Covid-19 vaccine access in the South Caucasus

This study is part of the series "No one is safe until everyone is safe - Global perspectives on Covid-19 vaccination" by the Heinrich-Böll-Stiftung's European Union and Washington, DC offices.

Introduction

After the first cases of COVID-19 were detected in Armenia, Azerbaijan, and Georgia last spring, the three countries embarked on very different courses of action to tackle the virus.

While Georgia moved to quickly close its borders and initiated a strict lockdown, Armenia and Azerbaijan were slower to respond, though both eventually instituted lockdowns of their own.

Over the last year, other events in the region have overshadowed the pandemic to some extent.

On 27 September, war broke out between Armenia and Azerbaijan over the disputed Nagorno-Karabakh region. The 44-day war saw the most intense fighting in the region since the early 1990s, leaving at least 6,900 people dead.

Their defeat in the war had a particularly devastating effect on Armenia. Since then, this and the subsequent political crisis triggered by their defeat has dominated all other issues in Armenia, including COVID-19. Since the war, Armenia has had almost no restrictions in place in an attempt to recover economically from the dual shocks of war and pandemic.

The impact of the war was less severe on Azerbaijan; however, the oil-rich country has also had to contend with low global oil prices.

Georgia, meanwhile, lifted most restrictions in the run-up to the 31 October parliamentary elections. After opposition parties disputed the results of these elections, the country has also been embroiled in a political crisis, which is still ongoing. This has included several large protests. However, the country re-imposed lockdown measures in late November.

These factors, combined with the pandemic, have led to the largest economic contractions in all three countries since the 2009 financial crash. The almost complete loss of tourism revenue has particularly affected Georgia and Armenia.

The three countries have also taken widely divergent paths in their vaccination strategies. All three signed up to the COVAX Facility, an initiative attempting to ensure a more equitable distribution of vaccines co-led by the Coalition for Epidemic Preparedness Innovations (CEPI), the Gavi Vaccine Alliance, and the World Health Organization (WHO). However, geopolitical considerations have also dramatically affected their choices.

Armenia, whose dependence on Russia has deepened further since the war, has pinned its hopes on Russia’s Sputnik V vaccine, even hoping to manufacture it themselves.

Azerbaijan has procured Chinese-made Sinovac vaccines in close cooperation with their close ally Turkey, which also tested the vaccines for them. The large number of Sinovac vaccines they have received has allowed them to lead the region in terms of the number of vaccinations.

Georgia, meanwhile, as by far the most pro-Western country in the region, initially only attempted to procure vaccines produced and approved by Western countries, with the only vaccines to have arrived in the country coming through COVAX. The country has since sought to procure Chinese-made vaccines.

Vaccine hesitancy has also proved to be a significant problem in all three countries. This can partly be attributed to the widespread dissemination of misinformation about the vaccines, especially on social media. There is also a widespread perception that the possible side effects of the current vaccines are not yet known.

The death of a nurse in southern Georgia due to a likely allergic reaction to the Oxford-AstraZeneca vaccine has also had a devastating effect on the vaccination process in Georgia, and to a lesser extent, the region as a whole.

Armenia

The first case of COVID-19 was registered in Armenia on 1 March 2020. As of 28 April, around 214,900 people have been infected and 4,071 people have died. As of 19 April, the COVID-19 mortality rate in the country is 1.9%.

On 16 March 2020, Armenia established a state of emergency, shutting down educational institutions and places of entertainment. Since September 1, 2020, the state of emergency has been replaced with a quarantine regime, which was temporarily lifted during and after the 44-day war when martial law was declared in the country. The quarantine regime was re-established in mid-spring 2021.

After case numbers dropped in the summer of 2020, the authorities lifted most restrictions to prioritise the economy. Wearing facemasks in public areas remains mandatory.

Case numbers began to increase dramatically in the autumn of 2020; however, with the outbreak of the Second Nagorno-Karabakh War between Armenia and Azerbaijan, no restrictions were established.

The lack of restrictions and the mobilisation of the armed forces and volunteers, as well as the displacement of tens of thousands of people from Nagorno-Karabakh, resulted in a dramatic increase in COVID-19 in the country. According to the de facto authorities of Nagorno-Karabakh, the virus also affected combatants and those working in the conflict areas.

The peak of the coronavirus pandemic in Armenia coincided with the war and its immediate aftermath. From 15 October to 20 November, about 1,050 deaths from the coronavirus were registered in Armenia.

Unlike their neighbours, Armenia’s health authorities separate those who have died as a direct result of COVID-19 from those who have tested positive and die from “other causes”. The Ministry of Health does not specify how such cases are distinguished. As of April 28, 1,009 such deaths have been recorded in the country.

The joint shocks of COVID-19 and the war in Nagorno-Karabakh meant that Armenia’s economy contracted by 7.6% in 2020, the largest decline since the 2009 financial crisis. For 2020, Armenia’s central bank projected a decline of around 4% in GDP in late summer; this projection was revised to a decline of up to 7.8% earlier this year.

As in most parts of the world, the most affected sectors in Armenia due to the COVID-19 pandemic were tourism and entertainment. The number of international tourists visiting the country fell by over 80%.

The current state of the vaccine deployment in Armenia

Armenia did not begin the vaccination process until 13 April 2021. During the first two days of vaccination, just 60 people were vaccinated. There has been no public data on the number of daily vaccinations since then.

The country has so far approved the Sputnik V, Oxford-AstraZeneca and Pfizer-BioNTech vaccines for use. On 26 April, Armenia received a new batch of 28,000 doses of the Sputnik V vaccine, enough for 14,000 people․

The country received the first 24,000 doses of the Oxford-AstraZeneca vaccine through the COVAX Facility in late March and 15,000 doses of Sputnik V vaccines on 8 April.

In early March, Russia donated around 2,000 doses of the Russian-made Sputnik V vaccine to Armenia, which were used to vaccinate health workers and other risk groups.

During a press conference on 12 April, the Health Minister Anahit Avanesyan announced that the two currently available vaccines would be allocated to different groups.

Oxford-AstraZeneca will be given to people over 65, medical workers and people aged 55–65 who suffer from chronic diseases, as well as to residents and staff of care homes. The Sputnik V vaccine will be administered to medical workers, people aged 18–54 who suffer from chronic diseases and residents and staff of social care centres, such as day-care centres for children.

 For the first phase, Armenia plans to vaccinate several groups of people։

• Medical workers
• Care centre staff
• Citizens 65 years and older
• Patients with chronic illnesses aged 16 to 64 years
•  Nursing home staff and residents

The second stage of vaccinations will include the following groups:

• Teachers and university lecturers
• Ministry of Emergency Situations staff
• Military service members
• Workers in the justice sector
• Workers in public transportation
• Civil servants

The vaccines are being provided to the population for free and on a voluntary basis. In late April, the Ministry of Health lifted the limits on Oxford-AstraZeneca vaccines, allowing everyone (including foreign citizens) over 18 to get the vaccine. According to the deputy director of the National Centre for Disease Control (NCDC), Gayane Sahakyan, this is a way to support the volunteers who want to be vaccinated regardless of the age limits. The Sputnik V vaccine is still allocated for certain groups of people only.

Armenia is a member of the COVAX Facility and is awaiting deliveries of additional doses of several vaccines.

Officials have stated that the country expects to receive the Novavax vaccine. The country has also completed negotiations with the Chinese government to purchase an unspecified Chinese vaccine or vaccines.

Given the political situation in Armenia after its defeat in the recent war and Russia’s increased influence in the region, cooperation between Armenia and Russia has become more active over vaccines, along with other spheres as well.

After receiving the first doses of Sputnik V in April, Armenia expects to receive over one million doses of Russian-made vaccines. According to Armenian and Russian officials, the two countries are also negotiating the possibility of launching joint production of the Sputnik V vaccine in Armenia.

According to the Health Minister, the government’s objective is to vaccinate between 600,000 and 700,000 of Armenia’s three million people within a year. She said that this would be enough to develop herd immunity against COVID-19.

Through vaccination and programmes supporting businesses in Armenia, The Central Bank of Armenia has projected GDP growth of 1.4% for 2021. Armenia’s Minister of Economy stated in April that they expected tourism income to be just 20% below 2019 in 2021.

The International Monetary Fund’s projection for Armenia’s economic growth is 1% for 2021 and 3.5% for 2022. The World Bank forecasts that Armenia’s GDP will grow by 3.4% in 2021 and 4.3% in 2022, recovering to pre-pandemic levels. However, they noted that these forecasts assumed that Armenia would not enact additional lockdown measures in 2021, and that the political situation in the country would stabilise.

Acceptance of the vaccine and cultural and socio-political implications

During the initial stages of vaccine development, conspiracy theories proliferated regarding the coronavirus, vaccines in general and any future coronavirus vaccines. The widespread conspiracies about COVID-19, such as those relating to microchipping through vaccination or plans to reduce the population, raised hesitancy and scepticism towards vaccines. There were coordinated disinformation campaigns about the coronavirus, its mortality rates and the differences from “ordinary” flu.

In the early months of the pandemic, there were unsubstantiated reports that the government was paying people to register their relatives’ deaths as being due to COVID-19. In one instance, a US government-funded news portal was found to be spreading disinformation about the vaccine. After a journalistic investigation by OpenDemocracy, the US suspended funding for the site.

Hesitancy and scepticism towards vaccination remains widespread on social media. Recent deaths linked to blood clots caused by the Oxford-AstraZeneca vaccine and the death of a nurse in neighbouring Georgia after receiving the virus have received widespread coverage.

While Armenia is not releasing data on the number of vaccines administered, on 9 April, four days before vaccination began, the authorities reported that only 600 people had signed up to be vaccinated, suggesting widespread hesitancy. As of 26 April, around two weeks after the start of the vaccine roll out, only 2,200 people had been vaccinated.

Health officials have said that people do not want to be vaccinated or claim to be “allergic to vaccines”.

According to a poll conducted in March by the Caucasus Research Resource Center (CRRC) Armenia, at the request of Civilnet.am, 56% of Armenians will not apply for vaccination, while 30% said they will apply for vaccination, and 13% refused to answer. Almost half of the population (49%) do not trust vaccines at all, and 44% of those who do not intend to be vaccinated will not apply for the vaccine unless the vaccine is considered safe.

Expectations regarding international actors

Armenia’s choice of vaccines has been highly connected with the political situation in the country and, more broadly, in the South Caucasus region.

While Armenia is participating in the COVAX Facility, its main expectations have focused on Russia. The country is a member of Russian-led economic and political alliances the Collective Security Treaty Organization and the Eurasian Economic Union.

Since the war in Nagorno-Karabakh, which ended with a Russian-brokered ceasefire and the deployment of Russian peacekeepers to the disputed Nagorno-Karabakh region, Armenia has become even more dependent on Russia.

The growing dependence on Russia in political, economic and military sectors is reflected in the vaccine rollout — making the Sputnik V the leading vaccine in the country.

The expected purchase of Russian-made vaccines for most of the population lessens the possibility of buying other types of vaccines through COVAX or cooperation with other countries. However, the country hopes to get at least the Pfizer-BioNTech and Moderna vaccines in the future.

With Russian support, Armenia hopes to begin manufacturing Russia’s Sputnik V vaccine. Health Minister Anahit Avanesyan and Russian Ambassador to Armenia Sergey Koprikin have stated that the countries are discussing this possibility.

Armenia is also planning to buy around one million Sputnik V vaccines (enough for 500,000 people), which is by far the highest number of vaccines Armenia has stated it will purchase. Anahit Avanesyan has stated that the two countries already have an agreement on vaccine deployment.

Along with its cooperation with Russia, Armenia does have high expectations from the West, and specifically the COVAX Facility, as an opportunity to receive alternative vaccines at a relatively low cost.

In the summer of 2020, Armenia expressed hopes of purchasing vaccines from American biotechnology firm Moderna, as one of the company’s key figures is of Armenian descent. Nubar Afeyan is one of the company’s founders and chairs the board of directors, and currently owns a 0.5% stake in the company. In July 2020, then–Health Minister Arsen Torosyan stated that the Moderna vaccine would be one of the main vaccines that Armenia would try to purchase, in cooperation with Afeyan.

However, most of Moderna’s early doses were earmarked for the US and the Armenian government refocused on purchasing other vaccines. This has included plans to procure Chinese-made vaccines.

Azerbaijan

Since the first case of COVID-19 was registered in Azerbaijan on 28 February 2020, the total number of people infected is 287,144, with the total number of registered deaths being 3,944 (as at time of writing).

Both the pandemic and low oil prices contributed to a weakening of the Azerbaijani economy in 2020. According to the IMF, the economy contracted by 4.3% in 2020. According to official statistics non-oil sectors of the economy contracted by 2.9%.

The pandemic had the most significant negative impact on the country’s tourism sector, resulting in a 58.9% decline in the tourist accommodation and catering industries.

The IMF has projected an economic recovery in 2021, growing by 2.3%. The S&P Global Ratings expects Azerbaijan’s economy to grow 2.1% in 2021.

According to the World Bank, output is not expected to return to pre-COVID-19 levels until the end of 2022. However, they noted Azerbaijan’s early start in vaccinating the public, which could see the economic recovery sooner.

The current state of the vaccine deployment in Azerbaijan

Azerbaijan was the first country in the South Caucasus to start vaccinating its population and is planning to vaccinate at least 20% of its population in 2021. As of 15 April, over 837,000 people (8% of the population) have received one dose and 434,000 (4% of the population) have been fully vaccinated.

Vaccination started in Azerbaijan on 18 January with the Chinese-made Sinovac vaccine. The first batch of the vaccines was initially shipped to Turkey, where they underwent testing, with subsequent shipments going directly to Azerbaijan.

According to Shahmar Movsumov, an assistant to the president, four million doses of the vaccine, enough for two million people, will be delivered from Sinovac’s regional office.

According to Soltan Mammadov, a member of the Health Committee of the Azerbaijani parliament, Sinovac was chosen because it was the simplest to store and because it had an effectiveness of ‘around 92%’.

The Medical Territorial Units Management Association (TABIB), which is responsible for coordinating measures against the pandemic, has also stated that the Sinovac vaccine is safer than other options.

Mammadov said that: ‘The population of Azerbaijan has long been vaccinated with inactivated vaccines, so this method is “more reliable”.’

The Sinovac vaccine uses inactivated vaccine technology, which has been successful in producing widely-used vaccines in the past including against rabies and polio. This contrasts with the more novel technologies used in the Oxford-AstraZeneca vaccine (viral vector) and Pfizer-BioNTech and Moderna vaccines (mRNA).

The vaccines are being provided to the population for free, and on a voluntary basis, in several stages. The first vaccination stage included people at risk, starting with health workers, people over 65 years of age and law enforcement staff involved in anti-epidemic measures. People can currently register for vaccination on an online portal run by the state’s Agency for Compulsory Health Insurance.

On 1 February, 2021, Azerbaijan started the second stage of the vaccination, including people with chronic respiratory diseases, diabetes, and obesity, people aged 50 and over, those in need of hemodialysis, educators, social security workers, and others.

On 8 February, the Ministry of Health approved clinical trials to assess the immunogenicity and safety of the combined use of the Sputnik V and Oxford-AstraZeneca vaccines. The research programme will last six months in several countries. It is planned to involve 100 volunteers from each country in this research.

On 11 March, Prime Minister Ali Asadov signed a bilateral agreement with Russia to import 300,000 doses of the Russian-made Sputnik V vaccine.

Azerbaijan is also purchasing vaccines through the COVAX Facility. On 4 April, the first batch of 84,000 Oxford-AstraZeneca vaccines was delivered from Korea via COVAX. Azerbaijan expects a further 432,000 doses of the Oxford-AstraZeneca vaccine by the end of May.

It is unclear when vaccines are expected to be widely available to the general public and there is no discussion of developing or manufacturing vaccines in Azerbaijan.

The Azerbaijani government has said that it is following IMF recommendations in seeing rapid and equal access to the vaccines as central to economic recovery.

Local economists have predicted that the economic crisis will continue in 2021, as the pandemic has not yet been contained. Mass vaccinations are likely to continue until the end of the year. According to economist Zohrab Ismayil: ‘A crisis will accompany this, and increased poverty and stratification in Azerbaijan will continue.’

According to Vusal Gasimli, Executive Director of the Center for Economic Reforms Analysis and Communication, Azerbaijan as one of the first countries to begin vaccinations and it ‘applies the most appropriate “recipe” for the national recovery of the economy, continuing fiscal expansion, and soft monetary policy.’

Local economists have also emphasised the possible economic boost from reopening regional transport routes that have been closed since the 1990s following the war in Nagorno-Karabakh.

Acceptance of the vaccine and cultural and socio-political implications

According to various surveys, many Azerbaijanis do not want to be vaccinated against COVID-19 because they are afraid of possible side effects from the current vaccines, they do not trust the quality of the vaccines, or do not trust the vaccines because they are relatively new.

A study conducted by the Centre for Social Research in Baku, Absheron, and seven other economic regions involving 1,200 randomly selected respondents, found out that 58.3% of people believed they would be negatively impacted if they were vaccinated.

Some respondents said they did not want to be vaccinated because their current health status does not allow it, or because they do not belong to at-risk groups for COVID-19.

According to a poll carried out by the Centre for Media Analysis, among supporters of vaccination, 53% attach great importance to the vaccine’s country of origin. Only 15.3% said they were willing to be vaccinated with any proposed vaccine and 31.7% would trust only vaccines that the state purchases.

Vasif Ismayil, a Doctor of Philosophy and a Doctor of Medicine, has said that medical workers in Azerbaijan have volunteered for testing the vaccine. He said that this had led to a more positive attitude towards vaccination.

Both polls suggest that around only 40% of people were currently willing to be vaccinated, with around 16% against and 40% waiting for a reaction from those who have already been vaccinated.

Some polls have contradicted each other on the issue of concerns over the virus. In the polling by the Centre for Media Analysis, 53% said they were afraid of contracting COVID-19, while the poll by the Centre for Social Research indicates that 52.2% were not afraid of being infected. These contradictions make it challenging to assess whether it is the virus or the vaccine that is the largest concern for the public.

From the beginning of the vaccine rollout, the government has insisted that vaccination will be voluntary. However, TABIB has several times had to comment to deny claims in the media that some health workers were being forced to be vaccinated.

According to the Center for Social Research, the two main sources from which people receive information about COVID-19 vaccines are local television (67.3%) and social networks (43.2%).

Several polls suggest that negative information about vaccines in the media hinder their administration. Some have also suggested that mistrust towards the Azerbaijani health system is also a deterrent.

Vaccination in Azerbaijan has been introduced with the Soviet-era system in which a health certificate confirming that a child has been vaccinated would be required for admission to the first grade of school. Children are already vaccinated against 11 major infectious diseases.

According to the State Statistics Committee, in 2019, 98% of children under one year of age were vaccinated against hepatitis B, 96% against tuberculosis, 94.5% against diphtheria, pertussis, tetanus, and b-type hemophilic influenza, 96% against polio, and 97% were vaccinated against measles and mumps.

In October 2020, the TABIB began vaccination against seasonal flu for the first time. This decision was made after assessing the risks aggravating the situation as a result of the pandemic.

Expectations regarding international actors

Azerbaijan is leading the South Caucasus in the deployment of the vaccines and has managed this through its recently strengthened alliance with Turkey, and consequently with China. Azerbaijan’s relationships with its “brotherly” state Turkey received a boost in 2020 when the Turkish government firmly supported Azerbaijan during the Second Nagorno-Karabakh War. In the pre-war period, cooperation had already consolidated significantly in the areas of weapons supply and military training.

As a result of the alliance, in 2020 Ankara sent medical and humanitarian aid to Azerbaijan to fight the virus. After the Turkish embassy said in August that, “of course, we will give the vaccine to Azerbaijan”, they created a public expectation.

The first batch of the Sinovac vaccine was delivered to Azerbaijan with the assistance of Turkish firm Keymen İlaç, which has been connected to Turkey’s ruling party.

In fact, the cooperation between the Chinese Sinovac Biotech Co. Ltd., Beijing, with Keymen İlaç utilised by the Turkish Ministry of Health, started back in 2014.

Before starting the vaccination process themselves, Turkey said in an interim assessment of tests that the Sinovac vaccine was 91.25% effective. Azerbaijani officials often referred to the results of the clinical test stages in Turkey.

According to Chinese media, the second batch of vaccines was directly delivered from China to Azerbaijan. In recent years cooperation between China and Azerbaijan has been developing, for instance with projects such as the joint construction of the Trans-Caspian International Transport Route, a land transport network stretching from China and Southeast Asia to Europe.

At the peak of the pandemic in China, Azerbaijan also provided humanitarian and medical assistance. Months later, when the Chinese economy had begun to recover, Beijing decided to pay this back with a ‘green corridor’ for the vaccines.

In late April, China sent 150,000 doses of vaccine to Azerbaijan free of charge. At the handover ceremony, Ambassador Go Min noted that China and Azerbaijan have a reliable friendship and partnership and are ready to deepen these relations. With the premise of restoration of ‘all transport links in the region’ as a result of the Second Nagorno-Karabakh War, it is clear that Beijing’s interests are being consolidated in the region.

The President of Azerbaijan has stated that the country has provided financial and humanitarian assistance to more than 30 countries during the pandemic, as well as to some international organisations, including the World Health Organisation.

Azerbaijan’s president has criticised Western countries over ​​​​​​​their unequal distribution of the COVID-19 vaccines many times, referring to the crisis between the UK and the EU, for instance. As the current chair of the Non-Aligned Movement, he has continuously advocated for more vaccines to be provided to less developed countries.

According to Aliyev, the struggle for vaccines, especially between rich countries, negatively affects vaccine producers and inflames mistrust between countries throughout the world. In one interview, Aliyev said he was witnessing ‘an unofficial neo-colonial period or an undeclared colonisation’.

Azerbaijan was one of the first countries to join the COVAX Facility and in September 2020, a contract between the facility and Azerbaijan’s State Agency for Compulsory Health Insurance was signed for the purchase of the Oxford-AstraZeneca vaccine. Delays in the delivery of vaccines caused visible tensions in 2021.

Many Azerbaijani officials have accused COVAX of failing to deliver vaccines to Azerbaijan on time. In March, MP Jeyhun Mammadov said: ‘ It has recently become known that COVAX will deliver less than promised, without even naming the delivery time,’ and ‘Obviously, double standards are applied in such important issues as health care and vaccination.’

Although Assistant to the President, Shahmar Movsumov, said in January that Azerbaijan would get two million doses as part of the COVAX Facility, Azerbaijan was later not included in a list of 18 countries that would receive the Pfizer-BioNTech vaccines from COVAX.

The first 84,000 doses of the 432,000 Oxford-AstraZeneca vaccines promised by COVAX were received on 4 April 2021. It is not clear when the next batch will be delivered.

Georgia

Georgia is currently experiencing what the national medical authorities have dubbed the beginning of a ‘third wave’ of the coronavirus pandemic. Despite pledges to do so, the government has refrained from implementing tighter nationwide restrictions after the national daily test positivity rate exceeded 4% in mid-April. As of 28 April, The National Centre for Disease Control (NCDC) has reported 1,551 confirmed cases out of 29,487 tests within the previous 24 hours. The rolling seven-day average positivity rate on 28 April stood at 4.39%.

In April, medical authorities identified eateries and ritual social gatherings such as funeral dinners as the main source of cluster-based outbreaks that, according to them, led to a wider spread of the infection in the country. The government made 4 to 11 May official holidays to mitigate the fallout from anticipated increased mobility among Orthodox Christians, as they traditionally greet Easter morning (on the night of 1 and 2 May this year) in churches and visit cemeteries en masse on the following day.

As of 28 April, Georgia has reported a total of 307,401 infections and 4,077 COVID-19-related fatalities (1.3% mortality rate).

In late January, the National Statistics Office reported a 6.1% decline in GDP in 2020. The tourism sector, which in 2019 accounted for 11.5% of GDP, has been especially affected. According to the National Tourism Administration, 80% fewer international visitors arrived in Georgia in 2020 compared to the previous year.

In their Regional Economic Outlook released in April, the International Monetary Fund estimated that Georgia’s tourism sector was expected to recover gradually ‘by the end of 2024 or 2025’.

On 31 March, the World Bank forecasted that Georgia’s economy would rebound with 4% growth in 2021, but that it would not return to pre-COVID levels ‘until late 2022’. However, they noted that this growth would be ‘contingent on vaccine rollout and the restoration of international trade and investment.’ The report also stated that ‘Delayed vaccinations, further restrictions and prolonged political tensions represent the key downside risks to this outlook’. The World Bank said that such conditions could mean that output would not return to pre-COVID levels until 2024.

The current state of the vaccine deployment in Georgia

As of 28 April, the National Center for Disease Control and Public Health (NCDC) reports that 41,801 doses of the vaccines have been administered since the rollout began on 15 March. All of them will need a repeated dosage of the respective vaccine to be administered at a later date.

The Georgian authorities confirmed the first case of COVID-19 infection on 26 February 2020, 15 days before the World Health Organisation designated the outbreak a pandemic.

During the COVID-19 outbreak, the ruling Georgian Dream party has closely cooperated with the NCDC under the ad-hoc Inter-Agency Coordination Council, which was created on 28 January 2020.

The authorities have taken pride in taking early steps to prepare the country for the pandemic, followed with protocols for hospitalisation, contact tracing and responding to clusters of the outbreak with local lockdowns. However, the nationwide lockdown imposed on population mobility and the economy since May have triggered a wave of criticism, including from political groups, over its impact on the economy.

In summer 2020, the government relaxed some of the restrictions in the run-up to national elections in an attempt to save the tourism industry and in-person national university entry exams.

The eased regulations in Georgia led to a ‘second wave’ of the outbreak, with daily cases rising since last September, something that brought the country’s healthcare system to the brink of collapse.

In November, the government responded to the alarming daily numbers with a nationwide lockdown, including a curfew and stoppage of intercity connections and public transport, which pushed parts of the labour and education sectors online.

After topping all European countries in mid-December with its 7-day cumulative incidence rate, Georgia’s numbers gradually subsided. By mid-February, Georgia stood positioned at 32 among 52 European countries, with 94.9 cases per 100,000.

Georgia is neither developing nor manufacturing any vaccines against COVID-19. While the authorities say that they have made efforts to negotiate for scarce supplies directly with manufacturer companies (apart from additional batches of Pfizer-BioNTech and Oxford-AstraZeneca , Georgia expects one million doses of Novavax vaccines for late summer and is also eyeing the Johnson & Johnson vaccine), the country is currently heavily dependent on the global vaccine-sharing mechanism, COVAX.

Georgia signed an agreement with the COVAX Facility in September to receive 1,484,400 vaccines and committed to preparing facilities to store the Pfizer-BioNTech and Moderna vaccines, which require -70°C and -25ºC to -15ºC refrigerators, respectively.

In January, the Georgian Parliament amended the Law on Public Health making the state liable for any harm from imported vaccines in order to streamline the reception of COVAX-distributed vaccines.

The government vowed that the vaccine would be voluntary and free, including for people residing in the regions of Abkhazia and South Ossetia, which are not under the control of the central government.

On 13 March, Georgia received its first batch of 43,200 doses of the Oxford-AstraZeneca vaccine, followed by 29,250 doses of the US-German Pfizer-BioNTech vaccine on 25 March.

Following the slow vaccine take-up by medical workers in March, the government floated the idea of opening up vaccination to other groups earlier than planned.

The National Vaccination Plan developed in January did not include specific dates for the stages of rollout, but Georgia expanded eligibility to everyone aged above 65 only 10 days after receiving the first vaccines. Later, the government allowed anyone aged 18 to 60 to register for the Sinopharm vaccine in the period from 4 to 15 May.

Initially, the government aimed to receive 3,979,300 doses of vaccine to implement their mass inoculation plan for 2021. With Georgia entering a renewed period of peaking numbers and enthusiasm for being vaccinated still low, the prospects for economic recovery in the country remain uncertain.

Acceptance of the vaccine and cultural and socio-political implications

The mass inoculation plan, initially rolled out only for medical workers on 15 March, faced serious risks of being impeded after a 27-year-old nurse died of complications on 19 March; she reportedly experienced an acute allergic reaction to the Oxford-AstraZeneca vaccine.

Several weeks later, the attending medical workers were criminally charged with negligence, something that has softened the link between the vaccine and perceived risk from dying from it. However, the authorities were already voicing misgivings that Georgia could end up failing to use up the small number of supplies it had due to elevated hesitancy among the public, including among medical workers.

‘A doctor is a doctor for a reason: one should […] get familiarised with scientific materials, not rumours’, said Deputy Director of NCDC Paata Imnadze, who did not hide his frustration with the low number of medical doctors registering for vaccination by15 March.

Paata Imnadze sounded more optimistic six weeks later on 27 April, after over 6,700 people registered online for the Sinopharm vaccine in just two hours. The online registration revealed a large divide, as approximately 4,500 out of those 6,700, according to Imnadze, were booked in the capital city Tbilisi.

A number of sources indicate that vaccine hesitancy was already prevalent in Georgia and that the fatal incident with the nurse in March was not the sole contributor to it.

A day before the incident was reported (two days after the launch of vaccine rollout), the NCDC reported that only 1,842 medical workers had been vaccinated.

In a study conducted two months earlier by the CRRC, 40% of Georgians surveyed said they would not be vaccinated for COVID-19, while an additional 12% reported that they were uncertain.

In another study by the CRRC, commissioned by the US-based National Democratic Institute (NDI) in February 53% said they did not wish to be vaccinated, while 35% said they wished to.

In a public opinion survey conducted in February, released by the US-based International Republican Institute (IRI), 39% of respondents said they would not get vaccinated and another 6% said they would do so only if a law or an employer mandated it.

The idea that misconceptions about vaccines are rampant among Georgians has been confirmed by several waves of surveys by the CRRC between late April and early June 2020. According to one such study, one in five surveyed believed that the vaccines caused autism or that they could cause serious problems for their children.

Nevertheless, those responsible for the mass immunisation against COVID-19 might find it useful to scrutinise the public opinion surveys, as strong conspiratorial attitudes do not seem to dominate among Georgians distrusting the COVID-19 vaccines.

A low or lowered trust towards the Oxford-AstraZeneca vaccine following the death of the Georgian nurse on 19 March could also have played a role in vaccine hesitancy: many Georgians claimed that they were willing to wait to receive the Pfizer-BioNTech vaccine for its perceived better quality.

According to the CRRC/NDI poll conducted in mid-February, out of the 65% who said that they would not be vaccinated, a mistrust towards the ‘quality of the COVID-19 vaccine’ came on top of all other reasons (48%). In the February IRI poll, 24% said they would get vaccinated ‘after some time passes’.

Throughout the pandemic, despite appeals from the medical authorities, the Georgian Orthodox Church, the most trusted institution in Georgia, has sent mixed signals about vaccination.

While mid-level clergy heading various parishes and several members of the Church’s Holy Synod promoted conspiracy theories about the vaccines, Church authorities focused primarily on resisting any compulsory vaccination, a possibility that was never voiced by the authorities.

On 12 February, the Church’s Holy Synod came up with a final statement in which they reiterated that they would not engage in ‘propaganda’ in favour of mass inoculation against coronavirus as it was not their place to do so.

The Synod’s statement also mentioned ‘bioethics’, possibly referring to the involvement of foetus cell lines, as a matter of their concern while noting the lack of information on available or upcoming vaccines at that time.

After increasing cases of measles since 2017, mass immunisation became among the top challenges for the NCDC. Following an outbreak of 312 registered cases during the first half of January 2019 in Georgia, the authorities made inoculation against measles, mumps and rubella free and compulsory. However, the campaign struggled with misinformation, mostly spread online, about a debunked link between the measles vaccines and autism, or the incompatibility of vaccines against measles and the vaccines against the flu.

Expectations regarding international actors

Since late March, the NCDC and Georgia’s Health Ministry have largely focused on countering disinformation, as well as mass hesitancy among medical staff and the elderly, priority groups according to the national vaccination plan, to be registered for the vaccine jabs.

These problems, to a great extent, eclipsed the challenge of the scarcity of vaccines and how the authorities would safeguard contracts with international stakeholders, top issues that were previously vigorously discussed in the media.

In early 2021, frustration grew after Georgia did not get its first batches of Pfizer-BioNTech vaccines by the end of February, as was originally planned.

While the reason behind the delay remained obscure, and the Georgian Health Ministry even floated the idea of suing COVAX, public frustration was mostly directed at the local authorities, which critics accused of mismanaging the process.

In early March, Georgia's Regulation Agency for Medical and Pharmaceutical Activities claimed in vague terms that they were swiftly authorising each vaccine that the WHO was approving for emergency use.

According to the National Vaccination Plan, the government is seeking any coronavirus vaccines that are approved by the WHO or highly trusted national regulators ‘like the FDA (USA), EMA (EU), [and national regulators of] the UK, Japan, Australia and so on (regulators of a total 37 countries)’. The medical authorities indicated that they did not discriminate between vaccines beyond these criteria.

On 26 March, as the authorities launched online registration for the Pfizer-BioNTech vaccine for elderly people via the booking.moh.gov.ge web portal, the Georgian Health Minister Ekaterine Kikaradze called Pfizer-BioNTech ‘the most trendy’. This was understood by some as her supporting one of the vaccines at the expense of Oxford-AstraZeneca, which suffered a drop in trust among the public. Several days later, Tikaradze herself warned the public that Georgia had received a complaint from ‘international partners’ for discriminating between the vaccines.

Georgian authorities, however, have differentiated between Chinese- and Russian-produced vaccines, despite both lacking WHO approval, favouring the former.

The import of Chinese vaccines to Georgia could be considered a part of China’s public diplomacy that has proven successful in some central and eastern European countries.

While Georgian medical authorities have said they expect the WHO to authorise it before making it available for the general public from 4 May, they have also hinted that they might go ahead with vaccinations, even without this.

Georgia also expects to receive 100,000 doses of the Sinovac vaccine as a gift from China, which is also pending WHO authorisation.

Unlike in Armenia, Belarus, Slovakia, Moldova and Hungary, the Russian-produced Sputnik V vaccine, which also lacks emergency approval by the WHO, was never publicly considered by Georgian authorities as a serious option.

Despite positive, and mostly misleading, coverage of Sputnik V in Georgia by pro-Russian media outlet Sakinform, and by the Russian state-run Georgian language media agency Sputnik, and despite the one-time coordinated demand by pro-Russian groups in Georgia for the Sputnik V vaccine to be imported into the country, public demand for the vaccine has not gained strong traction in the country.

This has included a lack of support from several groups considered by some to be pro-Russian. While the opposition Alliance of Patriots group continues to advocate for Georgian military neutrality, and the Obiektivi TV channel affiliated with them helped to disseminate anti-vaxxer sentiments among viewers, the Sputnik V vaccine, or any other help from Russia in Georgia’s fight against the pandemic, has largely been absent from the party’s main agenda.

Nino Burjanadze, leader of the Democratic Movement-United Georgia party, which has been highly critical of Georgia’s Western partners in recent years, also never floated any potentially substantial Russian role in Georgia’s efforts to mitigate the pandemic.

In the first half of 2020, and also recently, some pro-Western liberal groups, or individuals associated with them, have accused the government of not facilitating the commercial import of coronavirus vaccines into Georgia, something that the authorities dismissed as a baseless and unrealistic endeavour considering the shortages of supplies.

Georgian medical authorities rushing to acquire two vaccines produced by China-based manufacturers could be indicative of their concerns over the scarce supply, in which provisions from COVAX would not be sufficient. Georgia is expected to seek bilateral agreements with specific manufacturers to ensure uninterrupted mass immunisation of the population, so as to reach their goal of having at least 60% of people vaccinated in total.

Currently, however, the Georgian leadership could be experiencing a sort of shock from not getting support for mass public vaccination from the Georgian Orthodox Church. The pro-vaccination campaign has been faltering, and larger involvement from international partners such as the EU and USA, that had mobilised around €365.5 million and $5.7 million in emergency health assistance, respectively, could be crucial.

The tentative list of countries that Georgia’s authorities trust the national regulators of has indicated Georgia’s underdeveloped infrastructure and the Georgian authorities’ preference to trust more economically developed countries, including those that are manufacturing COVID-19 vaccines. These did not include the regulators of Russia and China, while the endorsement of vaccines produced by China-based companies hints at Georgia’s desperation to gain sufficient supplies.

In recent years, Georgians have remained overwhelmingly supportive of the idea of Georgia joining NATO and the EU, the former seen as a chance to be more militarily secure from Russia, while the latter being associated with better economic prospects. In a February poll by IRI, 58% named a strengthened economy, more jobs or visa liberalisation as the main benefits of joining the EU.

While closer ties with the US and the EU were never strongly associated with public health issues, the pandemic could highlight this as a new and important factor. However, there is also a risk that if the crisis deepens, Georgians could start to feel ‘left behind’ by rich Western countries as they continue to open up their economies and public life. As of spring 2021, criticism of the Western developed world over the imbalance in the global distribution of vaccines has been virtually absent in Georgia.

Conclusion

The countries of the South Caucasus were relatively late to begin vaccinating, especially when compared to more developed countries in the West. This was largely due to the difficulty in procuring supplies of vaccines.

The regional leader in vaccination, Azerbaijan, has succeeded through their partnerships with Turkey and China, not the West.

The only country with any prospects of manufacturing a vaccine, meanwhile, is Armenia, and that with Russian support.

While the COVAX Facility has remained an important part of the vaccination strategies in all three countries, limited and delayed supplies from the programme have forced the countries to look elsewhere.

In defiance of WHO recommendations, support for funding a more international effort to confront the pandemic worldwide has not been prioritised. Western countries have instead overwhelmingly prioritised vaccinating all of their own populations first.

While it must be acknowledged that crucial improvements have to be made for intergovernmental cooperation to establish an effective global response to the pandemic, less developed countries, such as those in the South Caucasus, are unlikely to see vaccines widely available to the public in 2021.

Vaccine hesitancy has also played a large role in the slowness of the vaccine rollouts in the South Caucasus. This has been fuelled by both misinformation and conspiracy theories, as well as a reluctance to receive vaccines using novel technologies.

The World Bank has warned that their economic forecasts regarding recoveries in all three countries are contingent on containing the pandemic and avoiding more lockdown measures, including through vaccinations. For Georgia especially, the World Bank has said that a slow vaccine rollout could delay the country’s recovery to pre-pandemic levels of output by a year or more. In Armenia and Azerbaijan, it has said that economic recovery would also be largely contingent on other factors, including global oil prices and a return to domestic political stability, respectively.

Recommendations

1. Make more vaccines available, either through the COVAX Facility or through direct bilateral deals with South Caucasus countries.
2. Make a wider choice of vaccines available to people in the South Caucasus, especially given the perceived danger of the Oxford-AstraZeneca vaccine.
3. Consider waiving vaccine patents to facilitate quicker and easier access to vaccines for all. As a result of local production, trust in the vaccines might consequently evolve.
4. Assist in promoting vaccination as safe and effective. This could be done through diplomatic missions in the South Caucasus, as the public vaccination of well-respected figures has been seen as a key to promoting vaccination globally.

 

Reference list

Abrahamyan, G. (2021, 15 April). Curbing COVID-19: The World Gets Vaccinated. EVN Report. https://www.evnreport.com/raw-unfiltered/curbing-covid-19-the-world-gets-vaccinated (accessed May 13, 2021)

Ambassador: a batch of Russian Sputnik V vaccine to arrive in Armenia very soon. (2021, 26 March). ARKA News Agency. http://arka.am/en/news/society/ambassador_a_batch_of_russian_sputnik_v_vaccine_to_arrive_in_armenia_very_soon/ (accessed May 13, 2021)

A new batch of Russian Sputnik-V vaccine for 14,000 people has been imported to Armenia. (2021, 26 April). HETQ. https://hetq.am/hy/article/130189 (accessed May 13, 2021)

Anti-Western disinformation in the pre-election period September-October 2020. (2020). Grass Reformanda & Open Information Partnership. https://grass.org.ge/uploads/other/2021-01-06/825.pdf (accessed May 13, 2021)

AstraZeneca can already vaccinate all citizens over 18 years of age. (2021, 28 April). Ministry of Health. https://www.facebook.com/watch/?v=232426178652388 (accessed May 13, 2021)

Avetisyan, A. (2021, 8 April). POWs, the economy, and vaccines discussed as Pashinyan meets Putin. OC Media. https://oc-media.org/pows-the-economy-and-vaccines-discussed-as-pashinyan-meets-putin/ (accessed May 13, 2021)

Azerbaijan allowed for the first in the world to study a combination of “Sputnik V” vaccine and COVID-19 vaccine developed by “AstraZeneca” Company. (2021, 9 February). Azerbaijan Republic. Ministry of Health. http://health.gov.az/xeberler/3356-azrbaycan-dnyada-ilk-olaraq-sputnik-v-v-astrazeneca-irktlrinin-covid-19-a-qar-olan-vaksinlrin-birg-ttbiqi-tdqiqatna-icaz-verdi.html (accessed May 13, 2021)

Azerbaijan’s GDP decreases by 4.3%. (2020, 11 December). APA. https://apa.az/en/xeber/finance-news/Azerbaijans-GDP-decreases-by-43percent-337594 (accessed May 13, 2021)

Can private medical facilities also bring vaccines?. (2021, 9 February). Azadliq. https://www.azadliq.org/a/31093701.html (accessed May 13, 2021)

Children covered by prophylactic vaccination in 2019 – Excel Sheet. (2019, 4 June). The State Statistical Committee of the Republic of Azerbaijan. http://www.stat.gov.az/source/demoqraphy/au/az/u004_6.xls (accessed May 13, 2021)

Chkareuli, T. (2020, 12 November). Coronavirus deaths pile up in Georgia amidst political unrest. OC Media. https://oc-media.org/features/coronavirus-deaths-pile-up-in-georgia-amidst-political-unrest/ (accessed May 13, 2021)

Compared to 2020, this year we will have a 319% growth in the tourism sector - Minister of Economy. (2021, 26 March). Tert.am. https://www.youtube.com/watch?v=TInV7vg4hq4 (accessed May 13, 2021)

Coronavirus confirmed as pandemic by World Health Organization. (2020, 11 March). BBC News. https://www.bbc.com/news/world-51839944 (accessed May 13, 2021)

COVAX demonstrates frivolous approach and does not fulfill promises - Azerbaijani MP. (2021, 27 March). Trend News Agency. https://en.trend.az/azerbaijan/society/3400018.html (accessed May 13, 2021)

COVAX vaccine roll-out. AZERBAIJAN. (2021, 4 April). GAVI – The Vaccine Alliance. https://www.gavi.org/covax-vaccine-roll-out/azerbaijan (accessed May 13, 2021)

"Covid 19 Impact on Tourism: Georgian and World Tourism Trends". (n.d.). Georgia. https://gnta.ge/ge/კოვიდ-19-გავლენა-ტურიზმზე/ (accessed May 13, 2021)

Daily new confirmed COVID-19 cases per million people. (n.d.). Our World in Data. https://ourworldindata.org/explorers/coronavirus-data-explorer?zoomToSelection=true&time=2020-09-01..latest&pickerSort=desc&pickerMetric=positive_rate&Metric=Confirmed+cases&Interval=7-day+rolling+average&Relative+to+Population=true&Align+outbreaks=false&country=GEO~Europe (accessed May 13, 2021)

Decree №164 of the Government of Georgia (2020, January 28). Government of Georgia. http://gov.ge/files/545_75017_863443_164.pdf (accessed June 07, 2021)

Europe and Central Asia Economic Update, Spring 2021: Data, Digitalization, and Governance. (2021, 30 March). World Bank Group. https://openknowledge.worldbank.org/handle/10986/35273 (accessed May 13, 2021)

First coronavirus case confirmed in Georgia. (2020, 26 February). OC Media. https://oc-media.org/first-coronavirus-case-confirmed-in-georgia/ (accessed May 13, 2021)

First day of clashes between Armenia and Azerbaijan. (2020, 27 September). OC Media. https://oc-media.org/breaking-stepanakert-shelled-as-azerbaijan-launches-counter-attack/ (accessed May 13, 2021)

From September 11 the state of emergency will be replaced by quarantine. (2020, 4 September). 1 News. https://www.1lurer.am/hy/2020/09/04/%D5%8Dեպտեմբերի-11-ից-արտակարգ-դրությունը-կփոխարինվի-կարանտինով-ԱԺ-ն-երկրորդ-ընթերցմամբ-ընդունեց-օրենսդր/305837 (accessed May 13, 2021).

Gabil, A. (2021, 10 March). Value of agreement for purchase of 4 million doses of Coronavac vaccine for Azerbaijan revealed. APA. https://apa.az/en/xeber/social-news/Value-of-agreement-for-purchase-of-4-million-doses-of-Coronavac-vaccine-for-Azerbaijan-revealed-344321 (accessed May 13, 2021)

Ghazaryan, S. (2020, 29 April). The effect of a broken phone in the Armenian media․In the footsteps of 100,000 coronaviruses. Fip.am. https://fip.am/11295 (accessed May 13, 2021)

Gilbreath, D. (2020, 27 July). Analysis | Georgia has a vaccine misinformation problem. OC Media. https://oc-media.org/features/analysis-georgia-has-a-vaccine-misinformation-problem/ (accessed May 13, 2021)

Giyasbayli, H. (2021, 11 March). Azerbaijan leads South Caucasus in COVID-19 vaccinations. OC Media. https://oc-media.org/azerbaijan-leads-south-caucasus-in-covid-19-vaccinations/ (accessed May 13, 2021)

Giyasbayli, H. (2021, 18 January). Azerbaijan starts rolling out China’s Sinovac vaccine. OC Media. https://oc-media.org/azerbaijan-starts-rolling-out-chinas-sinovac-vaccine/ (accessed May 13, 2021)

Giyasbayli, H. (2021, 14 April). Is an interconnected Caucasus on the horizon?. OC Media. https://oc-media.org/features/is-an-interconnected-caucasus-on-the-horizon/ (accessed May 13, 2021)

Half of Armenians do not trust vaccines․ Survey results. (2021, 19 April). Civilnet. https://www.civilnet.am/news/599996/հայաստանցիների-կեսը-չի-վստահում-պատվաստանյութերին-և-չի-պատրաստվում-պատվաստվել%E2%80%A4-հարցման-արդյունքներ/ (accessed May 13, 2021)

Harutyunyan, S. (2020, 16 March). A one-month state of emergency was declared in Armenia. Azatutyun. https://www.azatutyun.am/a/30491289.html (accessed May 13, 2021)

Hayrapetian, S. (2021, 15 April). Armenians In No Rush To Get COVID-19 Vaccine. Azatutyun. https://www.azatutyun.am/a/31205872.html (accessed May 13, 2021)

Hovhannisyan, T. (2020, 28 May). Revealed: US-funded website spreading COVID misinformation in Armenia. Open Democracy. https://www.opendemocracy.net/en/5050/us-money-armenia-misinformation-covid-vaccines/ (accessed May 13, 2021)

Ilham Aliyev and First Lady Mehriban Aliyeva inaugurated new building of Absheron District Central Hospital. (2021, 1 February). President of the Republic of Azerbaijan Ilham Aliyev. https://en.president.az/articles/50466 (accessed May 13, 2021)

Incidence of coronavirus (COVID-19) cases in the past seven days in Europe as of May 10, 2021, by country. (2021, May). Statista. https://www.statista.com/statistics/1139048/coronavirus-case-rates-in-the-past-7-days-in-europe-by-country/ (accessed May 13, 2021)

Influenza vaccination process has started in Azerbaijan. (2020, 6 November). IQTISADIYYAT. https://www.iqtisadiyyat.az/news/az/30875/Azrbaycanda-qrip-qar-vaksinasiya-prosesi-balayb?fbclid=IwAR3_20FXbWaih1i1ECuTloE23h3c3CQVbyDevkfEKAfQWV6K0urvx_FNrBY (accessed May 13, 2021)

Information of the Operative Headquarters at the Cabinet of Ministers of the Republic of Azerbaijan: Infection. (2021, 15 April). KoronaVirus.info. https://koronavirusinfo.az/az/post/766 (accessed May 13, 2021)

Information of the Operative Headquarters at the Cabinet of Ministers of the Republic of Azerbaijan: Infection. (2021, 12 April). KoronaVirus.info. https://koronavirusinfo.az/az/post/760 (accessed May 13, 2021)

Introductory Speech by Ambassador Degnan Virtual Press Conference. (2020, 20 May). U.S. Embassy in Georgia. https://ge.usembassy.gov/ka/ambassador-degnans-opening-remarks-during-her-virtual-press-conference-may-20-ka/ (accessed May 13, 2021)

İsmayılbəyli, S. (2021, 1 February). Do Baku residents trust the coronavirus vaccine? JAM News. https://jam-news.net/az/koronavirus-coronavac-cin-vaksini-baki-sakinlər-sorgu-video-azərbaycan-xəbərlər/ (accessed May 13, 2021)

Is vaccination mandatory for health workers? - Statement from the Doctor. (2021, 23 January). Konkret. https://konkret.az/tibb-iscileri-ucun-vaksinasiya-mecburidir-tebib-den-aciqlama/ (accessed May 13, 2021)

Jariel, C. M. (2021, 24 January). S&P revises outlook on Azerbaijan to stable on reduced war-related risks. S&P Global. https://www.spglobal.com/marketintelligence/en/news-insights/latest-news-headlines/s-p-revises-outlook-on-azerbaijan-to-stable-on-reduced-war-related-risks-62259046 (accessed May 13, 2021)

Johnston, M. (2021, 14 April). Top Moderna Shareholders. Investopedia. https://www.investopedia.com/top-moderna-shareholders-5176519 (accessed May 13, 2021)

Karimli, I. (2021, 30 March). Azerbaijan Continues Vaccination Drive, Accuses COVAX of Injustice. Caspian News. https://caspiannews.com/news-detail/azerbaijan-continues-vaccination-drive-accuses-covax-of-injustice-2021-3-29-22/ (accessed May 13, 2021)

Kincha, S. (2021, 9 April). ‘Fatal negligence’ behind death of Georgia nurse following vaccination. OC Media. https://oc-media.org/fatal-negligence-behind-death-of-georgia-nurse-following-vaccination/ (accessed May 13, 2021)

Kincha, S. (2021, 20 March). Fears of vaccine hesitancy grow after nurse dies in Georgia. OC Media. https://oc-media.org/fears-of-vaccine-hesitancy-grow-after-nurse-dies-in-georgia/ (accessed May 13, 2021)

Kintsurashvili, T. (2020). Infodemic in Georgia. Media Development Agency. http://mdfgeorgia.ge/uploads/Publication-GEO-with%20hyperlink-web.pdf (accessed May 13, 2021)

Kocharyan, S. (2021, 2 February). Armenian cenbank changes 2020 recession projection from 7,2% to 7,8%. Armenpress. https://armenpress.am/arm/news/1042147/ (accessed May 13, 2021)

Kocharyan, S. (2021, 11 March). Armenia starts vaccinating health workers with Sputnik-V. Armenpress. https://armenpress.am/arm/news/1045788.html (accessed May 13, 2021)

Lachashvili, I. (2020, 1 October). Russian Vaccine Against COVID-19 and Reaction to Georgian Pro-Russian Sources Part IV. Grass FactCheck. https://factcheck.ge/ka/story/38670-covid-19-ის-საწინააღმდეგო-რუსულ-ვაქცინა-და-ქართული-პრორუსული-წყაროების-რეაქცია-ნაწილი-iv (accessed May 13, 2021)

Law of Georgia. (2021, 28 January). Parliament of Georgia. https://info.parliament.ge/file/1/BillReviewContent/267435? (accessed May 13, 2021)

Macro Poverty Outlook. Country-by-country Analysis and Projections for the Developing World. (2021). World Bank Group. https://pubdocs.worldbank.org/en/107191492012467509/mpo-eca.pdf (accessed May 13, 2021)

Mammadov, S. (2020, 3 April). How Chinese vaccines are saving the world. ChinaDaily. https://www.chinadaily.com.cn/a/202104/03/WS6067e1cba31024ad0bab36e6.html (accessed May 13, 2021)

Martial law was lifted. (2021, 24 March). Free News TV. https://www.youtube.com/watch?v=H_7XZv4tlyQ (accessed May 13, 2021)

National plan for introduction of COVID-19 vaccine in Georgia. (2021, January). Ministry of Internally Displaced Persons from the occupied Territories, Labour, Health, and Social Affairs of Georgia. https://www.moh.gov.ge/uploads/files/2020/Failebi/akordeoni/axali_korona/pr-NVPD-Update-Jan-17-2021-V5-GEO.pdf (accessed May 13, 2021)

Nadareishvili, T. (2021, 31 March). Ekaterine Tikaradze - We have already received a notice from international partners that we distinguish between vaccines, nowhere in the world is a vaccine selected by name and manufacturer. (2021, 31 March). First Channel. https://1tv.ge/news/ekaterine-tikaradze-saertashoriso-partniorebisgan-ukve-mivighet-shenishvna-rom-vaqcinebs-vaskhvavebt-msoflioshi-arsad-adamianebi-ar-archeven-vaqcinas-sakhelisa-da-mwarmoeblis-mikhedvit/ (accessed May 13, 2021)

Nozadze, T. (2021, 12 April). Amiran Gamkrelidze - We can actually say that the third wave of the virus has started in Georgia as well. First Channel. https://1tv.ge/news/amiran-gamyrelidze-realurad-shegvidzlia-vtqvat-rom-virusis-gavrcelebis-mesame-talgha-saqartveloshic-daiwyo/ (accessed May 13, 2021)

On approval of the list of activities subject to compulsory prophylactic immunization. (2019, 22 January). Legilative Herald of Georgia. https://matsne.gov.ge/en/document/view/4454340?publication=0 (accessed May 13, 2021)

Open letter to the Prime Minister of Georgia G. Gakharia. (2021, 14 February). National Congress of Slavic Peoples of Georgia. https://www.facebook.com/slavyanskiy.kongress/photos/a.303486489856979/1615650461973902 (accessed June 07, 2021).

Pfizer-BioNtech COVID-19 Vaccine U.S. Distribution Fact Sheet. (2020, November). Pfizer. https://www.pfizer.com/news/hot-topics/covid_19_vaccine_u_s_distribution_fact_sheet (accessed May 13, 2021)

Preliminary assessment of economic growth December 2020. (2021, 29 January). National Statistics Office of Georgia, https://www.geostat.ge/media/36176/ეკონომიკური-ზრდის-წინასწარი-შეფასება---დეკემბერი-2020.pdf (accessed June 07, 2021)

Press Conference of Minister of Health Anahit Avanesyan. (2021, 12 April). Ministry of Health. https://www.youtube.com/watch?v=ueLtGLXMRCc (accessed May 13, 2021)

Public Opinion Survey: Residents of Georgia. (2021, February). Center of Insights in Survey Research. https://www.iri.org/sites/default/files/iri_poll_presentation-georgia_february_2021_1.pdf (accessed May 13, 2021)

Real GDP growth. (2021). International Monetary Fund. https://www.imf.org/external/datamapper/NGDP_RPCH@WEO/OEMDC/ADVEC/WEOWORLD (accessed May 13, 2021)

Regional Economic Outlook: Arising from the Pandemic: Building Forward Better. (2021, April). International Monetary Fund. https://www.imf.org/en/Publications/REO/MECA/Issues/2021/04/11/regional-economic-outlook-middle-east-central-asia (accessed May 13, 2021)

Rendezvous at the polyclinic: Azerbaijan has started a new stage of vaccination against coronavirus. (2021, 2 February). Sputnik News. https://az.sputniknews.ru/health/20210202/426122403/opros-lekarstva-vakcinacija.html (accessed May 13, 2021)

Sichinava, D., The Caucasus Datablog. (2021, 30 March). Datablog | Georgia among worst in the world for vaccine hesitancy. OC Media. https://oc-media.org/features/datablog-georgia-among-worst-in-the-world-for-vaccine-hesitancy/ (accessed May 13, 2021)

Storage & Handling. (n.d.). Moderna. https://www.modernatx.com/covid19vaccine-eua/providers/storage-handling (accessed May 13, 2021)

The Patriarchate announces the ruling of the Holy Synod. (2021, 12 February). First Channel. https://1tv.ge/news/sapatriarqo-wminda-sinodis-ganchinebas-avrcelebs/ (accessed May 13, 2021)

The price of the same vaccine is different from Turkey and Brazil. (2020, 25 December). Azadliq. https://www.azadliq.org/a/eyni-vaksinə-türkiyədən-və-braziliyadan-fərqli-nəticə/31019307.html (accessed May 13, 2021)

There is an agreement to purchase 1 million doses of vaccine from Russia - Anahit Avanesyan. (2021, 14 April). Tert.am. https://www.youtube.com/watch?v=VubRHGP9Olk (accessed May 13, 2021)

Tkeshelashvili, S. (2021, 4 March). How did Georgia authorize Pfizer and AstraZeneca vaccines – Definition. Business Media Georgia.

https://bm.ge/ka/article/ra-procedurit-moaxdina-saqartvelom-pfizer-is-da-astrazeneca-s-vaqcinebis-avtorizacia---ganmarteba/77211/ (accessed May 13, 2021)

Together Against COVID-19. (n.d.). The European Union for Georgia. https://eu4georgia.ge/together-against-covid-19/ (accessed May 13, 2021)

Vaccination against COVID-19 in Georgia - 17 March. (2021, 17 March). National Center for Disease Control & Public Health, Georgia. https://www.facebook.com/ncdcgeorgia/posts/3822862844468284 (accessed June 07, 2021)

Vaccination ... will be accompanied by a crisis. (2021, 6 January). Azadliq. https://www.azadliq.org/a/31036233.html (accessed May 13, 2021)

Vusal Gasimli: The construction boom in Karabakh can revive the whole economy. (2021, 2 March). Interfax Azerbaijan. http://interfax.az/view/828350/az (accessed May 13, 2021)

We have a chance to get rid of the coronavirus - "Of course, we will give the vaccine to Azerbaijan". (2020, 10 August). Sputnik News. https://sputnik.az/health/20200810/424645042/turkey-azerbaijan-coronavirus-vaccine.html (accessed May 13, 2021)

What ist he attitude oft he population to vaccination in Azerbaijan? – Survey. (2021, 3 February). Konkret. https://konkret.az/azerbaycanda-ehalinin-vaksinasiyaya-munasibeti-necedir-sorgu/ (accessed May 13, 2021)

Why are children afraid to be vaccinated in Azerbaijan? (2019, 4 September). AZPost.info. https://azpost.info/azərbaycanda-usaqlari-peyvənd-etməyə-niyə-qorxurlar/ (accessed May 13, 2021)

WILLVACC19: Would you or would you not get vaccinated against Covid-19? (%). (2021, February). Caucasus Research Resource Center. https://caucasusbarometer.org/en/nf2021ge/WILLVACC19/ (accessed May 13, 2021)

Zargaryan, R. (2021, 17 March). The Central Bank forecasts 1.4% economic growth for 2021. Azatutyun. https://www.azatutyun.am/a/31154975.html (accessed May 13, 2021)

84,000 doses of COVID-19 vaccine produced by AstraZeneca delivered to Azerbaijan via COVAX platform. (2021, 4 April). Azerbaijan Republic. Ministry of Health. http://health.gov.az/xeberler/3382-covax-platformas-vasitsil-lkmiz-astrazeneca-trfindn-istehsal-olunan-84-min-doza-covid-19-peyvndi-gtirilib.html (accessed May 13, 2021)