Non-Communicable Disease and Healthcare System Developments
EMA Human Medicines Committee: June 2026
EMA’s Committee for Medicinal Products for Human Use (CHMP) concluded its June 2026 meeting with a substantive output that carries both immediate clinical and broader regulatory significance. Six medicines were recommended for marketing authorisation, three received negative opinions, and one previously refused product was approved on re-examination for a restricted indication.
Among the positive opinions, two are of particular clinical relevance. Aujemflu—an inactivated influenza vaccine containing haemagglutinin and neuraminidase surface antigens—received authorisation specifically for adults aged 50 years and older, adding a dedicated formulation to the influenza vaccination toolbox for a population stratum in which influenza-associated hospitalisation and mortality risk is disproportionately concentrated. Onswik (insulin efsitora alfa) received a positive opinion for type 2 diabetes mellitus in adults, representing a new insulin analogue class with a pharmacokinetic profile designed for extended dosing intervals. Hopledo (levodopa/carbidopa) was recommended for Parkinson’s disease patients with moderate-to-severe motor fluctuations inadequately managed on conventional oral therapy. The two biosimilars approved—Denosumab Ascend and Nylaspeg (pegfilgrastim)—expand access to oncology supportive care products. Daybu (trofinetide), initially refused for Rett syndrome, was approved on re-examination for a restricted neurobehavioural indication covering patients aged five years and older.
Three negative opinions are notable for their clinical context. Tacquell (autologous melanoma-derived tumour-infiltrating lymphocytes) was refused for advanced melanoma, a cell therapy application that underscores the ongoing methodological and manufacturing challenges in this therapeutic space. Xervyteg (allogeneic faecal microbiota, pooled) was refused for acute graft-versus-host disease, and Yartemlea (narsoplimab) for haematopoietic stem cell transplant-associated thrombotic microangiopathy, both in conditions of high unmet need where the evidence base evidently did not meet the benefit-risk threshold required.
Two regulatory actions with immediate public health implications require specific note. The CHMP recommended extending the authorisation of Imvanex—the Modified Vaccinia Ankara-based vaccine against smallpox, mpox, and vaccinia—downward from 12 years to 2 years of age, a significant broadening given the ongoing circulation of both mpox clades in the EU/EEA and the documented paediatric transmission risk in DRC. This extension is procedurally separate from the PRAC restriction of the chikungunya vaccine Ixchiq documented in the prior reporting period but reflects a parallel logic: the regulatory framework for arboviral and poxviral countermeasures is actively adapting in real time to emerging epidemiological conditions. Second, the CHMP finalised the revocation of marketing authorisation for Tavneos (avacopan), used for ANCA-associated vasculitides, following concerns about data integrity in the pivotal trial underpinning its authorisation—a significant regulatory action that leaves patients with refractory granulomatosis with polyangiitis or microscopic polyangiitis without an approved treatment option in this class. Prescribers should transition affected patients to alternative regimens and monitor closely. A CHMP review of rifampicin (Rifadin 20 mg/ml oral suspension) has also been opened following Dutch regulatory authority concerns about diethanolamine excipient levels and carcinogenic potential, a review of relevance to tuberculosis and other serious infection treatment pathways in children for whom oral liquid formulations are frequently used.
Research Highlights: Bepirovirsen for Chronic Hepatitis B and the Shigella Vaccine Pipeline
Two publications from the current reporting cycle carry sufficient clinical and epidemiological weight to warrant summary in the context of this report series. The first, published in the New England Journal of Medicine on 28 May 2026, reports the phase 3 results of bepirovirsen (B-Well 1 and B-Well 2 trials) in chronic hepatitis B virus (HBV) infection. Bepirovirsen is an antisense oligonucleotide that targets HBV transcripts and thereby suppresses both HBV DNA replication and HBsAg production simultaneously. The primary endpoint was functional cure—defined as sustained HBV DNA below the lower limit of quantification and HBsAg loss at 72 weeks following a 24-week treatment course, with nucleoside/nucleotide analogue (NA) therapy discontinued at week 48. Functional cure was achieved in 20% of bepirovirsen recipients in B-Well 1 (127 of 650) and 19% in B-Well 2 (106 of 570), with zero functional cures in either placebo arm. Adverse events occurred in 91% of treated patients versus 73% in placebo recipients; grade ≥3 events were reported in 16% of treated and 3% of placebo patients, with ALT elevations (6%) the most common severe adverse event. No functional cure had previously been demonstrated at this scale with any fixed-duration regimen, making this a methodologically important result even as the absolute cure proportion—roughly one in five treated patients—and the 16% rate of grade ≥3 adverse events both signal that the therapy is not yet ready for broad deployment without further benefit-risk characterisation. The public health relevance is considerable given Bulgaria’s documented sustained excess in acute viral hepatitis ABCDEN across the 2026 surveillance year (detailed below), within which hepatitis B represents a substantial and partially preventable component.
The second publication, from The Lancet, reports phase 2 results of WRSs2, a live-attenuated Shigella sonnei vaccine, in a controlled human infection model. Pooled two-dose vaccine efficacy against endpoint-review-committee-adjudicated shigellosis was 89% (95% CI 71–96%; p<0.0001), with shigellosis occurring in 9% of vaccinated versus 81% of placebo recipients. The result is significant because no licensed shigella vaccine currently exists despite the pathogen’s status as a leading cause of bacterial diarrhoea globally, and because rising azithromycin resistance among circulating Shigella strains is progressively narrowing empirical treatment options. Grade 3 post-vaccination adverse events in a small number of participants prompted two Data and Safety Monitoring Board reviews and a protocol amendment reducing the vaccine dose, indicating that safety–efficacy optimisation work remains necessary before any regulatory pathway can proceed. The EU/EEA relevance is modest in the short term but non-trivial: the multi-country Salmonella Stanley cluster noted in the EU/EEA section below and the structural challenges of enteric pathogen surveillance in travel contexts both illustrate the gap that a licensed shigella vaccine would address.
Infectious Diseases: Global Perspective
Contact and Bloodborne Transmission
Ebola Disease Outbreak (Bundibugyo Virus) — Democratic Republic of the Congo and Uganda, with First Importation into the EU/EEA
The Bundibugyo virus Ebola disease outbreak in the Democratic Republic of the Congo and Uganda has entered a new phase with the first documented case importation into the European Union. On 24 June 2026, France’s Ministry of Health confirmed a laboratory-positive case in a humanitarian doctor returning from a mission in an affected area of DRC; the case is hospitalised in isolation at a designated facility, contact tracing is underway, and five contacts identified on the flight from Kinshasa have been placed in isolation. This is the highest-consequence event reported in the current edition of the CDTR and its epidemiological significance for EU/EEA preparedness is substantial.
The outbreak itself has now reached 1,155 confirmed cases with 304 deaths in DRC as of 26 June 2026, distributed across Ituri (1,054 cases, 250 deaths), North Kivu (98 cases, 53 deaths), and South Kivu (three cases, one death), with 34 of 104 health zones currently affected. Reporting indicates 37 new confirmed cases and five new deaths in the 24 hours preceding 26 June, confirming ongoing transmission at high intensity in Ituri and North Kivu. In Uganda, 20 confirmed cases and two deaths have been reported as of 25 June, with no new cases since 21 June; 15 of 20 Ugandan cases had documented travel links to DRC, and five arose from local transmission events concentrated in Kampala and Wakiso district.
Bundibugyo virus (Orthoebolavirus bundibugyo) was first identified in Uganda in 2007. The current outbreak is epidemiologically distinct from prior Ebola events in DRC in two critical respects. First, it is caused by Bundibugyo virus rather than the more commonly encountered Zaire ebolavirus (Orthoebolavirus zairense): unlike the Zaire species, there are no licensed vaccines or specific treatments available for Bundibugyo virus disease, removing the principal countermeasure toolkit that was decisive in containing the 2018–2020 North Kivu/Ituri outbreak. Second, the scale—over 1,100 confirmed cases—already exceeds the first Bundibugyo virus outbreak in Uganda in 2007, which produced 149 cases, and the 2012 DRC event, which produced 36 cases. Genomes published from DRC and Uganda show distinct sequences from all previous Bundibugyo virus outbreaks, indicating a new emergence event rather than persistence of a prior chain.
Transmission is characterised by close direct contact with the body fluids of symptomatic individuals or deceased cases, with healthcare workers disproportionately affected (75 confirmed cases, 17 deaths, as of 18 June). The incubation period is 2–21 days, and CFR across the two prior Bundibugyo virus outbreaks ranged from 25% to 34%; the current outbreak’s apparent CFR of approximately 26% is consistent with that historical range, though it may be underestimated given the large proportion of cases still under care. DRC has issued a public health decree mandating 21-day active self-monitoring for contacts of confirmed or probable cases, with restrictions on domestic and international movement; exit screening is operational at DRC, Uganda, and South Sudan points of entry, and several countries including the US, Canada, Tunisia, and Thailand have implemented entry health screening for travellers from high-risk countries.
WHO classified the risk as very high nationally for DRC, high for Uganda, high for countries sharing land borders with DRC, and low globally. WHO declared a PHEIC on 17 May 2026, and Africa CDC declared a Public Health Emergency of Continental Security on 18 May. ECDC has deployed experts to Addis Ababa (Africa CDC headquarters) and Kampala, conducted a Point of Entry fact-finding mission in Kinshasa and Kampala (15–22 June), and published a series of technical documents including Threat Assessment Briefs, RAGIDA guidance for aircraft transmission risk, IPC guidance for EU/EEA healthcare settings, and SoHO transmission risk assessments. ECDC’s current assessment is that the risk of infection for EU/EEA residents is very low given the very low likelihood of secondary transmission following importation, and that entry screening of arriving travellers would not be an efficient use of resources—lessons drawn from the 2014–2016 West Africa outbreak are explicitly invoked. The French importation does not alter this risk stratification but underscores the importance of healthcare practitioner familiarity with Ebola disease presentation and the need for travellers to and from affected areas to understand symptom recognition and self-reporting obligations.
Nipah Virus Disease — Kerala, India
On 11 June 2026, the Kerala State Health Department confirmed a single laboratory-positive case of Nipah virus (NiV) disease in Kozhikode district, involving an adult male with symptom onset on 30 May, admitted on 10 June with a primarily neurological presentation requiring intensive ventilatory support. As of 18 June, 104 contacts had been identified—including 45 healthcare workers—with no secondary cases reported. The source of infection has not been identified, and the index case’s link to bats or contaminated food products remains unestablished despite environmental sampling across a 5 km radius including bat specimens dispatched for testing.
Nipah virus (Henipavirus nipahense) is a zoonotic paramyxovirus transmitted from fruit bats (Pteropus spp.) to humans through direct contact, consumption of bat-contaminated food products (particularly raw date palm sap), or close contact with symptomatic patients. The incubation period ranges from 3 to 14 days. Human disease presents as a febrile illness progressing to encephalitis, with CFR ranging from 40% to 75% across documented outbreaks in South and Southeast Asia; no licensed vaccine or specific antiviral treatment exists, placing Nipah on the WHO R&D Blueprint for Epidemics. Person-to-person transmission has been documented in healthcare settings and among household contacts, requiring contact and droplet precautions with airborne precautions for aerosol-generating procedures. The current event is the second NiV notification in India in 2026, following two epidemiologically linked cases in West Bengal in January. Kerala has experienced NiV events in 2018, 2019, 2021, 2023, 2025, and now 2026 in Kozhikode specifically, and has established rapid response infrastructure including Rapid Response Teams, laboratory capacity at the National Institute of Virology in Pune, and multi-sectoral high-power committees for seasonal response. WHO assesses the ongoing sub-national risk as moderate driven by recurrent zoonotic spillover, with regional and global risk remaining low in the absence of any cross-border spread. The significance for EU/EEA surveillance lies primarily in the potential for rare imported cases among returning travellers, a risk category that warrants awareness at infectious disease and emergency care entry points throughout the summer travel season.
Vector-Borne Transmission
Yellow Fever — Americas and Africa
Yellow fever transmission continued in both the Americas and Africa through the first five months of 2026, with 79 confirmed human cases from six countries in the Americas (Bolivia, Brazil, Colombia, Ecuador, Peru, Venezuela) and 16 confirmed cases in three African countries (Burkina Faso, Cameroon, Central African Republic) as of 26 May 2026. Colombia is the most affected country in the Americas due to sylvatic exposure among unvaccinated visitors to forested areas. The current global case burden, while lower than the same period in 2025 (when the Americas alone recorded 241 cases and 100 deaths between late 2024 and early 2025, an eightfold increase year-on-year), reflects a maintained transmission baseline with seasonal ecological drivers rather than a quiescent period. Yellow fever is an acute viral disease transmitted by day-biting Aedes, Haemaglogus, and Sabethes mosquitoes in sylvatic, intermediate, and urban transmission cycles; approximately 15% of infected individuals develop severe disease characterised by jaundice, haemorrhage, and multi-organ failure with a case fatality of approximately 50%, though the overall CFR at population level is substantially lower given that the majority of infections are asymptomatic or mild. Vaccination provides lifelong immunity after a single dose and remains the cornerstone of prevention. The primary public health significance for EU/EEA public health systems is the risk of imported cases in unvaccinated travellers to endemic areas during the summer travel season, with Colombia particularly flagged this period.
Fecal-Oral Transmission
Cholera — Global Update
Global cholera burden as of 22 June 2026 stands at 105,813 cases and 1,216 deaths since 1 January 2026, a modest reduction compared with the 121,736 cases and 1,576 deaths recorded in the equivalent period of 2025. The most affected countries are Nigeria (8,994 cases, 96 deaths), DRC (29,341 cases, 838 deaths—an increase of more than 140% versus the same period in 2025), Angola (5,076 cases, 104 deaths), Malawi (2,615 cases), and Mozambique (7,186 cases). The DRC burden is particularly salient given the concurrent Ebola outbreak, as cholera and Ebola compete for the same overstretched health system resources and contact tracing infrastructure in Ituri and North Kivu—a compounding humanitarian and public health emergency. A locally-acquired case of cholera in a woman in her seventies with no recent travel history was reported by Taiwan on 23 June, confirmed as Vibrio cholerae O1 Hikojima serotype; Taiwan has documented sporadic environmentally-acquired cases in 2020, 2022, 2023, and now 2026, a pattern consistent with residual environmental reservoir rather than sustained local transmission. The risk to EU/EEA travellers visiting cholera-endemic areas remains low, with sporadic importation possible.
Infectious Diseases: European Union / European Economic Area
Contact and Bloodborne Transmission
Ebola Disease — First EU/EEA Importation (France)
As detailed in the global section above, France reported its first confirmed Ebola case of the current outbreak on 24 June—a humanitarian doctor returning from DRC. Five flight contacts were identified and placed in isolation as of the evening of 24 June, with the airline providing a passenger list to facilitate further contact tracing. French and DRC health authorities are cooperating on contact identification. ECDC is in direct communication with French health authorities and has reaffirmed that the import risk management framework for Ebola in EU/EEA healthcare settings—set out in IPC guidance published on 2 June and preparedness guidance published on 18 June—is operationally current. The salient points for clinical practice are: any patient presenting with compatible symptoms (fever, haemorrhage, neurological features, vomiting, weakness) and a history of travel to or transit through Ituri or North Kivu in DRC, or contact with a confirmed case, should be assessed using standard contact and droplet precautions with immediate specialist infectious disease consultation, and specimens handled only by staff with appropriate PPE under biosafety-level-3 conditions. This importation does not change ECDC’s overall risk stratification for EU/EEA residents, which remains very low for secondary transmission.
Mpox — EU/EEA (Clades I and II)
The May 2026 EU/EEA mpox report shows the first signal of deceleration in clade I transmission since the late-2025 escalation: 94 clade I cases were reported by 12 countries in May, down from 140 in April, 111 in March, and 87 in February, though still substantially above the level of mid-2025. Spain reported the highest national clade I count in May (19), followed by France and Germany (17 each). Clade II continues a sustained declining trend, with 22 cases in May from six countries (down from 40 in March and 34 in April), with Germany (13 cases) predominating. Across the past 12 months, 608 clade I and 854 clade II cases have been reported by 18 and 19 countries respectively, with clade Ib and IIb accounting for the overwhelming majority of confirmed clade-typed cases and virtually no deaths reported (one death associated with clade II). Transmission occurs predominantly within networks of men who have sex with men, with 92% of cases in both clade groups reporting this epidemiological characteristic; 21% of clade I and 17% of clade II cases with known vaccination status had received two vaccine doses, confirming that the majority of transmission continues to occur in unvaccinated individuals. ECDC maintains its October 2025 risk stratification: moderate risk for men who have sex with men for clade Ib infection, low for the general population; low and very low respectively for clade IIb. The summer season, with its associated increase in travel and attendance at mass gatherings including Pride events, is specifically identified as a period of heightened risk for further spread of both clades, a concern reinforced by the CHMP’s timely extension of the Imvanex vaccine to children aged two and above.
Vector-Borne Transmission
West Nile Virus — Season Opening
West Nile virus (WNV) seasonal surveillance has opened for 2026 with three human cases reported by two countries as of 24 June: Italy and North Macedonia. Three geographic areas are currently classified as risk zones. WNV is transmitted to humans by Culex species mosquitoes, with birds as the primary amplifying hosts; human infection is asymptomatic in approximately 80% of cases, and severe neuroinvasive disease (encephalitis, meningitis, acute flaccid paralysis) occurs in roughly 1% of all infections, predominantly in older adults and immunocompromised individuals. ECDC assesses that seasonal weather conditions are currently favourable for mosquito-borne transmission and that case counts will rise in subsequent weeks, consistent with the seasonal pattern in prior years. Blood safety directives (2004/33/EC and 2014/110/EU) mandate 28-day deferral for allogeneic blood donors who have left a risk area for locally acquired WNV infection, unless a nucleic acid test is negative—a criterion now activated for the notified Italian and North Macedonian risk areas.
Dengue — EU/EEA and Global
No locally acquired dengue cases have been reported in EU/EEA mainland countries in 2026; the EU/EEA outermost regions (Martinique, Guadeloupe, Réunion, French Guiana) continue to report low-level endemic transmission. However, ECDC assesses that the environmental conditions in most EU/EEA areas where Aedes albopictus or Ae. aegypti are established are now favourable for mosquito activity and virus replication, meaning that locally acquired dengue transmission is possible in the coming weeks following introduction by viraemic returning travellers. This risk is structurally elevated compared with earlier in the year by the recently documented Maldives-linked dengue cluster (at least 107 imported EU/EEA cases since late 2025), though the Maldives-associated import wave shows a declining trend in recent weeks from three EU/EEA reporting countries. Globally, over one million dengue cases and more than 1,000 deaths have been reported since 1 January 2026, a decrease compared with the record burden of the same period in 2025. Sri Lanka shows a notable 34% week-over-week increase in the most recent reporting week (3,265 cases in week 23), with a cumulative 2026 total 48% above the same period in 2025. Cambodia and Malaysia also show increasing trends. A joint ECDC–EFSA rapid outbreak assessment for the multi-country Salmonella Bovismorbificans cluster linked to sprouted seeds was published on 25 June 2026, with a further assessment for Salmonella Stanley ST2045 expected by 1 July.
Chikungunya — EU/EEA (Travel-Associated, Seychelles Origin)
More than 166 travel-related chikungunya cases have been reported by 13 EU/EEA countries since November 2025 among travellers returning from the Seychelles, representing the first documented chikungunya emergence in that island group and a broader pattern of Indian Ocean regional spread. Three reporting EU/EEA countries now indicate a declining trend, with no cases reported with symptom onset after mid-May, consistent with either reduced Seychelles transmission or reduced travel volumes. ECDC’s assessment mirrors that for dengue: environmental conditions in vector-competent areas of the EU/EEA are now favourable for local amplification of imported virus, and locally acquired chikungunya cases may occur in the coming weeks.
Crimean-Congo Haemorrhagic Fever — Spain
One locally-acquired case of CCHF has been reported in Spain (Salamanca) since the start of 2026. ECDC assesses this as unsurprising given the documented presence of Hyalomma spp. vectors and known CCHF virus circulation in animal populations in that region; the timing is consistent with the expected seasonal CCHF peak linked to increased tick activity. The risk to the general population in CCHF-risk areas remains low but is elevated for those with occupational or recreational tick exposure (farming, forestry, hunting, hiking). Hyalomma marginatum, the principal vector in human transmission, is broadly distributed across southern and eastern Europe including Bulgaria.
Fecal-Oral Transmission
Multi-Country Salmonella Clusters — EU/EEA
Two active Salmonella multi-country investigations are proceeding concurrently. The Salmonella Stanley ST2045 cluster, documented in prior reporting periods at 83 cases across nine countries with chicken-flavoured instant noodle products as the suspected vehicle, is receiving a dedicated ECDC–EFSA rapid outbreak assessment expected by 1 July. A new Salmonella Bovismorbificans cluster linked to sprouted seeds was assessed by ECDC and EFSA jointly on 25 June, a signal with particular significance given the historical pattern of sprouted seed contamination events causing large multi-country Salmonella outbreaks in the EU (notably the 2011 E. coli O104:H4 outbreak linked to fenugreek seeds). Both investigations are ongoing, and their conclusions are expected to clarify the vehicle attribution and population distribution of risk.
Respiratory and Droplet Transmission
Respiratory Virus Epidemiology — EU/EEA
Respiratory virus activity across the EU/EEA is at interseasonal baseline levels. SARS-CoV-2 activity in primary and secondary care remains low, with pooled influenza test positivity at 0.4% in primary care and 1.4% in hospitals, RSV at 0% in primary care, and SARS-CoV-2 at 3.4% in primary care—all metrics consistent with the expected interseasonal trough. Circulating SARS-CoV-2 variants as of weeks 23–24 are BA.3.2 (VUM, 60% distribution) and XFG (VUM, 40% distribution), neither of which carries an altered risk classification relative to prior variants. A single human case of avian influenza A(H9N2) was reported from the Guangxi Zhuang Autonomous Region of China on 23 June 2026—a child under five years with symptom onset on 31 May—consistent with the sporadic pattern of paediatric poultry-contact cases from southern China documented across prior surveillance periods. No human-to-human transmission has been documented for H9N2, and the ECDC risk assessment for EU/EEA residents remains very low.
It is worth noting that this is the first ERVISS publication following the transition from TESSy to EpiPulse Cases (EPC) as the primary EU/EEA surveillance data repository; ECDC has flagged potential data inconsistencies from individual countries during the transition period, and GitHub data downloads have been temporarily paused while these are resolved. Interpretation of interseasonal baselines should account for this transitional limitation.
Infectious Diseases: Bulgaria
Respiratory and Droplet Transmission
Measles
Regional surveillance data for Week 26 recorded 22 measles cases distributed across four districts: Pleven (9), Vratsa (6), Kustendil (6), and Ruse (1). The NCIPD national operational analysis records zero measles cases for this week—a structural feature of Bulgarian measles surveillance architecture noted throughout this report series, whereby measles flows through the regional district-level system (NCOZA) rather than the NCIPD aggregate, rendering NCIPD figures consistently uninformative for this disease and cross-validation against ZRZ data essential. The persistence of measles activity in Week 26—well into the post-school-year period and therefore outside the congregate paediatric transmission context that drove much of the earlier outbreak—indicates sustained community transmission independent of school-based amplification. The appearance of six cases in Kustendil this week represents geographic expansion from the established epidemic focus in the northwest and north-central corridor (Vratsa, Pleven, Lovech), a development warranting specific attention in outbreak response planning. Bulgaria’s cumulative measles caseload as of early June was 364 cases (as documented in Week 23–24), the second-highest in the EU/EEA after England, with 56% of cases with known vaccination status confirmed as unvaccinated.
Varicella
Varicella registered 256 cases in Week 26, a 76-case (23%) decline from the 332 cases recorded in Week 25—a change that exceeds the 20% signal threshold and is consistent with the expected post-school-year reduction in congregate paediatric transmission. The year-to-date cumulative total of 14,826 cases is essentially equivalent to the 14,880 recorded at the same point in 2025, indicating a 2026 varicella season that has tracked very closely to the prior year in aggregate despite week-to-week variation. Sofia-grad remains the largest single contributing district. The week-over-week decline is likely to continue as the summer holiday period progresses, consistent with the secular seasonal pattern for varicella in Bulgaria documented across this series.
Scarlet Fever
Scarlet fever registered 30 cases in Week 26, a one-case decline from Week 25 (31 cases), remaining essentially stable at a level that falls well short of the 20% inclusion threshold for week-over-week reporting. The year-to-date cumulative total of 1,650 cases is 33% below the 2,462 cases recorded in the same period of 2025—a sustained reduction that has characterised the 2026 scarlet fever season throughout its course. This cumulative deficit, consistent across the season, suggests a genuine reduction in Streptococcus pyogenes group A transmission intensity for 2026 relative to 2025, though the mechanistic driver remains uncharacterised in available surveillance data.
Fecal-Oral Transmission
Campylobacteriosis
Campylobacteriosis registered 14 cases in Week 26, a five-case (56%) increase from the nine cases recorded in Week 25—a week-over-week change that exceeds the inclusion threshold. The year-to-date cumulative total of 283 cases is 62% above the 175 cases recorded in the same period of 2025 (an absolute excess of 108 cases), sustaining the pronounced year-over-year upward trend in campylobacteriosis documented across this report series since the start of 2026. Campylobacter jejuni and C. coli, transmitted primarily through consumption of undercooked poultry and unpasteurised milk and through exposure to contaminated water or animal contact, represent the most frequently isolated bacterial enteric pathogen group in the EU/EEA; the week-over-week increase in Week 26 is consistent with the expected early-summer amplification of transmission risk associated with outdoor food preparation, increased handling of raw poultry at barbecues, and the warming temperatures that shorten the time-to-spoilage of inadequately refrigerated animal products. The sustained 62% year-over-year excess across twenty-six reporting weeks cannot, however, be attributed to seasonal factors alone and warrants formal investigation.
Vector-Borne Transmission
Lyme Borreliosis
Lyme borreliosis registered 15 cases in Week 26, a four-case (36%) increase from the 11 cases recorded in Week 25, exceeding the inclusion threshold. This represents a meaningful reversal from the week-to-week declines documented in prior recent weeks: the year-to-date cumulative total of 131 cases remains 11% below the 148 cases recorded at this point in 2025, so the prior-year comparison remains mildly below-baseline despite the current-week increase. Borrelia burgdorferi sensu lato, transmitted by Ixodes ricinus, circulates in Bulgaria throughout the tick-active season (April through October), and Week 26 falls at the peak of the second seasonal activity wave for Ixodes following egg hatching. The ZRZ regional data show cases distributed across multiple districts including Lovech (1), Gabrovo (2), Targovishte (1), and Sofia region (3), with Sofia-grad and surrounding districts collectively contributing the majority of the weekly total, consistent with the pattern of peri-urban tick exposure associated with recreational outdoor activity in the forest-agricultural ecotone around the capital.
Marseille Fever (Mediterranean Spotted Fever)
Marseille fever registered three cases in Week 26, with a stable week-over-week count (zero change from Week 25). The year-to-date cumulative total of 28 cases is 33% below the 42 cases recorded in the same period of 2025, continuing a below-baseline trajectory for this tick-borne rickettsiosis. Rickettsia conorii, transmitted by Rhipicephalus sanguineus (the brown dog tick), produces a febrile eschar disease with the characteristic tache noire at the bite site; cases in Bulgaria peak in summer months coinciding with peak tick activity and human outdoor exposure. The current below-baseline trend does not constitute a signal of concern but is noted for continuity with the time series.
Chikungunya
A single confirmed case of chikungunya was registered in Week 26—the first in the most recent reporting period—bringing the year-to-date total to five cases, compared with zero cases in the same period of 2025. Bulgaria’s chikungunya surveillance records no established local transmission, and this case is presumptively travel-acquired given the absence of competent Aedes vector establishment at sufficient density for autochthonous transmission in Bulgaria. The five YTD cases in 2026 are consistent with the EU/EEA pattern of travel-associated chikungunya importations from the Seychelles documented in the EU/EEA section, and the specific confirmed case in Week 26 likely falls within this travel-related cluster.
Contact and Sexual Transmission
Syphilis
Syphilis registered 16 cases in Week 26—a ten-case (167%) increase from the six cases recorded in Week 25—the largest single-week percentage change among notifiable sexually transmitted infections in this reporting week. The year-to-date cumulative total of 207 cases is 29% above the 160 cases recorded in the same period of 2025. One additional case of congenital syphilis was reported in Week 26, bringing the year-to-date total to 20 congenital cases versus 15 in the equivalent 2025 period, a 33% excess. The week-over-week spike in adult syphilis notifications should be interpreted with some caution given the moderate absolute case count (16 cases), as week-to-week variability in notification timing can produce apparent surges that are partially artefactual. Nonetheless, the sustained year-over-year excess in cumulative adult syphilis, combined with the persistently elevated congenital syphilis burden, continues to indicate structural gaps in sexual health services access and antenatal screening completion in Bulgaria that routine surveillance cannot resolve independently.
Gonorrhea
Gonorrhea registered three cases in Week 26, a five-case (63%) decline from the eight cases in Week 25. The week-over-week decrease does not alter the year-to-date picture: 122 cumulative cases against 45 in the same period of 2025, a 171% year-over-year excess that is the most pronounced relative increase of any notifiable sexually transmitted infection tracked in Bulgarian surveillance in 2026. As documented throughout this series, routine Bulgarian gonorrhea surveillance captures case counts but not antimicrobial susceptibility data, a significant structural limitation in the context of the global emergence of multidrug-resistant and extensively drug-resistant Neisseria gonorrhoeae; treatment failure under empirical therapy cannot be monitored without susceptibility testing at the national level.
Urogenital Chlamydial Infection
Urogenital chlamydial infection registered five cases in Week 26, a three-case (38%) decline from the eight cases in Week 25. The year-to-date cumulative total of 177 cases is 130% above the 77 cases recorded in the same period of 2025. Chlamydia trachomatis is consistently the most frequently reported bacterial sexually transmitted infection across the EU/EEA and is characterised by high rates of asymptomatic carriage in both sexes, making routine surveillance notifications a systematic undercount of true incidence. The sustained and large year-over-year excess in 2026 likely reflects some combination of genuine transmission increase, expanded testing capacity, and improved case ascertainment, components that cannot be disaggregated without testing volume data.
Surveillance Notes and Signal Inclusion Rationale
The Bulgarian measles caseload in Week 26 derives exclusively from ZRZ/NCOZA district-level surveillance (22 cases across four districts) and is not reflected in NCIPD’s national operational analysis, which records zero cases. This structural divergence is an established feature of Bulgarian measles surveillance architecture documented throughout this series and does not represent a data discrepancy; it underscores the requirement to prioritise ZRZ regional data for measles signal identification and to treat the Kustendil cluster (six cases) as a documented geographic expansion warranting specific response attention.
The syphilis week-over-week increase (167%) is reported as a signal given its absolute magnitude (ten additional cases) and its coherence with the sustained year-over-year excess trajectory. The week-over-week varicella decline (23%) is reported as a signal consistent with the expected post-school-year transmission reduction rather than an unanticipated change; it is included to document seasonal transition in the time series.
The following diseases registered zero cases in Week 26 and are excluded: pertussis, leptospirosis, botulism, viral meningitis and meningoencephalitis (acute), haemorrhagic fever with renal syndrome, Q fever, ornithosis, tetanus, anthrax, West Nile fever, Creutzfeldt-Jakob disease, COVID-19, and cholera. Legionnaires’ disease shows a 125% year-over-year excess (nine cases vs four in 2025 through Week 26) but registered zero cases this week; the cumulative trend warrants monitoring but does not produce a signal against the 20% week-over-week threshold in Week 26 itself.
The WOAH/WAHIS animal disease data for the current reporting period document ongoing high-pathogenicity avian influenza A(H5N1) activity in wild birds and poultry across multiple EU/EEA member states (UK, Sweden, Germany, Canada, USA, among others). Bulgaria’s own WAHIS entry (sheep pox and goat pox, July 2025 recurrence) carries no zoonotic potential. The breadth of H5N1 activity across the region represents a sustained spillover risk substrate that warrants continued One Health surveillance co-ordination.
Surveillance data are subject to reporting delays and may not reflect the true burden of disease. Case counts are provisional and may be revised. Risk assessments represent the situation at the time of writing and may change as new information becomes available.
Sources: NCIPD Weekly Operational Analysis, Week 26, 2026 (22–28 June 2026); NCOZA/ZRZ Weekly Regional Surveillance Data, Week 26, 2026; ECDC Communicable Disease Threats Report, Week 26 (20–26 June 2026); WHO Disease Outbreak News: Nipah virus disease – India, 25 June 2026; WHO Disease Outbreak News: Yellow fever – Global, 24 June 2026; WOAH/WAHIS Follow-Up Reports (FURs), accessed 26–27 June 2026; EMA CHMP June 2026 Meeting Highlights; Hou J et al., “Phase 3 Results of Bepirovirsen Treatment for Chronic Hepatitis B Virus Infection,” NEJM 2026;394:2395–2406; Rouphael N et al., “Efficacy of WRSs2, a live-attenuated Shigella sonnei vaccine, against shigellosis in a controlled human infection model,” Lancet (published online 2026).