Time Zone: +2 hours. (+3 from last Sunday in March to last Sunday in October).
Tel. Country Code: 359
USADirect Tel.: 0
Electrical Standards: Electrical current is 220/50 (volts/hz). European Style Adaptor Plug. Grounding Adaptor Plug D.
Travel Advisory - Bulgaria
Europe, Russia and former the Soviet Union countries vary widely in travel risks and adequacy of health care delivery. Water- and food-borne illnesses such as travelers' diarrhea, typhoid and Giardia are threats outside of Western Europe. Insect-transmitted diseases, such as Lyme disease and tick-borne encephalitis are common in wooded, rural areas in most countries, including Western Europe.
Dr. Rose Recommends for Travel to Bulgaria
• U.S. Embassy
16, Kozyak St.
Tel:  (2) 937-5100
Fax:  (2) 937-5209
Questions regarding consular services may be directed via email to: firstname.lastname@example.org (for non-immigrant visa matters); email@example.com (for immigrant visa matters) and firstname.lastname@example.org (for American Citizen Services matters).
• Canadian Embassy
Tel:  (2) 943-3700
Fax:  (2) 943-3707
• British Embassy
9 Moskovska Street
Tel:  (2) 933 9222
HIV Test: Required for all intending immigrants (and may be required for foreigners staying longer than 1 month for purposes of study or work).
Required Vaccinations: None required.
Passport/Visa: A United States passport is required for U.S. citizens who are not also Bulgarian nationals. As of September 1, 2006, U.S. citizens who enter the country without a Bulgarian visa are authorized to stay for a total of 90 days within a six-month period. This law is strictly enforced. An application to extend one’s stay beyond the original 90 days can be filed for urgent or humanitarian reasons, but must be submitted to regional police authorities no later than five days prior to the end of the original 90-day period. Travelers who have been in the country for 90 days, and then leave, will not be able to reenter Bulgaria before the six-month period expires.
American citizens who marry Bulgarian nationals and want to switch to long-term status must also leave the country, present their marriage license at a Bulgarian embassy or consulate in a neighboring country, and apply for a •D• visa.
For further information concerning entry requirements, travelers should contact the Embassy of the Republic of Bulgaria at 1621 22nd St. N.W., Washington, D.C. 20008; http://www.bulgaria-embassy.org; tel. (202) 387-7969 (main switchboard (202) 387-0174), or the Bulgarian Consulate in New York City at 121 East 62nd Street, New York, NY 10021.
Tel: (212) 935-4646.
Vaccinations: Recommended and Routine
Hepatitis A: Recommended for all travelers >1 year of age not previously immunized against hepatitis A.
Hepatitis B: Recommended for all non-immune travelers who might be exposed to blood or body fluids from unsafe/unprotected sexual contact; from injecting drug use with shared/re-used needles and syringes; from medical treatment with non-sterile (re-used) needles and syringes. Recommended for any traveler requesting protection against hepatitis B infection.
Influenza: Vaccination recommended for all travelers >6 months of age who have not received a flu shot in the previous 12 months.
Rabies: Rabies vaccine is recommended for: persons anticipating an extended stay; for those whose work or activities may bring them into contact with animals; for people going to rural or remote locations where medical care is not readily available; for travelers desiring extra protection.
Routine Immunizations: Immunizations against tetanus-diphtheria, measles, mumps, rubella (MMR vaccine) and varicella (chickenpox) should be updated, if necessary, before departure. MMR protection is especially important for any female of childbearing age who may become pregnant.
• The new Tdap vaccine, ADACEL, which also boosts immunity against pertussis (whooping cough) should be considered when a tetanus-diphtheria booster is indicated.
• An outbreak of mumps was reported in January 2007, starting in the town of Plovdiv in southern central Bulgaria.
Typhoid: Recommended for all travelers with the exception of short-term visitors who restrict their meals to major restaurants and hotels, such as business travelers.
Hospitals / Doctors
Medical care in Bulgaria is below Western standards. Bulgarian physicians are often well-trained, but most hospitals and clinics, especially in village areas, are not well-equipped. Most physicians work in government-owned hospitals and clinics.
All travelers should be up-to-date on their immunizations and are advised to carry a medical kit as well as stand-by antibiotics to treat travelers’ diarrhea or other infections. Travelers who are taking regular medications should carry them properly labeled and in sufficient quantity to last for the duration of their trip; they should not expect to obtain prescription or over-the-counter drugs in local stores or pharmacies in this country—the equivalent drugs may not be available; may be of dubious origin; may be counterfeit, or of unreliable quality.
• Travelers are advised to obtain travel insurance that provides for medical evacuawes in Western Europe in the event of serious illness or injury requiring specialty care not available in this country.
For guide to physicians, clinics, and other hospitals in Bulgaria, go to the U.S. Embassy website at: http://sofia.usembassy.gov/hospitals4.html
Recommended medical facilities:
• Multiprofile Hospital for Active Treatment and Emergency Medicine /MHATEM/ “N.I.Pirogov”
21 Totleben Blvd
The best hospital for emergency care in Sofia.
• Vita Hospital
9, Dragovitza Street
Tel: 943-4398; 846-5376; 960-4950
Private hospital, preferred by expatriates.
Destination Health Info for Travelers
AIDS/HIV: Central Europe has been relatively spared by the epidemic, with the incidence of both AIDS cases and newly diagnosed HIV infections remaining low. However, this region accounts for the largest proportion of pediatric AIDS cases following an outbreak of infection among young children in hospitals in Romania around 1990.
The HIV prevalence in the adult population of Bulgaria is <0.1 percent.
• Transmission of HIV can be prevented by avoiding: sexual contact with a high-risk partner; injecting drug use with shared needles; non-sterile medical injections; unscreened blood transfusions.
• The threat of HIV/AIDS should not be a primary concern for the traveler. However, there may be a concern for a subset of travelers who may be exposed to HIV, the virus that causes AIDS, through contact with another person’s body fluids or blood. Although travel has contributed in a general way to the global spread of AIDS, fear of traveling because of this disease is not warranted.
Accidents & Medical Insurance: Accidents and injuries are the leading cause of death among travelers under the age of 55 and are most often caused by motor vehicle and motorcycle crashes; drownings, aircraft crashes, homicides, and burns are lesser causes.
• Heart attacks cause most fatalities in older travelers.
• Infections cause only 1% of fatalities in overseas travelers, but, overall, infections are the most common cause of travel-related illness.
• MEDICAL INSURANCE: Travelers are advised to obtain, prior to departure, supplemental travel health insurance with specific overseas coverage. The policy should provide for direct payment to the overseas hospital and/or physician at the time of service and include a medical evacuation benefit. The policy should also provide 24-hour hotline access to a multilingual assistance center that can help arrange and monitor delivery of medical care and determine if medevac or air ambulance services are required.
Avian Influenza A (Bird Flu): In the end of 2005 and the beginning of 2006, avian influenza A(H5N1) virus caused outbreaks among domestic poultry and was isolated from wild swans in many European countries, including Bulgaria. Between January and March 2006, samples were collected from 26 patients who had been in close contact with ill or dead birds and developed a subsequent respiratory illness. In three patients, human subtype А(H1N1) influenza virus, but not H5N1, was identified.
• The risk to humans from avian influenza is believed to be very low and no travel restrictions are advised, except travelers should avoid visiting animal markets, poultry farms and other places where they may come into close contact with live or dead poultry, or domestic, caged or wild birds and their excretions. In addition, travelers are advised to:
1. Cook poultry and egg dishes thoroughly. (Well-cooked poultry is safe to eat.)
2. Wash hands frequently with soap and water if around poultry.
• The World Health Organization (WHO) does not recommend travel restrictions to countries experiencing outbreaks of H5N1 avian influenza in birds, including those countries which have reported associated cases of human infection.
The usual vaccines against influenza are not protective against “bird flu.”
Oseltamivir (Tamiflu) is somewhat effective in the treatment of H5N1 avian influenza. It seems to be effective in some cases, but may fail in others. Recently, resistant strains have been reported. In addition, the dosage and duration of treatment appear to be different in severe H5N1 cases.
Brucellosis: An outbreak of brucellosis caused by contact with sick farm animals (sheep and goats) was reported in 2007 in the Haskovo region. Additional cases occurred in 2005. Brucellosis is usually acquired by consumption of unpasteurized dairy products or by direct contact with the tissues of infected animals. Brucellosis is uncommon in Bulgaria. Travelers are at low risk.
Crimean-Congo Hemorrhagic Fever: Crimean-Congo hemorrhagic fever is a viral encephalitis transmitted by ticks. Peak transmission season is from April through August. Main risk areas are the southern provinces of Kurdzhali and Khaskovo and the southeastern provinces of Yambol and Burgas.
• All travelers should tick-bite prevention measures which include applying a DEET-containing repellent to exposed skin and permethrin spray or solution to clothing and gear.
Echinococcosis: Human cystic echinococcosis (also known as hydatid disease) is prevalent throughout the country, and is a major health and economic problem. The frequency of echinococcosis in Bulgaria has been increasing in the last decade. Basic hygiene practices such as thoroughly cooking food and vigorous hand washing before meals can prevent the infective eggs entering the human digestive tract.
European Tick-Borne Encephalitis (TBE): There is a possible risk of TBE is some areas of the country below 1,400 meters (4500 feet) elevation. More specific information is not available. The transmission season varies, however; ticks are most active during early spring to late autumn (March to November). The tick vector for this disease, (the same tick that transmits Lyme disease), is widely distributed in brushy and forested areas.
• Vaccination should be considered by those camping near forests, by hikers and campers on extended itineraries, and for forest workers. The standard vaccination schedule consists of 3 doses given at 0, 1-3 months, and at 9-12 months. An 2-dose accelerated schedule is possible (0, 21 days), with 85% protection resulting. The European vaccine (FSME-IMMUN-Baxter) is available in health clinics in Germany, Austria, Slovakia, Czech Republic and Poland, as well as Canada, but the traveler would have to initiate the vaccine after arriving in the area and hiking/camping delayed for 3 weeks before adequate protection to kick in. This makes administration of vaccine impractical for the average traveler. Tick-bite protection is therefore essential.
• Travelers, especially those engaging in outdoor activities in rural areas, are advised to take measures to prevent tick bites during the peak transmission season, March to November. Tick-bite prevention measures include applying a DEET-containing repellent to exposed skin and permethrin spray or solution to clothing and gear.
• A map showing the distribution of TBE is here: http://www.nathnac.org/includes/contents/documents/TBEmap.gif
More information on TBE at: http://www.cdc.gov/ncidod/dvrd/spb/mnpages/dispages/TBE.htm
Hepatitis: An outbreak of hepatitis A was reported in September 2006 from the Plovdiv region in southern central Bulgaria. More than 1300 cases were reported. Bulgaria has among the highest rates of hepatitis A in Europe. All travelers over age 1 year, not previously vaccinated, should receive hepatitis A vaccine. Hepatitis A is transmitted through contaminated food and water. Travelers who will have access to safe food and water are at lower risk. Those at higher risk include travelers visiting friends and relatives, long-term travelers, and those visiting areas of poor sanitation.
• Hepatitis E is probably endemic but levels are unclear. Sporadic cases may be underdiagnosed or underreported. Transmission of the hepatitis E virus (HEV) occurs primarily through drinking water contaminated by sewage and also through raw or uncooked shellfish. Farm animals, such as swine, and also deer and wild boar, may serve as a viral reservoirs. (HEV is one of the few viruses which has been shown to be transmitted directly from animals through food.) In developing countries, prevention of hepatitis E relies primarily on the provision of clean water supplies and overall improved sanitation and hygiene. There is no vaccine.
• The overall hepatitis B carrier rate in the general population is estimated at 3% to 5%. Hepatitis B is transmitted via infected blood or bodily fluids. Travelers may be exposed by needle sharing and unprotected sex; from non-sterile medical or dental injections, and acupuncture; from unscreened blood transfusions; by direct contact with open skin lesions of an infected person. The average traveler is at low risk for acquiring this infection. Vaccination against hepatitis B is recommended for: persons having casual/unprotected sex with new partners; sexual tourists; injecting drug users; long-term visitors; expatriates, and anybody wanting increased protection against the hepatitis B virus.
• Hepatitis C is endemic. About 1.1% of the adult population is seropositive. Most hepatitis C virus (HCV) is spread either through intravenous drug use or, in lesser-developed countries, through blood contamination during medical procedures. Over 200 million people around the world are infected with hepatitis C - an overall incidence of around 3.3% of the population of the world. Statistically, as many people are infected with HCV as are with HIV, the virus that causes AIDS.
Influenza: Influenza is transmitted from November through March. Flu vaccine is recommended for all travelers over age 6 months.
Lyme Disease: This tick-borne disease occurs focally in rural forested areas up to 1,500 meters elevation. Ticks are most abundant and active from April through September.
• Lyme disease is transmitted by Ixodes ticks that are found in wooded, brushy areas, although transmission can also occur in backyards. All travelers who engage in hiking, camping, or similar outdoor activities in rural wooded regions of endemic areas during the peak transmission season should take measures to prevent tick bites.
• Tick-bite prevention measures include applying a DEET-containing repellent to exposed skin and permethrin spray or solution to clothing and gear.
• A single 200-mg dose of doxycycline is effective in preventing Lyme disease in someone who has just been bitten by an infected tick. Reference: http://content.nejm.org/cgi/content/abstract/345/2/79
Mediterranean Spotted (Boutonneuse) Fever: This tick-transmitted rickettsial disease is endemic in eastern regions and along the Black Sea coast in brushy and/or forested areas. Tick-bite prevention measures include applying a DEET-containing repellent to exposed skin and applying permethrin (spray or solution) to clothing and gear.
Other Diseases/Hazards: Anthrax (cutaneous form; from exposure to livestock in rural areas)
• Brucellosis (four human cases of brucellosis were reported in September 2007 from the villages of Harmanli and Valche pole in the southern part of Bulgaria. Twenty new human cases of brucellosis were reported in Haskovo province in 2007. A total of 36 animal cases were reported earlier in the same province; risk associated with consumption of unpasteurized dairy products and meat of infected animals. Source: ProMED-mail 27 September 2007)
• Q fever (an outbreak of Q fever pneumonia was reported from Botevgrad in May 2004)
• Rabies (animal rabies occurs in stray dogs and cats, jackals, foxes, and wolves; rare in humans; country is officially “rabies free”, but cases sometimes occur)
• Salmonellosis-ProMED reports an outbreak of salmonella enteridis in July 2009 in Pazardzhik (also spelled as Pazardjik or Pazarjik), a town situated along the banks of the Maritsa river in Bulgaria. It is the capital of
Pazardzhik Province. The illness affected 22 people and originated in a schwarma fast food outlet. In June 2008 an outbreak of gastroenteritis was registered in Sunny Beach resort situated on the Black Sea coast in Bulgaria, affecting 14 employees of a hotel, five of whom tested positive for Salmonella enteritidis. During June-July 2008 four sporadic S. enteritidis cases were also reported and two of them were foreign tourists.
• Tick-borne encephalitis (low-risk in Bulgaria; TBE is widespread in warmer months in the southern part of the nontropical forested regions of Europe. Most intense transmission has been reported in Russia, the Czech Republic, Latvia, Lithuania, Estonia, Hungary, Poland, and Slovenia.)
• Tick-borne relapsing fever (risk in rocky, rural livestock areas)
• Tularemia (reported near the western border; transmitted by ticks as well as infected animals that have been butchered, e.g., rabbits)
• Murine typhus (probably occurs)
• Helminthic infections (roundworm, hookworm, and whipworm infections reported occasionally).
Q Fever: Q fever outbreaks occur regularly in Bulgaria. Q fever is usually acquired through inhalation of aerosols produced by goat excrement and bodily fluids, including milk; slaughterhouse workers and those raising goats are most affected.
• As a result of political and economic changes in the beginning of the 1990s, Q-fever epidemiology in Bulgaria has changed. The number of goats almost tripled; contact between goat owners (and their families) and goats, as well as goats and other animals, increased; consumption of raw goat milk and its products increased; and goats replaced cattle and sheep as the main source of human Coxiella burnetii (Q fever) infections. Hundreds of overt, serologically confirmed human cases of acute Q fever have been reported in the past decade.
Rabies: PRO-Med reports that a woman in the Sofia area was bitten by a cat, which later tested positive for rabies. The woman and four other people were hospitalized. Rabies in Europe is generally confined to the wild animal population (usually foxes and wolves), but spillover into domestic animals and pets can occur.
Pre-exposure rabies vaccine is recommended for: persons anticipating an extended stay; for those whose work or activities may bring them into contact with animals; for people going to rural or remote locations where medical care is not readily available; for travelers desiring extra protection. Children are considered at higher risk because they tend to play with animals and may not report bites.
• All animal bite wounds, especially from a dog, should be thoroughly cleansed with soap and water and then medically evaluated for possible post-exposure treatment, regardless of your vaccination status. Pre-exposure vaccination eliminates the need for rabies immune globulin, but does not eliminate the need for two additional booster doses of vaccine.
• Even if rabies vaccine was administered before travel, a 2-dose booster series of vaccine is needed after the bite of a rabid animal.
Travelers' Diarrhea: Outside of hotels and resorts, we recommend that you boil, filter or purify all drinking water or drink only bottled water or other bottled beverages and do not use ice cubes. Avoid unpasteurized milk and dairy products. Do not eat raw or undercooked food (especially meat, fish, raw vegetables—these may transmit intestinal parasites, as well as bacteria). Peel all fruits.
• Good hand hygiene reduces the incidence of travelers’ diarrhea by 30%.
• A quinolone antibiotic, or azithromycin, combined with loperamide (Imodium), is recommended for the treatment of diarrhea. Diarrhea not responding to antibiotic treatment may be due to a parasitic disease such as giardiasis, amebiasis, or cryptosporidiosis.
• Seek qualified medical care if you have bloody diarrhea and fever, severe abdominal pain, uncontrolled vomiting, or dehydration.
Typhoid Fever: Typhoid vaccine is recommended for all unvaccinated people traveling to or working in Central and Eastern Europe, especially if visiting smaller cities, villages, or rural areas and staying with friends or relatives where exposure might occur through food or water. Current vaccines against Salmonella typhi are only 50-80% protective and do not protect against Salmonella paratyphi. Travelers should practice strict food, water and personal hygiene precautions even if vaccinated.