BULGARIA Population 1999: Population 2000: Area: km 2

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1 WHO Surveillance Programme for Control of Foodborne Infections and Intoxications in Europe Country Reports: Bulgaria BfR BULGARIA Population 1999: 8 2 Population 2: 7 9 Area: km 2 1. General information In Bulgaria (country abbreviation: BG), notification of foodborne disease (FBDOs), defined as the occurrence of two or more cases of a similar illness resulting from the ingestion of a common food, is mandatory. The specific relevant legislation is set out in Ordinance No 4 of 21 June 2 concerning the notification, epidemiological investigation, registration and reporting of FBDOs (issued in the State Gazet No 54 from the year 2). At the central level, within the Ministry of Health, the Health Prophylaxis and State Sanitary Control Directorate, together with the Departments of State Sanitary Control, Anti- Epidemiological Control and the Information-Organisational Department, are involved in the surveillance of foodborne diseases. At the regional level, 28 Hygiene and Epidemiological Inspectorates (HEI), with Departments of State Sanitary Control, Laboratory Analyses, Health Prophylaxis and Promotion, Anti-Epidemiological Control and State Radiation Control and Protection, are responsible for foodborne diseases. Responsibility for the management and reporting of FBDOs lies with the local authorities (HEIs). All general practitioners and clinical doctors with direct responsibility for the care of patients must notify, on the basis of clinical diagnosis, the regional HEI of cases or suspected cases of foodborne illnesses or other notifiable diseases. The HEIs form the outbreak control groups (OCG) that carry out the epidemiological investigation. The composition of these groups varies according to the circumstances, but always includes an epidemiologist from the Anti-Epidemiological Control Department, a physician specialised in food safety and nutrition from the State Sanitary Control Department,

2 and a food microbiologist from the Laboratory Analyses Department. The OCG is assisted by sanitary inspectors specifically trained for this purpose. In the event of major, the Ministry of Health sends consultants (epidemiologists, experts in food safety, toxicologists, infection control doctors, etc.) for closer investigation. The HEIs are obliged to inform the Ministry of Health by telephone, , or fax at the beginning of the outbreak and to periodically provide information during the outbreak. At the end of the outbreak, a written summary report is prepared and the standard reporting form for epidemiological investigation of a FBDO, which reflects the format suggested by the WHO Surveillance Programme for Control of Foodborne Infections and Intoxications in Europe, is completed and sent to the Ministry of Health. The Ministry publishes notified summaries on an annual basis. At the regional and national levels, surveillance data provides information on the agents, vehicles of transmission, and contributing factors associated with FBDOs and assists in directing public health actions to reduce illness and death caused by FBDOs. In Bulgaria, there are 28 regional laboratories within the 28 HEIs and one National Reference Laboratory (NRL) at the National Centre of Infectious and Parasitic Diseases which carry out the laboratory control of foodborne diseases. The NRL carries out confirmation of every isolated case, biotyping, phage typing, etc. The NRL is a member of the WHO Global Salm Surv Programme and has received international certification. Figure BG 1 Foodborne diseases reporting system BULGARIA

3 2. Statutory notification A total of 1746 and 142 cases of foodborne diseases were notified in 1999 and 2 respectively. The most frequently notified foodborne disease was hepatitis A, comprising 68% and 71% of notified cases in 1999 and 2, followed by shigellosis, making up 17% and 16% of the cases notified in 1999 and 2 (Table BG 1). An overview of the foodborne diseases notified between 1993 and 2 is given in Figure BG 2. Table BG 1 Foodborne diseases notified in 1999 and 2 Disease cases Incidence rate cases Incidence rate Salmonellosis Staphylococcosis Botulism Shigellosis E.coli enteritis Listeriosis Brucellosis. 1. Other bacterial foodborne infections and.. intoxications Hepatitis A Other viral enteritis.. Infectious enteritis of unknown origin.. Other infectious enteritis.. Total Figure BG 2 cases Foodborne Diseases notified BULGARIA enterocolitis cases Shigellosis Hepatitis A Year Salmonellosis Listeriosis E.coli enteritis Botulism Trichinellosis Enterocolitis - 3 -

4 3. Epidemiologically investigated incidents In 1999, 14 foodborne disease with a total of 177 cases were investigated; in 2, 17 involving 511 cases were reported. Information on morbidity, mortality and clinical symptoms observed in these is shown in Table BG 2. Figure BG 3 gives an overview of the foodborne disease investigated between 1993 and 2. Table BG 2 Morbidity, mortality and clinical symptoms observed in foodborne disease Morbidity, mortality and clincial symptoms Morbidity people at risk people at risk -4 years old 41 people at risk 4-15 years old 2 7 people at risk 15-6 years old people at risk >6 years old 57 people ill people ill -4 years old 35 1 people ill 4-15 years old people ill 15-6 years old people ill >6 years old 3 Mortality people dead 1 people dead -4 years old people dead 4-15 years old people dead 15-6 years old 1 people dead >6 years old Mean duration of outbreak (d) 4,75 (range 2-9) 3,5 (range 2-5 ) Clinical symptoms people with nausea 2 4 people vomiting 1 13 people with diarrhoea 1 13 people with abdominal pain 4 12 people with fever 6 12 people with neurological symptoms 1 people with cardiovascular symptoms people with muscle pain

5 Figure BG Foodborne Disease Outbreaks Investigated BULGARIA * cases Outbreaks * no data available for 1994 and Causative Agent Year Cases The causative agent was identified in all investigated in 1999 and in 65% of the investigated in 2. In 1% and 47% of the investigated in 1999 and 2, the causative agent was confirmed by laboratory diagnosis. Table BG 3 Foodborne disease investigated by causative agent Causative agent cases cases Cl. botulinum E.coli O E.coli O S. Enteritidis Salmonella sp Shigella flexneri 1 8 Staph. Aureus Staph. Epidermidis 1 12 Staphylococcus sp. 1 5 Trichinella spiralis Unknown

6 The most frequently identified agent was S. Enteritidis, linked to 5% and 68% of the cases of investigated in 1999 and 2 (Table BG 3). Sixty percent of the cases in 2 were caused by one outbreak of S. Enteritidis enteritis through the consumption of meat products that had been contaminated by an infected person at a restaurant/hotel. Figure BG 4 shows an overview of the foodborne disease investigated between 1993 and 2 by causative agent. Figure BG 4 Foodborne Disease Outbreaks Investigated by Causative Agent BULGARIA * Salmonella,total S.Enteritidis S.Typhimurium S.Brandenburg Staph. aureus Trichinella Botulism Unknown *no data available for 1994 and Incriminated food The food responsible for the disease was identified in 86% and 1% of the investigated in 1999 and 2 respectively. In 29% and 24% of the in the years in question, the food was confirmed by laboratory diagnosis. The most frequently incriminated food items were fancy cakes, responsible in 34% of the cases in 1999, and meat products, implicated in 6% of the cases in 2 (Table BG 4). Forty-four of the 6 cases caused by consumption of fancy cakes in 1999 were due to contamination by Staph. aureus, and in 2, 12 of the 33 cases caused by fancy cakes were due to S. Enteritidis. The most frequently isolated causative agent in meat products was Trichinella spiralis in 1999 (19 of 19 cases) and S. Enteritidis in 2 (36 of 37 cases)

7 Table BG 4 Foodborne disease investigated by incriminated food Incriminated food cases cases Meat 1 9 Meat products Pork 1 1 Chicken 1 4 Sausages 1 1 Milk products 1 8 Cheese 1 6 Eggs, egg products Fancy cakes Puddings, creams 1 12 Chocolate, chocolate products Fish 1 5 Crust., shellf., moll Vegetable products Other 1 4 Unknown Place of contamination The place of contamination of the incriminated food was identified in 29% and 1% of the investigated in 1999 and 2. In 53% of the registered in 2, contamination took place in the private home, while 73% of the total reported cases were due to contamination in restaurants and hotels (Table BG 5). Figure BG 5 gives an overview of the foodborne disease investigated between 1993 and 2 by place of contamination or consumption

8 Table BG 5 Foodborne disease investigated by place of contamination Place of contamination cases cases Canteen Food processing est Private home Restaurant/hotel Unknown Figure BG Foodborne Disease Outbreaks Investigated by Place of Contamination or Consumption BULGARIA * Restaurant Private home Kindergarten Canteen Caterer Camp * no data available for 1994, 1997, 1998; for 1999 and 2 only places of contamination 3.4 Place of acquisition and/or consumption The place of acquisition and/or consumption of the incriminated food was identified in 93% and 1% of the investigated in 1999 and 2 respectively. Results are shown in Table BG

9 Table BG 6 Foodborne disease investigated by place of acquisition/consumption Place of acquisition/consumption cases cases Canteen Mass catering for specific groups 3 43 Private home Restaurant/hotel School/kindergarten 1 12 Unknown Contributing factors In 57% and 71% of the foodborne disease investigated in 1999 and 2 respectively, at least one contributing factor was identified. Information on the contributing factors involved in foodborne disease investigated in 1999 and 2 is shown in Table BG 7. Table BG 7 Foodborne disease investigated by factors Contributing factors cases cases Most important contributing factors Contamination by infected person Food obtained from unsafe source Use of contaminated ingredients 2 35 Food prepared in advance Improper storage 1 44 Inadequate refrigeration 5 28 Other Unknown Other contributing factors Food obtained from unsafe source 1 23 Other Unknown

10 4. Additional information Information on the structure and activities of the Ministry of Health of Bulgaria may be found online at For further reference on national and international data on foodborne diseases, please visit the web page -