The Deadly Triple M (Mistrust, Misinformation, and Missed Opportunities): Understanding Romania's COVID-19 Vaccination Campaign and Its Lasting Impact on Public Health

Stefan Dascalu^1*Catalin Valentin Raiu²Emilian Olteanu^3,4Adrian Vasile Comanici^5,6Mihaela Maria Comanici⁷Tudor P Toma^8,9Bogdan Ionut Robu¹⁰Raul Mihailov^11,12Laura Mina-Raiu¹³Gindrovel Gheorghe Dumitra¹⁴Doina Azoicai¹⁵Emilian Damian Popovici^16,17Cristian Apetrei^18,19*

• ¹Department of Biology, University of Oxford, Oxford, United Kingdom
• ²Faculty of Business and Administration, University of Bucharest, Bucharest, Romania
• ³Department of Pathology, British Columbia Cancer Agency, Vancouver, BC, Canada
• ⁴Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
• ⁵Department of Endocrinology "Titu Maiorescu" University of Medicine and Pharmacy, Bucharest, Romania
• ⁶Department of Endocrinology, C.F.2 Clinical Hospital, Bucharest, Romania
• ⁷Department of Immunology, "Titu Mairescu" University of Medicine and Pharmacy, Bucharest, Romania
• ⁸Lewisham & Greenwich NHS Trust, London, United Kingdom
• ⁹King’s College, London, United Kingdom
• ¹⁰Great Western Hospitals NHS Foundation Trust, Swindon, United Kingdom
• ¹¹Dunarea de Jos University, Faculty of Medicine and Pharmacy, Galati, Romania
• ¹²Clinical Emergency Hospital “Sf Ap Andrei”, Galati, Romania
• ¹³Bucharest University of Economic Studies, Bucharest, Romania
• ¹⁴Family Medicine Department, University of Medicine and Pharmacy of Craiova, Craiova, Romania
• ¹⁵Department of Epidemiology, School of Medicine, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
• ¹⁶Department of Epidemiology, School of Medicine, Victor Babeş University of Medicine and Pharmacy, Timisoara, Romania
• ¹⁷Regional Centre of Public Health, Timisoara, Romania
• ¹⁸Division of Infectious Diseases, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
• ¹⁹Department of Infectious Diseases and Immunology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States

Romania's COVID-19 vaccination campaign presents a compelling case study on the intersection of public health policy, societal dynamics, and political influences in pandemic response. Despite an initially promising rollout, Romania ultimately achieved one of the lowest vaccination rates in the European Union, with severe consequences during the subsequent pandemic waves. This review examines the key factors contributing to the campaign's shortcomings, including pre-existing vaccine hesitancy, widespread misinformation, inadequate governmental communication strategies, and the politicisation of public health efforts. We explore the deep-seated mistrust in governmental institutions, exacerbated by restrictive measures implemented without adequate public engagement, as well as the influential role of religious communities and the rise of populist political forces that actively opposed vaccination efforts. Additionally, we discuss the impact of media sensationalism, conspiracy theories, and the failure to regulate anti-vaccine rhetoric within the medical profession. While logistical and infrastructural challenges were largely addressed, the inability to effectively engage key societal stakeholders led to lagging of vaccine uptake. The consequences of this failure extended beyond COVID-19, contributing to a severe measles outbreak in 2023, which underscored the long-term deleterious effects of vaccine hesitancy. Drawing from Romania's experience, we highlight critical lessons for future public health campaigns, emphasising the need for trust-building initiatives, targeted misinformation countermeasures, stronger community engagement, and enhanced collaboration with religious and cultural institutions. By addressing these challenges, countries worldwide can strengthen their public health frameworks and improve the resilience of their immunisation programmes in the face of future crises.