Opinion: Romania’s vaccination problems were visible before the pandemic

Years before the COVID-19 pandemic, Romania was already facing significant difficulties in maintaining adequate childhood vaccination coverage. An INSP analysis of children born in July 2016 and assessed at 24 months of age shows coverage below the 95% target for most of the vaccines analysed, very large differences between counties and, perhaps most importantly, a problem that cannot be explained by vaccine refusal alone. Failure to attend for vaccination was, by far, the most frequently reported reason.

The document produced by the National Centre for Surveillance and Control of Communicable Diseases, part of Romania’s National Institute of Public Health (INSP), was published on the Institute’s website on 6 July 2026, although the assessment itself was carried out in August 2018. It provides a relevant snapshot of Romania’s National Vaccination Programme at that time. Vaccination histories were analysed for 14,916 children born in July 2016, representing 85.7% of the corresponding live-birth cohort.

The data are even more interesting when viewed from the perspective of 2026. They show that the problems observed later in Romania did not begin with the pandemic, but were superimposed on vulnerabilities that already existed: difficulties in tracking children, failure to attend for vaccination, major territorial disparities, selective refusal of certain vaccines and inconsistencies in vaccination records.

By 24 months, coverage for most vaccines was already below the 95% target

Among the children assessed, BCG coverage reached 95.8%, making it the only national indicator to exceed the 95% target used by INSP in its analysis.

Coverage was lower for the other vaccines: 93.4% for three doses of paediatric hepatitis B vaccine, 87.7% for three doses of DTaP, IPV and Hib, and 90.2% for one dose of MMR vaccine.

This is where one of the most important cautions in interpreting the document arises. INSP presents both coverage among the 14,916 children whose vaccination histories were assessed and the values obtained when all live births in the cohort are used as the denominator.

For example, MMR coverage is 90.2% in the assessed group, while the proportion relative to the entire live-birth cohort is 77.4%. The difference is 12.8 percentage points.

This does not mean, however, that all children who could not be assessed were unvaccinated. The document does not describe the vaccination status of the entire group that remained outside the assessment, so these children cannot automatically be considered unvaccinated. The figure calculated using all live births is particularly useful in illustrating the size of the system’s area of uncertainty.

One of the most important findings: refusal was not the main reported reason

Among the children assessed, 2,617, or 17.5%, were incompletely vaccinated for their age.

The most frequent reason recorded by INSP was not vaccine refusal but failure to attend, reported for 46.7% of children who had not been vaccinated according to schedule.

This was followed by being “born abroad/having moved abroad”, at 17.1%, refusal of MMR vaccination, at 11.3%, medical contraindications, at 10.6%, and general refusal of all vaccines, at 7.4%.

These percentages must be interpreted with caution and cannot simply be added together: the document includes both general reasons and reasons specific to particular vaccines, meaning that the categories do not necessarily represent entirely distinct groups.

Another detail is relevant. Vaccine shortages were not reported as a reason for missed vaccination for Hep B, DTaP/IPV/Hib or MMR in this assessment. For BCG, lack of vaccine accounted for 1.1% of the reasons recorded and was reported in only one county, Vrancea.

The overall message nevertheless remains important. The data do not support a simple explanation according to which inadequate vaccination coverage was predominantly caused by parents rejecting vaccination. A significant part of the problem appears to have involved continuity of contact with medical services and the ability to bring back for vaccination children who failed to attend.

The 2018 data resemble barriers identified years later

This interpretation is also supported by much more recent official research.

In 2025, WHO and INSP presented the results of a qualitative study carried out in late 2024 in rural and semi-urban communities in Brașov, Timiș and Covasna counties. The problems identified included missed appointments and the absence of additional reminders afterwards, difficulties in accessing easy-to-understand information, lack of documents, problems registering with a family doctor and practical difficulties in accessing services.

The apparently simple category of “failure to attend”, which accounted for almost half of the situations identified by INSP in the 2016 cohort, may cover very different mechanisms. In some cases there may be vaccine hesitancy, while in others the factors may include family mobility, administrative difficulties, insufficient communication, access problems or simply loss of contact between the family and the healthcare system.

The 2018 report does not allow these mechanisms to be distinguished within the “failure to attend” category. The later WHO-INSP study does, however, show why this category should not automatically be equated with vaccine refusal.

The urban paradox: coverage was lower in cities for several vaccines

The INSP document also complicates another intuitive explanation: that vaccination problems should primarily be sought in rural areas.

For three doses of DTaP, IPV and Hib, coverage was 86.3% in urban areas and 89.7% in rural areas. For MMR, the gap was even greater: 87.9% in urban areas compared with 93.5% in rural areas.

Of the 2,617 incompletely vaccinated children, 1,702 came from urban areas and 915 from rural areas. A calculation based on the numbers presented in the report shows that approximately 19.7% of the assessed urban children were incompletely vaccinated, compared with approximately 14.6% of those in rural areas.

The reported reasons also differed. Failure to attend was recorded for 50.6% of children not vaccinated according to schedule in urban areas and for 39.5% in rural areas. Refusal of MMR was also more frequent in urban areas: 13.5% compared with 7.4%.

These results do not mean that access to vaccination is not a problem in certain rural communities. Recent WHO-INSP research shows the opposite in some vulnerable areas. They do indicate, however, that a national policy treating low vaccination coverage exclusively as a rural access problem would miss an important part of the phenomenon.

Bucharest was one of the clearest warning signs

The most striking differences emerge when the data are analysed territorially.

For DTaP, IPV and Hib, only four of the 42 territorial units analysed had coverage of at least 95%, while 18 were below 90%.

For MMR vaccination, 15 reached at least 95%, while eight were below 90%.

Bucharest represented the lowest extreme for both categories: only 69.9% coverage with three doses of DTaP/IPV/Hib and 68.5% for one dose of MMR. At the same time, BCG coverage was 99.3%.

The contrast is worth noting. Under the national schedule, BCG is administered in maternity hospitals during the first days of life, while subsequent vaccines require the child to return to the primary healthcare system. The difference may suggest a problem with continuity of vaccination after discharge from maternity care, but the INSP data do not allow the cause to be established.

In the particular case of Bucharest, the report does not show to what extent the figures were influenced by population mobility, failure to attend, refusal, incomplete records or other factors.

The national average concealed communities with very different levels of protection

For MMR, the difference between the extremes exceeded 30 percentage points: 68.5% in Bucharest and 99.3% in Harghita.

For DTaP/IPV/Hib, coverage ranged from 69.9% in Bucharest to 97.3% in Giurgiu.

This variation is important from a public health perspective. Particularly in the case of measles, a relatively high national average does not compensate for the existence of communities in which large numbers of susceptible people accumulate. WHO recommends at least 95% measles vaccination coverage every year to prevent outbreaks and maintain population immunity.

Romania’s recent experience also supports the need for locally adapted interventions. In 2026, WHO announced that preliminary monitoring by INSP following interventions in Brașov, Covasna and Timiș – including training for primary healthcare professionals, communication activities and community outreach – indicated an average increase of approximately 20 percentage points in first-dose MMR vaccination among children aged 12–24 months compared with August 2025.

The result is preliminary and cannot automatically be extrapolated to the entire country, but it shows that territorial differences may require locally adapted solutions rather than only uniform nationwide campaigns.

Another warning sign in the document: records were not perfectly consistent

The INSP analysis also includes a check of consistency between the information used in the assessment and the data recorded in the National Electronic Vaccination Register.

A sample of 56.2% of vaccinators was checked. The data matched for 4,762 of the 5,413 family doctors included in the verification, corresponding to 88% of cases.

In other words, for approximately 12% of the doctors included in this verification, the compared data were not consistent. This percentage does not mean that 12% of vaccinations were incorrectly reported, nor does it allow the scale of errors in the register to be estimated directly. It does show, however, that monitoring vaccination coverage depends not only on administering vaccines, but also on maintaining complete and up-to-date individual records.

What happened after 2018 confirms that the warning was not temporary

Official data available for subsequent years show that the problem was not corrected.

According to WHO, national coverage with the first dose of MMR in Romania fell from 90% in 2018 to 78% in 2024. For the second dose, coverage fell from 81% to 62%.

In December 2023, Romania’s Ministry of Health declared a nationwide measles epidemic, at a time when almost 2,000 cases had been recorded across 29 counties.

In 2024, Romania reported 30,692 measles cases, the highest number recorded by any country in the WHO European Region that year.

It would not be correct to attribute this epidemic to the children in the cohort analysed by INSP in 2018. The epidemic resulted from the accumulation over time of susceptible people across multiple cohorts and communities. The 2018 document is important, however, precisely because it shows that some of the conditions underlying the problem were visible much earlier.

What the 2016 cohort actually tells us

Taken together, the data support several conclusions relevant to vaccination policy today.

First, Romania’s problem of inadequate vaccination coverage cannot be explained exclusively by the effects of the pandemic. In 2018, DTaP, IPV, Hib and MMR coverage was already below the 95% target, with substantial gaps in many counties.

Second, vaccine refusal is only one component of the problem. Failure to attend dominated the reasons reported in this cohort, while later WHO-INSP research shows that missed vaccinations can result from very different mechanisms, ranging from hesitancy to problems with access, communication or continuity of contact with healthcare services.

Third, the national average can conceal important local vulnerabilities. Differences of more than 20–30 percentage points between territories show that the accumulation of susceptible people is not uniform and that interventions must also be designed around local realities.

Fourth, catching up children who are behind schedule must remain a permanent component of the vaccination programme. Recall systems, accurate individual records, doctor-parent communication and community interventions are essential to reducing the number of children who remain incompletely vaccinated.

What the INSP document does not tell us

There are also important limitations. The study does not analyse all children born in Romania in 2016, but only the cohort born in July. In addition, vaccination histories were assessed for 85.7% of live births in this cohort.

The analysis describes the situation at 24 months of age and does not show how many of the incompletely vaccinated children subsequently received their missing doses. Children born in July 2016 are now ten years old, but their current vaccination status cannot be inferred from this document.

For this reason, the INSP report should not be read as a statistical inventory of children who are unvaccinated today, but as an early warning of structural vulnerabilities in the vaccination programme. The problems that would become much more visible in subsequent years – inadequate coverage, territorial disparities, loss of some children to follow-up and the accumulation of susceptible cohorts – were already present in the 2018 data.