

In early December 2020, President Rumen Radev vowed to get vaccinated only once there are no people waiting in line,[94] while Boyko Borisov stated he would have been eager to do it, but had antibodies after recovering from COVID-19 in November 2020.[95]

The first person to be vaccinated in Bulgaria was Minister of Health Kostadin Angelov, which occurred in the morning of 27 December in Sofia.[96] The second was Bulgarian Orthodox Church Bishop Tikhon, followed by a doctor and a nurse.[97] Over 1500 people, mostly medical personnel, had been vaccinated by the evening of 28 December.[98] By the late hours of 29 December, close to 3800 people had received a vaccine shot.[99] By the first day of the New Year, the number of vaccinated people had reached 4739.[100]

On 4 January 2021, the first batch of vaccines for this month arrived, numbering approximately 25 000 doses.[101] Unlike in the case of the first delivery of the vaccines, no specialized transport was needed for them, as they were received in boxes with dry ice, which could retain its properties for 5 days.[101] These vaccines were to cover the remaining front line medical personnel from the first phase as well as some social workers, social service users and educators (phase two priority groups).[102]

As of 11 January 2021,[c] 13,473 people had been vaccinated.[103][104]

The first Moderna vaccine doses reached the country on 13 January 2021, numbering 2400 and designated for priority groups in Sofia.[105] Тhe vaccinations with Moderna commencеd on the next day, with obstetrician Sofia Yordanova being the first one to receive it.[65]

As of 13 January 2021, approximately 16 500 vaccine shots had been administered.[106]

As of 27 January 2021, Bulgaria had vaccinated less than 35 000 citizens, which corresponded to 0.47 per 100 people, putting it in last place on a per capita basis among EU countries.[107]

Between 27 January and 30 January 2021, some residents and staff of care homes for elderly people in Sofia received their injections, though a substantial number opted out.[108][109]

As of 30 January 2021, 40 805 jabs had been administered, with 12 949 people receiving two doses.[110]

On 1 February 2021, educators and staff at kindergartens and schools began to be vaccinated.[111]

As of 4 February 2021, 94 920 vaccines had been delivered and 50 124 vaccine doses had been used, with 16 433 people having undergone the two-step vaccination process.[67]

On 6 February 2021, the first doses of Oxford-AstraZeneca, numbering 28 800, made their arrival in the country.[70] They began to be put to use on the next day, kickstarting Bulgaria's third phase of the vaccination campaign, which is to include members of the Central Electoral Commission and other people in charge of the procedural matters concerning the elections.[69][112] One of the first to receive it was 76-year old Ilina Bineva, an employee at the pharmaceutical company BulBio.[69]

On 8 February 2021, the National Vaccination Operational Headquarters announced that all of the so far delivered AstraZeneca vaccines will be used for administering the first doses to people, in order to cover larger segments of the population and speed up the vaccination campaign.[113]

On 19 February 2021, in what was regarded as the beginning of the mass vaccinations,[114] Boyko Borisov ordered (after discussions with members of the National Vaccination Operational Headquarters, the National Operational Headquarters for the fight against the coronavirus, and the Health Minister) that "green corridors" be established alongside the fourth phase of the vaccination plan,[115] allowing all adult citizens who do not fall within the priority groups to visit a vaccination point on Saturday, Sunday or the afternoon hours of working days[116] without the need for a prior appointment[117] and receive a first dose of the AstraZeneca vaccine.[118] The people who preferred one of the two approved RNA vaccines were to register at the Military Medical Academy and wait for a follow-up call once Pfizer-BioNTech or Moderna doses are available.[118] The Prime Minister insisted that at least 10 000 people are to be vaccinated per day.[115][118] Borisov's decision was viewed as in practice resulting in the abandonment of the phased approach to vaccinations.[118] The U-turn in the government's policies has been attributed to the need to expedite the vaccination process[118] and the vaccine reservations displayed by members of priority groups such as medical practitioners and educators, with only 24% of the latter expressing a wish to be vaccinated.[118] The changed approach sped up the tempo of the vaccinations, with more than 30 000 doses administered in the first three days since the opening of the "green corridors".[119][120]

However, while medical practitioners carried on with the vaccinations, even if at a reduced pace, in a number of smaller cities,[121] between 25 and 28 February[116] the "green corridors" were temporarily discontinued in Sofia and other large cities because of the country mostly running out of AstraZeneca vaccines,[122] with the remaining Pfizer-BioNTech and Moderna ones set aside for priority groups.[123]

After the arrival and distribution of 52 800 Oxford-AstraZeneca doses, the vaccinations involving non-priority targets resumed on 28 February.[116] In contrast to the previous days, they saw a significantly more active role of the general practitioners than of the health inspectorates and the large hospitals, proceeding only if there are no people from phases 1-4 willing to be vaccinated.[124]

On 8 March 2021, the Health Ministry took the decision to distribute a larger quantity of vaccines for the provinces where the infection rate is higher, such as Kyustendil.[125]

On 11 March 2021, the people who had registered via the electronic system for vaccinations began receiving their injections,[126] with all of them covered by either a Pfizer-BioNTech or a Moderna vaccine between 12 and 18 March due to a safety concern pertaining to AstraZeneca.[127] However, the booking of slots via the electronic registration system was put on hold, as the bulk of the vaccinations were to be with AstraZeneca.[128] Vaccinations with the adenovirus vector vaccine resumed on 19 March,[129] with the electronic registration option for new users restored on 20 March.[130]

During the month of March a significant number of physicians and teachers (falling within the first two phases of the vaccination plan) who had initially not made use of their priority status expressed a wish to be vaccinated.[131]

The month of April saw a much reduced interest in the AstraZeneca vaccine among the members of the general public,[132][133] with a strong preference for the RNA vaccines.[132][134] As a result of the plummeting popularity of AstraZeneca, described as sinking to "symbolic percentages" by the Health Minister, Kostadin Angelov stated on 12 April 2021 that Bulgaria will withdraw the vaccine from the vaccination programme if the enthusiasm for it reaches rock bottom.[135]

On 6 April 2021, general practitioners began receiving flasks of RNA vaccines for their patients, though the quantities were limited.[136]

On 15 April 2021, the first doses of Johnson & Johnson-Janssen, numbering 14 400, were delivered to Bulgaria, but they remained in storage,[72] as the National Vaccination Operational Headquarters in Bulgaria had not yet made a decision as to their use after the U.S. Centers for Disease Control and Prevention (CDC) and Food and Drug Administration (FDA) had earlier begun investigations of very rare cases of cerebral venous sinus thrombosis associated with this vaccine, with EMA also reviewing the matter.[137]

On 26 April 2021, Chief Health Inspector Angel Kunchev confirmed that Bulgaria will give the green light to the Johnson & Johnson vaccine and it may be especially useful for vaccinating certain groups, such as those employed within the tourism sector as well as demographics that are less easily reachable like the Romani people.[138]

An arrow guiding the people towards a COVID-19 vaccination point during the first mass vaccinations.

Medical aspects pertaining to the vaccinations[edit]

General considerations[edit]

Asparouh Iliev, a Bulgarian specialist in molecular neuroinfectiology from the University of Bern, has praised the two RNA vaccines, characterizing them as extremely safe and also regarding them as very similar to each other.[139] He pointed out that the AstraZeneca vaccine may actually be offering even better protection than shown from the preliminary studies and considered the whole comparison exercise between the three vaccines to be pointless, urging people to take up the opportunity to get themselves vaccinated.[140]

In April 2021, pulmonologist Kosta Kostov, while acknowledging the issue of vaccine reservations in Bulgaria, also stated that the narrative that all approved vaccines on the EU level are equally safe and effective is fallacious.[14]

Andrey Chorbanov, a member of the Institute of Microbiology at BAS and a leading figure behind the ongoing development of the Bulgarian vaccine,[141] while supportive of vaccinating vulnerable groups, maintains that naturally acquired immunity is much stronger than the vaccine-induced one, believing that the people who have recovered from COVID-19 have very durable immunity.[54] In his view, the major question mark surrounding the vaccines remains their actual effectiveness while their safety and the side effects are not an issue.[54] Similarly, immunologist Velizar Shivarov affirms that people who have antibodies can afford to wait to be vaccinated.[142] In February 2021, Todor Kantardzhiev, a member of the National Operational Headquarters for the fight against the coronavirus in Bulgaria, claimed that one vaccine dose may be sufficient for the people who have recovered from a COVID-19 infection.[143]

People who have recovered from COVID-19 may undergo the two-dose vaccination process no earlier than 3 months after the laboratory confirmation of their diagnosis.[144]

In the case of citizens who become infected after receiving their first injection (in the case of two-shot vaccines), the second dose of the vaccine is to be administered at least 6 months after the laboratory diagnosis has become official.[144]

The recommendations of the National Vaccination Operational Headquarters in Bulgaria are that the second dose of the Oxford-AstraZeneca vaccine be administered at least 10 weeks after the first.[145]

The mixing of different types of vaccines, especially when it comes to attempting to complete the second step of the vaccination process by using another vaccine, was initially not advised,[146] but was still considered a possibility, depending on the conclusions of further studies.[143]

In April 2021 the Health Minister clarified that Oxford-AstraZeneca will not be administered to women under the age of 60 with an elevated risk for thrombosis and/or a history of thrombocytopenia.[144] Chief Health Inspector Angel Kunchev stated that women under 30 who are heavy smokers, take contraceptives and are overweight are the most at risk for blood clots.[147] The people who have received the first dose of this vaccine without experiencing any serious adverse effects may complete the vaccination process with the same one while those who do not wish so may choose one of the two RNA vaccines for their second jab, but no earlier than 84 days after the first Oxford-AstraZeneca injection.[144] Bulgaria had previously also considered combining the AstraZeneca and Johnson & Johnson vaccines.[135]

Pre-vaccination and immediate aftermath[edit]

According to experts, there is no need for a person who is asymptomatic or mildly symptomatic to be tested for COVID-19 prior to getting the vaccine.[148][149] A person who has been vaccinated is generally recommended to be kept for observation for 15–20 minutes in the rare case any potential side effects need to be managed.[8]

Post-vaccination[edit]

As of 4 January 2021, only 4 adverse reactions to the vaccines administered had been reported - they included headaches and muscle pain, with all of the recipients' symptoms quickly subsiding.[101] As of 12 March 2021, slightly over 830 messages regarding unwelcome side effects had been filed.[150] As of 19 March 2021, about 1200 such reports had been submitted, with the frequency being 4 for every 1000 vaccinated for AstraZeneca, 3 for every 1000 individuals for Moderna, and slightly over 2 per 1000 for Pfizer.[151] Bogdan Kirilov, the executive director of the Bulgarian Drug Agency, has noted that all of the serious adverse reactions in the case of AstraZeneca have occurred after the first dose.[152]

Kantardzhiev stated in January 2021 that the side effects of the COVID-19 vaccines are no different from those of the influenza vaccines.[153]

In March 2021, a number of EU countries temporarily suspended vaccinations with Oxford AstraZeneca after reports of fatal or life-threatening blood clots in a few people who had recently received a dose, even though no direct causal link has been established with the vaccine.[154] Bulgaria is among the 17 EU recipients of vaccines that are part of the ABV5300 batch,[155] which has been under investigation by the Austrian health authorities as well as by the European Medicines Agency.[156] Bulgaria had received 31 200 doses from this batch on 12 February, with most of them administered, but no serious adverse effects were reported until 12 March.[156] Bogdan Kirilov, the executive director of the Bulgarian Drug Agency, initially stated that the country intended to continue the vaccination process as planned.[156] However, on 12 March 2021, Boyko Borisov ordered that vaccinations with AstraZeneca be halted until a written opinion is provided by the European Medicines Agency, clearing all doubts regarding the vaccine's safety.[157][158] As a result, Kirilov mandated that all of the AstraZeneca doses in the country are temporarily blocked from distribution and use.[159] The decision had also been influenced by the reported fatality of a 57-year old woman from Plovdiv with multiple comorbidities shortly after vaccination.[128] On 18 March 2021, the European Medicines Agency released a statement that it still considers the benefit-risk balance of the vaccine to be positive.[160] It was also determined that no thrombosis had been observed in the case of the 57-year old Bulgarian citizen.[161] AstraZeneca vaccinations recommenced in Bulgaria on the next day.[129]

Leading immunological laboratories in the country will be monitoring at least 1000 Bulgarians for a period of two years in order to assess the nature and durability of their immunity to COVID-19.[162]

A screenshot from the electronic registration system after vaccinations with Oxford-AstraZeneca were temporarily put to a halt.

Procedures relating to the vaccinations[edit]

Vaccination is voluntary and free for all citizens.[163] The issuing of the vaccination certificate will also be at no cost for the citizen.[164] The medical professionals administering vaccines will be paid 10 leva per injection by the state.[165] While the process had unofficially begun as early as December 2020,[166] in late January 2021, many citizens started signing up for vaccinations with their general practitioners,[167] with an online registration system beginning to function on 4 March 2021.[168][169] More than 40 000 Bulgarian citizens had registered by the late afternoon hours of 5 March.[170] As of 10 March 2021, approximately 70 000 people had selected vaccination slots for the period between 11 and 31 March.[126]

A clinic in Poduyane, Sofia where people can be tested for the virus and also receive COVID-19 vaccines.

Effects on the pandemic[edit]

Alpha Research sociologists speculated, based on the results of a survey for the period between 11 and 18 December 2020, that 670 000 Bulgarians may have had the virus and recovered from it.[171] Мathematician Nikolay Vitanov estimated in late January 2021 that some 20% of Bulgarians may have encountered the virus in some form.[172] In February 2021, a Gallup survey drew the conclusion that 1.5 million Bulgarians may have had the virus.[173] In March 2021, physician Emil Hristov, drawing on various sources, provided an even higher estimate of between 2 and 2.5 million while also expessing skepticism that the number of vaccinated will start to exceed those who have recovered from infection any time soon.[174]

According to experts, 60% vaccinated people plus those who have had the disease and recovered from it may be sufficient for herd immunity to kick in.[175] Health Minister Kostadin Angelov stated in February 2021 that at least 70% will need to be vaccinated in order to guarantee the return of normal life.[176]

Asen Baltov, the director of Pirogov Hospital, cautioned in March 2021 that at least 3 million people will have to be vaccinated by August–September if the country is to avoid a fourth wave in the autumn.[177]

Ognyan Kunchev, a member of the Informatics and Mathematics Institute of BAS, estimated in March 2021 that the pandemic will peter out by the end of 2021 if 100 000-120 000 people are vaccinated per month, viewing it as likely that approximately 1 million Bulgarians have already had the virus.[178]

In April 2021, the Health Minister stated that in an optimistic scenario herd immunity could be attained by the end of June, with the more realistic estimate being the end of July and the most pessimistic one considered to be the end of August.[179]

Controversies and criticism[edit]

Government policies[edit]

The government has come under scrutiny for the delay in ordering a number of vaccines,[31][180] the lack of sufficient transparency regarding the quantities,[181] the call to give up on doses of the two RNA vaccines, for which Bulgaria had been eligible, during the initial pre-orders[182][183] as well as the reasons behind its decision to center its vaccination campaign on Oxford-AstraZeneca in particular.[184][185] In the case of the Oxford vaccine, due to the cheaper cost of AstraZeneca relative to the RNA vaccines and the former's easier storage requirements,[186] the authorities have mainly been criticized for allowing financial considerations to take precedence over health-related ones.[31] Concerns have also been raised due to the government not outlining a plan for creating special vaccination centers[187] and training additional personnel capable of administering vaccine shots,[188] which has contributed to a slow pace of the vaccinations.[8][51] The lack of expediency with the vaccinations has been assessed as entailing significant risks for the country being able to meet its economic growth targets for 2021.[189]

Pulmonologist Kosta Kostov has been very critical of the way in which the vaccination campaign has been organized and implemented, regarding it as not premised on empathy,[14] being incredulous that people over 65 and clinically vulnerable individuals are in phase 4 rather than being the top priority targets[190] and maintaining that people who have recovered from the disease should not be vaccinated as long as there is an insufficient quantity of vaccines.[191]

The decision taken by the government on 19 February 2021 to set in motion the mass vaccination process has been criticized for inviting chaos,[54][192] with general practitioners complaining of a lack of vaccines provided to them for their registered patients who belong mainly to high-risk groups,[193][192] with most of the doses allocated to the hospitals for random vaccinations,[123][194] not allowing for thorough medical check-ups of the people prior to the administering of vaccines.[195] Concerns have also been raised that the citizens who had already received one shot may not be able to get their second injection as scheduled.[123] The shift in the modus operandi has been contested for its dubious legal basis due to being in apparent contradiction with the authorities' own phased approach to the vaccinations, entailing the prioritization of vulnerable groups such as the elderly,[192][196] and has been characterized as a desperate attempt to boost the vaccination statistics.[192] As of 1 April 2021, only 9% of the elderly and chronically ill had been vaccinated.[147]

In March 2021, some medical experts in Bulgaria criticized the temporary suspension of the vaccinations with Oxford Astra-Zeneca as an overreaction and potentially dangerous in terms of stoking fears among the already vaccinated.[174]

A number of media sources have taken issue with the government's manner of reporting the official figures regarding the number of individuals who have been vaccinated, believing that it invites confusion.[1]

Specific incidents[edit]

Some of the vaccines that arrived Sofia on 26 December were subsequently transported to Plovdiv by using a Leki food industry minibus, and were then stored in a ZiL refrigerator on reaching their destination, which resulted in criticism and mockery on social media, but the Health Ministry cited examples of such reliance on the services of private companies not being an unusual practice in Western countries and maintained that all the proper guidelines had been observed.[197]

On 9 January 2021, the Ministry of Health revealed that it was conducting an urgent investigation after receiving information that councillors in Sandanski Municipality had already received vaccines despite not being part of the groups prioritized during the first phase, as stipulated by the vaccination plan.[198] The director of the hospital in Sandanski, Iliya Tonev, subsequently claimed that a number of the people who were to have priority in terms of vaccinations had ultimately decided against it, so appointments were set up with the councillors (who were among the volunteers in popularizing the Pfizer-BioNTech vaccine) at a short notice in order for the doses not to go to waste.[199] However, after the review of the facts, the Minister of Health was adamant that the protocols had not been adhered to in vaccinating 24 of the people, as there had been sufficient time for a proper redistribution of the vaccines, claiming that if he had the authority, he would have released the hospital director from his duties.[106][200]

Health Minister Kostadin Angelov has expressed criticism of those medical practitioners who have encouraged their patients not to get themselves vaccinated.[176]

In February 2021, chief national health inspector Angel Kunchev revealed that people holding anti-vaccination views had in a number of instances deliberately signed up for receiving their injections and then failed to show up in the hopes of sabotaging the vaccination process.[201] The online registration system for vaccinations has been subjected to hacker attacks.[202]

In late February 2021, a young couple from Pleven was refused vaccination because of not having proper health insurance. The Health Minister ordered that the case be looked into,[203] confirming that each Bulgarian citizen is eligible for vaccination regardless of his or her health insurance status.[204] Yordan Georgiev, the director of the St. Pantaleymon hospital where the situation had transpired, was criticized for not being familiar with the Health Ministry's policies, with journalists also drawing attention to the multitude of instances of British citizens without health insurance having received vaccinations in Bulgaria.[204] The man and the woman were subsequently invited by other hospitals in the city to be administered their doses.[204]

In March 2021, Angelov revealed that some people had been signing up to participate as electoral commission members (without intending to follow through with their commitments) just so that they could get themselves vaccinated.[205]

Commitments to North Macedonia[edit]

In December 2020, Bulgaria stated that it will take the initiative in securing vaccines for North Macedonia and other states from the Western Balkans,[206] but as of mid February 2021, with the country struggling to obtain enough vaccines for its own citizens, this has not materialized, generating critical headlines in the North Macedonian media.[207][208]

Attitudes of the general public[edit]

According to an April 2020 Gallup survey, over 75% of the citizens expressed support for the lockdown-related pandemic control measures taken by the government and the members of the National Operational Headquarters for the fight against the coronavirus in Bulgaria,[209] but the subsequent loosening of restrictions and the exponential rise in cases in October and November caused public support for the authorities' strategy to plummet to slightly over 30%.[210] The lack of trust in the government and the health providers is believed likely to provide additional fuel for vaccine hesitancy attitudes, which have been characterized as prominent in Bulgarian society,[211][212] with one January 2021 Gallup poll seeing 46% of interviewees declaring that they will not take a COVID-19 vaccine.[213] Due to the vaccine skepticism and the proliferation of conspiracy theories in Bulgaria pertaining to the nature of the virus itself,[214] an information and explanation campaign pertaining to the vaccines and directed at the general public, including educated groups such as teachers,[215] has been identified by some journalists as the real challenge with regard to vaccinating a sufficient number of people, so that herd immunity could be reached.[216] There have been regional differences regarding the interest in the vaccinations.[34]

According to a March 2021 survey, 65.8% of the general practitioners' patients preferred one of the two RNA vaccines, 28.9% expressed no preference while 5.3% gave the nod to Oxford-AstraZeneca.[217]

A small protest against the vaccinations took place on 17 March 2021, in front of the Ministry of Health.[218]

See also[edit]

Notes[edit]

  1. ^ These official figures are not equivalent to the number of unique individuals who have received at least one injection, as the doses administered include those who have had their second shots.[1]
  2. ^ Until the end of 2021, option for additional 1.55 million doses from Novavax.[36]
  3. ^ The dates that use the "as of" formulation cover the number of vaccine shots administered up to the evening hours of the previous day, but may not reflect the most recent figures when it comes to the date that is mentioned, e.g. as of 11 January includes the vaccines used up to the evening of 10 January, though it may not provide the most current information with regard to the vaccination status of the population as of the late hours of 11 January.

References[edit]

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External links[edit]

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