Serbia’s most famous citizen, the tennis champion Novak Djokovic, has been vocally cautious about vaccines. A government adviser on the pandemic told the media last March that Covid-19 “exists only on Facebook”. When cases of measles spiked three years ago, authorities blamed the influence of a powerful anti-vaccination lobby.
Serbia is an unlikely candidate for continental Europe’s most vaccinated nation so far. But since January the western Balkans nation has raced ahead of most of the world, delivering more than 31 jabs for every 100 people, according to statistics from Our World In Data, leaving countries such as Germany (13 doses per 100 people) and Canada (10.8 doses) in its wake.
Its success has illuminated the pockets of the country where suspicion of the vaccine is proving stubborn, forcing Serbian authorities to confront a question that might await others in the Balkans and eastern Europe, where polls show that hesitancy to get the jab is a significant force. Once supply of doses outstrips demand, how do you convince sceptical communities to be vaccinated?
Fewer than eight vaccinations per 100 people have been administered in Novi Pazar, the largest city in Sandžak, a rural region and centre for the country’s Bosniak minority, despite at least four different vaccines on offer.
“I think it’s too early to say the vaccine is safe,” says Semin Martinovic, 20, on the streets of Tutin, a town in Sandžak. “Around the world there are lots of examples of side-effects, and there is also the question of which is the most effective. In my area, people are afraid.”
Misinformation is rife in a country the European parliament has called a launchpad for Russian disinformation campaigns, and so is mistrust in a health system that, under the cold war-era communist regime, made mass vaccinations mandatory. Jabs for childhood diseases are still a legal requirement but eschewed by many.
“There is a lot of half truths on social networks, or blunt lies about the vaccines,” says Ervin Corovic, a physician and head of a health centre in Novi Pazar. “We had to fight for years with people that did not wanted to vaccinate children. We got good results with that, but then the pandemic came and those anti-vaccine voices became loud again.”
Quick GuideCovid vaccine side-effects: what are they, who gets them and why?
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What are the most common side-effects from the Covid vaccines?
According to Public Health England, most side-effects from the Covid vaccines – Pfizer/BioNTech and Oxford/AstraZeneca – are mild and short-lived. These include soreness where the jab was given, feeling tired or achy and headaches. Uncommon side-effects include having swollen lymph nodes.
Why do the common side-effects occur?
“The sore arm can be either due to the trauma of the needle in the muscle, or local inflammation in the muscle probably because of the chemicals in the injection,” said Prof Robert Read, head of clinical and experimental sciences within medicine at the University of Southampton and director of the NIHR Southampton Biomedical Research Centre.
“The other common side-effects – the muscle aches, flu-like illness and fatigue – are probably due to generalised activation of the immune system caused by the vaccine. What this means is that the white blood cells that are stimulated by the vaccine to make antibodies themselves have to secrete chemicals called cytokines, interferons and chemokines, which function to send messages from cell to cell to become activated.”
Are blood clots a side-effect of the vaccines?
The Oxford/AstraZeneca jab has been linked to a small but concerning number of reports of blood clots combined with low platelet counts (platelets are cell fragments in our blood that help it to clot). Distribution of the Johnson & Johnson vaccine has been "paused" in the US while scientists investigate six incidences of a rare type of blood clot.
These include a rare clot in the brain called cerebral venous sinus thrombosis (CVST). In an unvaccinated population, upper estimates suggest there may be 15 to 16 cases per million people per year.
The Medicines and Healthcare products Regulatory Agency (MHRA) said recipients of the Oxford/AstraZeneca jab should look out for new headaches, blurred vision, confusion or seizures that occur four days or more after vaccination. The MHRA also flagged shortness of breath, chest pain, abdominal pain, leg swelling and unusual skin bruising as reasons to seek medical advice.
Up to and including 31 March, the MHRA said it received 79 reports of cases of blood clots combined with low platelets, including 19 deaths, following more than 20m doses of the Oxford/AstraZeneca jab. That equates to about four cases for every million vaccinated individuals.
Two cases of blood clots with a low platelet count have also been reported among recipients of the Pfizer/BioNTech jab. The European Medicines Agency is also examining three cases of venous thromboembolism blood clots involving the Johnson & Johnson jab.
The MHRA says blood clots combined with low platelets can occur naturally in unvaccinated people as well as in those who have caught Covid, and that while evidence of a link with the Oxford/AstraZeneca vaccine has become stronger, more research is needed.
Nicola Davis Science correspondent
Residents know what Covid-19 can do. Novi Pazar and the surrounding region have been among the hardest hit in Serbia, where about 4,900 deaths have officially been recorded but the true figure is thought to be higher. An emergency situation was declared last July when hospitals exceeded their capacity. “[They] were overcrowded, there was a lack of equipment in them,” says Corovic.
Covid-19 rates in the country are climbing again, and regional officials are racing to avoid another crisis, blanketing local media with advertisements for the vaccine, sending mobile teams to villages in rural areas, and easing bureaucratic requirements to receive the jab.
Years of jostling for strategic influence in Serbia between China, Russia and western Europe has translated into a bonanza of vaccine deals from manufacturers. “We have more vaccines on offer than those who applied for them,” the prime minister, Ana Brnabić, told media last week.
Its president, Aleksandar Vučić, a bulldozing leader whose dominance of institutions that led a watchdog to conclude Serbia is no longer a democracy, has characterised the abundance of vaccines as a personal triumph.
“I am begging you people, call to get the vaccine,” he said in an address this month. “We have them and we will have them even more, I am begging you like a God, take it.”
In a country polarised by pro-European Union elements and those who favour Russia, the buffet of vaccines on offer has helped to overcome some scepticism, says Milan Krstić, associate professor in political science Belgrade.
“Whether people prefer the eastern powers, like China or Russia, or western ones like the EU or US, it plays into their choice of vaccine,” he says.
Vučić has said he will choose to take the Sinopharm formulation “out of spite”, to thumb his nose at EU regulators who are yet to approve the Chinese vaccine for emergency use.
That vaccines have become so politicised, and synonymous with one political figure, is a source of concern for some public-health experts, who fear the early success of the country’s vaccination programme may be obscuring a low ceiling – short of the 70% thought to be required to achieve herd immunity.
“It was important for the regime to show that Serbia has more vaccines than other countries, but at the same time we have neglected the crucial part: educating people about the vaccine,” says Zoran Radovanović, an epidemiologist.
“Education about vaccine before mass vaccination is like artillery during war. You start breaking the enemy’s line with artillery. In this case, that would be education. But this has not been the case in Serbia.”