1. 1 Country report - Bulgaria Plamen Dimitrov National Center of Public Health Protection, Sofia, Bulgaria HEM - Closing the Gap - Reducing Premature Mortality. Baseline for Monitoring Health Evolution Following Enlargement Meeting on Country Coordinators 5-6 March, 2007 Warsaw, Poland

2. 2

3. 3 Sources Data provided by HEM Project team WHO mortality data base FAO data Official publication of the National Statistical Institute, Bulgaria Official publications of the National Center of Public Health Protection, Bulgaria Official publications of the National Center of Health Information, Bulgaria CINDI-Bulgaria Program data Scientific publications in periodical journals – international and Bulgarian

4. 4 1. From 1960 (45.1% o ) to 1988 (13.6% o ) - annual decrease by 3.62% 2. Until 1997 (17.5% o ) - annual increase by 1.37% 3. After 1997 - annual decrease by 4.61% - 11.6% o in 2004. 4. The onset of the transition period in Bulgaria – increase of infant mortality 5. Male infant mortality rate was higher than female infant mortality rate 6. Rural infant mortality rate was higher than urban infant mortality rate. Source: National Statistical Institute, Bulgaria

5. 5 Infant mortality Source: WHO mortality statistics database After a prolonged downward trend followed by slight increase until mid-90s, when the transition in Bulgaria began, it again shaped a significant downward trend as of the end of the 90s, The level reached during the first years of the 21st century was typical for the mid-80s and high compared to the EU countries, as well.

6. 6 Source: WHO mortality statistics database Infant mortality - rank position of Bulgaria

7. 7 Life expectancy Source: WHO mortality statistics database

8. 8

9. 9 Life expectancy – rank position

10. 10 Overall mortality Source: WHO mortality database

11. 11 Premature mortality Increases for males aged 20-44, 45-64 Decreases in females, aged 20-44, and 45-64

12. 12 Change in structure of leading causes of death with the advancement of age in Bulgaria, in 2002

13. 13 Cardiovascular mortality in Bulgaria The absolute number of CVD deaths increased for the period 1964-2002, 3 times for males and 2.4 times for females. The proportion of CVD deaths is leading. For 1964 - 39% for males and 53% for females, in 2002 reached - 63% for males and 71% for females. Source: National Center for Health Information, Bulgaria

14. 14 Cardiovascular mortality in Bulgaria CVD crude mortality rates for both sexes had almost equal levels in 1964 They have increased at various rate until 1997, thereafter decreasing. The upward CVD mortality rate trend was more pronounced among males

15. 15 Cardiovascular mortality in Bulgaria CVD mortality among males aged 20-44 yrs - increasing until 1993 then decreasing until 2002 reaching 61.8% ooo. Among the females of the same age decreasing until 1983, thereafter increasing reaching a level of 23.9% ooo in 2002, lower than that in 1964.

16. 16 Cardiovascular mortality in Bulgaria Among males aged 45-64, an increasing trend until 1997, followed by slow decrease to a level of 783.3% ooo in 2002, a level 2.5 higher than baseline. Among females aged 45-64 increase at a low rate for the period 1964- 2002, reaching a level of 298.1% ooo at the end of the period.

17. 17 Cardiovascular mortality at age 20-64, rank position

18. 18 Cancer mortality Second leading cause of death of Bulgarian population, with a proportion of 14.0 % in 2002. In 2002, the leading among males was lung cancer (27.1%) followed by cancer of the stomach, prostate, colon, etc. Among females, leading was breast cancer (16.5%) followed by stomach cancer, colon cancer, while lung cancer was in the fourth place with a proportion of 7.8% of deaths

19. 19 Lung cancer mortality Crude lung cancer mortality rate has increased from 36.0‰ oo among males in 1964 to 39.7‰ oo in 2002, while among females it has decreased from 7.8‰ oo to 6.3‰ oo. The crude lung cancer mortality rate reached highest level among males in 1994 (43.7% ooo ), while among females in 1995 -7.2% ooo.

20. 20 The deaths from lung cancer in males aged 20-44 years have increased from 1964 until 1994, then it began to decrease. In 1964 crude lung cancer mortality rate among females was two times lower than that among males, and it decreased until 1976, followed by an increase until 2002.

21. 21 Lung cancer mortality rate among males aged 45-64 was increasing until 1992, followed by a decrease until 2002. Among females, the rate has decreased slightly until 1970, and thereafter it has increased at a low rate until the end of the period not exceeding the1964 level

22. 22 Lung cancer mortality at age 20-64, rank position

23. 23 Liver cirrhosis mortality The absolute number of deaths from liver cirrhosis increased significantly in Bulgaria for the period 1964-2002 – 4-fold among males and over 2-fold among females.

24. 24 Liver cirrhosis mortality at age 20-64, rank position

25. 25 Death from injuries Injury took place 4 in the pattern of the mortality by causes in Bulgaria for 2002 with a proportion of 3.8% (5.3% for males and 2% for females). Suicides, self-inflicted injuries, and road traffic injuries take leading place

26. 26 Death from injuries

27. 27 Death from injuries at age 20-64, rank position

28. 28 Risk factors and premature mortality

29. 29 Tobacco In Bulgaria for the past 50 years, tobacco use increased 3-fold times, from 1,020 cigarettes per capita in 1948 to 3,150 cigarettes in 2001. The mean number of cigarettes smoked daily in 2001 was 67.9 million and the mean annual number per person aged 15 years and over was 3,700 cigarettes. The total number of cigarettes smoked in Bulgaria in 2001 was 25 billion. The content of tars and nicotine in the cigarettes is still above the permissible one.

30. 30 Proportion of smokers in Bulgaria among the individuals aged 15 years and over Source: Ch. Merdjanov, 1995, NSI – 1996 and 2001 studies

31. 31 Smoking categories

32. 32 Smoking intensity of current smokers in Bulgaria SMOKING INTENSITY MALES (%)FEMALES (%) 19962001Change19962001Change Up to 10 cigarettes/day 37.033.8(-3.2)68.260.2 (-8.0) From 11 to 20 cigarettes/day 48.947.6(-1.3)27.633.5(+5.9) Over 20 cigarettes/day 14.118.4(+4.3)4.26.3(+2.1) Source: National Statistical Institute, Bulgaria 1996, 2001

33. 33 AGESMOKING INTENSITY – males Up to 10 cigarettes/day (%)11 to 20 cigarettes/day (%)Over 20 cigarettes/day (%) 19962001Change19962001Change19962001Change 15-24 yrs 52.6 52.0(-0.6)42.838.1(-4.7)4.69.9(+5.3) 25-44 yrs 32.9 31.5(-1.4)52.349.7(-2.6)14.818.8(+4.0) 45-64 yrs 31.1 28.1(-3.0)50.448.6(-1.8)18.523.3(+4.8) 64 + yrs 49.6 40.7(-8.9)38.048.2(+10.2)12.411.1(-1.3) AGESMOKING INTENSITY - females Up to 10 cigarettes/day (%)11 to 20 cigarettes/day (%)Over 20 cigarettes/day (%) 19962001Change19962001Change19962001Change 15-24 yrs77.863.7(-14.1)18.930.7(+11.8)3.35.6(+2.3) 25-44 yrs65.759.1(-6.6)30.234.7(+4.5)4.16.2(+2.1) 45-64 yrs64.760.1(-4.6)30.032.1(+2.1)5.37.8(+2.5) 64 + yrs63.059.4(-3.6)29.640.6(+11.0)7.40(-7.4)

34. 34 Smoking habits in 2002/1997 Average FTND score Average number of cigarettes smoked per day Average age of starting smoking Average age of smoking cessation Duration of smoking (years) % of filter cigarette smokers Males2.59 17 16.3 2541 19 18 90 Females2.55 13 10 2638 16 14 98 Source: CINDI Bulgaria

35. 35 Tobacco related deaths

36. 36 Tobacco related deaths

37. 37 The data indicated that the tobacco-related mortality from all causes at age 35-44 in 2002 was 28% among males and 5% among females. At age 45- 64 it was 44% and 8% accordingly. In age group 35-44 among males the greatest proportion demonstrated the group of the malignant neoplasms - 44%, followed by CVD – 43%, and respiratory diseases deaths – 35% In the age group 45-64 – deaths from cancers due to smoking are 55%, and deaths from CVD are 48%. Among females aged 35-44, and 45-64 the leading are CVD and diseases of respiratory system Death from lung cancer due to smoking is 85% and 93% among males aged 35-44 and 45-64. In females these numbers are – 21% and 50% respectively. Tobacco-related mortality was highest at the age group 45-64 in both genders.

38. 38 Overview of tobacco control programs and policy In the recent years, Bulgaria has implemented a line of activities in the area of tobacco smoking reduction and control. The more important among them are included in the: –Health Act and the Ordinance on the Conditions and Procedure Whereby as an Exception Smoking is Allowed in Designated Areas of Closed Public Places and Closed Working Premises. –The National Tobacco Control Programme for the period 2002- 2005г. (there is 2006/2010 continuation); –Ordinance on the Requirements for Labelling, Marking and Outer Layout of Tobacco Products and on the Setting of Standards for Assessment of the Compliance of Hazardous Ingredient Content in Cigarettes; –Framework Convention on Tobacco Control Ratification Act, etc.

39. 39 Tobacco - Conclusions Still, the tobacco smoking epidemic cannot be placed under control in Bulgaria. The existing tobacco control legislation is not complied with in its entirety. Tobacco product prices are relatively high, however cigarettes are still accessible to all ages. Extremely bad example is given by the great number of smoking healthcare professionals at all levels of the system, as well as by the teachers in the educational system, and the high-ranking officials in the governmental institutions. Although available, the efforts for health promotion and tobacco smoking prevalence control are not sufficiently efficient due to poor funding. The number of operational smoking cessation offices in Bulgaria is insufficient and they do not have appropriate equipment. The drugs used for smoking cessation purposes are not reimbursed. Until recently, national tobacco control policy was absent, as well. Its availability now, however, has not improved yet the funding and implementation of the activities under the developed programme.

40. 40 Future steps The currently existing situation necessitates: activation of the activities under the National Tobacco Control Programme and provision of funds for the latter; development of local tobacco control policies; complete ban on tobacco product advertising; ongoing increase of taxes on and the prices of tobacco products; limiting the supply; introducing stringent measures for tobacco smoke free environment discontinuing tobacco production subsidies and restructuring the industry; deployment of extensive health education activity on the issues of tobacco by the health system structures, predominantly in schools, with staff trained for this purposes.

41. 41 Alcohol Source: National Statistical Institute, Bulgaria

42. 42 Alcohol Source: National Statistical Institute, Bulgaria

43. 43 Alcohol related mortality

44. 44 Alcohol related mortality

45. 45 Alcohol-attributable deaths at age 20-64, rank position

46. 46 Overview of alcohol control programs and policy A. Advertising of alcoholic products B. Alcohol abuse in workplaces and public places C. Identification and legal regulation of alcoholic products: D. Pricing and taxation policy: E. Alcohol control strategy and action plans F. Challenges in alcohol control

47. 47 Nutrition Fat consumption – FAO data

48. 48 Fats and oils consumption in Bulgaria, EU-10 and EU-15

49. 49 Vegetable fat consumption Sunflower oil use prevailed; soybean oil use was low; olive oil use was low; no rapeseed consumption

50. 50 Sunflower oil, rapeseed and mustard oil, and soybean oil consumption in Bulgaria, EU10 and EU15

51. 51 Fruit and vegetable consumption

52. 52 Consumption trends of fruits and vegetables in Bulgaria, EU10 and EU15

53. 53 Body Mass Index Three national surveys: 1997 and 1998 reported weight and height 2004 – measured weight and height

54. 54 The proportion of individuals from both sexes with normal body mass has been decreasing continuously. Data indicated an ongoing upward trend of the proportion of individuals with overweight and obesity among females in both age groups and among males at age 18-30 yrs. For the male population at age 30-60, the level of obese individuals increased from 13.2% to 21.3%, while for females, from 11.2% to 16.7%. For the young individuals (19-30 yrs) from both sexes, the upward obesity prevalence trend was similar, from 2.0% to 5.9% among males and from 2.7% to 5.3% among females. High level and even increasing prevalence of underweight young females has been observed, however, from 15% in 1997 to 16.8% in 2004.

55. 55 Body Mass Index – CINDI 2002 Body weight and height measured. Sample size – 9621 persons (4751 males and 4870 females) Data demonstrate that only 30% of males and 43% of females have BMI in normal range

56. 56 General conclusions Regardless of the downward trend, infant mortality stays at a level considerably higher than the level in EU member states. Life expectancy among males began increasing slowly during the recent years. However the indicator has significantly lower level than the level among males in most EU member states. Life expectancy among females is higher than that among males in the country, however its level is also lower than the level among the females in almost all EU member states. All-cause mortality demonstrates an increasing trend in Bulgaria, especially at active age (20-44 and 45-64 yrs), and it is more pronounced among males and has levels higher vs. many EU member states. The higher all-cause mortality rate is associated with three disease categories, predominantly: CVD, cancer, and injuries and poisoning. CVDs are leading cause of deaths, with an increasing trend from the 60s almost to the end of the last century and proportion of 68% in 2002.

57. 57 General conclusions Malignant neoplasms take the 2nd position in the pattern of deaths. Leading disease entity in the pattern of deaths from malignant neoplasms among males is malignant neoplasm of lung, while among females it takes rank position 4. Mortality from external causes has been decreasing during the past decade, however this remains to be a major issue for the country because these causes are largely preventable, especially in the age groups 20-44 yrs and 45-64 yrs. Mortality from liver cirrhosis has demonstrated steep increase among males and moderate increase among females. The trends in the population health status at large indicate existence of significant differences between the health status in the EU and in Bulgaria. The existing health status of the Bulgarian population results from the action of the health determinants and health risk factors.

58. 58 General conclusions The prevalence of various major behavioural and other risk factors, such as tobacco smoking, unhealthy diet, alcohol abuse, low physical activity, obesity, hypertension, diabetes, has increased. This increases the population health risk. Tobacco attributable deaths amount to about 20,000 people annually, with males nine times as many as females among them. The alcohol-attributable mortality among males in active age is 8.29% of the all-cause mortality, while among females it is 0.83%.