Non-Communicable Disease and Healthcare System Developments
Asundexian for Secondary Stroke Prevention: OCEANIC-STROKE Trial
A landmark phase 3 trial published this week in the New England Journal of Medicine has substantively advanced the evidence base for secondary stroke prevention. The OCEANIC-STROKE trial evaluated asundexian—an oral inhibitor of activated factor XI (FXIa)—as an adjunct to antiplatelet therapy in 12,327 patients with recent noncardioembolic ischemic stroke or high-risk transient ischemic attack (TIA). Patients were enrolled within 72 hours of event onset and randomised to asundexian 50 mg once daily or placebo on a background of planned dual or single antiplatelet therapy. Eligibility required at least one of the following features: a nonlacunar infarct on imaging, a history of atherosclerosis, or evidence of atherosclerotic plaque on cerebrovascular imaging—criteria that delineate the subgroup most likely to benefit from additional thrombotic burden reduction beyond conventional antiplatelet strategies.
The primary efficacy outcome—incidence of ischemic stroke—was significantly lower in the asundexian arm (6.2%) compared with placebo (8.4%), yielding a cause-specific hazard ratio of 0.74 (95% CI: 0.65–0.84; p<0.001). This corresponds to an absolute risk reduction of 2.2 percentage points—clinically meaningful given the high recurrence rates in this population, where the risk of second ischemic stroke within the first 90 days can approach 10–15% in high-risk subgroups. The key secondary composite outcome of cardiovascular death, myocardial infarction, or stroke was also reduced in the asundexian group. Critically for a drug administered atop antiplatelet therapy—a combination historically associated with hemorrhagic amplification—major bleeding incidence was comparable between arms (1.9% versus 1.7%; cause-specific hazard ratio 1.10; 95% CI: 0.85–1.44), and overall adverse event profiles were similarly distributed.
The mechanism of asundexian is of particular physiological relevance in this indication. Factor XI participates in the contact activation pathway of coagulation—a pathway that contributes substantially to pathological intraluminal thrombosis but plays a lesser role in hemostatic plug formation at sites of vessel injury. Low plasma factor XI levels are epidemiologically associated with reduced ischemic stroke risk, providing biological prior plausibility for therapeutic inhibition. The OCEANIC-STROKE results suggest that FXIa inhibition achieves a favorable dissociation between antithrombotic efficacy and bleeding risk that has historically been difficult to realise with conventional anticoagulants in this setting. Asundexian has not yet received regulatory approval from EMA or FDA; post-trial regulatory submissions are anticipated. If approved, it would represent the first anticoagulant to demonstrate benefit in noncardioembolic ischemic stroke prevention, a therapeutic gap that has persisted for decades.
EMA Committee on Veterinary Medicinal Products (CVMP): April 2026 Outcomes
The CVMP adopted a positive opinion for Nobivac NXT HCPChFeLV, a feline multivalent vaccine against herpesvirus type 1, calicivirus, panleucopenia virus, Chlamydia felis, and feline leukaemia virus. This product carries notable regulatory significance as the first veterinary vaccine recommended for authorisation in the EU whose active substance consists of self-amplifying RNA (saRNA) packaged within a replication-deficient replicon viral particle. The use of saRNA platform technology in a licensed veterinary product represents a meaningful regulatory precedent with potential implications for the speed and adaptability of future veterinary vaccine development.
Of direct public health relevance is the conclusion of a referral procedure concerning albendazole oral suspension in sheep. The referral, initiated by Germany under Article 82 of Regulation (EU) 2019/6, addressed concerns that authorised dose limits of 3.75–5 mg/kg bodyweight may no longer ensure effective control of gastrointestinal nematodes—raising the prospect that subtherapeutic dosing at population level is driving antiparasitic resistance in ovine nematode communities. The CVMP adopted an opinion recommending dose adjustments and the addition of explicit warnings on effective use in product information. This determination is pertinent to antimicrobial and antiparasitic stewardship frameworks, as accelerating anthelmintic resistance in livestock represents a growing threat to both veterinary therapeutics and, indirectly, to food security.
Infectious Diseases: Global Perspective
Respiratory and Droplet Transmission
Measles
The global measles situation in Week 16 remains severe and warrants characterisation as a multi-continental public health emergency, with catastrophic transmission across the Americas, South Asia, and Sub-Saharan Africa proceeding simultaneously.
In the Americas, the United States has reported 1,714 confirmed cases between January and 9 April 2026, across 17 concurrent outbreaks—94% of which are outbreak-associated, reflecting consolidated chains of transmission rather than isolated importations. This figure compares with 2,287 total cases for the entirety of 2025. Children constitute 73% of cases, and 92% of confirmed cases involve unvaccinated individuals—a profile that unambiguously implicates vaccination gaps, not vaccine failure, as the operational driver of transmission. Mexico continues to bear the largest burden in the Americas, with 15,945 confirmed cases and 36 deaths since the outbreak began in 2025; in 2026 alone, 9,458 confirmed cases and nine deaths have been recorded, with the state of Jalisco most severely affected (3,823 cases; three deaths). Although case counts are declining from the outbreak peak in Week 6, the ongoing burden represents a profound public health failure in a middle-income country with long-established measles immunisation infrastructure. Canada reports 789 cases across seven jurisdictions, remaining in active multi-provincial transmission.
Of particular operational concern for EU/EEA countries is the forthcoming FIFA World Cup 2026, co-hosted by the United States, Canada, and Mexico—all currently experiencing active measles transmission. This event will generate substantial bidirectional travel flows, including from EU/EEA countries with suboptimal measles-containing vaccine (MCV) coverage, creating conditions for measles importation in both directions.
In South Asia, Bangladesh is experiencing a public health emergency of healthcare system-straining proportions. As of 7 April 2026, 9,883 suspected measles cases have been reported nationally, including 1,398 laboratory-confirmed cases and at least 128 suspected deaths (21 confirmed). The age distribution is particularly alarming: 81% of cases are in children under five years, including 34% among infants under nine months of age who are not yet eligible for routine measles vaccination—a group for which the primary prevention tool is herd immunity from older cohorts. National MMR vaccine stockpiles are depleted, constraining outbreak response capacity. In collaboration with UNICEF and partners, the Government of Bangladesh launched an emergency measles–rubella vaccination campaign targeting 18 high-burden districts on 5 April 2026, simultaneously with vitamin A supplementation distribution and health facility capacity reinforcement.
In East Asia, Japan reports 236 measles cases in weeks 1–14 of 2026—a number approaching the entire 2025 annual total of 265 cases. Notably, 72% of cases in 2026 are in teenagers and adults (15–49 years), with 30 imported cases identified, including 12 from Indonesia and seven from New Zealand. This adult-skewed age distribution reflects cohorts that may have received only one dose of measles vaccine under older schedules and who lack the secondary immune responses conferred by natural infection in high-transmission eras. Indonesia declared an Extraordinary Event in seven areas of South Sulawesi province following a national measles spread since December 2025, with 8,810 suspected cases and 572 laboratory-confirmed cases documented in January–February 2026.
Africa CDC reported, as of 13 April 2026, 1,603 confirmed and 50,252 suspected measles cases with 388 deaths across 18 African Union Member State countries in 2026. Mali and Senegal are classified as high-risk for measles spread; Malawi and Mozambique face moderate risk. The case fatality rates suggested by these figures reflect the intersection of malnutrition, limited healthcare access, and the severity of measles complications—including pneumonia, croup, encephalitis, and secondary bacterial infections—in high-burden settings.
Avian Influenza A(H5N1) in Poultry
Two new HPAI A(H5N1) detections in domestic poultry were notified during the week. Poland reported a confirmed detection with event reporting initiated on 14 April 2026, and Chile reported a confirmed poultry detection with reporting initiated on 10 April 2026. Both notifications are classified as “recurrence of an eradicated disease,” consistent with WOAH reporting terminology for countries that had previously achieved eradication in these populations. The Polish detection is of direct relevance to EU/EEA biosecurity; Bulgaria, sharing epidemiological connectivity through migratory bird flyways and regional poultry trade, should maintain heightened surveillance at live bird markets, backyard holdings, and wild bird–poultry interfaces.
Vector-Borne Transmission
Chikungunya Virus — French Guiana and Suriname
Chikungunya virus transmission continues to expand in two geographically linked settings with implications for European travellers. In French Guiana, the number of confirmed autochthonous cases since January 2026 has surpassed 85, with 8 cases in Week 14, 11 in Week 13, and 12 in Week 12. The majority of cases (87%) are concentrated in the Littoral Ouest sector—currently in an outbreak cluster phase—near the border with Suriname. Virological characterisation has identified the ECSA genotype without the E1-A226V mutation that confers adaptation to Aedes albopictus, with close genetic relationships to recent sequences from Cuba and Brazil. The ongoing rainy season (January–July) sustains favourable conditions for Aedes mosquito proliferation and viral amplification. ECDC assesses the likelihood of infection for travellers as low, with very low onward transmission risk in mainland Europe at this time of year.
Suriname, bordering western French Guiana, reported 2,579 chikungunya virus disease cases between 1 January and mid-March 2026—its first autochthonous transmission since 2016. One EU Member State has already documented a marked increase in travel-associated chikungunya detections among returnees from Suriname and Paramaribo specifically. ECDC assesses the risk of infection for travellers to Suriname as moderate—a materially higher designation than for French Guiana, reflecting the scale of transmission and the urban concentration of cases in Paramaribo. Chikungunya virus causes a febrile illness with incapacitating polyarthralgia, myalgia, and rash, with an incubation period of 2–12 days; severe disease, including neonatal chikungunya following peripartum maternal viremia, can be life-threatening. Protective measures for travellers include insect repellent use, protective clothing, and mosquito-proof accommodation; vaccination is recommended in accordance with national guidelines.
Travel-Associated Zika Virus Disease — France (ex Indonesia)
France has reported 11 travel-associated Zika virus (ZIKV) cases linked to Indonesia between July 2025 and March 2026, including four cases detected in early 2026. Most exposures were associated with travel to Bali and neighbouring islands; all were laboratory confirmed, with Asian lineage identified in sequenced samples. Travel pattern analysis indicates that France, Germany, and the Netherlands account for the largest volumes of EU traveller arrivals to Indonesia, which may explain why France detected this cluster first. ECDC assesses the likelihood of ZIKV infection for travellers to Indonesia as low, and onward transmission in mainland Europe as very low given the current absence of permissive vector conditions. Of primary clinical concern is the well-established association between ZIKV infection during pregnancy and fetal microcephaly and other neurological malformations; travel medicine consultations for Indonesia-bound pregnant women or women planning conception should include ZIKV counselling and pre-travel risk assessment.
Bloodborne and Zoonotic Transmission
Rabies — Bhutan and Armenia
Animal rabies events were notified for Bhutan (classified as first detection in an unvaccinated fur-farming context, reported 18–22 April 2026) and Armenia (untyped, reported 16–17 April 2026). While these notifications are geographically distant from the EU/EEA, they are relevant as reminders of the continuing global burden of rabies in regions with variable animal vaccination coverage. Travellers to rabies-endemic countries should be counselled on pre-exposure prophylaxis and the management of animal bite exposures.
Infectious Diseases: European Union / European Economic Area
Respiratory and Droplet Transmission
Respiratory Virus Season — Transition to Inter-Seasonal Baseline
The 2025–26 respiratory virus season has effectively concluded in the EU/EEA. In Week 15, primary care and hospital consultations for respiratory illness were at baseline levels in all but one country, and influenza virus activity has returned to inter-seasonal levels across nearly all countries, with low circulation and hospitalisation rates in all age groups. In primary care virological surveillance, influenza test positivity stands at 1.8% (median; IQR 1.1–5%), with influenza A comprising all subtyped detections—predominantly A(H3N2) subclade 2a.3a.1(K) which has dominated the season, representing 90% of subtyped A(H3) strains. Influenza B and SARS-CoV-2 have receded to negligible detection levels.
Respiratory syncytial virus (RSV) activity remains elevated in primary care and hospital settings at 5.5% positivity (median; IQR 7.3–11%), although the EU/EEA seasonal peak has passed and hospital admissions in children aged 0–4 years have fallen steadily in recent weeks. RSV-B (68%) has slightly predominated over RSV-A (32%) in primary care detections this season. SARS-CoV-2 circulation is at 1% positivity in primary care, classified as very low in all countries and age groups. The transition to inter-seasonal baseline represents a positive epidemiological development, though it warrants no complacency—the timing and severity of the 2026–27 season will depend on the accumulation of susceptible cohorts, particularly in age groups with low residual immunity to A(H3N2) and A(H1N1)pdm09.
Measles — Multi-Country EU/EEA
Measles transmission within the EU/EEA remains a sustained public health concern. In February 2026, eleven countries reported 139 cases; the highest case counts were in Italy (63), Spain (36), France (16), and Poland (5). In the preceding 12-month period (March 2025–February 2026), 30 EU/EEA countries reported a cumulative total of 4,623 measles cases, of which 83.5% were laboratory confirmed. The age distribution reveals bimodal vulnerability: 33.2% of cases were in children under five years, and 42.3% in those aged 15 or above—the latter group reflecting cohort-specific immunity gaps from era-dependent vaccination schedules. The highest notification rates were in infants under one year (124.0 per million) and children aged 1–4 years (65.3 per million). Of cases with known vaccination status, 79.9% were unvaccinated—again confirming that vaccination gaps, not waning immunity in fully vaccinated individuals, underlie ongoing transmission. Six deaths (case fatality rate 0.13%) were attributed to measles in the 12-month period: four in France, one in Romania, one in the Netherlands.
Active outbreaks are ongoing in Bulgaria (detailed in the national section below) and Latvia. The Latvian outbreak, the country’s first since 2018, has reached 47 cases (43 laboratory confirmed) since its onset in March 2026, primarily affecting unvaccinated children. All cases are epidemiologically linked, and genotype D8 was detected in the first 10 samples. National authorities classify the risk as moderate to high for non-immune individuals. Germany has reported 59 cases across weeks 1–15 of 2026 (an increase of 21 since Week 10); Spain has reported 97 cases year-to-date, including 7 imported; England has reported 371 laboratory-confirmed cases through 6 April 2026, concentrated in London (57%), West Midlands (24%), and North West (7%), with 69% of cases involving children under ten years. The intersection of ongoing EU/EEA transmission and massive global measles burden—particularly in FIFA World Cup 2026 host countries—heightens the risk of imported cases and secondary transmission in the coming months.
ECDC urges EU/EEA public health authorities to close immunity gaps by achieving and maintaining MCV coverage above 95% with the second dose, to strengthen outbreak detection and response capacity, and to intensify pre-travel vaccination counselling given the approaching summer travel season.
Infectious Diseases: Bulgaria
Respiratory and Droplet Transmission
Measles
The measles outbreak in Bulgaria represents the most significant acute infectious disease event in the country in Week 16 and demands continued intensive public health response. As of Week 15, ECDC documented 104 cumulative cases, with the geographic distribution heavily concentrated in Vratsa region (n=80), followed by Pleven (n=12), Lovech (n=6), Sofia city (n=2), and Sofia region (n=1). In Week 16, a further 28 cases were registered: the district-level breakdown from ZRZ data confirms Vraца (19 cases) as the continued epicentre, with additional cases in Pleven (5), Lovech (3), and Varna (1). Eleven adults aged 19–53 years have been affected; the majority of total cases were unvaccinated. As an emergency response measure, over 13,000 MMR vaccine doses have been administered to close immunity gaps in the outbreak region—a substantial mobilisation that reflects the scale of the perceived transmission risk but whose impact on interrupting chains will only become apparent after a 7–21-day incubation lag.
Measles is transmitted via the airborne and droplet respiratory routes with an extremely high basic reproduction number (R₀ of 12–18 in fully susceptible populations), meaning that even small gaps in immunity coverage rapidly translate into sustained community transmission. Complications include otitis media (approximately 7–9% of cases), pneumonia (1–6%), and measles encephalitis (0.1–0.2%), the latter carrying a mortality risk of 15% and neurological sequelae in up to 25% of survivors. The concentration in Vratsa, a region with historically lower vaccination coverage and significant Roma population concentrated in close-contact living conditions, follows a pattern familiar from prior Bulgarian outbreak experience. The situation requires sustained active case-finding, contact tracing, rapid ring vaccination, and daily epidemiological monitoring to assess whether the emergency vaccination response is achieving the required reproductive ratio reduction.
Varicella
Varicella activity surged markedly in Week 16, with 777 registered cases—an increase of 176 over Week 15 (+29% week-over-week). This is the highest weekly total of 2026 to date. Despite this spike, the year-to-date cumulative total of 9,899 cases is essentially equivalent to 9,912 cases registered in the same period of 2025, indicating that the sharp week-over-week increase reflects a seasonal acceleration within expected inter-annual bounds rather than a departure from the established epidemiological trajectory. The geographic distribution is nationwide and corresponds to the pattern of school-age transmission: Sofia-grad leads with 201 cases, followed by Blagoevgrad (64), Varna (55), V. Tarnovo (32), Kyustendil (36), Lovech (32), Shumen (60), Pleven (49), Haskovo (22), Burgas (25), and cases registered in most remaining districts. The spring academic term, with accumulated susceptible cohorts and sustained indoor contact, provides optimal conditions for varicella’s highly efficient airborne and contact transmission. In the absence of universal childhood vaccination in Bulgaria, annual spring surges of this magnitude are to be anticipated.
Scarlet fever
Scarlet fever has continued its week-over-week decline: 36 cases were registered in Week 16, down 20 from the 56 cases of Week 15 (a 36% decrease). The year-to-date cumulative total of 1,159 cases remains 28% below the 1,613 cases in the same period of 2025, suggesting that the 2026 scarlet fever season, while still clinically significant, is tracking materially below the prior year’s baseline. The decline is consistent with the approach of late spring, when Streptococcus pyogenes transmission in school-age children typically subsides. While the current trajectory is reassuring, group A streptococcal disease remains a monitored condition given international experience with severe invasive presentations.
Fecal-Oral Transmission
Campylobacteriosis
Campylobacteriosis registered 12 confirmed cases in Week 16, doubling from the 6 cases of Week 15—a 100% week-over-week increase that, combined with a cumulative year-to-date burden of 161 cases against 60 in the same period of 2025 (a 168% year-over-year excess), establishes this as one of the most prominent sustained epidemiological signals of 2026. Campylobacter species—predominantly C. jejuni and C. coli—are thermotolerant, zoonotic enteropathogens transmitted primarily through undercooked poultry, contaminated water, and raw milk, with an incubation period of 2–5 days. Clinical disease is typically self-limiting (3–7 days of diarrhoea, fever, and abdominal pain), but post-infectious complications—Guillain-Barré syndrome, reactive arthritis—may occur in a small proportion of cases. The magnitude and persistence of the year-over-year excess in Bulgaria strongly suggests a structural driver: increased poultry consumption or changes in poultry slaughter and handling practices, possible expansion of testing capacity or reporting sensitivity, or genuine epidemiological change in source-population campylobacter prevalence. The district-level ZRZ data for Week 16 show Sofia-grad (6 cases), Varna (2), and Lovech (1), Vraca (1), and Kyustendil (1), but the dispersion across the country and relatively small weekly case numbers complicate outbreak-type source attribution investigations. Coordinated investigation with the food safety authority (Bulgarian Food Safety Agency) using whole-genome sequencing for source attribution is warranted given the scale of the year-over-year excess.
Rotavirus Gastroenteritis
Rotavirus gastroenteritis registered 16 confirmed cases in Week 16—double the 8 cases of Week 15 (+100% week-over-week). Despite this relative spike, the year-to-date cumulative total of 235 cases remains 23% below the 307 cases registered through the same period in 2025, indicating that the 2026 rotavirus season has so far been milder than the prior year. The week-over-week doubling may represent a transient rebound rather than a sustained increase; continued monitoring over subsequent weeks is required to determine whether the rotavirus season is generating a late spring secondary peak.
Contact and Sexual Transmission
Syphilis
Syphilis registrations surged to 21 confirmed cases in Week 16, compared with 3 cases in Week 15—an increase of 18 cases that represents a 600% single-week change. Such a dramatic single-week variation in syphilis notifications—a condition with an incubation period of 10–90 days—almost certainly reflects a batch reporting artifact, wherein multiple cases diagnosed over preceding weeks were entered into the surveillance system simultaneously rather than at the time of diagnosis. This interpretation is supported by the year-to-date cumulative total of 117 cases being virtually equivalent to the 119 cases in the same period of 2025, which would be inconsistent with a genuine acute epidemic surge concentrated in a single week. Nonetheless, the congenital syphilis signal warrants independent attention: three cases of congenital and infant syphilis were recorded this week, bringing the year-to-date total to 13 compared with 11 in 2025. Congenital syphilis is a sentinel indicator of failures in antenatal syphilis screening and treatment programmes and represents a preventable burden of disease that should trigger review of obstetric care pathways in affected regions.
Gonorrhea
Three confirmed cases of gonorrhea were registered in Week 16, four fewer than the prior week. The week-over-week decline does not alter the broader epidemiological picture: the year-to-date cumulative total of 77 cases represents a 221% excess over the 24 cases in the same period of 2025—the largest proportional year-over-year increase among reported STIs in Bulgaria. This 2026 trajectory is consistent with trends documented across multiple EU/EEA countries, where gonorrhea notification rates have risen substantially alongside expanded testing and, in some settings, increased sexual risk behaviour. The public health significance of the sustained increase is amplified by antimicrobial resistance concerns: Neisseria gonorrhoeae has demonstrated capacity for resistance to all previously recommended treatment classes, and Bulgaria’s national surveillance system does not routinely report antimicrobial susceptibility data alongside case counts—a gap that limits the ability to monitor the emergence of resistant strains.
Urogenital Chlamydial Infection
Seven confirmed cases of urogenital chlamydial infection were registered in Week 16 (+2 from Week 15). The year-to-date cumulative total of 108 cases exceeds the 43 cases in the same period of 2025 by 151%. Chlamydia trachomatis, as the most commonly notified STI in EU/EEA countries, is frequently asymptomatic—particularly in women—leading to substantial underdetection and potential complications including pelvic inflammatory disease, tubal factor infertility, and ectopic pregnancy. The sustained year-over-year increase may reflect genuine epidemiological change, expanded testing uptake, or reporting improvements; distinguishing between these mechanisms would require analysis of testing denominators alongside case counts.