COVID-19 vaccination campaign in Bulgaria

The COVID-19 vaccination campaign in Bulgaria began on 27 December 2020, in line with most other countries in the EU. It is in response to the ongoing pandemic in Bulgaria. As of 11 January 2021, 13,473 people have been vaccinated.[1][2]

COVID-19 vaccination campaign in Bulgaria
Native name Национален план за ваксиниране срещу COVID-19 в Република България
DateDecember 27, 2020 (2020-12-27) -
Locationnationwide
CauseCOVID-19 pandemic
Organised byBulgarian Ministry of Health, National Vaccination Operational Headquarters
Participants50,124 doses administered Pfizer–BioNTech and Moderna
(4 February 2021)

Background

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),[3] but was heavily hit during the autumn months, with the health system coming under severe strain.[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] an absence of an adequate exit strategy after the first lockdown,[7][8] resulting in rather loose general measures against the spread of the virus during the summer of 2020,[9][10] limited preparedness of the country's health system for the second wave of the pandemic,[11] contradictory and inconsistent messaging[5][12] as well as not following some of the recommendations of health experts[4][8] due to concerns that the imposition of tight measures could pile on public pressure on the government,[5] which has been facing political protests since July 2020. 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.[13][14] 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.[15]

In the early months of the pandemic, there was speculation that the BCG vaccine,[16][17] of which the country is a major producer and which has been part of the mandatory vaccination package for newborns in Bulgaria since 1951,[16] offers some degree of protection against COVID-19,[17] with studies in the Netherlands suggesting that it serves as a powerful immune stimulator.[18] However, this has not been corroborated by most scientific sources[19] and the WHO maintains that there is so far a lack of evidence that the vaccine demonstrates effectiveness against COVID-19.[20]

Vaccines
Map of Bulgaria showing total cumulative vaccination numbers per province as of 17th of January 2021.

Bulgaria eventually agreed to purchase all seven vaccines included in the European portfolio - Moderna, Pfizer-BioNTech, Oxford–AstraZeneca vaccine, Sanofi, CureVac, Novavax, and Johnson & Johnson-Janssen,[21] even though it had some reservations regarding its participation in the contract with Janssen Pharmaceutica[22] and reportedly regarded the vaccine portfolio as overly diverse.[23] The country is mostly reliant on the Oxford–AstraZeneca COVID-19 vaccine, expecting to receive enough doses for vaccinating 2.5 m citizens.[24] In total, the amount of all vaccines pre-ordered or set to be ordered by the country is expected to be equivalent to 18 million doses, enough for 9 m citizens.[25][26]

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 other vaccines, such as Sputnik and Sinopharm, as long as EU regulations are observed[27] and especially if there is a delay regarding the delivery of the other vaccines.[28]

A COVID-19 vaccine based on nanoparticles is presently under development by the Bulgarian Academy of Sciences,[29][30] with issues relating to funding expected to significantly slow down the progress when it comes to the vaccine trials.[31]

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.[32]

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),[33] with the initial doses delivered to Bulgaria 26 December.[34]

On 6 January 2021, following the same regulatory procedure, the Moderna vaccine was also given the green light by the European Commission,[35] arriving in Bulgaria a week later.[36]

On 29 January 2021, Oxford–AstraZeneca vaccine received conditional authorization by the European Commission, paving the way for its use in EU countries.[37] 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.[32] 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.[38] The first batch of this vaccine reached Bulgaria on 6 February 2021.[39]

Vaccine Approval Deployment
Pfizer–BioNTech 21 December 2020 27 December 2020
Moderna 6 January 2021 14 January 2021
Oxford-AstraZeneca 29 January 2021 Pending

Rollout schedule and vaccine priority groups

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).[40][41] 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, England, and a number of US states, while also taking into account the specific conditions pertaining to Bulgarian health care, territory and infrastructure.[40] A National Vaccination Operational Headquarters, chaired by Krasimir Gigov, the general director of the Bulgarian Red Cross, was also established.[40] 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.[42]

Order Priority group Number eligible (estimated)[40]
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 m
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

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.[43] On 7 December, Bourgas became the second city in the country equipped with such a refrigerator,[44] followed by Plovdiv on 9 December[45] and Varna on the 18th.[46] Each freezer can hold more than 100 000 vaccine doses.[47] The first vaccination site in the country was opened on 15 December 2020, being located in Sofia.[48]

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.[49] Over 40 such vaccination units are expected to cover the whole country.[48][50]

Chronology and vaccination process

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.[34] Just over 60 000 doses of this vaccine were expected to be available in January 2021.[34][51]

The first person to be vaccinated in Bulgaria was Minister of Health Kostadin Angelov, which occurred in the morning of 27 December in Sofia.[52] The second was Bulgarian Orthodox Church Bishop Tikhon, followed by a doctor and a nurse.[53] Over 1500 people, mostly medical personnel, had been vaccinated by the evening of 28 December.[54] By the late hours of 29 December, close to 3800 people had received a vaccine shot.[55] By the first day of the New Year, the number of vaccinated people had reached 4739.[56]

On 4 January 2021, the first batch of vaccines for this month arrived, numbering approximately 25 000 doses.[57] 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.[57] 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).[58]

The first Moderna vaccine doses reached the country on 13 January 2021, numbering 2400 and designated for priority groups in Sofia.[59] Тhe vaccinations with Moderna commencеd on the next day, with obstetrician Sofia Yordanova being the first one to receive it.[36]

As of 13 January 2021,[lower-alpha 1] approximately 16 500 vaccine shots had been administered.[60]

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.[61]

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.[62][63]

As of 30 January 2021, 40 805 people have been vaccinated, with 12 949 receiving two doses.[64]

On 1 February 2021, educators and staff at kindergartens and schools began to be vaccinated.[65]

As of 4 February 2021, 50 124 people had received a vaccine, with 16 433 having undergone the two-step vaccination process.[38]

On 6 February 2021, the first doses of Oxford-AstraZeneca, numbering 28 800, made their arrival in the country.[39]

Medical and procedural aspects pertaining to the vaccinations

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.[57] Todor Kantardzhiev, a member of the National Operational Headquarters for the fight against the coronavirus in Bulgaria, stated on 8 January that the side effects of the COVID-19 vaccines are no different from those of the influenza vaccines.[66] According to experts, there is no need for a person who is asymptomatic to be tested for COVID-19 prior to getting the vaccine.[67]

Vaccination is voluntary and free for all citizens.[68] The medical professionals administering vaccines will be paid 10 leva per injection by the state.[69] In late January 2021, citizens started signing up for vaccinations with their general practitioners,[70] with an online registration system expected to begin functioning by early March.[71]

Effects on the pandemic

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,[72] with mathematician Nikolay Vitanov estimating in late January 2021 that some 20% of Bulgarians may have encountered the virus in some form.[73]

Controversies and criticism

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.[74]

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.[75] 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 vaccine) at a short notice in order for the doses not to go to waste.[76] 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.[60][77]

The government has come under scrutiny for the delay in ordering a number of vaccines,[78] the lack of sufficient transparency regarding the quantities[79] as well as the reasons behind its decision to center its vaccination campaign on Oxford-AstraZeneca in particular.[80] It has also been criticized for not outlining a plan for creating special vaccination centers and training additional personnel capable of administering vaccine shots,[81] contributing to a slow pace of vaccinations.[27] Pulmonologist Kosta Kostov has been very critical of the way in which the vaccination campaign has been organized and implemented, also expressing incredulity that people over 65 and clinically vulnerable individuals are in phase 4 rather than being the top priority targets[82] and maintaining that people who have recovered from the disease should not be vaccinated as long as there is an insufficient quantity of vaccines.[83]

Attitudes of the general public

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,[84] 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%.[85] 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,[86] with one January 2021 Gallup poll seeing 46% of interviewees declaring that they will not take a COVID-19 vaccine.[87] Due to the vaccine skepticism and the proliferation of conspiracy theories in Bulgaria pertaining to the nature of the virus itself,[88] an information and explanation campaign pertaining to the vaccines and directed at the general public 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.[89]

See also

Notes
  1. 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 13 January includes the vaccines used up to the evening of 12 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 13 January.

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