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The COVID-19 pandemic followed a unique trajectory in Eastern Europe compared to other heavily affected regions, with most countries there only experiencing a major surge of cases and deaths towards the end of 2020 after a relatively uneventful first half of the year. However, the consequences of that surge have not received as much attention as the situation in Western countries. Bulgaria, even though it has been one of the most heavily affected countries, has been one of those neglected cases. We use mortality and mobility data from Eurostat, official governmental and other sources to examine the development and impact of the COVID-19 pandemic in Bulgaria and other European countries. We find a very high level of excess mortality in Eastern European countries measured by several metrics including excess mortality rate (EMR), P-scores, potential years of life lost (PYLL) and its age standardised version (ASYR), and working years of life lost (WYLL). By the last three metrics Eastern Europe emerges as the hardest hit region by the pandemic in Europe in 2020. With a record EMR at ~0.27% and a strikingly large and mostly unique to it mortality rate in the working age (15–64 years) demographics, Bulgaria emerges as one of the most affected countries in Eastern Europe. The high excess mortality in Bulgaria correlates with insufficient intensity of testing, with delayed imposition of “lockdown” measures, and with high prevalence of cardiovascular diseases. We also find major geographic and demographic disparities within the country, with considerably lower mortality observed in major cities relative to more remote areas (likely due to disparities in the availability of medical resources). Analysis of the course of the epidemic revealed that individual mobility measures were predictive of the eventual decline in cases and deaths. However, while mobility declined as a result of the imposition of a lockdown, it already trended downwards before such measures were introduced, which resulted in a reduction of deaths independent of the effect of restrictions. Large excess mortality and high numbers of potential years of life lost are observed as a result of the COVID pandemic in Bulgaria, as well as in several other countries in Eastern Europe. Significant delays in the imposition of stringent mobility-reducing measures combined with a lack of medical resources likely caused a substantial loss of life, including in the working age population.

The COVID-19 pandemic has had a devastating impact on the world over the past two years (2020-2021). One of the key questions about its future trajectory is the protection from subsequent infections and disease conferred by a previous infection, as the SARS-CoV-2 virus belongs to the coronaviruses, a group of viruses the members of which are known for their ability to reinfect convalescent individuals. Bulgaria, with high rates of previous infections combined with low vaccination rates and an elderly population, presents a somewhat unique context to study this question. We use detailed governmental data on registered COVID-19 cases to evaluate the incidence and outcomes of COVID-19 reinfections in Bulgaria in the period between March 2020 and early December 2021. For the period analyzed, a total of 4,106 cases of individuals infected more than once were observed, including 31 cases of three infections and one of four infections. The number of reinfections increased dramatically during the Delta variant-driven wave of the pandemic towards the end of 2021. We observe a moderate reduction of severe outcomes (hospitalization and death) in reinfections relative to primary infections, and a more substantial reduction of severe outcomes in breakthrough infections in vaccinated individuals. In the available datasets from Bulgaria, prior infection appears to provide some protection from severe outcomes, but to a lower degree than the reduction in severity of breakthrough infections in the vaccinated compared to primary infections in the unvaccinated.

Background The COVID-19 pandemic has had a devastating impact on the world over the past two years (2020-2021). One of the key questions about its future trajectory is the protection from subsequent infections and disease conferred by a previous infection, as the SARS-CoV-2 virus belongs to the coronaviruses, a group of viruses the members of which are known for their ability to reinfect convalescent individuals. Bulgaria, with high rates of previous infections combined with low vaccination rates and an elderly population, presents a somewhat unique context to study this question. Methods We use detailed governmental data on registered COVID-19 cases to evaluate the incidence and outcomes of COVID-19 reinfections in Bulgaria in the period between March 2020 and early December 2021. Results For the period analyzed, a total of 4,106 cases of individuals infected more than once were observed, including 31 cases of three infections and one of four infections. The number of reinfections increased dramatically during the Delta variant-driven wave of the pandemic towards the end of 2021. We observe a moderate reduction of severe outcomes (hospitalization and death) in reinfections relative to primary infections, and a more substantial reduction of severe outcomes in breakthrough infections in vaccinated individuals. Conclusions In the available datasets from Bulgaria, prior infection appears to provide some protection from severe outcomes, but to a lower degree than the reduction in severity of breakthrough infections in the vaccinated compared to primary infections in the unvaccinated.

After initially having low levels of SARS-CoV-2 infections for much of the year, Bulgaria experienced a major epidemic surge at the end of 2020, which caused the highest recorded excess mortality in Europe, among the highest in the word (Excess Mortality Rate, or EMR ∼0.25%). Two more major waves followed in 2021, followed by another one in early 2022. In this study, we analyze the temporal and spatial patterns of excess mortality at the national and local levels and across different demographic groups in Bulgaria and compare those to the European levels. Bulgaria has continued to exhibit the previous pattern of extremely high excess mortality, as measured both by crude mortality metrics (an EMR of ∼1.05%, up to the end of March 2022) and by standardized ones—Potential Years of Life Lost (PYLL) and Aged-Standardized Years of life lost Rate (ASYR). Unlike Western Europe, the bulk of excess mortality in Bulgaria, as well as in several other countries in Eastern Europe, occurred in the second year of the pandemic, likely related to the differences in the levels of vaccination coverage between these regions. We also observe even more extreme levels of excess mortality at the regional level and in some subpopulations (e.g., total EMR values for males ≥ 2% and EMR values for males aged 40–64 ≥ 1% in certain areas). We discuss these observations in light of the estimates of infection fatality rate (IFR) and eventual population fatality rate (PFR) made early in the course of the pandemic.

This compilation of essays by scholars from the region, Western Europe, and the US, explores the intersection of international politics in the post-Yugoslav states with a focus on the influence and impact of the European Union, the United States, Russia, China, and Turkey. The implications of external actors’ policy in the region for its Euro-Atlantic integration, its security, and stability are examined and discussed. In assessing the importance of the post-Yugoslav states for the EU and US and the current trend of disengagement by these two democratic actors in the region, answers are revealed regarding the question whether we are seeing a new Eastern Question emerging in the post-Yugoslav states. Likewise, when looking at the role of Russia, China, and Turkey in the region—and in contrast to European and US policies—, it becomes obvious to what extent the region, once again, is becoming the playground of Great Power games and wider geopolitical strategic interests. The analytical time frame covers the period 1991–2018. The changes in the foreign policies of great powers are explored as they relate to the institutional set-up of the region. For instance, do the changes affect the EU’s hegemony in the region? Do Russia, China, and Turkey actively contribute to changing the rules of the game in the region—be it the accession process or regional cooperation?

[This corrects the article DOI: 10.1371/journal.pone.0274509.].