Romania’s prepandemic profile did not place the country in a favorable position to manage the consequences of COVID-19. Indeed, the country was already facing major challenges with regards to the provisioning of hospitals, their adequate staffing, vaccine acceptance by the overall population, and appropriate funding of the health sector as a whole (6). With regard to the infectious diseases management, just a few years before the COVID-19 pandemic, between 2016 and 2019, Romania faced one of the worst European measles epidemics of the current century, with more than 17,000 cases and 59 deaths (28). Additionally, seeding events occurred in many other countries, both within Europe and beyond. The major cause of the devastating measles epidemic was the decline in measles, mumps, and rubella (MMR) vaccination coverage, which had maintained suboptimal levels for at least 6 years before the epidemic began (28). Unfortunately, the measles debacle was insufficient to prompt adequate measures of epidemic preparedness in terms of either prevention and control measures per se, or public awareness towards vaccine-preventable diseases (5, 6, 29). These failures had dramatic consequences during the COVID-19 pandemic a few years later, as both the healthcare system and Romanian society were underprepared for the crisis that would unfold.

An important catalyst of the 2016–2018 measles epidemic and, later on, a driver of the COVID-19 vaccination outcomes was the general public perception of vaccinations in Romania (28, 30). From the early 2000s, the anti-vaccine movement has slowly but firmly embedded itself in Romanian society, gaining support from average citizens, influencers, and even medical professionals. As such, Romania is a case in point for the devastating consequences of the “bad advice” [see ref. (31)]. As a result, the past two decades have seen not only a major increase in anti-vaccine propaganda, such as NGOs, books, websites, social media pages, but also the aggressive mediatization of anti-vaccine influencers, some of them with a medical degree, which further exacerbated the already negative trends in vaccine acceptance, especially in terms of childhood vaccination program (6, 28, 32). For measles, this culminated with the 2016–2018 epidemic, but other public health prevention and control efforts have also been hindered. In 2008, the national human papillomavirus (HPV) vaccination campaign achieved little over 2% coverage of the target population of 9- to 11-year-old girls (33). As the anti-vaccine phenomenon has been virtually unaddressed by the authorities, the efforts of healthcare professionals and other vaccine advocates, as well as the national vaccination campaigns carried out in Romania prior to the COVID-19 pandemic, have had limited effects on overall vaccine acceptance (28, 29, 34).

The prepandemic hesitancy of the Romanian population towards vaccinations was further fueled by the severe restrictions and lockdowns implemented during the first year of the COVID-19 pandemic (6). These were not particular to Romania, as they were implemented worldwide with the goal of halting/slowing the spread of the epidemic. Specific to Romania is the sizable diaspora. Many Romanians returned from abroad, often from highly affected regions, driven by the fear of infection, the threat of being isolated in a foreign country, and the economic insecurity associated with lockdowns. However, the major threats to public health were controlled by implementing harsh quarantine rules for returning citizens and, later on, general lockdowns (6, 35). With this in mind, while the first lockdown and governmental restrictions on individual freedoms were understandably implemented on an emergency basis through military ordinances (6), these legislative circumstances did not change for the subsequent lockdown and restrictions, and a legal, more democratic framework was not created for their implementation.

This triggered a general sentiment of frustration and mistrust in national authorities, which was revealed by a survey carried out in May 2020, just after the first lockdown, when only 36% of respondents favorably viewed the Government as a trustful partner following the early COVID-19 crisis (36). Unfortunately, this impacted both public trust and compliance—feelings which were reflected in peoples’ attitudes towards the vaccine. In the same survey mentioned above, only 44% of Romanians declared that they would be willing to receive a vaccine, should a vaccine become available, with another 22% stating that they would be hesitant towards this prospect (36). As such, it is likely that the cumulative effect of the early pandemic responses was the exacerbation of mistrust in the government and public health authorities, especially given the parallels that were drawn to Romania’s authoritative communist past in the collective mind (28). These factors, coupled with widespread misinformation and conspiracy theories (37), which propagated with often little to no reaction from the medical community, medical professional societies, and public health authorities, had a profound impact on the implementation and overall success of the national COVID-19 vaccination campaign in Romania (5).

Since the dawn of the COVID-19 epidemic, Romanian media coverage of the subject varied vastly in terms of scientific accuracy. It was generally filled with sensationalist stories (many of which were hypothetical scenarios) mixed with factual news. For the public, this made genuine information difficult to disentangle from alarmist scenarios and sometimes even conspiracy theories (38). Furthermore, many of the anti-vaccine voices that had been present in the public space before the pandemic, were once again offered a platform once the prospect of vaccines became a topic of discussion (39). Their presence was also notable on social media, where conspiracy theories and anti-vaccine views were widely distributed by the members of the public. Furthermore, the feelings of fear and uncertainty that were continuously reinforced on communication channels such as the radio, television, and social media unavoidably impacted the emotional state of the Romanians (40–42), fueling the general mistrust in authorities.

Moreover, the scientific communication efforts on pandemic matters were generally unstructured and inconsistent in Romania (5). No core of highly reputable professionals from within the medical field was assembled in an official capacity as pandemic communicators. Instead, information on pandemic matters was communicated on various media platforms by a wide range of medical and scientific professionals, who varied in terms of reputation, charisma, and even specialized views on topics such as infectious disease management. Furthermore, national media debates on pandemic issues often involved politicians with no formal medical training or scientific expertise on the matter (43).

The cultural context also played an important role; religious identity and religiosity proved to be important catalysts for public health policy implementation in Romania [for a comprehensive review, see ref. (44)]. Up to 85% of Romanians identify as Orthodox Christians and adhere to the Romanian Orthodox Church, a highly influential institution in the country, which enjoys a high degree of trust from its followers. The restrictions imposed by the Romanian authorities during the pandemic profoundly impacted religious practice. In Romania, the dialogue between governmental authorities and religious organizations was carried out only behind closed doors and with no participation of other stakeholders, such as the press, human rights experts, or representatives of the opposition (45). By comparison, the UK’s strategy aimed at a very transparent public communication, consulting all stakeholders (46) and identifying consensual solutions precisely so that the lifting of restrictions simultaneously met public health requirements, and also those of religious freedom (47).

An illustrative example of the lack of dialogue with religious communities in Romania was the total ban on visits to cemeteries in 2020, from 16 March until 15 May (48). In a highly religious country such as Romania, with most of the Eastern Orthodox believers particularly dedicated to the remembrance of their dead, this measure was acutely felt (44, 48). In addition to the ban on attending places of worship, this was perceived as a direct violation of principles of freedom of religion and belief (44). As a consequence, although most of the Romanian religious leaders have tacitly endorsed the early pandemic restrictions, major divisions were created within the churches, paralleling the broader Romanian society (48). Indeed, this societal polarization extended to all pandemic-related topics, including COVID-19 vaccination.

General elections were held in December 2020, at the end of pandemic’s first year, and led to the emergence of a new political party, highly conservative and nationalistic in its ideology: the Alliance for the Union of Romanians (AUR) (49). Within a little over a year of its existence, AUR secured 10% of parliamentary seats, mainly through an electoral rhetoric focused on criticizing the measures for pandemic control, from lockdowns to church closures, and even the mask mandates (50). This party’s campaign heavily capitalized on people’s frustrations and growing distrust in governmental authorities, and on religious feelings stemming from events such as the above-mentioned ban on cemetery visits. After the election, AUR became the main political force opposing the COVID-19 mitigation efforts, with many of their most vocal members actively challenging public health measures and spreading misinformation and disinformation (e.g., the pandemic being fake, the virus being harmless, the COVID-19 death toll being artificially inflated, or even the inexistence of SARS-CoV-2), which on several occasions caused public unrest amongst their supporters (51).

The anti-restriction and anti-vaccine campaign of AUR was also indirectly fueled by the governmental measures that impacted freedom of religion and belief (52). As such, restrictions affecting places of worship, the ban on cemeteries (see above), and the inadequate levels of dialogue between state officials and religious leaders were exploited by right-wing populist voices in the media and further framed by AUR as a threat to the “purity of the nation” (45, 51). Later, once the vaccines became available, the same narrative targeted the COVID-19 vaccination campaign. Moreover, AUR encouraged and further legitimized anti-vaccine voices in Romania (43). Notable examples are the “medical conferences” hosted in the Romanian parliament building which promoted myths and disinformation on vaccines (51, 53).

Altogether, although it is difficult to quantify, the events that occurred during the first year of the pandemic likely shifted public perception towards an incremental dissatisfaction with the way the pandemic was handled by the Romanian authorities, and they further eroded the public trust in COVID-19 control efforts.

In the first months of 2021, the CNCAV faced significant logistical and operational challenges to an optimal vaccine rollout (29). The committee was tasked with coordinating vaccine distribution across the country and needed to rapidly establish efficient infrastructure for vaccine storage, transport, and administration, while navigating a complex landscape of public skepticism, misinformation and disinformation. Public opinion was already unfavorable to a large-scale vaccination campaign (36). Public mistrust in government institutions, stemming from years of political instability and perceived corruption, had eroded confidence in health authorities long before the pandemic (28). This existing skepticism likely served as fertile ground for the rapid spread of misinformation and disinformation regarding vaccines. Conspiracy theories questioning the safety and the actual need of the vaccines proliferated across social media and traditional news platforms, amplifying doubts about their efficacy.

In the initial stages of the vaccination campaign, Romania achieved one of the fastest COVID-19 vaccine uptakes in the European Union (55). However, the momentum rapidly waned, and vaccine administration plateaued at suboptimal levels, leading to one of the lowest coverage levels in the European Union by the end of 2021 (5). The initial numbers were mainly due to the prioritized vaccination of the healthcare workers and of the vulnerable groups (55). Subsequently, in May 2021, once the quantities of vaccines became sufficient for the total population, the next phase of the campaign began. However, this was the time when the stagnation became evident, mainly driven by public skepticism, which was fueled by misinformation, mistrust in authorities, and inconsistent government messaging (5). By mid-2021, it became clear that vaccine coverage in Romania lagged significantly when compared to other EU countries, with less than 30% of the population being fully vaccinated by autumn 2021 (5).

The Romanian healthcare professional community, despite achieving higher vaccination rates, was still confronted with refusals of the vaccine by some health professionals (56). More concerningly, some vocal anti-vaccine doctors played a major role in spreading misinformation, disinformation, and false claims about vaccines (51, 57). These individuals quickly became public figures, gaining visibility through television networks and other media outlets.

Some of these doctors promoted unproven treatments, exaggerated vaccine risks, or downplayed the severity of the pandemic, while others denied the existence of viruses, questioned vaccine efficacy, or spread conspiracy theories (51). Their medical credentials lent credibility to misinformation, thereby misleading the public and fueling vaccine hesitancy. Unfortunately, while the National College of Physicians (the regulatory authority for the medical profession in Romania) has taken steps to address misconduct among physicians, these actions have often been limited and largely ineffective due to the absence of a legal framework that would allow the College to sanction them (57, 58). This underscores the urgent need to revise existing legislation to ensure that professional misconduct, particularly when it poses risks to public health, is addressed promptly and effectively to prevent harmful consequences.

Unlike other EU countries, where misinformation was met with firm sanctions and professional outrage, Romania saw little reaction from the medical professions. Very few voices consistently raised against this flood of misinformation and disinformation (59). Some of these public figures held influential positions in medical organizations or academia, which likely further amplified their reach. While a few individuals faced judicial consequences, most continued to shape public perception with minimal repercussions. Their influence extended beyond healthcare, resonating in religious (see below) and social circles, deepening public distrust in the medical system.

The CNCAV’s approach regarding religious organizations aimed at eliciting clear statements in favour of vaccination from their leaders and clergymen (44, 60). This was done through direct messaging in the media, urging the church to take a more active stance in supporting vaccination. However, this approach was complicated by the strained relationship between the government and the church, as the lockdown dramatically impacted religious life during the pandemic and had been imposed without any prior consultation with church leaders (see above) (45). This lack of dialogue during the earlier phases of the pandemic fostered profound mistrust among believers towards government authorities, which extended to the vaccination campaign (44). The Romanian Orthodox Church, is majoritarian (and most influential) in Romania, and one of the best outcomes that public authorities could achieve were endorsements from the Patriarch and other influential religious figures, who urged followers to “listen to the doctors” (61). While this was a positive and reasonable message, it did not explicitly refer to doctors that were in favour of vaccination and not the ones that were contributing to the spread of misinformation (see above).

Efforts by the authorities to involve the Romanian Orthodox Church and other religious groups more actively in the vaccination campaign, such as requesting priests to receive vaccinations live on television or suggesting churches as vaccination sites, did little to sway public opinion (62). These initiatives, while well-intended, failed to resonate with the faithful (44) as the deeply rooted mistrust in government authorities, compounded by the prior lack of consultation with the church during the strict lockdown, overshadowed these gestures (44, 45, 52). The idea of priests being vaccinated on live TV was seen by many as a symbolic action without genuine impact, as it did not address the underlying concerns and skepticism prevalent among the religious population. Similarly, the proposal to use church spaces as vaccination sites did not gain traction, as it was perceived by some as a superficial attempt to align with religious institutions rather than a meaningful engagement with the church’s leadership and community. In the end, these efforts did little to break through the existing mistrust, and the polarization of opinions about vaccination, even among doctors, further diminished their effectiveness (44, 52).

Conspiracy theories, often fueled by online misinformation and religious fundamentalist rhetoric, further deepened mistrust. Notably, on numerous occasions, certain priests [or even bishops, see ref. (44)] discouraged vaccination by suggesting it could lead to physical deformities, such as growing fish scales (63), or other harmful unproven effects (64). The “fish scale sermon” became viral; unfortunately, the news that its unvaccinated author nearly died few months later in the Infectious Diseases Hospital did not (59).

The COVID-19 vaccination campaign in Romania quickly became a highly politicized issue, with statements from the country’s leadership playing a key role in framing the narrative. The Prime Minister and the President both declared in June 2021 that Romania had effectively “ended the pandemic” through vaccination efforts, a claim that was premature and ultimately misleading, as it could be seen few months later by the onset of the fourth Delta wave that followed their declarations and was the most lethal (5). However, such triumphalist messages probably deterred the vaccination efforts, as the public did not see a need to vaccinate since the epidemic ended. On the other hand, opposition parties such as AUR capitalized on this discrepancy by spreading misinformation about the vaccines and using anti-vaccine rhetoric to rally their base (43, 50). Overall, it is likely that the politicization of the vaccination effort not only hindered the campaign’s progress but also deepened societal divisions, allowing misinformation to flourish across political lines and impacting the uptake of COVID-19 vaccines in Romania.

The challenges faced by the Romanian COVID-19 vaccination campaign were also compounded by longstanding inequities in access to healthcare that predated the pandemic. Rural communities, low-income groups, and marginalized minorities such as the Roma population often faced barriers of availability and acceptance of care. For example, one study that focused on Central and South-East European countries (including Romania) found that Roma children had substantially lower vaccination coverage compared with non-Roma peers, in some cases less than half for essential vaccines such as DPT, MMR, polio, and BCG (65). This disparity has historically contributed to Romania’s past vulnerability to outbreaks, including the devastating 2016–2019 measles epidemic (28, 66, 67). Overall, the systemic gaps in healthcare access, although difficult to quantify, likely hindered the rollout of COVID-19 vaccines in Romania and the public health efforts in the country.