Non-Communicable Disease and Healthcare System Developments
EMA CHMP May 2026 Meeting: New Medicine Approvals
The EMA Committee for Medicinal Products for Human Use (CHMP) convened from 18 to 21 May 2026 and recommended eight new medicines for marketing authorisation, alongside thirteen extensions of therapeutic indication for already-authorised products.
The most clinically significant new approval is nerandomilast (Jascayd) for idiopathic pulmonary fibrosis (IPF) and progressive pulmonary fibrosis (PPF). Both conditions are characterised by progressive and irreversible parenchymal fibrosis with a median survival of two to five years from diagnosis, and the current therapeutic arsenal remains limited to two approved antifibrotic agents with modest effect sizes. Nerandomilast represents the first addition to this class in several years. The CHMP also granted conditional marketing authorisation to alpelisib (Vijoice) for severe PIK3CA-related overgrowth spectrum (PROS) disorders—a heterogeneous group of rare genetic conditions involving uncontrolled tissue growth for which no previously authorised medicine existed—reflecting the clinical urgency of rare disease where the usual evidentiary thresholds are appropriately relaxed. A positive opinion was issued for camizestrant (Etcamah) for adults with locally advanced or metastatic breast cancer harbouring ESR1 gene mutations, a genotype associated with acquired resistance to endocrine therapy and representing a growing proportion of the metastatic breast cancer population.
The most public-health-consequential update among the CHMP actions is the extension of Wegovy (semaglutide) to include a daily oral tablet formulation as an alternative to weekly subcutaneous injections for weight management in adults with obesity or overweight with at least one weight-related comorbidity. This is the first glucagon-like peptide-1 (GLP-1) receptor agonist approved for weight management via the oral route, with implications for patient uptake, access equity, and adherence. Given the rapidly expanding global burden of obesity and the established cardiovascular and metabolic benefits of this drug class, oral availability is a meaningful formulation advance. Additional hybrid applications approved included liraglutide formulations (Ablymico, Liraglutide STADA) and colchicine (Colchicine AGEPHA Pharma) for secondary prevention of atherothrombotic events in stable coronary disease patients.
One negative opinion was issued: copper (64Cu) oxodotreotide (Deqtynet), a PET diagnostic agent for well-differentiated neuroendocrine tumours, was not recommended due to insufficient evidence.
EMA Recommendations for 2026/2027 Seasonal Influenza Vaccine Composition
In a development of direct operational relevance to national immunisation programmes, the CHMP formally endorsed the influenza vaccine strain composition for the 2026/2027 season in March 2026 (updated in May). For egg-derived and live-attenuated vaccines, the recommended trivalent formulation includes an A/Missouri/11/2025 (H1N1)pdm09-like virus, an A/Darwin/1454/2025 (H3N2)-like virus, and a B/Tokyo/EIS13-175/2025 (B/Victoria lineage)-like virus. Cell-based vaccine manufacturers should substitute the H3N2 component with an A/Darwin/1415/2025-like virus and the B component with a B/Pennsylvania/14/2025-like virus. Notably, the 2026/2027 season marks the second consecutive year without a B/Yamagata strain recommendation, reflecting the sustained absence of this lineage from global circulation since March 2020. The transition from quadrivalent to trivalent vaccine formulations is therefore formally consolidated at the EU level for this season, with provision only for residual quadrivalent production where the transition to trivalent has not yet been completed.
Research Highlights: Pulmonary Embolism Management and Screening Cost-Effectiveness
Two publications of direct public health and clinical relevance appeared in high-impact journals this week. The HI-PEITHO trial, published in the New England Journal of Medicine (Rosenfield et al., 2026), enrolled 544 patients with acute intermediate-risk pulmonary embolism—defined by a right ventricular to left ventricular end-diastolic diameter ratio ≥1.0, elevated troponin, and at least two indicators of cardiorespiratory distress—and randomly assigned them to ultrasound-facilitated, catheter-directed fibrinolysis with alteplase plus anticoagulation versus anticoagulation alone. The primary composite outcome of PE-related death, cardiorespiratory decompensation or collapse, or symptomatic PE recurrence within seven days occurred in 4.0% (95% CI 2.3–7.1%) of the intervention group versus 10.3% (95% CI 7.2–14.5%) of the control group (relative risk 0.39; 95% CI 0.20–0.77; P=0.005). The benefit was driven primarily by a reduced risk of cardiorespiratory decompensation. Major bleeding rates at seven days were 4.1% versus 2.2% (P=0.32), and notably no intracranial haemorrhage occurred in either group. These findings provide the strongest randomised evidence to date supporting catheter-directed fibrinolysis in intermediate-risk PE, a population in which the risk-benefit calculus of systemic thrombolysis has historically been considered unfavourable.
A cost-effectiveness analysis published in JAMA (Lee et al., 2026) evaluated the addition of one-time Helicobacter pylori stool antigen testing to biennial faecal immunochemical testing (FIT) for colorectal cancer screening in a pragmatic Taiwanese cohort of 240 000 participants. The co-testing strategy was dominant (more effective and less costly) under base-case assumptions, with an incremental cost-effectiveness ratio of $2,094 saved per QALY gained and a benefit-cost ratio of approximately 5.1. In probabilistic sensitivity analysis, co-testing was cost-saving in 65.7% of 100 000 simulations and cost-effective in the remaining 34.3%. The dominant driver in sensitivity analyses was H. pylori prevalence, with co-testing becoming cost-ineffective below a prevalence threshold of approximately 22%. The findings are most directly applicable to settings with moderate-to-high H. pylori prevalence and are not straightforwardly transferable to European populations where prevalence varies substantially by age cohort, ethnicity, and socioeconomic background—but they strengthen the public health case for integrating H. pylori screening into existing bowel cancer screening infrastructure.
Infectious Diseases: Global Perspective
Contact and Bloodborne Transmission
Bundibugyo Virus Disease — Democratic Republic of the Congo and Uganda
The Bundibugyo virus disease (BVD) outbreak in the Democratic Republic of the Congo (DRC) and Uganda represents the most significant acute public health threat of the current reporting period and the highest-consequence infectious disease event globally since the declaration of the PHEIC. As of 29 May 2026, a total of 134 confirmed cases (125 in DRC, nine in Uganda) including 18 confirmed deaths (CFR 13%) have been reported across the two countries, alongside 906 suspected cases and 223 suspected deaths in DRC. Since the previous WHO Disease Outbreak News on 21 May, an additional 49 confirmed cases, eight confirmed deaths, 160 suspected cases, and 47 suspected deaths have been added, indicating continued and rapid epidemic growth. WHO Director-General Dr Tedros Adhanom Ghebreyesus travelled to DRC on 28 May to support the response.
Bundibugyo virus disease is a severe, often fatal illness caused by Bundibugyo virus (Orthoebolavirus bundibuguyoense), one of five recognised species within the Orthoebolavirus genus. Fruit bats are the suspected natural reservoir; human index cases are thought to result from spillover through contact with blood or secretions of infected wildlife, with subsequent amplification via direct contact with bodily fluids of infected individuals or contaminated surfaces. Transmission is substantially amplified in healthcare settings with inadequate infection prevention and control (IPC), and through unsafe burial practices involving direct contact with the deceased. The incubation period ranges from 2 to 21 days, with individuals non-infectious before symptom onset. Initial manifestations are non-specific—fever, fatigue, myalgia, headache, and pharyngitis—complicating early recognition and permitting undetected community circulation. These progress to gastrointestinal involvement, multi-organ dysfunction, and haemorrhagic manifestations in a proportion of cases. Historical CFRs in the two prior BVD outbreaks (Uganda 2007, DRC 2012) ranged from approximately 30% to 50%; the current confirmed CFR of 13% may reflect earlier case ascertainment among surviving patients, or it may change as the epidemic evolves and more severe cases accumulate.
A critical virological finding is that preliminary genomic analysis confirms the circulating sequences are distinct from both the 2007 and 2012 Bundibugyo virus outbreaks. The public health significance of this genomic divergence is substantial: unlike Orthoebolavirus zairense (Zaire ebolavirus), for which licensed vaccines (rVSV-ZEBOV and Ad26.ZEBOV/MVA-BN-Filo) and investigational therapeutics (monoclonal antibodies) exist, no licensed vaccines or specific treatments are currently available for Bundibugyo virus. This differentiates the current outbreak from recent Ebola disease events in DRC where medical countermeasure deployment meaningfully reduced mortality and accelerated outbreak control.
Geographically, the outbreak remains concentrated in Ituri Province, which accounts for 88% of confirmed DRC cases, primarily across the Bunia (37), Rwampara (33), Mongbwalu (20), and Nyankunde (10) health zones. However, transmission has extended to five health zones in North Kivu and one in South Kivu, reflecting progressive geographic diffusion in a region characterised by complex humanitarian conditions, displacement, active armed conflict, and limited health system capacity. Sixteen confirmed cases among healthcare and care workers have been documented, indicative of nosocomial amplification and placing additional pressure on an already strained response workforce. Security incidents including community resistance, arson attacks targeting treatment facilities, and intimidation of health workers in Mongbwalu and Rwampara health zones represent severe operational disruptions that impede case detection, isolation, and contact tracing—the cornerstones of Ebola disease control. As of 27 May, 2,635 contacts had been listed in Ituri and North Kivu, but follow-up capacity is severely constrained. A test positivity rate of 19.2% among samples analysed (648 of 774 collected) is likely an underestimate of true positivity given a substantial backlog of samples awaiting processing in Kinshasa.
Cross-border spread to Uganda is confirmed and evolving. Nine confirmed cases have been reported in Kampala (n=8) and Wakiso (n=1), including a Ugandan driver who transported the Congolese index case, a Ugandan woman who travelled to Uganda for medical care, and two Ugandan healthcare workers. One confirmed case has recovered. Importantly, an American medical doctor who provided patient care in DRC tested positive on 17 May and is receiving treatment in Germany, with six high-risk contacts transferred concurrently. A suspected case in a volunteer worker in Austria tested negative on initial laboratory assessment. A suspected imported case in India (Gujarat) was also found negative. These events highlight the feasibility of international case exportation in a context of globalised air travel and underscore the relevance of travel health guidance for individuals deployed to affected areas.
Bunia airport has been temporarily closed. Exit screening has been implemented at DRC, Uganda, and South Sudan points of entry, and coordinated public health measures have been announced by the United States, Mexico, and Canada in the context of the upcoming FIFA World Cup 2026. On 17 May 2026, WHO declared a PHEIC, and on 18 May 2026, Africa CDC declared a Public Health Emergency of Continental Security. ECDC has published a Threat Assessment Brief (21 May) and Laboratory Guidance (27 May), deployed an expert to Africa CDC headquarters, and assesses the risk of infection for EU/EEA residents as very low given the low likelihood of importation and secondary transmission in this context.
Respiratory and Droplet Transmission
Andes Hantavirus — Cruise Ship Outbreak, South Atlantic
Since the Week 21 update, two additional confirmed cases have been reported in the Andes virus (ANDV) disease outbreak linked to the cruise ship M/V Hondius: a Dutch national in home quarantine following documented close contact with confirmed ANDV cases onboard, and an asymptomatic Spanish national—a former passenger evacuated from Tenerife on 10 May—placed under hospital quarantine in Spain. Both were reclassified as confirmed following alignment of the case definition with WHO criteria (laboratory confirmation by PCR and/or serology). As of 29 May, the cumulative outbreak total stands at 13 cases (11 confirmed, 2 probable) and three deaths. The ship arrived in Rotterdam on 18 May and is undergoing disinfection; all remaining persons on board have disembarked and are in quarantine.
Genomic sequencing confirms a high degree of genetic similarity across isolates, supporting the hypothesis of an initial zoonotic spillover event during itinerary stops in Argentina (where ANDV is endemic in rodent populations, primarily Oligoryzomys longicaudatus), followed by limited human-to-human transmission aboard the vessel. ANDV is exceptional among hantaviruses in its capacity for person-to-person transmission, which has been documented following close and prolonged contact. The natural reservoir of ANDV is not present in Europe, precluding any risk of rodent-to-human transmission following return of passengers and crew. ECDC assesses the risk to the general EU/EEA population as very low.
Fecal-Oral Transmission
Cholera — Global Situation
The May 2026 ECDC monthly cholera update documents 68,749 cases and 944 deaths globally since 1 January 2026 and as of 26 May 2026—a marked improvement compared to the 119,702 cases and 1,570 deaths reported in the equivalent period of 2025. During the most recent reporting interval (28 April–26 May 2026), 3,596 new cases and 176 deaths were reported, substantially fewer than the 20,028 cases reported in the preceding interval (30 March–28 April), suggesting a global deceleration in cholera burden. The five countries reporting the most cases in the recent period were Angola (2,120), Mozambique (413), Somalia (271), Burundi (224), and DRC (172), with the five highest death-reporting countries being DRC (115), Angola (36), Congo (21), Zambia (3), and Mozambique (1). The DRC thus accounts for a disproportionate share of cholera mortality relative to case burden, likely reflecting healthcare system disruption compounded by the concurrent BVD outbreak response. Active cholera transmission also continues in Asia and the Americas, though surveillance updates from Afghanistan, Myanmar, Pakistan, Yemen, and India were not available since the previous reporting period. The risk of cholera infection for travellers to affected regions remains low overall, though sporadic importation to the EU/EEA is possible.
Infectious Diseases: European Union/European Economic Area
Bloodborne and Contact Transmission
Bundibugyo Virus Disease — EU/EEA Importation Risk
The directly EU/EEA-relevant dimension of the BVD outbreak has been addressed above in the Global section but warrants specific contextualisation at the EU level. Germany is currently managing a confirmed case (an American medical professional repatriated from DRC), while a suspected case in Austria tested negative on initial assessment but remained in isolation pending confirmatory testing. Czechia received a high-risk contact for monitoring. These events operationalise the pre-positioned EU response infrastructure—including the EU Health Task Force deployed in coordination with DG ECHO, DG INTPA, and GOARN—and demonstrate the capacity for rapid international repatriation of exposed individuals. ECDC’s laboratory guidance for EU/EEA countries, published 27 May, provides specific recommendations on sampling procedures, diagnostic algorithms, biosafety classification requirements, and the network of EU/EEA laboratories offering BVD diagnostic support. For public health authorities in EU/EEA countries, the key immediate actions are: maintenance of clinical awareness among infection disease and emergency medicine clinicians, clear patient pathways for travellers returning symptomatic from DRC, Uganda, and bordering high-risk countries, and readiness to implement standard VHF (viral haemorrhagic fever) IPC precautions.
Vector-Borne Transmission
West Nile Virus — 2026 Seasonal Surveillance Initiation
ECDC has initiated weekly seasonal surveillance reporting for West Nile virus (WNV) infections in 2026. As of 27 May, only one human case has been reported in Europe, in North Macedonia (Vardarski region). While a single case at this point in the season is not unusual, current seasonal weather conditions are considered favourable for Culex mosquito activity and transmission in established WNV-endemic areas across southern and southeastern Europe. Bulgaria, as a historically affected country with documented WNV circulation in the Danube and Thrace regions, enters the active monitoring period. The ECDC WNV surveillance map and case table will be updated weekly through November. Blood safety directives (Commission Directives 2004/33/EC and 2014/110/EU) require blood establishments to apply 28-day deferral or individual NAT screening for donors returning from risk areas, and public health authorities should confirm preparedness of regional blood establishments for the forthcoming season.
One Health: Animal Disease Events in the European Region
WAHIS/WOAH notifications published during the Week 22 reporting period document multiple active animal disease events across the EU/EEA with direct relevance to public and veterinary health. African swine fever (ASF) continues to circulate extensively across EU member states, with active follow-up reports from Romania, Poland (multiple zones), Hungary, Estonia, and Spain, as well as Serbia and Ukraine. The breadth and persistence of ASF across this geographic range represents a major agricultural and biosecurity concern, though ASF does not pose a direct human health risk. High pathogenicity avian influenza (HPAI) A(H5N1) in wild birds and poultry maintains an active front across multiple European countries including France, United Kingdom, Spain, Denmark, Finland, and Lithuania, underscoring the importance of continued HPAI surveillance in the context of ongoing global A(H5N1) diversification and sporadic human exposure risk. Italy has an active rabies follow-up report (RABV strain, first occurrence 27 May), a development of significance given the country’s long-standing rabies-free status and the proximity of affected areas to the Slovenian and Croatian borders, warranting heightened vigilance across southeastern EU member states. Greece continues active Sheep pox and goat pox reports originating from June 2025, alongside a Foot-and-mouth disease (FMD) serotype SAT 1 event initiated in March 2026—the latter of particular concern given SAT serotypes’ historical absence from the European endemic pool and the absence of SAT-matching components in current European FMD vaccine banks. The United Kingdom reports multiple concurrent bluetongue virus events involving serotypes 3, 8, and 12, reflecting the complex arboviral landscape facing EU/EEA livestock sectors ahead of the summer vector season.
Infectious Diseases: Bulgaria
Data for Week 22 (25–31 May 2026) are drawn from the NCIPD analytical bulletin and the NCOZA regional district breakdown (ZRZ). As established in prior reports, the ZRZ district-level data carry a structural one-week lag relative to the NCIPD national aggregate. Measles case distributions reflect NCOZA reporting, which may differ from NCIPD aggregate totals due to institutional routing differences in the national surveillance architecture.
Respiratory and Droplet Transmission
Varicella
Week 22 registered 488 varicella cases, a reduction of 106 from the 594 cases in Week 21 (−18% week-over-week). While this decline falls short of the 20% threshold and is therefore not reported as a signal per se, the absolute volume—488 cases in a single week—remains epidemiologically substantial and consistent with the late-spring transmission peak characteristic of Varicella-zoster virus in temperate climates. The year-to-date cumulative total of 13,308 cases is marginally above the 13,172 cases for the same period in 2025 (+1%), indicating near-parity with 2025 at the aggregate seasonal level. The ZRZ breakdown shows widespread multiregional distribution with the highest burdens in Sofia-grad (128), Varna (48), Blagoevgrad (43), Sofia-oblast (44), and Stara Zagora (19). The relative stability of the overall season compared to 2025 does not exclude local transmission concentrations warranting district-level monitoring.
Scarlet Fever
A total of 46 scarlet fever cases were registered in Week 22, a decline of 19 from the 65 cases in Week 21 (−29% week-over-week). The year-to-date total of 1,485 cases is 33% below the 2,209 cases accumulated through the same period of 2025 (−724 cases), indicating that the 2026 scarlet fever season remains substantially less intense than its preceding year. The week-over-week decline continues a pattern of deceleration consistent with the close of the school year and the reduction of group-setting Streptococcus pyogenes transmission opportunities that typically accompanies late May. The ZRZ breakdown shows residual activity concentrated in Varna (14), Blagoevgrad (4), Plovdiv (4), and Sofia-grad (13). Scarlet fever does not currently constitute a surveillance signal in the Bulgarian context for Week 22.
Measles
The ZRZ regional breakdown records 26 measles cases in Week 22 across Bulgaria, distributed across multiple districts: Vracha (6), Kyustendil (8), Montana (4), Pleven (7), and Sofia-grad (1). This distribution pattern—with four districts reporting simultaneous measles activity—is consistent with the sustained multiregional outbreak trajectory that has characterised the 2026 season. The persistence of geographic spread across districts not previously at the outbreak epicentre warrants continued heightened surveillance and targeted vaccination catch-up in affected communities. As noted throughout this report series, measles in Bulgaria is notified primarily through NCOZA rather than through the NCIPD analytical bulletin, and direct comparison between the two sources may reflect institutional routing differences rather than true case count discrepancies. The ongoing measles signal in Bulgaria occurs against the backdrop of a continued global and European decline in measles vaccination coverage, with known immunity gaps particularly in Roma communities and in cohorts who missed scheduled vaccinations during pandemic-related service disruptions.
Fecal-Oral Transmission
Campylobacteriosis
Twelve confirmed campylobacteriosis cases were registered in Week 22, one fewer than in Week 21 (−8% week-over-week). While the weekly decline is marginal and below threshold, the year-to-date cumulative total of 240 cases is 95% above the 123 cases registered in the same period of 2025 (+117 cases). This sustained, near-doubling of the year-over-year burden across 22 weeks constitutes a standing and unresolved surveillance signal. Campylobacter spp. infection—the most commonly reported foodborne bacterial illness in the EU—is transmitted primarily through consumption of undercooked poultry or contaminated water and has an incubation period of two to five days. In most cases the illness is self-limiting, but invasive disease can occur in immunocompromised hosts and antimicrobial resistance, particularly fluoroquinolone resistance, is a documented and growing concern in Campylobacter isolates across EU/EEA. The ZRZ breakdown for Week 22 shows clustering in Sofia-grad (7), Silistra (1), and Sliveni (1), with Varna (3) also contributing. The structural absence of routinely reported susceptibility data from the Bulgarian surveillance system limits the ability to characterise the AMR profile of this excess.
Salmonellosis
Fifteen confirmed salmonellosis cases were registered in Week 22, three fewer than Week 21 (−17% week-over-week). The year-to-date total of 230 cases is below the 249 cases for the same period in 2025 (−8%), indicating no current surveillance signal. The ZRZ distribution (Varna 1, Sofia-grad 11, Stara Zagora 1, Targovishte 1) does not suggest geographic concentration.
Vector-Borne Transmission
Lyme Borreliosis
Eleven confirmed Lyme borreliosis cases were registered in Week 22, four more than Week 21 (+57% week-over-week). This weekly increase exceeds the 20% threshold and is consistent with the expected peak of Ixodes ricinus questing activity in late May. The year-to-date cumulative total of 82 cases is marginally below the 85 cases for the same period in 2025 (−4%), indicating an overall season broadly comparable to 2025. One case of Lyme neuroborreliosis was also registered, the first in 2026 (total YTD: 2 cases). The ZRZ breakdown shows cases distributed across Burgas (1), Gabrovo (1), Ruse (1), Sofia-oblast (1), and Targovishte (2), consistent with forest-edge and rural exposure patterns. Weekly Lyme borreliosis counts are expected to remain elevated or increase through June, reflecting sustained tick season activity.
Marseille Fever
Four cases of Marseille fever (Mediterranean spotted fever, Rickettsia conorii) were registered in Week 22, unchanged from Week 21. The year-to-date total of 15 cases is below the 21 cases for the same period in 2025 (−29%). Activity is consistent with the expected seasonal onset as brown dog tick (Rhipicephalus sanguineus) populations become active in warmer months.
Contact and Sexual Transmission
Gonorrhea
Nine confirmed gonorrhea cases were registered in Week 22, four more than Week 21 (+80% week-over-week). The year-to-date cumulative total of 106 cases is 221% above the 33 cases registered in the same period of 2025 (+73 cases). This is the most pronounced sustained year-over-year percentage excess of any tracked infection in Bulgaria in 2026. The 80% week-over-week spike, while based on small absolute numbers, reinforces the upward trajectory. As previously documented, the Bulgarian routine surveillance system does not report antimicrobial susceptibility data alongside gonorrhea notifications, leaving the AMR profile of the current excess entirely uncharacterised—a significant gap given the global emergence of extensively drug-resistant Neisseria gonorrhoeae and the clinical urgency of identifying ceftriaxone-resistant strains.
Urogenital Chlamydial Infection
Twelve confirmed cases of urogenital chlamydial infection were registered in Week 22, four more than Week 21 (+50% week-over-week). The year-to-date cumulative total of 150 cases is 159% above the 58 cases registered in the same period of 2025 (+92 cases). Chlamydia trachomatis remains the most commonly reported STI in the EU/EEA and is systematically under-ascertained due to the predominantly asymptomatic clinical course, particularly in women. The sustained excess across 22 weeks is unlikely to be attributable to testing artefact alone and suggests genuine increases in transmission burden in the surveilled population.
Syphilis
Seventeen confirmed syphilis cases were registered in Week 22, eight more than Week 21 (+89% week-over-week). The year-to-date total of 168 cases is 20% above the 140 cases registered in the same period of 2025 (+28 cases), a modest but persistent excess. Congenital syphilis has accumulated 17 cases YTD versus 13 cases in the same period of 2025 (+31%), representing a continued burden of preventable vertical transmission. The ZRZ Week 22 distribution shows Sofia-grad (13) contributing the dominant share. The single-week spike of 17 cases—the highest weekly total in the 2026 series—may partially reflect reporting consolidation but warrants monitoring over the subsequent two to three weeks.
HIV
Four confirmed HIV cases were registered in Week 22, two fewer than Week 21 (−33% week-over-week). The year-to-date total of 100 cases is 21% below the 127 cases registered in the same period of 2025. As documented in prior reports, the year-over-year decline may reflect reporting delays, changes in testing uptake, or earlier diagnosis in prior years reducing the detectable pool of newly ascertainable infections. Bulgaria’s HIV surveillance context, characterised by a high proportion of late diagnoses, limits the epidemiological interpretation of notification trends as a proxy for incidence.
Methodology and Data Limitations
Surveillance data presented in this report are provisional and subject to retrospective revision. Bulgarian national data originate from two parallel sources: the NCIPD analytical bulletin (aggregate national weekly counts) and the NCOZA/ZRZ district breakdown (regional case distributions), which carries a structural one-week lag relative to the NCIPD aggregate and should be interpreted with this temporal offset in mind. Measles case reporting flows primarily through NCOZA rather than NCIPD, and apparent discrepancies between national aggregates and ZRZ distributions reflect institutional routing differences in the national surveillance architecture rather than data quality issues. The ABCDEN acute viral hepatitis aggregate does not permit serotype-level attribution from routine surveillance data; case-level serotyping data from the reference laboratory level would be required to characterise this signal. Gonorrhea and campylobacteriosis notifications do not include antimicrobial susceptibility data in the routine reporting stream. Global and EU/EEA data are drawn from the ECDC Communicable Disease Threats Report, Week 22 (23–29 May 2026), WHO Disease Outbreak News, and WAHIS/WOAH animal disease notifications as of the reporting date. Risk assessments represent the situation at the time of writing and may change as new information becomes available.