Non-Communicable Disease and Healthcare System Developments
Pharmacovigilance, Regulatory Procedures and Medicine Safety
During August 2026, the European Medicines Agency maintained its regulatory and post-marketing surveillance cadence through scheduled committee work and written procedures. While the Committee for Medicinal Products for Human Use does not hold a standard plenary assembly in August, formal written procedures were conducted between 17 and 20 August to advance urgent medicine evaluations, marketing authorisation variations, and orphan designations. In parallel, the Pharmacovigilance Risk Assessment Committee convened for its scheduled plenary meeting from 3 to 6 August 2026 to review ongoing safety signals, risk management plans, and post-authorisation safety studies across the European Union. A substantial component of this surveillance cycle focused on the continued safety monitoring of Janus kinase inhibitors, particularly following updated warnings for ritlecitinib regarding systemic infection risks, opportunistic pathogens, and cardiovascular considerations, ensuring uniform product information across member states.
The committee also reviewed pharmacovigilance commitments for updated respiratory formulations ahead of the approaching autumn vaccination campaigns. Following the positive scientific opinions adopted in late July for the XFG-adapted COVID-19 vaccine compositions across mRNA and recombinant protein platforms, regulatory oversight in August concentrated on distribution logistics, lot release protocols, and real-world safety tracking systems. For health systems across Central and Eastern Europe, including Bulgaria, these regulatory frameworks provide the technical foundation for seasonal immunization guidelines, targeting vulnerable demographics, elderly cohorts, and individuals with underlying immunocompromising conditions.
Environmental Epidemiology, Maternal Health and Cancer Survivorship
Environmental and life-course epidemiology featured prominently in international peer-reviewed journals during August 2026. A prospective parallel cohort study published in The Lancet Public Health on 18 August evaluated the long-term impact of London’s Ultra Low Emission Zone on lung function development among primary school children. Comparing annual spirometric trajectories between children attending primary schools within central and inner London against an external comparator cohort in Luton, the investigators demonstrated that meaningful reductions in ambient nitrogen dioxide and fine particulate matter (PM2.5) concentrations were accompanied by significant improvements in annual forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) growth rates. Children in areas with the greatest air quality improvements exhibited an additional 25 to 30 millilitres of annual FEV1 gain compared to unmitigated environments, providing robust empirical proof that municipal traffic emissions abatement directly translates into measurable physiological benefits during critical windows of childhood lung development.
In maternal and perinatal epidemiology, a population-based cohort study published in The Lancet Public Health in August analysed electronic medical records covering more than 2.2 million pregnancies to quantify the risks associated with maternal multimorbidity. Women entering pregnancy with two or more co-existing long-term physical or psychiatric conditions experienced sharply elevated risks of adverse obstetric and neonatal outcomes. The presence of physical-mental health multimorbidity was associated with an adjusted relative risk of 1.68 for severe maternal morbidity, 1.45 for spontaneous preterm delivery before 37 weeks of gestation, and 1.38 for emergency caesarean section, compared to women with no pre-existing chronic conditions. The authors highlighted that contemporary antenatal care models remain heavily siloed along single-disease pathways, arguing for integrated, multidisciplinary obstetric and chronic disease management models to mitigate escalating perinatal risks in increasingly multimorbid maternal populations.
In oncology survivorship and metabolic health, a large-scale retrospective cohort study published in JAMA Oncology in August 2026 investigated the incidence and predictors of metabolic syndrome among patients receiving combined androgen-deprivation therapy (ADT) and novel androgen receptor pathway inhibitors (ARPIs) for advanced or high-risk localised prostate cancer. Utilizing real-world data from the Epic Cosmos clinical network, the analysis revealed that nearly 40% of patients initiating concurrent ADT and ARPI therapy developed new-onset metabolic syndrome within the first 12 months of treatment, characterized by rapid visceral weight gain, dyslipidaemia, hypertension, and insulin resistance. The rapid onset of metabolic dysfunction under potent androgen axis suppression was strongly associated with subsequent cardiovascular events and major adverse cardiac outcomes. The authors recommended routine baseline cardiometabolic profiling, early nutritional and exercise interventions, and active pharmacological management of lipids and blood pressure for all prostate cancer patients initiating intensified androgen pathway blockade.
Infectious Diseases: Global Perspective
Contact and Body-Fluid Transmission
Bundibugyo Ebola Virus Disease in the Democratic Republic of the Congo; Ongoing Regional Containment
The large-scale outbreak of Ebola disease caused by Bundibugyo virus continued its intense geographic and numerical expansion across the eastern Democratic Republic of the Congo throughout Weeks 32, 33, and 34 of 2026. According to successive surveillance updates compiled by the European Centre for Disease Prevention and Control and the World Health Organization, confirmed cases and fatalities in the Democratic Republic of the Congo rose without interruption. In the Week 32 update, cumulative confirmed cases reached 4,053 with 1,850 confirmed related deaths as of 6 August, spanning five provinces: Ituri, North Kivu, South Kivu, Tshopo, and Haut-Uele. By the Week 33 assessment on 13 August, confirmed cases had increased to 4,665 with 2,184 deaths, with transmission newly detected in a sixth administrative jurisdiction, Bas-Uele province. By the Week 34 report, based on surveillance data consolidated to 20 August, the outbreak stood at 5,290 laboratory-confirmed cases and 2,516 confirmed related deaths.
The progression across these three reporting weeks represents an addition of 1,848 confirmed cases and 995 deaths since the Week 31 benchmark of 3,442 cases and 1,521 deaths. The crude confirmed case fatality ratio edged upward from 44.2% in Week 31 to 45.6% in Week 32, 46.8% in Week 33, and 47.6% in Week 34. This persistently elevated case fatality ratio reflects severe clinical presentation, late presentation to isolation facilities, and substantial operational constraints in conflict-affected regions of eastern Congo, particularly within Ituri and North Kivu, where community distrust, armed skirmishes, and population displacement hinder contact identification and clinical follow-up. While contact tracing mechanisms have registered thousands of contacts across more than fifty active health zones, follow-up completion rates hover between 78% and 82%, leaving an unmonitored margin capable of propagating cryptic transmission chains.
In contrast to the deteriorating situation in the Democratic Republic of the Congo, neighbouring Uganda has maintained full containment. Following the discharge of its final confirmed patient and the completion of the standard 42-day surveillance countdown—representing twice the maximum 21-day incubation period of the virus—Uganda’s Ministry of Health formally declared the end of its Ebola outbreak on 28 July 2026. Uganda documented a cumulative total of 20 confirmed cases and two deaths, with no incident cases registered after 21 June 2026. The successful termination of transmission in Uganda demonstrates that rigorous contact tracing, rapid clinical triage, immediate patient isolation, and transparent cross-border coordination can interrupt Bundibugyo virus spread even in the absence of licensed species-specific countermeasures.
Unlike Zaire ebolavirus, for which the recombinant vesicular stomatitis virus-based vaccine and monoclonal antibody therapies such as ansuvimab and atoltivimab-maftivimab-odesivimab provide proven clinical protection, no licensed vaccine or targeted therapeutic exists for Bundibugyo ebolavirus. Clinical management relies strictly on early aggressive supportive care, fluid and electrolyte rehydration, organ support, and empirical treatment of co-infections. The initiation of the world’s first Phase 1 clinical trial of a candidate Bundibugyo virus vaccine at the University of Oxford represents an essential scientific milestone, but deployed field options remain constrained. ECDC maintains its standing risk evaluation: the probability of infection remains low for European Union and European Economic Area citizens living in or travelling to affected provinces, and very low for the general population within the EU/EEA. For Bulgarian healthcare institutions and border entry points, the operational stance remains focused on clinician awareness, obtaining accurate travel histories for febrile patients arriving from Central Africa, and maintaining validated laboratory referral and isolation pathways.
Respiratory and Droplet Transmission
Zoonotic Avian and Swine Influenza Detections
Global surveillance for zoonotic influenza viruses registered isolated spillover events into human hosts during the reporting period, emphasizing the continued requirement for integrated One Health monitoring. In China, the World Health Organization reported a single laboratory-confirmed case of avian influenza A(H9N2) in a female child under five years of age residing in Yunnan Province. The child, who had underlying medical conditions, developed acute respiratory symptoms on 28 July 2026, required inpatient hospitalisation, and subsequently achieved full recovery and clinical discharge. Exposure investigation identified prior contact with domestic poultry environments. Since 2015, a cumulative total of 175 laboratory-confirmed human cases of avian influenza A(H9N2), including two deaths, have been formally reported from China to the World Health Organization. Avian influenza A(H9N2) viruses circulate endemically in poultry populations across Asia and parts of Africa; human infections remain sporadic and zoonotic, with no documented instances of sustained human-to-human transmission. ECDC assesses the risk of A(H9N2) infection to the general population in the EU/EEA as very low.
In North America, the Michigan Department of Health and Human Services and the United States Centers for Disease Control and Prevention confirmed a human case of variant swine influenza A(H1N2)v virus infection. The patient, a resident of Ionia County, Michigan, was an exhibitor of swine at an agricultural county fair held from 3 to 8 August 2026. Diagnostic confirmation of A(H1N2)v was completed by the US CDC on 14 August 2026. Comprehensive contact tracing and active symptom monitoring identified no secondary respiratory illnesses among family members, fair attendees, or healthcare contacts. Variant influenza infections occur sporadically when human populations interact closely with swine exhibiting respiratory illness at agricultural exhibitions or farming operations. While swine serve as potential mixing vessels for genetic reassortment among avian, swine, and human influenza strains, sporadic isolated cases without secondary transmission do not indicate increased human-to-human transmissibility.
Infectious Diseases: European Union/European Economic Area
Contact and Sexual Transmission
Emerging Multi-Country Outbreak of Dermatophilus congolensis Skin Infections
A distinctive and rapidly evolving epidemiological event in the European Union and European Economic Area during August 2026 was the expanding documentation of human cutaneous infections caused by Dermatophilus congolensis. Following an initial Rapid Risk Assessment issued in mid-June, the ECDC Week 34 surveillance report confirmed that cumulative human infections have climbed to 126 confirmed cases across ten European countries: Austria, Denmark, France, Germany, the Netherlands, Norway, Spain, Sweden, Switzerland, and the United Kingdom. Four nations—Denmark, the Netherlands, Switzerland, and the United Kingdom—notified cases for the first time during the current reporting interval.
Dermatophilus congolensis is a Gram-positive, facultatively anaerobic actinomycete classically recognised as a veterinary pathogen responsible for dermatophilosis, an exudative, scabby epidermitis affecting cattle, sheep, goats, and horses in tropical and temperate farming regions. Historically, human infections have been exceedingly rare, manifesting almost exclusively as isolated occupational pustules among livestock handlers, shearers, and veterinarians exposed to wet animal fleeces. The current European outbreak, however, reflects a substantial shift in host transmission dynamics. Whole genome sequencing of clinical isolates from Austria, Denmark, France, the Netherlands, Spain, Sweden, and Switzerland demonstrated tight phylogenetic clustering, indicating the propagation of closely related bacterial strains.
Epidemiologically, the predominant proportion of reported cases has been identified among gay, bisexual, and other men who have sex with men, particularly individuals reporting recent attendance at sex-on-premises venues, communal bathhouses, and saunas across several European metropolitan hubs. However, secondary clusters and sporadic cases unrelated to sexual networks have also been identified, including transmissions associated with martial arts clubs, combat sports facilities, and communal athletic settings in Norway, Spain, and Switzerland. Clinical presentation has been uniform and benign: patients present with localised papular, pustular, follicular, or crusted skin lesions on the torso, limbs, buttocks, or groin. Lesions have responded consistently to standard topical antiseptics and oral antibiotic regimens, including macrolides and beta-lactams, with uneventful resolution. The outbreak pattern provides compelling evidence of sustained human-to-human transmission mediated by direct skin-to-skin contact in warm, humid microenvironments where microtrauma and skin friction facilitate bacterial entry, alongside potential indirect transmission through contaminated towels, upholstery, or damp shared surfaces. ECDC emphasizes the importance of clinical awareness among dermatologists, sexual health specialists, and sports medicine practitioners, the adoption of rigorous hygiene and environmental disinfection protocols in commercial and athletic venues, and the avoidance of direct contact with active skin lesions.
Mpox Surveillance and Mass Gathering Conclusion
European mpox surveillance during Weeks 32–34 reflected ongoing, stable transmission dynamics dominated by monkeypox virus clade I. In data reported for July 2026, twelve EU/EEA countries registered 153 confirmed cases of clade I infection, indicating steady transmission following the incidence elevations detected during the spring months. Concurrently, twelve cases caused by MPXV clade II were notified across five countries, continuing the established multi-month declining trajectory of the clade II epidemic. Transmission for both viral clades remains heavily concentrated within networks of men who have sex with men, with the large majority of notifications occurring among unvaccinated individuals or those who received only a single vaccine dose during previous campaigns. Clinical severity has remained generally mild to moderate, with very low hospitalisation rates and no reported fatalities in the reporting period.
In parallel, public health authorities in the Netherlands and ECDC concluded enhanced event-based surveillance for the Amsterdam World Pride festival, which ran from 25 July to 8 August 2026. Epidemic intelligence monitoring detected no unusual spikes, cross-border clusters, or super-spreading events involving mpox, sexually transmitted infections, shigellosis, or enteric pathogens associated with the gathering. The conclusion of this major mass gathering without secondary epidemic amplification demonstrates the effectiveness of targeted pre-event risk communication, community engagement, and accessible vaccination services.
Fecal-Oral Transmission
Multi-Country Outbreak of Salmonella Enteritidis ST11 Linked to Poultry and Eggs
In enteric disease surveillance, ECDC and the European Food Safety Authority consolidated investigations into a protracted, multi-country outbreak of Salmonella enterica serovar Enteritidis sequence type 11 (ST11). Between May 2025 and August 2026, a total of 341 confirmed outbreak cases were identified across seven European nations: the United Kingdom (207 cases, 60.7%), the Netherlands (106 cases, 31.1%), Belgium (15 cases), Germany (6 cases), France (4 cases), Austria (2 cases), and Denmark (1 case). The outbreak has displayed sustained longevity, with a pronounced resurgence in transmission observed during the late spring and summer of 2026; 152 cases, representing 44.6% of the cumulative total, were notified after May 2026.
Case demographics span an age range from infancy to 90 years, with a median age of 31 years and equal gender distribution. Disease severity has been notable, with at least 34 documented hospitalisations due to severe dehydration, systemic invasiveness, or enterocolitis in elderly patients. Whole genome sequencing in the ECDC database confirmed that clinical isolates clustered tightly within five allelic distances via single-linkage analysis, establishing a shared microbiological origin. Epidemiological traceback investigations in the United Kingdom identified contaminated imported table eggs as the principal vehicle of transmission, whereas complementary investigations in the Netherlands implicated poultry and chicken meat products. Control measures, including veterinary sampling at laying farms, enhanced border testing of imported egg consignments, and product recalls, remain active to disrupt the cross-border distribution of contaminated poultry products.
Environmental Suitability for Coastal Vibrio Bacteria
ECDC’s operational Vibrio Viewer monitoring during Weeks 32–34 highlighted persistent, high environmental suitability for autochthonous Vibrio species growth across vulnerable European coastlines. Driven by elevated sea surface temperatures and low salinity levels during mid-August, the five-day forecast consolidated in Week 34 identified 40 coastal municipalities across eight administrative regions in three countries exhibiting high suitability for pathogenic Vibrio proliferation, including Vibrio vulnificus, Vibrio parahaemolyticus, and non-toxigenic Vibrio cholerae.
The geographic distribution was concentrated predominantly along the western Black Sea and Atlantic French coastlines. In Bulgaria, thirteen coastal municipalities across three administrative regions exceeded the high-suitability threshold: Avren, Byala, Dolni chiflik, and Varna in Varna region; Balchik, Kavarna, and Shabla in Dobrich region; and six municipalities in Burgas region. In neighbouring Romania, twelve municipalities across Constanța and Tulcea regions exhibited elevated suitability, while France recorded fifteen suitable municipalities across Gironde, Charente-Maritime, and Bouches-du-Rhône. Environmental suitability models serve as predictive early warning indicators rather than clinical morbidity reports. Public health guidance continues to advise thorough cooking of shellfish and seafood, and warns individuals with open skin wounds, chronic hepatic impairment, diabetes mellitus, or immunocompromising conditions to avoid immersion in warm brackish waters.
Vector-Borne Transmission
Rapid Seasonal Surge of West Nile Virus Infections
Vector-borne disease transmission intensified markedly across Southern, Central, and Eastern Europe during Weeks 32–34, driven by sustained high ambient temperatures and peak vector densities of Culex pipiens and Culex modestus mosquitoes. Surveillance data published in ECDC’s weekly and monthly reports demonstrated a steep geographic expansion of West Nile virus transmission areas. From 49 affected areas across seven countries in Week 31, the total rose to 59 areas in Week 32, and reached 98 affected administrative areas across twelve European nations by Week 34.
The 98 affected areas consolidated by 21 August 2026 were distributed across Italy (46 areas), Greece (16 areas), Romania (14 areas), France (eight areas), North Macedonia (three areas), Spain (three areas), Serbia (three areas), Albania (one area), Austria (one area), Germany (one area), Kosovo (one area), and the Netherlands (one area). A total of 21 administrative areas reported locally acquired human cases for the first time in the 2026 season during Week 34. This intense transmission in neighbouring Balkan jurisdictions, particularly Romania, Greece, North Macedonia, and Serbia, underscored an elevated regional transmission pressure directly relevant to Bulgaria. Enhanced blood safety measures, including nucleic acid testing of blood donations or temporary deferral of donors residing in or visiting affected areas, remain essential across the European blood transfusion network to prevent transfusion-transmitted West Nile neuroinvasive disease.
Autochthonous Chikungunya, Dengue and Crimean-Congo Haemorrhagic Fever
Surveillance for exotic vector-borne arboviruses in mainland Europe registered critical autochthonous developments during the three-week interval. In France, locally acquired chikungunya virus disease cases increased substantially. Following the initial isolated case reported in Week 31, France notified six additional locally acquired cases in Week 32, reaching a cumulative total of seven cases. Transmission accelerated further over subsequent weeks, with ten new locally acquired cases confirmed in Week 34 alone, bringing the French national cumulative total to 25 autochthonous chikungunya cases across multiple localized transmission clusters in southern departments where Aedes albopictus is established. In parallel, France recorded four locally acquired cases of dengue virus infection across three discrete epidemiological clusters, two of which have been successfully controlled and closed, while vector control and active case-finding continue around the single active cluster.
Crimean-Congo haemorrhagic fever surveillance recorded sporadic local transmission in Southern Europe and the Western Balkans. In Spain, where Hyalomma lusitanicum and Hyalomma marginatum ticks maintain enzootic viral cycles among wildlife and livestock, a fourth locally acquired human case of CCHF was confirmed in Week 34, following earlier notifications from Ciudad Real and Salamanca provinces. In the Western Balkans, public health authorities in Albania notified a confirmed case of CCHF on 11 August 2026 in a livestock farmer residing in Tropojë district in northern Albania. The patient developed acute febrile symptoms on 22 July, was hospitalised on 24 July, and achieved full recovery prior to discharge. Tropojë district had not previously been recognised as an endemic CCHF focus in Albania, demonstrating tick vector expansion into highland pastoral environments. ECDC maintains that while general population risk remains low, individuals engaged in outdoor agricultural, forestry, or hunting activities face elevated exposure and should rigorously employ personal protective measures against tick bites.
Respiratory and Vaccine-Preventable Transmission
Multi-Region Measles Outbreak Linked to a Swedish Music Festival
In vaccine-preventable disease surveillance, ECDC documented a cross-border measles outbreak originating from a mass gathering event in Northern Europe. As of 21 August 2026, a total of 27 laboratory-confirmed and epidemiologically linked measles cases were identified across nine administrative regions in Sweden (26 cases) and the autonomous Åland Islands in Finland (one case). All identified cases were traced to attendance at a music festival held in the Västernorrland region of northern Sweden between 30 July and 1 August 2026.
The festival drew approximately 10,000 attendees, of whom an estimated 10% were international visitors, primarily from Norway and neighbouring Nordic regions. Epidemiological investigations established that the vast majority of infected individuals were unvaccinated school-age children, adolescents, and young adults under 25 years of age. The secondary case in Finland involved an individual who travelled aboard two passenger ferries between Sweden and Åland while in the prodromal phase of illness, prompting widespread contact tracing across maritime routes. The outbreak illustrates the extreme transmissibility of the measles virus in crowded social settings where local pockets of sub-optimal vaccine coverage exist, demonstrating that high national headline coverage figures can obscure sub-national immunity gaps that leave adolescents and young adults vulnerable to explosive transmission.
In broader respiratory monitoring, European respiratory virus activity remained at low inter-seasonal baseline levels throughout Weeks 31 to 34. Sentinel primary care consultations for influenza-like illness and acute respiratory infections showed minimal circulation of influenza A and B viruses, while respiratory syncytial virus activity remained negligible. SARS-CoV-2 transmission remained low across all age demographics, although sporadic, minor upticks in wastewater concentrations and secondary-care admissions were noted in a small subset of reporting countries.
One Health: Animal Disease Events in the European Region
African Swine Fever Expansion in Finland and Ongoing European Animal Health Notifications
Animal disease surveillance coordinated through the World Organisation for Animal Health (WOAH) and the European Commission’s Animal Disease Information System highlighted significant cross-border veterinary developments during August 2026. Most notably, Finland notified its first-ever detection of African swine fever virus infection in wild boar. By 12 August 2026, fourteen confirmed cases of African swine fever had been identified among wild boars in the Virolahti municipality in southeastern Finland, adjacent to the international border with the Russian Federation. Finnish veterinary authorities immediately established designated restriction zones, prohibited wild boar hunting to avoid dispersing herds, and intensified active surveillance in commercial and domestic swine holdings. This first occurrence in Finland underscores that African swine fever continues to expand its wild reservoir into previously unaffected northern European ecosystems.
Across Central and Southern Europe, African swine fever notifications in domestic swine herds and wild boar populations remained dense. Ongoing disease recurrences and follow-up reports were submitted to WOAH by Poland, Romania, Italy, Germany, Greece, Serbia, and Bosnia and Herzegovina. The persistence of African swine fever in neighbouring Balkan jurisdictions, particularly Romania and Serbia, maintains intense biosecurity requirements for Bulgarian swine producers and hunters. In parallel, Bluetongue virus serotype 3 (BTV-3) continued its rapid summer spread across Western and Central Europe, causing severe clinical disease in sheep and cattle holdings across the Netherlands, Germany, Belgium, France, and the United Kingdom, alongside sporadic detections in zoological collections and wild ungulates. In the Balkans, veterinary authorities in Romania and Greece maintained strict movement controls and culling operations following widespread outbreaks of peste des petits ruminants in sheep and goat flocks in Dobrogea and Thessaly. Epizootic haemorrhagic disease continued its northward spread through the Iberian Peninsula and southern France. These animal health events carry profound agricultural and economic implications, requiring sustained One Health coordination, active entomological monitoring, and rigorous biosecurity compliance across veterinary and public health sectors.
Infectious Diseases: Bulgaria
Vector-Borne and Zoonotic Transmission
First Domestic Detection of West Nile Virus
Bulgarian national communicable disease surveillance registered a landmark vector-borne event in Week 34 of 2026: the confirmation of the season’s first laboratory-diagnosed human case of West Nile fever. Prior to Week 34, no human West Nile virus cases had been notified in Bulgaria throughout 2026, matching the zero count recorded in the identical period of 2025. This domestic detection aligns directly with the substantial seasonal surge documented across the European continent, where 98 transmission areas have been activated across twelve countries, including extensive transmission throughout neighbouring Romania, Greece, North Macedonia, and Serbia.
West Nile virus is an enveloped flavivirus maintained in an enzootic cycle between avian amplifier hosts and ornithophilic mosquitoes, predominantly Culex pipiens. Humans and equines represent incidental, dead-end hosts who develop clinical illness following infectious mosquito bites. While approximately 80% of human infections remain asymptomatic and 20% manifest as West Nile fever—a self-limiting febrile syndrome with headache, myalgia, arthralgia, and rash—less than 1% of infected individuals develop severe West Nile neuroinvasive disease, encompassing encephalitis, meningitis, and acute flaccid paralysis, with significant mortality in elderly and immunocompromised patients. The confirmation of local transmission warrants enhanced clinical suspicion for viral meningitis and encephalitis of undetermined etiology, targeted municipal mosquito abatement, and strict adherence to blood safety deferral and screening algorithms for donors from affected areas.
Lyme Borreliosis and Mediterranean Spotted Fever
Tick-borne bacterial infections followed expected mid-summer seasonal kinetics across Weeks 32, 33, and 34. Lyme borreliosis, caused by the spirochete Borrelia burgdorferi sensu lato and transmitted by Ixodes ricinus ticks, registered 23 confirmed cases in Week 32, 23 confirmed cases in Week 33, and 14 confirmed cases in Week 34, yielding a three-week total of 60 cases. The week-over-week trajectory showed stability between Weeks 32 and 33 (deviation of zero) followed by a 39.1% reduction in Week 34 (deviation of minus nine). The national year-to-date cumulative total reached 309 confirmed cases, representing a modest 13.6% increase over the 272 cases recorded in the same period of 2025. This 13.6% year-over-year elevation remains below the series’ 20% signal threshold, reflecting normal seasonal fluctuations in outdoor recreational exposure and tick questing activity. District-level surveillance in the ZRZ reports documented cases across multiple jurisdictions, with Sofia-grad reporting the largest volume (nine cases in Week 32, eight in Week 33, four in Week 34, totaling 21 cases), followed by dispersed notifications in Gabrovo, Lovech, Stara Zagora, Blagoevgrad, and Pernik.
Mediterranean spotted fever, caused by Rickettsia conorii and transmitted by the brown dog tick Rhipicephalus sanguineus, accounted for four cases in Week 32, two cases in Week 33, and five cases in Week 34 (three probable, two confirmed), totaling eleven cases across the fortnight and a half. The year-to-date cumulative total of 62 cases is essentially identical to the 63 cases registered by the same point in 2025 (a minor decrease of 1.6%). Notifications remain confined to historically endemic southern and coastal districts.
Q Fever, Legionnaires’ Disease and Listeriosis
Among other zoonotic and environmental bacterial infections, Q fever, caused by Coxiella burnetii, was reported exclusively in Week 33 with three confirmed cases, comprising two notifications in Burgas and one in Stara Zagora; no cases were registered in Weeks 32 or 34. The year-to-date total of 37 cases stands 12.1% above the 33 cases of 2025, below the reporting threshold.
Legionnaires’ disease, caused by Legionella pneumophila, registered one confirmed case in Week 32 and three confirmed cases in Week 33, with no cases in Week 34, bringing the three-week volume to four cases. The cumulative year-to-date total of 14 cases represents a 100.0% doubling relative to the seven cases recorded in the same period of 2025. While absolute case numbers are low, this sustained doubling warrants continued monitoring of engineered water systems, cooling towers, and commercial aerosol-generating installations during the warm summer season. Listeriosis, caused by Listeria monocytogenes, registered one confirmed case in Week 32 and one in Week 34, with none in Week 33, bringing the annual cumulative total to nine cases versus four in 2025 (a 125.0% excess). No cases of anthrax, tularaemia, brucellosis, leptospirosis, tick-borne encephalitis, rabies, or viral Crimean-Congo haemorrhagic fever were reported during Weeks 32–34.
Respiratory and Vaccine-Preventable Diseases
Measles: Persistent Regional Transmission in Northwestern and North-Central Districts
District-level surveillance compiled in the ZRZ bulletins confirmed the persistence of the regional measles outbreak across northwestern and north-central Bulgaria throughout Weeks 32, 33, and 34. Across the three reporting weeks, Bulgaria registered a combined total of 45 measles cases: 24 cases in Week 32, 12 cases in Week 33, and nine cases in Week 34. In Week 32, notifications comprised 18 cases in Vratsa, four in Pleven, and two in Lovech. In Week 33, cases decreased to eight in Vratsa, three in Pleven, and one in Lovech. In Week 34, cases further resolved to four in Vratsa, three in Lovech, and two in Pleven.
Across the entire three-week reporting span, all 45 cases were strictly localized within the same three contiguous districts: Vratsa (30 cases, 66.7%), Pleven (nine cases, 20.0%), and Lovech (six cases, 13.3%). This distribution demonstrates direct continuity with preceding editions of this report series, which tracked 31 cases in Weeks 28–29 and an identical 31 cases in Weeks 30–31 across the exact same geographic focus. The three-week trajectory reveals a distinct epidemiological curve: an intensification to a peak of 24 cases in Week 32, followed by progressive week-over-week declines of 50.0% in Week 33 and 25.0% in Week 34. While this deceleration suggests that localized contact tracing, outbreak response immunization, and isolation measures implemented by regional health inspectorates are curtailing community transmission, the continuation of transmission into late August confirms that sub-national immunity gaps persist. As with prior editions, measles cases remain absent from the national aggregate operational analysis, underscoring the critical surveillance value of scrutinizing the 28-district ZRZ tables.
Other Respiratory and Vaccine-Preventable Infections
Other routine respiratory and vaccine-preventable infections remained subdued across the country. COVID-19 notifications remained at very low summer baseline levels, with one confirmed case in Week 32, three cases in Week 33, and two cases in Week 34, yielding six cases across the three weeks. The cumulative year-to-date total of 336 cases stands 38.7% below the 548 cases recorded by the same period in 2025, consistent with low inter-seasonal circulation.
Scarlet fever, caused by Streptococcus pyogenes, accounted for 12 cases in Week 32, nine cases in Week 33, and 13 cases in Week 34 (four possible, seven probable, two confirmed), totaling 34 cases. The cumulative total of 1,791 cases remains 32.7% lower than the 2,663 cases recorded in 2025. Pertussis, caused by Bordetella pertussis, registered zero cases in Week 32 and single confirmed cases in Weeks 33 and 34, bringing the year-to-date total to 13 cases versus 73 in 2025 (an 82.2% reduction). Varicella notifications declined seasonally from 66 cases in Week 32 to 70 in Week 33 and 52 in Week 34 (six possible, 44 probable, two confirmed), with a three-week total of 188 cases. The year-to-date total of 15,687 cases is 3.6% lower than the 16,270 of 2025, with weekly cases concentrated in Sofia-grad (48 combined cases), Blagoevgrad (21 cases), and Varna (21 cases).
Invasive bacterial and viral central nervous system infections remained rare. Viral meningitis and meningoencephalitis accounted for one case in Week 32, two cases in Week 33, and three cases in Week 34 (one probable, two confirmed), with the cumulative total of 30 cases standing 51.6% below the 62 cases of 2025. Bacterial meningitis and meningoencephalitis notifications were limited to single cases of pneumococcal etiology in Week 33 and six unspecified bacterial cases across the period, while invasive meningococcal disease registered zero cases (three year-to-date versus 12 in 2025).
Fecal-Oral Transmission
Campylobacteriosis: High Sustained Excess Concentrated in Sofia-Grad
Campylobacteriosis maintained its status as the clearest and most pronounced specific enteric bacterial signal in Bulgarian surveillance. The country recorded 21 confirmed cases in Week 32, 23 confirmed cases in Week 33, and 16 confirmed cases in Week 34, yielding 60 confirmed cases across the three weeks. The week-over-week trajectory displayed stability between Weeks 32 and 33 (+9.5%) followed by a 30.4% decline in Week 34. The cumulative year-to-date total reached 422 confirmed cases, representing a 46.5% excess over the 288 cases recorded in the same period of 2025—an absolute difference of 134 cases.
The district breakdown in the ZRZ bulletins revealed a remarkable geographic concentration: Sofia-grad accounted for 35 of the 60 cases reported across the three weeks (10 in Week 32, 15 in Week 33, and 10 in Week 34, representing 58.3% of the national total). Secondary volumes were reported in Ruse (11 cases) and Varna (seven cases), with single sporadic cases in Burgas, Kyustendil, Pernik, Razgrad, and Yambol. While enhanced diagnostic ascertainment and the routine use of multiplex enteric PCR panels in Sofia laboratories undoubtedly contribute to higher case detection, the consistency and magnitude of the 46.5% national excess indicate genuine underlying transmission driven by Campylobacter jejuni and Campylobacter coli through undercooked poultry, cross-contamination in domestic and commercial kitchens, and unpasteurised dairy products.
Gastroenteritis, Rotavirus and Salmonellosis
Non-specific gastroenteritis and enterocolitis registered high seasonal volumes consistent with historical warm-weather patterns. Bulgaria reported 336 cases in Week 32, 335 cases in Week 33, and 295 cases in Week 34, totaling 966 cases across the three weeks (22 confirmed, 596 probable, and 348 possible). The cumulative year-to-date total of 6,245 cases is essentially unchanged from the 6,147 cases recorded in the same period of 2025 (a minor 1.6% elevation). District volumes were heaviest in high-density and tourist coastal areas: Varna registered 236 cases across the three weeks (90, 83, and 63), Plovdiv recorded 118 cases (59, 0, and 59), Sofia-grad documented 103 cases (25, 39, and 39), Haskovo reported 57 cases, Shumen registered 51 cases, and Sofia-oblast reported 47 cases.
Rotavirus gastroenteritis accounted for 36 cases in Week 32, 44 cases in Week 33, and 40 cases in Week 34, totaling 120 confirmed cases. The year-to-date cumulative total of 572 cases stands 8.1% above the 529 cases of 2025. Transmission showed pronounced coastal clustering, with Varna accounting for 52 of the 120 cases (11 in Week 32, 17 in Week 33, and 24 in Week 34), alongside 23 cases in Sofia-grad.
Salmonellosis, caused by non-typhoidal Salmonella enterica, registered 20 cases in Week 32, 22 cases in Week 33, and 25 cases in Week 34, yielding 67 confirmed cases across the three weeks. The cumulative year-to-date total of 448 cases is virtually identical to the 453 cases of 2025 (-1.1%), demonstrating that domestic salmonellosis is currently tracking baseline seasonal levels despite the multi-country Salmonella Enteritidis ST11 outbreak ongoing in Western Europe. Colienteritis caused by pathogenic Escherichia coli contributed 29 confirmed cases (five in Week 32, 13 in Week 33, and 11 in Week 34), with the year-to-date total of 211 cases closely matching the 204 of 2025 (+3.4%). Shigellosis was reported only in Week 33 with a single confirmed case in Kardzhali (21 year-to-date versus 24). No cases of cholera, botulism, or STEC/VTEC were notified during Weeks 32–34.
Contact and Sexual Transmission
Domestic Mpox Detection
In sexual and contact transmission surveillance, Bulgaria registered one laboratory-confirmed case of mpox in Week 34 of 2026. This represents the second confirmed mpox case notified nationally in 2026, matching the two cumulative cases recorded by the same point in 2025. The case was confirmed against the backdrop of steady clade I circulation and low-level clade II activity reported across the EU/EEA during July and August. While domestic transmission remains rare and isolated, the detection emphasizes the importance of clinical suspicion for atypical anogenital or dermatological vesicular lesions, prompt PCR testing, contact tracing, and the maintenance of pre- and post-exposure vaccination pathways for individuals at elevated risk.
Sexually Transmitted Infections: Sustained Elevation in Gonorrhoea, Chlamydia and Syphilis
Sexually transmitted infections continued to demonstrate substantial and persistent year-to-date excesses above 2025 baselines, reinforcing the structural transmission signals highlighted in earlier editions. Gonorrhoea, caused by Neisseria gonorrhoeae, registered six confirmed cases in Week 32, five confirmed cases in Week 33, and one confirmed case in Week 34, totaling 12 cases across the period. Despite the low absolute count in Week 34, the national year-to-date cumulative total reached 159 confirmed cases, representing a 123.9% surge over the 71 cases recorded in the identical period of 2025 (an excess of 88 cases). In light of European-level surveillance alerts regarding ceftriaxone-resistant gonococcal strains, this domestic volume increase warrants enhanced laboratory antimicrobial susceptibility testing.
Urogenital chlamydial infection, caused by Chlamydia trachomatis, registered ten confirmed cases in Week 32, four confirmed cases in Week 33, and six confirmed cases in Week 34, totaling 20 cases. The year-to-date cumulative total reached 234 confirmed cases, representing a 101.7% increase over the 116 cases recorded by the same point in 2025 (an excess of 118 cases).
Syphilis, caused by Treponema pallidum, accounted for eight confirmed cases in Week 32, nine confirmed cases in Week 33, and ten confirmed cases in Week 34, totaling 27 cases. The cumulative year-to-date total reached 273 confirmed cases, standing 20.8% above the 226 cases of 2025 (an excess of 47 cases). Encouragingly, no cases of congenital or infant syphilis were notified during Weeks 32, 33, or 34, leaving the year-to-date total at 24 cases versus 22 in 2025 (+9.1%). Sustained antenatal screening protocols and early penicillin therapy remain vital to prevent vertical transmission.
Human immunodeficiency virus infection registered eight confirmed cases in Week 32, three confirmed cases in Week 33, and eight confirmed cases in Week 34, totaling 19 cases. The year-to-date cumulative total of 192 confirmed cases remains slightly below the 198 cases recorded in the same period of 2025 (-3.0%), reflecting stable diagnosis rates without evidence of a national surge.