* Seventeen Member States had disease-free status in 2023. Ten Member States, along with the United Kingdom (Northern Ireland), were under an eradication programme, of which three Member States (Italy, Portugal and Spain) had disease-free status zones.

* In the disease-free status zones, a total of 162 cattle herds (0.02%) were reported to be infected with the *M. tuberculosis* complex, 13 more than in 2022, confirming that infection occurs rarely in these areas.

* In the zones under an eradication programme 8659 cattle herds (1.5% of the total) tested positive for *M. tuberculosis* complex in 2023, a 10.7% decrease from the 9696 herds reported in 2022. The United Kingdom (Northern Ireland) (7.2%), Ireland (4.8%) and Spain (1.5%) were the only countries with prevalence higher than 1%. No positive herds were reported by Bulgaria, Cyprus or Malta. Over the last decade (2014–2023), the total number of positive cattle herds in eradication programme zones decreased by 49.4%, largely due to the withdrawal of the United Kingdom from the European Union in 2020.

## 5.2 | Surveillance and monitoring of tuberculosis due to *Mycobacterium bovis* or *Mycobacterium caprae* in the EU

### 5.2.1 | Humans

The notification of tuberculosis in humans is mandatory in all MSs and covers the whole population. Countries can update their data retroactively; reported numbers are therefore subject to change in the future or may vary from numbers reported in previous reports. The *M. bovis* and *M. caprae* EU notification rate is calculated using the combined population of the EU MSs that reported data in 2023. The proportion of tuberculosis cases caused by *M. bovis* or *M. caprae* was calculated using the preliminary estimate of the total number of confirmed tuberculosis cases in 2023 among reporting EU MSs' species-specific data. In 2023, no human data on *M. bovis* or *M. caprae* cases were available for France because this MS did not report species-specific data within the *M. tuberculosis* complex (MTBC) for human tuberculosis cases. France has not reported species-specific data in any previous years. In addition, Latvia did not report any MTBC data for 2019, 2020 or 2023.

Because tuberculosis is a chronic disease with a long incubation period, it is not possible to assess travel-associated cases in the same way as for diseases with acute onset. Instead, a distinction is made between individuals with the disease originating from an EU MS (cases of EU origin) and those originating from outside the EU (case originating outside of the EU). In the analysis, origin is mainly based on the reported birthplace, except for cases from Austria, Belgium, Greece, Hungary and Poland, whose origin is based on reported nationality.

### 5.2.2 | Animals

#### Bovine tuberculosis surveillance data

Article 2 of Regulation (EU) 2016/429²⁹ states that its scope applies to transmissible diseases, including zoonoses, without prejudice to the provisions laid down in Directive 2003/99/EC. Therefore, the annual zoonoses data reporting requirements for MSs, as stipulated in Directive 2003/99/EC and implemented by EFSA through specific tools, manuals and guidance, remain unaffected by the entry into force of Commission Implementing Regulation (CIR) (EU) 2020/2002.<fnref n="30" /> This latter CIR outlines the compulsory notification and annual reporting obligations that MSs must fulfil with respect to ADIS<fnref n="31" />: EU MSs need to report to ADIS outbreaks of infection with MTBC in bovine species (cattle, buffalo and bison), even-toed ungulates (Artiodactyla) and other terrestrial mammals. Summaries of these reports are regularly made available online.

In accordance with Directive 2003/99/EC, MSs must report annual surveillance data for bovine tuberculosis. These data are derived from compulsory national eradication and surveillance programmes implemented in compliance with EU legislation, including the AHL. The reports submitted by MSs are harmonised and enable the assessment of the epidemiological situation and trends analysis across MSs and their zones.

Article 36 of Regulation (EU) 2016/429 provides for the EC's approval of the disease-free status (DFS) of MSs or specific zones within them, with respect to MTBC infections. Due to the differing levels of infection risk between DFS zones and zones under an eradication programme (UEP), these zones have been treated separately in this chapter.

All cases of bovine tuberculosis caused by MTBC members (*M. bovis*, *M. caprae* or *M. tuberculosis*) were considered in summarising the EU situation on the disease in cattle. Whenever possible, reporting MSs provided detailed distinctions between these MTBC species.

<footnote n="29">²⁹Regulation (EU) 2016/429 of the European Parliament and of the Council of 9 March 2016 on transmissible animal diseases and amending and repealing certain acts in the area of animal health ('Animal Health Law').</footnote>

<footnote n="30">³⁰Commission Implementing Regulation (EU) 2020/2002 of 7 December 2020 laying down rules for the application of Regulation (EU) 2016/429 of the European Parliament and of the Council with regard to Union notification and Union reporting of listed diseases, to formats and procedures for submission and reporting of Union surveillance programmes and of eradication programmes and for application for recognition of disease-free status, and to the computerised information system, OJ L 412, 8.12.2020, p. 1–28.</footnote>

<footnote n="31">³¹EU Animal Diseases Information System (ADIS). More information is available at: https://food.ec.europa.eu/animals/animal-diseases/animal-disease-information-system-adis_en.</footnote>
## Mycobacterium surveillance data from food and from animals other than bovine animals

Mycobacterium spp. monitoring data from food and from animals other than bovine animals are submitted to EFSA in accordance with Directive 2003/99/EC. Data collected allow for descriptive summaries to be compiled at the EU level, but do not allow trend watching or trend analyses (Table 1).

In accordance with CIR (EU) 2020/2002, notification to ADIS and surveillance rules apply to artiodactyla mammals other than bovine animals (such as camelids, cervids, suids, ovine and caprine animals) and other terrestrial mammals susceptible to infection with MTBC.

## 5.3 | Results

### 5.3.1 | Overview of key statistics, EU, 2019–2023

**Table 37:** summarises the EU-level statistics on human tuberculosis due to *M. bovis* or *M. caprae* and on bovine tuberculosis during 2019–2023. More detailed descriptions of these statistics are provided in the subsections below.

<table><caption>**TABLE 37** Summary of tuberculosis due to *Mycobacterium bovis* and *Mycobacterium caprae* statistics relating to humans and bovine animals (stratified by disease status of MSs/ MS zones), EU, 2019–2023.</caption><thead><tr><th></th><th>2023<sup>a</sup></th><th>2022<sup>a</sup></th><th>2021<sup>a</sup></th><th>2020</th><th>2019<sup>b</sup></th><th>Data source</th></tr></thead><tbody><tr><td colspan="7"><strong>Humans</strong></td></tr><tr><td>Number of confirmed <em>M. bovis</em> cases</td><td>129</td><td>140</td><td>108</td><td>95</td><td>141</td><td>ECDC</td></tr><tr><td>Number of confirmed <em>M. caprae</em> cases</td><td>9</td><td>7</td><td>10</td><td>4</td><td>11</td><td>ECDC</td></tr><tr><td>Total number of confirmed cases</td><td>138</td><td>147</td><td>118</td><td>99</td><td>152</td><td>ECDC</td></tr><tr><td>Total number of confirmed cases/100,000 population (notification rates)</td><td>0.04</td><td>0.04</td><td>0.03</td><td>0.03</td><td>0.03</td><td>ECDC</td></tr><tr><td>Number of EU MSs that reported data on <em>M. bovis</em> or <em>M. caprae</em> cases</td><td>25</td><td>26</td><td>26</td><td>25</td><td>26</td><td>ECDC</td></tr><tr><td><em>M. bovis</em> or <em>M. caprae</em> cases in individuals of EU origin</td><td>67</td><td>93</td><td>63</td><td>60</td><td>107</td><td>ECDC</td></tr><tr><td><em>M. bovis</em> or <em>M. caprae</em> cases in individuals originating from outside the EU</td><td>62</td><td>47</td><td>49</td><td>35</td><td>40</td><td>ECDC</td></tr><tr><td><em>M. bovis</em> or <em>M. caprae</em> cases in individuals of unknown origin</td><td>9</td><td>7</td><td>6</td><td>4</td><td>5</td><td>ECDC</td></tr><tr><td>Total number of food-borne outbreaks<sup>c</sup></td><td>1</td><td>0</td><td>0</td><td>0</td><td>0</td><td>EFSA</td></tr><tr><td>Number of outbreak-related cases</td><td>3</td><td>0</td><td>0</td><td>0</td><td>0</td><td>EFSA</td></tr><tr><td colspan="7"><strong>Bovine animals</strong></td></tr><tr><td>Number of infected herds in disease-free status zones<sup>d</sup></td><td>162</td><td>149</td><td>139</td><td>139</td><td>143</td><td>EFSA</td></tr><tr><td>Number of reporting disease-free status MSs<sup>d</sup></td><td>17</td><td>17</td><td>17</td><td>17</td><td>17</td><td>EFSA</td></tr><tr><td>Number of infected herds in zones under an eradication programme<sup>e</sup></td><td>8659</td><td>9696</td><td>9255</td><td>7233</td><td>16,277</td><td>EFSA</td></tr><tr><td>Number of reporting MSs with zones under an eradication programme<sup>e</sup></td><td>11</td><td>11</td><td>11</td><td>9<sup>f</sup></td><td>11</td><td>EFSA</td></tr></tbody></table>

Abbreviations: ECDC, European Centre for Disease Prevention and Control; EFSA, European Food Safety Authority; MSs, Member States.

<footnote><sup>a</sup>Data from the United Kingdom (Northern Ireland) were taken into account for 2021–2023. In accordance with the Agreement on the withdrawal of the United Kingdom of Great Britain and Northern Ireland from the European Union and the European Atomic Energy Community, and in particular Article 5(4) of the Windsor Framework (see Joint Declaration No 1/2023 of the Union and the United Kingdom in the Joint Committee established by the Agreement on the withdrawal of the United Kingdom of Great Britain and Northern Ireland from the European Union and the European Atomic Energy Community of 24 March 2023, OJ L 102, 17.4.2023, p. 87) in conjunction with section 24 of Annex 2 to that Framework, for the purposes of this Regulation, references to Member States include the United Kingdom in respect of Northern Ireland.</footnote>

<footnote><sup>b</sup>Data from the United Kingdom were taken into account for the 2018–2019 period, since the United Kingdom was still an EU MS at that time. However, on 1 February 2020 it became a third country.</footnote>

<footnote><sup>c</sup>No information on the species was available for the *Mycobacterium* outbreak reported in 2023.</footnote>

<footnote><sup>d</sup>Member States, or zones thereof, with disease-free status regarding infection with the *Mycobacterium tuberculosis* complex *M. bovis*, *M. caprae*, *M. tuberculosis* (MTBC) in their bovine animal population.</footnote>

<footnote><sup>e</sup>The Member States or zones thereof with an approved eradication programme (UEP) for infection with MTBC. In addition, the United Kingdom (Northern Ireland) has an approved eradication programme for infection with MTBC.</footnote>

<footnote><sup>f</sup>No data reported from Bulgaria.</footnote>
### 5.3.2 | Tuberculosis due to *Mycobacterium bovis* or *Mycobacterium caprae* in humans

In 2023, 138 confirmed human cases of tuberculosis due to *M. bovis* or *M. caprae* were reported from 13 MSs (Austria, Belgium, Denmark, Finland, Germany, Greece, Hungary, Ireland, Italy, the Netherlands, Romania, Spain and Sweden) (Table 38). Tuberculosis cases due to *M. bovis* (129 cases) were reported from all the above-mentioned MSs except Hungary, which only reported cases caused by *M. caprae*. Austria, Germany and Spain also reported cases due to *M. caprae*, which accounted altogether for nine cases in the EU.

In 2023, tuberculosis cases due to *M. bovis* or *M. caprae* accounted for a small proportion (0.35%) of total tuberculosis cases reported in the EU, Iceland, Norway, Liechtenstein and Switzerland. Overall, 25 MSs reported species-specific data on MTBC and 12 MSs did not report any cases. Reported cases of human tuberculosis due to *M. bovis* or *M. caprae* in the EU decreased slightly in 2023 relative to 2022 but remained high compared to the 2020–2021 COVID-19 pandemic years.

The EU notification rate in 2023 was 0.036 cases per 100,000 population, which is a decrease of 6.1% compared with 2022, when the notification rate was 0.039 per 100,000 population. In 2023, the highest notification rate was reported by Ireland (0.15 per 100,000), followed by Spain (0.11 per 100,000).

Among the 17 DFS MSs in 2023, 15 MSs reported on MTBC species. *M. bovis* and *M. caprae* human cases were reported in eight MSs. The notification rate in these MSs reporting on MTBC species was 0.03 cases per 100,000 population. The notification rate for *M. bovis* and *M. caprae* human cases reported in the 10 non-DFS MSs in 2023 was 0.05 cases per 100,000 population.

The majority of the *M. bovis* and *M. caprae* human cases reported in 2023 (67/138; 48.6%) were of EU origin (native cases and/or cases originating from other MSs). The other cases originated from outside the EU (N=62; 44.9%) or had unknown origin (N=9; 6.5%) (Table 37). Notification rates of *M. bovis* and *M. caprae* human cases of EU origin were lower in disease-free MSs (N=26; 38.8%) than in non-disease-free MSs (N=41; 61.2%).

<table><caption>TABLE 38 Reported confirmed human cases of tuberculosis due to *Mycobacterium bovis* or *Mycobacterium caprae* and notification rates per 100,000 population in EU MS and non-MS countries, by country and year, 2019–2023.</caption><thead><tr><th rowspan="3">Country</th><th rowspan="3">Status</th><th rowspan="3">National coverage<sup>a</sup></th><th rowspan="3">Data format<sup>a</sup></th><th colspan="2">2023</th><th colspan="2">2022</th><th colspan="2">2021</th><th colspan="2">2020</th><th colspan="2">2019</th></tr><tr><th colspan="2">Confirmed cases and rates</th><th colspan="2">Confirmed cases and rates</th><th colspan="2">Confirmed cases and rates</th><th colspan="2">Confirmed cases and rates</th><th colspan="2">Confirmed cases and rates</th></tr><tr><th>Cases</th><th>Rate</th><th>Cases</th><th>Rate</th><th>Cases</th><th>Rate</th><th>Cases</th><th>Rate</th><th>Cases</th><th>Rate</th></tr></thead><tbody><tr><td>Austria</td><td>DFS</td><td>Y</td><td>C</td><td>3</td><td>0.03</td><td>5</td><td>0.06</td><td>4</td><td>0.04</td><td>0</td><td>0</td><td>3</td><td>0.03</td></tr><tr><td>Belgium</td><td>DFS</td><td>Y</td><td>C</td><td>3</td><td>0.03</td><td>9</td><td>0.08</td><td>10</td><td>0.09</td><td>6</td><td>0.05</td><td>0</td><td>0</td></tr><tr><td>Bulgaria</td><td></td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Croatia</td><td></td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Cyprus</td><td></td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Czechia</td><td>DFS</td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Denmark</td><td>DFS</td><td>Y</td><td>C</td><td>1</td><td>0.02</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Estonia</td><td>DFS</td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Finland</td><td>DFS</td><td>Y</td><td>C</td><td>1</td><td>0.02</td><td>0</td><td>0</td><td>0</td><td>0</td><td>1</td><td>0.02</td><td>0</td><td>0</td></tr><tr><td>France<sup>b</sup></td><td>DFS</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td></tr><tr><td>Germany</td><td>DFS</td><td>Y</td><td>C</td><td>48</td><td>0.06</td><td>38</td><td>0.05</td><td>44</td><td>0.05</td><td>37</td><td>0.04</td><td>51</td><td>0.06</td></tr><tr><td>Greece</td><td></td><td>Y</td><td>C</td><td>1</td><td>0.01</td><td>1</td><td>0.01</td><td>0</td><td>0</td><td>2</td><td>0.02</td><td>1</td><td>0.01</td></tr><tr><td>Hungary</td><td>DFS</td><td>Y</td><td>C</td><td>1</td><td>0.01</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Ireland</td><td></td><td>Y</td><td>C</td><td>8</td><td>0.15</td><td>7</td><td>0.14</td><td>2</td><td>0.04</td><td>4</td><td>0.08</td><td>7</td><td>0.14</td></tr><tr><td>Italy</td><td></td><td>Y</td><td>C</td><td>8</td><td>0.01</td><td>15</td><td>0.03</td><td>12</td><td>0.02</td><td>6</td><td>0.01</td><td>11</td><td>0.02</td></tr><tr><td>Latvia<sup>c</sup></td><td>DFS</td><td>Y</td><td>C</td><td>—</td><td>—</td><td>0</td><td>0</td><td>0</td><td>0</td><td>—</td><td>—</td><td>—</td><td>—</td></tr><tr><td>Lithuania</td><td>DFS</td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Luxembourg</td><td>DFS</td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Malta</td><td></td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Netherlands</td><td>DFS</td><td>Y</td><td>C</td><td>6</td><td>0.03</td><td>5</td><td>0.03</td><td>5</td><td>0.03</td><td>6</td><td>0.03</td><td>5</td><td>0.03</td></tr><tr><td>Poland</td><td>DFS</td><td>Y</td><td>C</td><td>0</td><td>0</td><td>1</td><td>&lt;0.01</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Portugal</td><td></td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Romania</td><td></td><td>Y</td><td>C</td><td>3</td><td>0.02</td><td>1</td><td>0.01</td><td>0</td><td>0</td><td>1</td><td>0.01</td><td>1</td><td>0.01</td></tr><tr><td>Slovakia</td><td>DFS</td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Slovenia</td><td>DFS</td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Spain</td><td></td><td>Y</td><td>C</td><td>54</td><td>0.11</td><td>59</td><td>0.12</td><td>37</td><td>0.08</td><td>30</td><td>0.06</td><td>35</td><td>0.07</td></tr><tr><td>Sweden</td><td>DFS</td><td>Y</td><td>C</td><td>1</td><td>0.01</td><td>6</td><td>0.06</td><td>4</td><td>0.04</td><td>6</td><td>0.06</td><td>3</td><td>0.03</td></tr><tr><td><strong>EU Total 27</strong></td><td></td><td></td><td></td><td><strong>138</strong></td><td><strong>0.04</strong></td><td><strong>147</strong></td><td><strong>0.04</strong></td><td><strong>118</strong></td><td><strong>0.03</strong></td><td><strong>99</strong></td><td><strong>0.03</strong></td><td><strong>117</strong></td><td><strong>0.03</strong></td></tr><tr><td>United Kingdom</td><td></td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>35</td><td>0.05</td></tr><tr><td><strong>EU Total</strong></td><td></td><td></td><td></td><td><strong>138</strong></td><td><strong>0.04</strong></td><td><strong>147</strong></td><td><strong>0.04</strong></td><td><strong>118</strong></td><td><strong>0.03</strong></td><td><strong>99</strong></td><td><strong>0.03</strong></td><td><strong>152</strong></td><td><strong>0.03</strong></td></tr><tr><td>Iceland<sup>d</sup></td><td></td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Norway</td><td>DFS</td><td>Y</td><td>C</td><td>1</td><td>0.02</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>1</td><td>0.02</td></tr></tbody></table>

(Continues)
<table><caption>TABLE 38 (Continued)</caption><thead><tr><th rowspan="3">Country</th><th colspan="3">2023</th><th colspan="6">2022</th><th colspan="6">2021</th><th colspan="6">2020</th><th colspan="6">2019</th></tr><tr><th rowspan="2">Status</th><th rowspan="2">National coverage<sup>a</sup></th><th rowspan="2">Data format<sup>a</sup></th><th colspan="2">Confirmed cases and rates</th><th colspan="2">Confirmed cases and rates</th><th colspan="2">Confirmed cases and rates</th><th colspan="2">Confirmed cases and rates</th><th colspan="2">Confirmed cases and rates</th><th colspan="2">Confirmed cases and rates</th><th colspan="2">Confirmed cases and rates</th><th colspan="2">Confirmed cases and rates</th><th colspan="2">Confirmed cases and rates</th></tr><tr><th>Cases</th><th>Rate</th><th>Cases</th><th>Rate</th><th>Cases</th><th>Rate</th><th>Cases</th><th>Rate</th><th>Cases</th><th>Rate</th><th>Cases</th><th>Rate</th><th>Cases</th><th>Rate</th><th>Cases</th><th>Rate</th><th>Cases</th><th>Rate</th></tr></thead><tbody><tr><td>Liechtenstein</td><td>DFS</td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>3</td><td>0.03</td><td>4</td><td>0.05</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Switzerland<sup>e</sup></td><td>DFS</td><td>Y</td><td>C</td><td>10</td><td>0.11</td><td>1</td><td>0.01</td><td>4</td><td>0.05</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td></tr></tbody></table>

Abbreviations: –, Data not reported; DFS, Disease-free status, i.e. free of infection with *M. bovis*, *M. caprae* or *M. tuberculosis* in the bovine animal population.

<sup>a</sup>Y: yes; N: no; A: aggregated data; C: case-based data.

<sup>b</sup>No surveillance system.

<sup>c</sup>Latvia did not report any MTBC data during 2019–2020 or 2023.

<sup>d</sup>In Iceland, which has no special agreement concerning animal health (status) with the EU, the last outbreak of bovine tuberculosis was in 1959.

<sup>e</sup>Switzerland provided data directly to EFSA.

<figure><img src="image_67.png" /></figure>

Figure 11: shows, for year 2023, the number of confirmed tuberculosis cases due to *M. bovis* or *M. caprae* in individuals of EU origin overlaid with the national aggregated herd prevalence of bovine tuberculosis.

<figure><img src="image_68.png" /></figure>

**FIGURE 11** Map of the number of confirmed tuberculosis cases due to *Mycobacterium bovis* or *Mycobacterium caprae* in individuals of EU origin, and national herd prevalence of tuberculosis in the bovine animal population in EU MS and non-MS countries, 2023. Member States that reported data at the national level without specifying the specific zones or overseas territories where the bovine tuberculosis-positive cattle herds were detected, were assigned the same colour for all their zones, including overseas territories. EU MSs and the United Kingdom (Northern Ireland) were represented with a blue label, the EFTA/EEA countries were represented with a grey label, and all the candidate countries were represented with an orange label. For Albania, Kosovo and Serbia, prevalence data are at the animal level. The designation of Kosovo is without prejudice to positions on status, and is in line with UNSCR 1244/1999 and the ICJ Opinion on the Kosovo declaration of independence.
### 5.3.3 | *Mycobacterium* in food

No *Mycobacterium* species monitoring data from food were submitted for the year 2023.

### 5.3.4 | Tuberculosis in bovine animals

Seventeen MSs had DFS regarding MTBC during 2023 (Table 38). Of the remaining 10 MSs and the United Kingdom (Northern Ireland), three MSs had DFS zones or provinces:

* Italy: 12 regions and 23 provinces;

* Portugal: two regions (Algarve and Azores, except the island of São Miguel);

* Spain: seven autonomous communities and three provinces.

Seven MSs had no zones with DFS regarding MTBC. The United Kingdom (Northern Ireland) had no DFS zones either.

Norway, Switzerland and Liechtenstein had DFS, in accordance with the EU legislation. In Iceland, which has no special agreement with the EU on animal health status, the last outbreak of bovine tuberculosis was reported in 1959. A map of EU MSs' disease status is available here.

In 2023, the overall proportion of cattle herds in the EU infected with MTBC was very low, 0.57%, a slight decrease from 0.61% in 2022. The total number of infected bovine herds in the EU also decreased, from 9845 in 2022 to 8821 in 2023.

Fifteen MSs (12 DFS and three UEP countries) reported no cases of bovine tuberculosis. The remaining 12 MSs and the United Kingdom (Northern Ireland) reported cases of bovine tuberculosis. The distribution of infected herds was heterogeneous and spatially clustered, with national herd-level prevalence ranging from < 0.01% (Austria, Germany, Poland, Romania) to 7.2% (the United Kingdom (Northern Ireland)). MTBC infections were primarily concentrated in UEP zones, where the overall prevalence of infected herds (1.5%) was 85 times higher than in DFS zones (0.02%).

Five MSs reported MTBC infections in cattle without specifying the *Mycobacterium* species. *M. bovis* was specifically detected in France, Germany, Ireland, Italy, Poland, Romania and the United Kingdom (Northern Ireland), while *M. caprae* was specifically reported in Austria, Germany and Romania. No cases of *M. tuberculosis* infection in cattle herds were reported.

**MSs and MS zones with disease-free status regarding *Mycobacterium tuberculosis* complex infection**

The majority of the EU's cattle population (61.4%) is located in the DFS zones across 20 MSs. However, the number of cattle herds in these zones has steadily declined, with a 27.6% decrease over the last decade (2014–2023). Over this 10-year period there was a slight increase in both the number of infected herds and the prevalence of MTBC-infected herds (Figure 12).

The total number of DFS zones in the EU increased during 2023 and in these zones seven MSs reported a total of 162 MTBC-infected bovine herds, confirming that the detection of bovine tuberculosis in DFS zones is rare. When comparing 2023 to 2022, the number of infected cattle herds increased by 13, while prevalence remained unchanged at 0.02%. The total number of cattle herds decreased by 2.9%.

<figure><img src="image_69.png" /><figcaption>**FIGURE 12** Prevalence of cattle herds infected with the *Mycobacterium tuberculosis* complex in disease-free status (DFS) zones, EU, 2014–2023.
\*In contrast to years 2014–2019, year 2020 does not include the United Kingdom (Scotland) data. Since 1 February 2020, the United Kingdom has withdrawn from the EU and has become a third country.</figcaption></figure>
MSs and MS zones with an approved eradication programme for infection with *Mycobacterium tuberculosis* complex

In 2023, cattle herds from UEP zones across 10 MSs and the United Kingdom (Northern Ireland) represented 38.6% of the total EU cattle herd population. This population has been steadily declining, with a 51.0% decrease compared to 2014 (Figure 13). Over the last decade (2014–2023), the prevalence of bovine tuberculosis in UEP zones has shown varying trends. From 2014 to 2019, data included the EU-28 MSs. However, the sharp decrease in 2020 can be attributed to the withdrawal of the United Kingdom from the EU and to the absence of data from Bulgaria in that year. Starting from 2021, the increase in the number of reported cattle herds can be mainly explained by the resumption of data from Bulgaria after its 2020 hiatus and by the inclusion of data from the United Kingdom (Northern Ireland). Over the last decade (2014–2023), the total number of positive cattle herds in UEP zones decreased by 49.4%, whereas prevalence increased by 3.1%.

Seven MSs and the United Kingdom (Northern Ireland) reported a total of 8659 herds positive for bovine tuberculosis in 2023, a 10.7% decrease from the 9696 positive herds in 2022. This reduction was primarily driven by the United Kingdom (Northern Ireland), which had reported 2785 (12.2%) MTBC-positive herds in 2022, compared to 1628 (7.2%) in 2023. The United Kingdom (Northern Ireland) (7.2%), Ireland (4.8%) and Spain (1.5%) were the only countries with a prevalence higher than 1%. No positive herds were reported by Bulgaria, Cyprus or Malta. Compared with 2022, the overall prevalence in UEP zones remained stable at around 1.5%.

<figure><img src="image_70.png" /></figure>

**FIGURE 13** Prevalence of cattle herds positive for bovine tuberculosis in zones under an eradication programme (UEP), EU, 2014–2023. *In contrast to years 2014–2019, year 2020 does not include the United Kingdom data. Since 1 February 2020, the United Kingdom has withdrawn from the EU and has become a third country. No 2020 data were reported from Bulgaria. **Data from the United Kingdom (Northern Ireland) were taken into account for 2021–2023. In accordance with the Agreement on the withdrawal of the United Kingdom of Great Britain and Northern Ireland from the European Union and the European Atomic Energy Community, and in particular Article 5(4) of the Windsor Framework (see Joint Declaration No 1/2023 of the Union and the United Kingdom in the Joint Committee established by the Agreement on the withdrawal of the United Kingdom of Great Britain and Northern Ireland from the European Union and the European Atomic Energy Community of 24 March 2023, OJ L 102, 17.4.2023, p. 87) in conjunction with Section 24 of Annex 2 to that Framework, for the purposes of this Regulation, references to MSs include the United Kingdom in respect of Northern Ireland.*

Non-MSs and pre-accession countries

Bovine tuberculosis was not detected in 2023 in Iceland, Liechtenstein or Switzerland, whereas Norway reported one infected cattle herd and a herd prevalence of 0.01%. Among the pre-accession countries, Montenegro, as in the previous 3 years, reported no infected herds; the Republic of North Macedonia reported a herd prevalence of 0.08% (10/12,621), whereas Albania reported a prevalence of 0.01% (7/94,252). Kosovo<fnref n="32" /> reported a prevalence of 0.07% intradermal tuberculin skin test-positive bovines (17/25,000).<fnref n="33" />

5.3.5 | *Mycobacterium tuberculosis* complex surveillance data from animals other than bovine animals

In 2023, two MSs (Finland, Sweden), the United Kingdom (Northern Ireland) and one non-MS (Norway) reported surveillance data on infection in farmed deer. In particular, Sweden reported data from a control programme in farmed deer. One case of MTBC infection in farmed deer was reported by the United Kingdom (Northern Ireland).

<footnote n="32">³²This designation is without prejudice to positions on status, and is in line with UNSCR 1244/1999 and the ICJ Opinion on the Kosovo declaration of independence.</footnote>

<footnote n="33">³³The prevalence reported by Kosovo in 2022 was 3.1% (78/2500).</footnote>
MSs also reported cases of MTBC infection in other mammal species. In particular, *M. bovis* was detected in farmed alpacas (Ireland), goats (France, Ireland), pigs (France, Ireland, Italy, the United Kingdom (Northern Ireland)), cats (France, Switzerland, the United Kingdom (Northern Ireland)), wild deer (Italy, Ireland), wild boar (Spain, France, Italy) and badgers (France, Ireland, the United Kingdom (Northern Ireland)). *M. caprae* was detected in laboratory monkeys (France). Finally, *M. tuberculosis* was detected in an African elephant (zoo animal) in Switzerland.

## 5.4 | Discussion

In 2023, the reporting of human tuberculosis due to *M. bovis* and *M. caprae* resulted in a total of 138 cases, a decrease compared with year 2022. This corresponds to a relative decrease in disease notification of 6.1% in 2023 (0.036 cases per 100,000) compared with 2022 (0.039 per 100,000 population). In particular, the decrease was due to *M. bovis* cases, by far the most frequent infection compared to *M. caprae* cases. The total number of *M. caprae* cases appears to be relatively constant over the years. It is important to highlight that, when analysing the trend over the last 5 years, notification rates were still higher in 2022–2023 than in the previous 3 years, but this upward trend is mainly due to the increased number of cases in Spain. Taken all together, the other countries observe a relatively stable epidemiological situation over the long term, suggesting the normalisation of the effect of the COVID-19 pandemic on human cases.

The specific analysis by country showed that 12 MSs reported no cases. In addition, notification of total cases noticeably decreased in Austria, Belgium, Italy, Spain and Sweden. In contrast, some countries showed an increase in total cases, particularly Germany. As expected, the total number of cases were highest in Germany and Spain, but when the data were examined on a per capita basis, the highest notification rates were observed in Ireland and Spain, i.e. both countries lack DFS at national level for tuberculosis in their bovine populations, demonstrating the importance of reaching full DFS. The number of notifications clearly depends on efficient surveillance standards and rapid diagnostic intervention. Finally, France and Latvia did not report any MTBC data in 2023. With regard to where the disease was acquired, the ratio of native to foreign origin approached 1 for the first time, with total native-origin disease notification being constant over recent years, whereas foreign acquired cases tended to increase, likely due to the resumption of population movement after the COVID-19 pandemic restrictions.

Tuberculosis cases of zoonotic origin (due to *M. bovis* or *M. caprae*) and notification rates are highly likely to have been underestimated. Bias is introduced by EU MSs that do not regularly perform routine tests to distinguish *M. bovis* and *M. caprae* from *M. tuberculosis*. This bias results in under-notification at the EU level, because all cases in these MSs are reported as *M. tuberculosis*, thereby undermining the possibility of tracing the origin of infections (Fujiwara & Olea-Popelka, 2016). Furthermore, a lower notification rate was observed in EU MSs with DFS compared with non-DFS MSs, supporting the effectiveness of the surveillance programmes.

In conclusion, despite the general warning that occupational exposure to zoonotic tuberculosis is an underestimated threat, particularly in developing countries (Devi et al., 2021), EU 2023 human data show positive short-term trends and, more generally, a relatively stable epidemiological situation, despite exceptions, over the long term, suggesting that disease control and surveillance in EU MSs are constant and efficient. Furthermore, for the future, the steady decline of the livestock population in the EU over recent years may help to better control zoonotic tuberculosis.

The regulatory framework for bovine tuberculosis changed substantially in the EU during 2021. Tuberculosis caused by MTBC infection is currently considered a disease to be controlled in all MSs with the goal of eradicating the disease in bovine animals throughout the EU, while being kept under surveillance in other mammals. All MSs are to have a surveillance programme, or a control and eradication programme approved by EC. This should lead, in the coming years, to progressive improvement in the already satisfactory epidemiological situation. In 2023, bovine tuberculosis was reported by 12 MSs and by the United Kingdom (Northern Ireland). Its distribution was heterogeneous and spatially clustered in the EU, with a national herd prevalence ranging from < 0.01% (Austria, Germany, Poland, Romania) to 7.2% (the United Kingdom (Northern Ireland)).

In 2023, 17 MSs had DFS. Of the remaining 10 MSs and the United Kingdom (Northern Ireland) three had DFS zones or provinces. The total number of DFS zones in the EU increased during 2023 and in these zones seven MSs detected bovine tuberculosis, which remained a rare event in these zones, as during the last decade (2014–2023). Seven of the 10 MSs with UEP zones, along with the United Kingdom (Northern Ireland), detected cases of bovine tuberculosis, resulting in an overall herd prevalence of 1.5%, similar to 2022. A 10.7% decrease in MTBC-positive herds was observed compared to 2022, primarily driven by a 41.5% reduction in MTBC-positive herds reported by the United Kingdom (Northern Ireland). Over the last decade (2014–2023), the total number of positive cattle herds in UEP zones decreased by 49.4%, whereas prevalence increased by 3.1%. These varying trends can be attributed for the most part to the decrease in the number of herds (–51.0%), the gradual progression of DFS in MSs with UEP and unfavourable environmental conditions hindering the eradication process in several UEP zones (Byrne et al., 2022; de la Cruz et al., 2019).

In 2023, *M. bovis* was reported to be isolated from a wide range of domestic and wild mammal species (other than bovine animals), which reflects the broad host range that this pathogen has. *M. caprae*, acknowledged to cause bovine tuberculosis, was reported only in cattle and in laboratory monkeys.

There is a major obstacle to eradication of bovine tuberculosis in areas where infection is endemic in wildlife. Successfully tackling bovine tuberculosis also involves addressing the wildlife reservoir of the disease. In 2018, Ireland introduced a vaccination policy in the Eurasian badger (*Meles meles*), a species known to be a maintenance host of *M. bovis*. Among other control measures, Ireland is actively reducing its badger population (Gormley et al., 2017). In contrast, no active badger
intervention or vaccination has been carried out in recent years in the United Kingdom (Northern Ireland), which may contribute to the persistently higher prevalence levels there. Stagnating or increasing trends in the prevalence of bovine tuberculosis demonstrate that eradication of this disease is a challenge, owing to the complex interactions between the pathogen, hosts and local environmental factors (EFSA AHAW Panel, 2014). MS-specific evaluations of status, trends and the relevance of bovine tuberculosis as a source of disease for humans can be found in the 2023 Annual National Zoonoses Country Reports available online [here](#).

## 6 | BRUCELLA

<figure><img src="image_71.png" /></figure>

<figure><img src="image_72.png" /></figure>

The summary data which make up this chapter, as well as additional information on related projects and internet sources, are published for this report on the EFSA Knowledge Junction at Zenodo [here](https://doi.org/10.2903/j.efsa.2024.9). Summary statistics on human surveillance data with downloadable files are retrievable using the ECDC Surveillance Atlas of Infectious Diseases available [here](https://www.ecdc.europa.eu/en/data-and-publications/publications/).

For additional information about *Brucella* and for the consultation of data collected, the following interactive tools are available:

Brucella

<figure><img src="image_73.png" /></figure>

DASHBOARD

<figure><img src="image_74.png" /></figure>

Brucella

<figure><img src="image_75.png" /></figure>

STORY MAP

<figure><img src="image_76.png" /></figure>

### 6.1 | Key facts

* In 2023, there were 259 confirmed cases of human brucellosis, corresponding to a European Union notification rate of 0.06 cases per 100,000 population. This was a relative increase of 14.1% compared with 2022 (0.05 cases per 100,000 population).

* The overall trend for *Brucella* infections showed no significant increase or decrease in 2019–2023.

* Most of the infections reported in humans were due to *Brucella melitensis*, with the aetiological agent for 68 of 74 (91.9%) cases characterised to the *Brucella* species level.

* No brucellosis food-borne outbreaks were reported for the year 2023.

* Twenty-two Member States and the United Kingdom (Northern Ireland) had the disease-free status for brucellosis in cattle in 2023. Five Member States (Bulgaria, Greece, Hungary, Italy and Portugal) were not disease-free (under an eradication programme), of which two Member States (Italy and Portugal) had disease-free status zones.
* In the disease-free status zones for brucellosis in cattle, a total of five infected herds were reported in 2023, in Italy only, indicating rare occurrence of the disease (prevalence < 0.001%). In the zones under an eradication programme the prevalence of *Brucella*-positive cattle herds continued to decrease, reaching 284 herds (0.25%). Compared to 2014, the number of positive cattle herds in these zones notably decreased by 68%.

* Twenty-one Member States and the United Kingdom (Northern Ireland) had the disease-free status for brucellosis in sheep and goats in 2023. Five Member States (Bulgaria, Croatia, Greece, Italy and Portugal) were under an eradication programme, of which two Member States (Italy and Portugal) had disease-free status zones. Malta had no disease status with regard to brucellosis in sheep and goats in 2023.

* In the disease-free status zones for brucellosis in sheep and goats, a total of four infected flocks were reported in 2023, in Italy only, indicating rare occurrence of the disease (prevalence < 0.001%). In zones under an eradication programme, the prevalence of *Brucella*-positive sheep and goat flocks continued to decrease, reaching 141 flocks (0.15%). Compared to 2014, the number of positive flocks in these zones notably decreased by 88%.

* Brucellosis is still an animal health concern with public health relevance in southern European and Balkan countries that are not disease-free for brucellosis.

## 6.2 | Surveillance and monitoring of *Brucella* in the EU

### 6.2.1 | Humans

For 2023, 26 MSs reported information on brucellosis in humans. Surveillance is mandatory in 25 MSs. Belgium has another (unspecified) system. Denmark has no surveillance system in place for brucellosis, and the disease is not notifiable or reported at the EU level. The EU case definition was used by 23 countries, while three countries (France, Germany and Italy) reported using another case definition. All countries had a comprehensive surveillance system, with full national coverage in all MSs reporting brucellosis data. All countries reported case-based data with the exception of Bulgaria, which reported aggregated data.

### 6.2.2 | Food and animals

#### Surveillance data for bovine brucellosis, and ovine and caprine brucellosis

Article 2 of Regulation (EU) 2016/429 states that its scope applies to transmissible diseases, including zoonoses, without prejudice to the provisions laid down in Directive 2003/99/EC. Therefore, the annual zoonosis data reporting requirements for MSs, as stipulated in Directive 2003/99/EC and implemented by EFSA through specific tools, manuals and guidance, remain unaffected by the entry into force of CIR (EU) 2020/2002. This latter CIR outlines the compulsory notification and annual reporting obligations that MSs must fulfil with respect to ADIS<fnref n="34" />: EU MSs are required to report to the EU ADIS outbreaks of infection with *Brucella abortus*, *B. melitensis* and *B. suis* in cattle, sheep and goat populations, in other even-toed ungulates (*Artiodactyla*) and in other terrestrial animals. Summaries of these reports are regularly made available online.

In accordance with Directive 2003/99/EC, MSs must report annual surveillance data for bovine brucellosis. These data are derived from compulsory national eradication and surveillance programmes implemented in compliance with EU legislation, including the AHL. The reports submitted by MSs are harmonised and enable the assessment of the epidemiological situation and trends analysis across MSs and their zones.

Regulation (EU) 2016/429 provides for the EC's approval of the disease-free status (DFS) of MSs or specific zones within them, with respect to infection with *B. abortus*, *B. melitensis* and *B. suis* in cattle and in sheep and goat populations, and of the non-vaccination status of MSs or zones or compartments. Due to the differing levels of infection risk between DFS zones and zones under an eradication programme (UEP), these zones have been treated separately in this chapter. Commission Implementing Regulation CIR (EU) 2018/1882³⁵ includes *Bos ssp.*, *Bubalus ssp.*, *Bison ssp.*, *Ovis ssp.* and *Capra ssp.* as species for notification, surveillance, prevention, certification and compulsory eradication. Commission Delegated Regulation<fnref n="36" /> (CDR) (EU) 2020/689 (Annex IV) describes the conditions required to grant, maintain or suspend the status of free from infection with *B. abortus*, *B. melitensis* and *B. suis* for an establishment keeping cattle or sheep and goats.

Annual surveillance programmes are carried out in DFS zones to confirm the absence of infection with *B. abortus*, *B. melitensis* and *B. suis* in cattle, and in sheep and goats. In UEP zones, control and eradication programmes are in place for brucellosis in cattle and in sheep and goats. These data are comparable across MSs because the monitoring schemes are harmonised, and the data collected and reported to EFSA originate from the census-as-sampling framework or a randomised design. These data can be used to carry out trend analyses both at the EU and MS levels, to perform trend watching and produce descriptive summaries, and to assess the impact of control and eradication programmes (Table 1).

<footnote n="34">³⁴EU Animal Diseases Information System (ADIS). More information is available at: https://food.ec.europa.eu/animals/animal-diseases/animal-disease-information-system-adis_en.</footnote>

<footnote n="35">³⁵Commission Implementing Regulation (EU) 2018/1882 of 3 December 2018 on the application of certain disease prevention and control rules to categories of listed diseases and establishing a list of species and groups of species posing a considerable risk for the spread of those listed diseases.</footnote>

<footnote n="36">³⁶Commission Delegated Regulation (EU) 2020/689 of 17 December 2019 supplementing Regulation (EU) 2016/429 of the European Parliament and of the Council as regards rules for surveillance, eradication programmes and disease-free status for certain listed and emerging diseases.</footnote>
## Surveillance data for *Brucella* from food and from animals other than cattle, sheep and goats

Monitoring data for *Brucella* from food and from animals other than cattle, sheep and goats are submitted to EFSA in accordance with Directive 2003/99/EC. Data collected allow for descriptive summaries to be compiled at the EU level, but do not enable trend watching or trend analyses (Table 1).

In accordance with CIR (EU) 2020/2002, notification to ADIS and surveillance rules apply to other *Artiodactyla* species (such as camelids or cervids) as susceptible species for brucellosis.

## 6.3 | Results

### 6.3.1 | Overview of key statistics, EU, 2019–2023

Table 39 displays statistics at the EU level on human and animal brucellosis, along with data on detection of *Brucella* in food, between 2019 and 2023. More detailed descriptions of these statistics are provided in the subsections below and in the chapter on food-borne outbreaks.

<table><caption>TABLE 39 Summary of *Brucella* statistics relating to humans, major food categories and animal species (stratified by status of disease of MSs/MS zones), EU, 2019–2023.</caption><thead><tr><th></th><th>2023<sup>a</sup></th><th>2022<sup>a</sup></th><th>2021<sup>a</sup></th><th>2020</th><th>2019<sup>b</sup></th><th>Data source</th></tr></thead><tbody><tr><td colspan="7"><strong>Humans</strong></td></tr><tr><td>Total number of confirmed cases</td><td>259</td><td>226</td><td>162</td><td>132</td><td>309</td><td>ECDC</td></tr><tr><td>Total number of confirmed cases/100,000 population (notification rates)</td><td>0.06</td><td>0.05</td><td>0.03</td><td>0.03</td><td>0.06</td><td>ECDC</td></tr><tr><td>Number of reporting MSs</td><td>26</td><td>26</td><td>26</td><td>26</td><td>27</td><td>ECDC</td></tr><tr><td>Infection acquired in the EU</td><td>87</td><td>66</td><td>75</td><td>68</td><td>126</td><td>ECDC</td></tr><tr><td>Infection acquired outside the EU</td><td>49</td><td>40</td><td>22</td><td>14</td><td>50</td><td>ECDC</td></tr><tr><td>Unknown travel status or unknown country of infection</td><td>123</td><td>120</td><td>65</td><td>50</td><td>133</td><td>ECDC</td></tr><tr><td>Total number of food-borne outbreaks</td><td>0</td><td>0</td><td>2</td><td>2</td><td>2</td><td>EFSA</td></tr><tr><td>Number of outbreak-related cases</td><td>0</td><td>0</td><td>1</td><td>1</td><td>1</td><td>EFSA</td></tr><tr><td colspan="7"><strong>Food</strong></td></tr><tr><td colspan="7"><strong>Milk and milk products</strong></td></tr><tr><td>Number of sampling units</td><td>200</td><td>182</td><td>320</td><td>275</td><td>586</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>3</td><td>3</td><td>3</td><td>3</td><td>2</td><td>EFSA</td></tr><tr><td colspan="7"><strong>Animals</strong></td></tr><tr><td colspan="7"><strong>Cattle (bovine animals)</strong></td></tr><tr><td>Number of infected herds in disease-free status zones<sup>c</sup></td><td>5</td><td>13</td><td>8</td><td>6</td><td>4</td><td>EFSA</td></tr><tr><td>Number of reporting disease-free status MSs<sup>c</sup></td><td>23</td><td>23</td><td>22</td><td>20</td><td>20</td><td>EFSA</td></tr><tr><td>Number of positive herds in zones under an eradication programme</td><td>284</td><td>428</td><td>546</td><td>603</td><td>485</td><td>EFSA</td></tr><tr><td>Number of reporting MSs with zones under an eradication programme</td><td>5</td><td>5</td><td>6</td><td>6<sup>d</sup></td><td>8</td><td>EFSA</td></tr><tr><td colspan="7"><strong>Sheep and goats</strong></td></tr><tr><td>Number of infected flocks in disease-free status zones<sup>e</sup></td><td>4</td><td>2</td><td>15</td><td>3</td><td>1</td><td>EFSA</td></tr><tr><td>Number of reporting disease-free status MSs<sup>e</sup></td><td>22</td><td>21</td><td>21</td><td>19</td><td>20</td><td>EFSA</td></tr><tr><td>Number of positive herds in zones under an eradication programme</td><td>141</td><td>234</td><td>331</td><td>349</td><td>451</td><td>EFSA</td></tr><tr><td>Number of reporting MSs with zones under an eradication programme</td><td>5<sup>d,f</sup></td><td>7<sup>g</sup></td><td>7</td><td>7<sup>d</sup></td><td>8</td><td>EFSA</td></tr></tbody></table>

Abbreviations: ECDC, European Centre for Disease Prevention and Control; EFSA, European Food Safety Authority; MSs, Member States.

<footnote><sup>a</sup>Data from the United Kingdom (Northern Ireland) were taken into account for 2021–2023. In accordance with the Agreement on the withdrawal of the United Kingdom of Great Britain and Northern Ireland from the European Union and the European Atomic Energy Community, and in particular Article 5(4) of the Windsor Framework (see Joint Declaration No 1/2023 of the Union and the United Kingdom in the Joint Committee established by the Agreement on the withdrawal of the United Kingdom of Great Britain and Northern Ireland from the European Union and the European Atomic Energy Community of 24 March 2023, OJ L 102, 17.4.2023, p. 87) in conjunction with Section 24 of Annex 2 to that Framework, for the purposes of this Regulation, references to MSs include the United Kingdom in respect of Northern Ireland.</footnote>

<footnote><sup>b</sup>Data from the United Kingdom were taken into account for the 2018–2019 period, since the United Kingdom was still an EU MS at that time. However, on 1 February 2020, it became a third country.</footnote>

<footnote><sup>c</sup>Member States, or zones thereof, with DFS regarding infection with *B. abortus*, *B. melitensis* and *B. suis* in their bovine animal populations. In addition, the United Kingdom (Northern Ireland) has DFS with regard to infection with *B. abortus*, *B. melitensis* and *B. suis* in bovine animal populations.</footnote>

<footnote><sup>d</sup>No data were reported by Bulgaria.</footnote>

<footnote><sup>e</sup>Member States, or zones thereof, with DFS regarding infection with *B. abortus*, *B. melitensis* and *B. suis* in their sheep and goat populations. In 2023, Malta had no disease status. In addition, the United Kingdom (Northern Ireland) has DFS with regard to *B. abortus*, *B. melitensis* and *B. suis* in sheep and goat populations.</footnote>

<footnote><sup>f</sup>Including Malta, which had no official status as regards infection with *B. abortus*, *B. melitensis* and *B. suis* in ovine and caprine animal populations, in 2023.</footnote>

<footnote><sup>g</sup>Including France, in which the whole of metropolitan France obtained DFS in 2022 whereas overseas French regions did not have this status.</footnote>
## 6.3.2 | Human brucellosis

In 2023, 259 confirmed cases were reported in the EU, which was a slight increase compared with 2022. The notification rate was 0.06 cases per 100,000 population, which was an increase of 14.1% compared with 2022 (0.05 cases per 100,000 population). In 2023, 26 MSs provided data and information on brucellosis in humans (Table 39). Greece and Slovakia reported the highest notification rates (0.28 and 0.18 per 100,000 population, respectively) (Table 40). Seven MSs (Cyprus, Estonia, Finland, Hungary, Latvia, Luxembourg and Malta) reported zero cases (Table 40).

In 2023, the proportion of human infections acquired in the EU was 64.0% (87 out of 136 cases with known travel status), which was an increase compared with 62.3% (66 out of 106) in 2022 and a decrease in contrast with 75.8% (269 out of 355) on average in 2019–2021 (Table 39). The proportion of cases with unknown travel status or travel destination was 47.5% (123 out of 259 cases), which was a decrease compared with 53.1% (120 out of 226) in 2022 and an increase compared to 41.1% (248 out of 603) in 2019–2021 (Table 39).

The number of confirmed, domestically acquired brucellosis cases in humans (patients not having been outside the country of notification during the disease incubation period) is overlaid with the national prevalence data on *Brucella*-positive cattle herds and sheep and goat flocks in the European Union in 2023 in Figure 15. Germany, Greece, Portugal, Slovakia and Spain had the highest number of confirmed domestic cases in humans. Italy, which reported a high number of human brucellosis cases over the years, did not provide information on the origin of infection for 2023. Greece, Portugal and Italy also had the highest prevalence of *Brucella*-positive ruminant herds.

<table><caption>TABLE 40 Reported confirmed human cases of brucellosis and notification rates per 100,000 population in EU MSs and non-MSs, by country and year, 2019–2023.</caption><thead><tr><th rowspan="3">Country</th><th colspan="5">2023</th><th colspan="2">2022</th><th colspan="2">2021</th><th colspan="2">2020</th><th colspan="2">2019</th></tr><tr><th colspan="3">Status</th><th rowspan="2">National coverage<sup>c</sup></th><th rowspan="2">Data format<sup>c</sup></th><th colspan="2">Confirmed cases and rate</th><th colspan="2">Confirmed cases and rate</th><th colspan="2">Confirmed cases and rate</th><th colspan="2">Confirmed cases and rate</th></tr><tr><th>Bv<sup>a</sup></th><th>Ov, Cp<sup>b</sup></th><th>Cases</th><th>Rate</th><th>Cases</th><th>Rate</th><th>Cases</th><th>Rate</th><th>Cases</th><th>Rate</th><th>Cases</th><th>Rate</th></tr></thead><tbody><tr><td>Austria</td><td>DFS</td><td>DFS</td><td>Y</td><td></td><td>C</td><td>8</td><td>0.09</td><td>7</td><td>0.08</td><td>6</td><td>0.07</td><td>8</td><td>0.09</td><td>6</td><td>0.07</td></tr><tr><td>Belgium</td><td>DFS</td><td>DFS</td><td>Y</td><td></td><td>C</td><td>5</td><td>0.04</td><td>3</td><td>0.03</td><td>7</td><td>0.06</td><td>4</td><td>0.03</td><td>3</td><td>0.03</td></tr><tr><td>Bulgaria</td><td></td><td></td><td>Y</td><td></td><td>A</td><td>1</td><td>0.02</td><td>2</td><td>0.03</td><td>0</td><td>0</td><td>1</td><td>0.01</td><td>0</td><td>0</td></tr><tr><td>Croatia</td><td>DFS</td><td></td><td>Y</td><td></td><td>C</td><td>2</td><td>0.05</td><td>2</td><td>0.05</td><td>2</td><td>0.05</td><td>1</td><td>0.02</td><td>3</td><td>0.07</td></tr><tr><td>Cyprus</td><td>DFS</td><td>DFS</td><td>Y</td><td></td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>1</td><td>0.11</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Czechia</td><td>DFS</td><td>DFS</td><td>Y</td><td></td><td>C</td><td>1</td><td>0.01</td><td>0</td><td>0</td><td>1</td><td>0.01</td><td>0</td><td>0</td><td>4</td><td>0.04</td></tr><tr><td>Denmark<sup>d</sup></td><td>DFS</td><td>DFS</td><td>Y</td><td></td><td>Y</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td></tr><tr><td>Estonia</td><td>DFS</td><td>DFS</td><td>Y</td><td></td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>1</td><td>0.08</td></tr><tr><td>Finland</td><td>DFS</td><td>DFS</td><td>Y</td><td></td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>France</td><td>DFS</td><td>DFS</td><td>Y</td><td></td><td>C</td><td>22</td><td>0.03</td><td>37</td><td>0.05</td><td>21</td><td>0.03</td><td>19</td><td>0.03</td><td>34</td><td>0.05</td></tr><tr><td>Germany</td><td>DFS</td><td>DFS</td><td>Y</td><td></td><td>C</td><td>36</td><td>0.04</td><td>35</td><td>0.04</td><td>13</td><td>0.02</td><td>19</td><td>0.02</td><td>36</td><td>0.04</td></tr><tr><td>Greece</td><td></td><td></td><td>Y</td><td></td><td>C</td><td>29</td><td>0.28</td><td>35</td><td>0.33</td><td>24</td><td>0.22</td><td>30</td><td>0.28</td><td>65</td><td>0.61</td></tr><tr><td>Hungary</td><td>DFS</td><td>DFS</td><td>Y</td><td></td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Ireland</td><td>DFS</td><td>DFS</td><td>Y</td><td></td><td>C</td><td>5</td><td>0.09</td><td>1</td><td>0.02</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Italy</td><td></td><td></td><td>Y</td><td></td><td>C</td><td>74</td><td>0.13</td><td>48</td><td>0.08</td><td>32</td><td>0.05</td><td>18</td><td>0.03</td><td>49</td><td>0.08</td></tr><tr><td>Latvia</td><td>DFS</td><td>DFS</td><td>Y</td><td></td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>1</td><td>0.05</td><td>0</td><td>0</td></tr><tr><td>Lithuania</td><td>DFS</td><td>DFS</td><td>Y</td><td></td><td>C</td><td>2</td><td>0.07</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Luxembourg</td><td>DFS</td><td>DFS</td><td>Y</td><td></td><td>C</td><td>0</td><td>0</td><td>1</td><td>0.15</td><td>1</td><td>0.16</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Malta<sup>e</sup></td><td>DFS</td><td></td><td>Y</td><td></td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Netherlands</td><td>DFS</td><td>DFS</td><td>Y</td><td></td><td>C</td><td>4</td><td>0.02</td><td>5</td><td>0.03</td><td>2</td><td>0.01</td><td>2</td><td>0.01</td><td>7</td><td>0.04</td></tr><tr><td>Poland</td><td>DFS</td><td>DFS</td><td>Y</td><td></td><td>C</td><td>4</td><td>0.01</td><td>1</td><td>0</td><td>1</td><td>&lt;0.01</td><td>0</td><td>0</td><td>2</td><td>0.01</td></tr><tr><td>Portugal</td><td></td><td></td><td>Y</td><td></td><td>C</td><td>14</td><td>0.13</td><td>13</td><td>0.13</td><td>10</td><td>0.10</td><td>9</td><td>0.09</td><td>33</td><td>0.32</td></tr><tr><td>Romania</td><td>DFS</td><td>DFS</td><td>Y</td><td></td><td>C</td><td>1</td><td>0.01</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>1</td><td>0.01</td></tr><tr><td>Slovakia</td><td>DFS</td><td>DFS</td><td>Y</td><td></td><td>C</td><td>10</td><td>0.18</td><td>3</td><td>0.06</td><td>6</td><td>0.11</td><td>2</td><td>0.04</td><td>1</td><td>0.02</td></tr><tr><td>Slovenia</td><td>DFS</td><td>DFS</td><td>Y</td><td></td><td>C</td><td>3</td><td>0.14</td><td>1</td><td>0.05</td><td>0</td><td>0</td><td>1</td><td>0.05</td><td>6</td><td>0.29</td></tr><tr><td>Spain<sup>f</sup></td><td>DFS</td><td>DFS</td><td>Y</td><td></td><td>C</td><td>28</td><td>0.06</td><td>22</td><td>0.05</td><td>25</td><td>—</td><td>10</td><td>—</td><td>20</td><td>0.04</td></tr><tr><td>Sweden</td><td>DFS</td><td>DFS</td><td>Y</td><td></td><td>C</td><td>10</td><td>0.10</td><td>10</td><td>0.10</td><td>10</td><td>0.10</td><td>7</td><td>0.07</td><td>14</td><td>0.14</td></tr><tr><td>EU Total 27</td><td></td><td></td><td></td><td></td><td></td><td>259</td><td>0.06</td><td>226</td><td>0.05</td><td>162</td><td>0.03</td><td>132</td><td>0.03</td><td>285</td><td>0.06</td></tr><tr><td>United Kingdom</td><td>—</td><td>—</td><td>—</td><td></td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>24</td><td>0.04</td></tr></tbody></table>

(Continues)
<table><caption>TABLE 40 (Continued)</caption><thead><tr><th rowspan="3">Country</th><th colspan="5">2023</th><th colspan="2">2022</th><th colspan="2">2021</th><th colspan="2">2020</th><th colspan="2">2019</th></tr><tr><th colspan="3">Status</th><th rowspan="2">National coverage<sup>c</sup></th><th rowspan="2">Data format<sup>c</sup></th><th colspan="2">Confirmed cases and rate</th><th colspan="2">Confirmed cases and rate</th><th colspan="2">Confirmed cases and rate</th><th colspan="2">Confirmed cases and rate</th></tr><tr><th>Bv<sup>a</sup></th><th>Ov, Cp<sup>b</sup></th><th>National coverage<sup>c</sup></th><th>Cases</th><th>Rate</th><th>Cases</th><th>Rate</th><th>Cases</th><th>Rate</th><th>Cases</th><th>Rate</th></tr></thead><tbody><tr><td>EU Total</td><td></td><td></td><td></td><td></td><td></td><td>259</td><td>0.06</td><td>226</td><td>0.05</td><td>162</td><td>0.03</td><td>132</td><td>0.03</td><td>309</td><td>0.06</td></tr><tr><td>Iceland</td><td></td><td></td><td></td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Norway</td><td>DFS</td><td>DFS</td><td>Y</td><td>C</td><td>1</td><td>0.02</td><td>1</td><td>0.02</td><td>3</td><td>0.06</td><td>2</td><td>0.04</td><td>4</td><td>0.08</td><td></td></tr><tr><td>Liechtenstein</td><td>DFS</td><td>DFS</td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>3</td><td>0.03</td><td>7</td><td>0.08</td><td></td></tr><tr><td>Switzerland<sup>g</sup></td><td>DFS</td><td>DFS</td><td>Y</td><td>C</td><td>9</td><td>0.10</td><td>6</td><td>0.07</td><td>6</td><td>0.07</td><td></td><td></td><td></td><td></td><td></td></tr></tbody></table>

Abbreviations: -, data not reported; DFS, disease-free status with regards to infection with *B. abortus*, *B. melitensis* and *B. suis* in cattle populations and/or in sheep and goat populations.

<sup>a</sup>Cattle populations.

<sup>b</sup>Sheep and goat populations.

<sup>c</sup>Y: yes; N: no; A: aggregated data; C: case-based data.

<sup>d</sup>No surveillance system.

<sup>e</sup>Malta had no official status as regards infection with *B. abortus*, *B. melitensis* and *B. suis* in ovine and caprine animal populations, in 2023.

<sup>f</sup>Data incomplete for 2020–2021, rate not estimated.

<sup>g</sup>Switzerland provided data directly to EFSA. The human data for Switzerland include data from Liechtenstein for the years 2019–2020.

<figure><img src="image_77.png" /></figure>

All zones of the MS have disease-free status.

Not all zones of the MS have disease-free status.

No zone of the MS has disease-free status.

No status.

In 2023, clear seasonality was observed in the number of confirmed brucellosis cases in the EU, with more cases reported from March to August (Figure 14). Over the 2019–2023 period, there was no statistically significant increase or decrease in the overall trend in the EU. The trend for one MS (Slovakia) was a significant increase over 5 years, from 2019 to 2023. None of the MSs reported a decreasing trend.

<figure><img src="image_78.png" /><figcaption>FIGURE 14 Trend in reported confirmed human cases of brucellosis in the EU, by month, 2019–2023. Source: Austria, Belgium, Cyprus, Czechia, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, the Netherlands, Poland, Portugal, Romania, Slovakia, Slovenia and Sweden.</figcaption></figure>
Out of 259 human cases, 74 (28.6%) were reported with information on *Brucella* species by 14 MSs. *Brucella melitensis* was reported as the aetiological agent in 68 cases (91.9%); *B. abortus* was reported in three cases (4.0%); *B. suis* in one case (1.3%); and other (unspecified) *Brucella* species in two cases (2.7%). The proportion of *B. melitensis* infections was slightly lower than in 2022 (94.4%). Italy did not provide any information regarding the typing of *Brucella* isolates. Conversely, Greece provided data for seven cases, all of which were identified as *B. melitensis*. Portugal also provided data for three cases, which were identified as *B. melitensis* (N = 1), *B. abortus* (N = 1) and other *Brucella* species (N = 1).

<figure><img src="image_79.png" /><figcaption>**FIGURE 15** Number of confirmed, domestically acquired brucellosis cases in humans and national prevalence of *Brucella*-positive cattle herds and sheep and goat flocks, in EU MSs and non-MSs, 2023. Member States that reported data at the national level without specifying the specific zones or overseas territories where the *Brucella*-positive animal herds were detected, were assigned the same colour for all their zones, including overseas territories. EU MSs and the United Kingdom (Northern Ireland) were represented with a blue label, the EFTA/EEA countries were represented with a grey label, and all the candidate countries were represented with an orange label. For Kosovo and Serbia, prevalence data are at the animal level. The designation of Kosovo is without prejudice to positions on status, and is in line with UNSCR 1244/1999 and the ICJ Opinion on the Kosovo declaration of independence.</figcaption></figure>

### 6.3.3 | *Brucella* in food

Very few monitoring data for *Brucella* were submitted in 2023, as was the case in previous years. In total, 200 single samples of milk and cheeses were collected from primary production, and from the manufacturing and distribution stages, by three MSs (Italy, Portugal and Spain). No positive sample was reported.

### 6.3.4 | *Brucella* in animals

#### Surveillance data for bovine brucellosis, and ovine and caprine brucellosis

##### Cattle

The status of countries for brucellosis in cattle was stable in 2023 compared with 2022, with 22 MSs and the United Kingdom (Northern Ireland) having DFS in 2023. Out of the five MSs with UEP zones (Bulgaria, Greece, Hungary, Italy and Portugal), only Italy reported an increasing number of DFS zones. Two countries had DFS zones or provinces in cattle:
* Italy: 13 regions and 12 provinces; and

* Portugal: one region (the autonomous region of the Azores) and nine districts (from the Central region and from the Azores islands).

Bulgaria, Greece and Hungary did not have any DFS zones.

Liechtenstein, Norway and Switzerland have DFS in accordance with EU legislation. Iceland, which does not have any special agreement on animal health (status) with the European Union, has never reported any brucellosis cases caused by *B. abortus*, *B. melitensis* or *B. suis*.

In 2023, infection of cattle herds with brucellosis in the EU remained a rare event (< 0.01%; 289 out of 1,528,397 herds), with 23 MSs reporting no cases. Greece and Italy had the highest numbers of infected herds.

Among the DFS zones, no infected cattle herds were reported in 2023, except in Italy, where five herds tested positive. The overall prevalence in DFS zones remained below 0.001%.

In 2023, within the UEP zones of the five non-DFS MSs, the prevalence of *Brucella*-positive cattle herds continued to decrease, reaching 284 herds (0.25%), down from 411 herds (0.39%) in 2022. Compared to 2020, the number of positive cattle herds notably decreased by 53%, from 603 to 284 in 2023. Italy reported 217 positive herds in its UEP zones (down from 346 in 2022), while Portugal reported 21 herds (the same as in 2022). Greece reported 35 positive herds (down from 42 in 2022) and Bulgaria reported 11 (up from two in 2022). Over the last decade (2014–2023), the total number of positive cattle herds in UEP zones decreased by 68% from 879 in 2014 to 284 in 2023, whereas the prevalence fluctuated around 0.25% (Figure 16).

<figure><img src="image_80.png" /></figure>

**FIGURE 16** Prevalence of *Brucella*-positive cattle herds, in zones under an eradication programme, EU, 2014–2023. UEP, under an eradication programme. *In contrast to years 2014–2019, the year 2020 does not include the United Kingdom data. Since 1 February 2020, the United Kingdom has withdrawn from the EU and has become a third country. **Data from the United Kingdom (Northern Ireland) were considered for 2021–2023. In accordance with the Agreement on the withdrawal of the United Kingdom of Great Britain and Northern Ireland from the European Union and the European Atomic Energy Community, and in particular Article 5(4) of the Windsor Framework (see Joint Declaration No 1/2023 of the Union and the United Kingdom in the Joint Committee established by the Agreement on the withdrawal of the United Kingdom of Great Britain and Northern Ireland from the European Union and the European Atomic Energy Community of 24 March 2023, OJ L 102, 17.4.2023, p. 87) in conjunction with Section 24 of Annex 2 to that Framework, for the purposes of this Regulation, references to MSs include the United Kingdom in respect of Northern Ireland.*

In 2024, no cases of bovine brucellosis were detected in the four non-MS countries of Iceland, Liechtenstein, Norway and Switzerland, which have DFS. In the Balkans, *Brucella* remains present in cattle. EU candidate countries reported seropositive results from national monitoring data, with Albania identifying five positive herds (0.005%) and the Republic of North Macedonia detecting 15 positive herds (0.12%). Additionally, Albania reported 1875 seropositive results (5.2%) from a total of 35,796 blood samples. The Republic of North Macedonia identified 422 seropositive animals (0.41%) out of 102,400 tested, while Serbia reported nine positives (0.002%) from 433,415 animals. Kosovo<fnref n="37" /> reported 0.35% positives, with 21 positive animals out of 6000 tested.

## Sheep and goats

In 2023, 21 MSs and the United Kingdom (Northern Ireland) had DFS with regard to ovine and caprine brucellosis, while 5 MSs had UEP zones (Bulgaria, Croatia, Greece, Italy and Portugal). Malta had no official status as regards infection with *B. abortus*, *B. melitensis* and *B. suis* in sheep and goats. Italy and Portugal had DFS zones:

<footnote n="37">³⁷This designation is subject to positions on status and is in line with UNSCR 1244/1999 and the ICJ Opinion on the Kosovo declaration of independence.</footnote>
* Italy: 15 regions and 10 provinces,

* Portugal: one region (the autonomous region of the Azores).

Italy reported an increasing number of DFS zones.

Bulgaria, Croatia and Greece no DFS zones.

Bulgaria did not report any data for sheep and goat brucellosis.

In 2023, the overall proportion of sheep and goat flocks infected with *B. abortus*, *B. melitensis* and *B. suis* in the EU remained very low (0.015%; 145 out of 974,714 flocks).

Among the DFS zones, no infected sheep and goat flocks were reported in 2023, except in Italy, where four flocks tested positive. The overall prevalence in DFS zones remained below 0.001%.

In 2023, within the UEP zones of the five non-DFS MSs and Malta, the prevalence of *Brucella*-positive sheep and goat flocks continued to decrease, reaching 141 flocks (0.15%), down from 234 flocks (0.11%) in 2022 (Figure 17). The number of positive flocks reported by these MSs was 34 in Italy (down from 66 in 2022), 3 in Greece (down from 13 in 2022) and 104 in Portugal (down from 154 in 2022). No positive flocks were reported by Croatia, Malta or Portugal. For the past 4 years, Croatia has reported zero infected herds, indicating that eradication of sheep and goat brucellosis is almost achieved. Over the last decade (2014–2023), the total number of positive sheep and goat flocks in UEP zones decreased by 88% from 1133 in 2014 to 141 in 2023, whereas the prevalence decreased by 66% from 0.32% in 2014 to 0.11% in 2023 (Figure 17).

<figure><img src="image_81.png" /><figcaption>**FIGURE 17** Prevalence of *Brucella*-positive sheep and goat flocks, in zones under an eradication programme, EU, 2014–2023. UEP, under an eradication programme. *In contrast to years 2014–2019, the year 2020 does not include the United Kingdom data. Since 1 February 2020, the United Kingdom has withdrawn from the EU and has become a third country. **Data from the United Kingdom (Northern Ireland) were considered for 2021–2023. In accordance with the Agreement on the withdrawal of the United Kingdom of Great Britain and Northern Ireland from the European Union and the European Atomic Energy Community, and in particular Article 5(4) of the Windsor Framework (see Joint Declaration No 1/2023 of the Union and the United Kingdom in the Joint Committee established by the Agreement on the withdrawal of the United Kingdom of Great Britain and Northern Ireland from the European Union and the European Atomic Energy Community of 24 March 2023, OJ L 102, 17.4.2023, p. 87) in conjunction with Section 24 of Annex 2 to that Framework, for the purposes of this Regulation, references to MSs include the United Kingdom in respect of Northern Ireland.*</figcaption></figure>

In 2023, no cases of brucellosis were detected in sheep and goat flocks in the following non-MS countries: Albania, Iceland, Montenegro, Norway and Switzerland. The Republic of North Macedonia reported 23 positive flocks and 966 (0.19%) seropositive small ruminants out of 500,949 tested. Serbia reported only seven infected animals out of 1,220,364 (0.0006%) based on national monitoring data for ovine and caprine brucellosis. Kosovo<fnref n="38" /> reported 0.1% positive sheep and goats, with 2 positives out of 2000 tested.

## Surveillance data for *Brucella* from animals other than cattle, sheep and goats

In contrast to 2022 reports on *Brucella* in animals other than cattle, sheep and goats, the detection of the *Brucella* genus (without species identification) was reported in a smaller range of animal species. Several strains of *B. canis* (N = 21) were reported in dogs from five countries (in France, Greece, Italy, Romania and the Netherlands). Moreover, *B. suis* biovar 2 was also isolated in three dogs (France and Italy). *Brucella* was detected in pigs in France, while seropositive animals were reported by two MSs (Germany and Romania) as well as by Switzerland. A total of 1249 negative microbiological or PCR analyses were reported for pigs and wild boars across seven MSs: Finland (17), France (2), Germany (938), Ireland (3), Italy (18), Romania (249) and Sweden (22). Additionally, 70,819 seronegative results were recorded in nine MSs: Bulgaria (4726),

<footnote n="38">³⁸This designation is subject to positions on status and is in line with UNSCR 1244/1999 and the ICJ Opinion on the Kosovo declaration of independence.</footnote>
Croatia (15), Finland (1536), Germany (20,631), Italy (6), Latvia (3267), Romania (35,812), Sweden (821) and Slovakia (786), along with the United Kingdom (Northern Ireland) with 648 and Norway with 2571 seronegative results. Moreover, one seropositive alpaca was detected in Switzerland, while no seropositive animals were reported by Finland, Italy, Sweden or the United Kingdom (Northern Ireland). Finally, serological tests for *Brucella* were carried out on llamas (in Italy), domestic solipeds (in Romania and Switzerland), deer (in Slovakia) and bison (in Slovakia), all yielding results.

## 6.4 | Discussion

The 5-year trend of confirmed cases of human brucellosis in the EU remained unchanged from 2019 to 2023. However, the EU notification rate was higher in 2023 (0.06 per 100,000 population) than in 2022, with Greece, Slovakia, Slovenia, Portugal, Italy and Sweden contributing most to this increase. All EU countries reported brucellosis data. Human brucellosis remains a persistent public health problem in some MSs, particularly in Greece, Portugal and Italy where the infection in cattle and small ruminants is present. Several different *Brucella* spp. genotypes, mostly of endemic origin and persisting in different foci, were detected in Greece in 1999–2009 (Brangsch et al., 2023). In Europe, 24.3% (0.18/0.74 billion) of people were at risk of contracting brucellosis in 2014–2018 (Laine et al., 2023). The consumption of unpasteurised milk products and the handling of contaminated tissues, such as aborted livestock placentas, are considered the primary sources of infection (Corbel et al., 2006). The overall regional risk assessment identified a major hotspot in the eastern Mediterranean and an increased risk in the central sub-region of Europe (Laine et al., 2023), as reported in the Balkan EU candidate countries.

In 2023, infections acquired in the EU increased slightly, which was mainly due to the rise of cases in Slovakia and Ireland, most of which were of domestic origin.

Like in 2022, a number of domestic human cases were reported in MSs that did not yet eradicated brucellosis in their cattle sheep and goat populations. This was the case of Greece and Portugal. Italy, as well, documented persistent *Brucella* infection in ruminant herds; however, no information on the origin of infection was provided and no link to the disease in ruminants was possible. Conversely, high numbers of domestic human cases were also recorded in DFS countries, such as in Germany, Ireland, Slovakia and Spain. Persons working with farm animals are known to be at increased risk of brucellosis, which remains the predominant occupational disease (Alzuheir et al., 2021; Pereira et al., 2020). Food-borne exposure is normally limited to the consumption of unpasteurised milk and dairy products or undercooked contaminated meat from countries where brucellosis is endemic in animals. The uncontrolled importation of dairy products from endemic regions may be a contributing factor to the acquisition of human *Brucella* infections in non-endemic EU countries (Jansen et al., 2019). Most domestic human cases in DFS countries were linked to travel outside the EU, with the greatest number of cases occurring in Germany, fewer cases in Spain and none in Slovakia. Interestingly, neither Hungary (non-DFS for cattle) nor Malta (non-DFS for sheep and goats) reported any cases of human brucellosis.

In 2023, data on *Brucella* species was available for 28.6% of reported human cases, with the vast majority attributed to infections caused by *B. melitensis*. This information is very important when optimising risk management to further reduce the disease in humans, considering that *B. melitensis* is mainly, if not completely, associated with brucellosis in sheep and goats. In contrast to 2022, *B. suis* caused infection in humans, albeit in only one case. This pathogen should be monitored over the coming years to detect any trend for a potentially emerging condition.

A recent retrospective study described the genetic diversity of sequenced isolates of *B. melitensis* circulating in Greece between 1999 and 2009 in humans (n = 15) and small ruminants (n = 28). In-silico genotyping revealed that the isolates belonged primarily to the eastern Mediterranean genotype and clustered with strains from the western Balkans or Turkey (Brangsch et al., 2023).

A new *Brucella* species has been described in French Guiana, isolated from two Brazilian gold miners working in the Amazon rainforest who were hospitalised with symptoms of brucellosis. Genetic and phenotypic analyses of the bacterial isolates from these patients revealed that they represented a new species, which was named *Brucella amazoniensis* (About et al., 2023). Until now, this species had not been detected in animals. The phylogenetic analysis classifies this species as being close to the classical *Brucella* core clade, especially *B. neotomae* and *B. nosferati*, another recent *Brucella* species discovered in bats from Costa Rica (Hernández-Mora et al., 2023). This new species highlights the importance of monitoring and studying zoonotic diseases, especially in regions with rich biodiversity like the Amazon.

Bovine brucellosis and ovine and caprine brucellosis have been eradicated by most EU MSs. In 2023, France was declared DFS for brucellosis in sheep and goats. In DFS MSs or DFS MSs' zones, very few infected herds or flocks were reported for 2023: five infected cattle herds, and four infected sheep and goat flocks, by Italy.

Some MSs were not yet officially free from bovine brucellosis or from brucellosis in sheep and goats, and both infections were mostly reported in Greece, Italy and Portugal. In Greece, the proportion of tested herds and flocks remained small, which may affect surveillance precision. The overall numbers of positive herds and flocks should be interpreted differently between countries, as the proportion of those tested was highly variable between MSs. Notably, Bulgaria reported an increase in *Brucella*-positive cattle herds but did not submit any surveillance data for brucellosis in sheep and goats.

Nevertheless, from 2014 to 2023, as well as from 2022 to 2023, the overall number of reported positive ruminants in the UEP zones decreased notably, with a decrease in prevalence. In Italy, remaining problems were concentrated in the southern part of the country. Moreover, the infection was present in water buffaloes from the provinces of Caserta, where the prevalence and incidence of infection have remained high in recent years. In UEP zones, non-food-borne transmission of brucellosis to humans may still occur through direct contact with infected animals. People working with farm animals,
including farmers, livestock breeders, butchers, slaughterhouse workers and veterinarians, are known to be at increased risk of brucellosis in endemic countries.

In the Balkans, in EU candidate countries, Albania reported positive results for bovine brucellosis, and Kosovo,<fnref n="39" /> the Republic of North Macedonia and Serbia reported positive results for brucellosis in cattle, sheep and goats.

Attention should also be paid to canine brucellosis cases, which are also considered zoonotic, even though this infection is not included in Directive 2003/99/EC. After 2020, an increased number of cases caused by *B. canis* was described in Western Europe (Djokic et al., 2023) and was associated with an updated risk assessment and new importation rules in the United Kingdom (UKHSA, 2023). Moreover, cases of *B. suis* infections in domestic dogs have been reported in France and Germany, with identification of *B. suis* biovar 2 (Girault et al., 2023) and biovar 1 (Aurich et al., 2023) respectively. The Netherlands already reported a case of *B. suis* biovar 1 in a dog in 2018 related to importation of hare meat (van Dijk et al., 2018). These new cases highlight the importance of diagnosing smooth *Brucella* strains in dogs, including *B. abortus*, *B. melitensis* and *B. suis*.

In conclusion, although cases of brucellosis in humans and ruminants are declining in the European Union, brucellosis is still an animal health concern with public health relevance, especially in southern European and Balkan countries that are not free from the disease.

## 7 | TRICHINELLA

### Human cases [EU, 2023]
Notification rate (per 100,000 population) 0.02

76 Cases of illness

68 Infections acquired in the EU

6 Infection acquired outside the EU

2 Unknown travel status or unknown country of infection

14 Hospitalisations (25.0%)*

<figure><img src="image_82.png" /></figure>

### Foodborne outbreaks & related cases [EU, 2023]

3 Foodborne outbreaks

2 Strong-evidence outbreaks

1 Weak-evidence outbreaks

31 Cases of illness

5 Hospitalisations (16.1%)*

N of outbreaks

N of outbreaks per 100,000 population **

N of outbreak cases per 100,000 population

<table><tr><td>Austria</td><td>0</td></tr><tr><td>Belgium</td><td>0</td></tr><tr><td>Bulgaria</td><td>1</td></tr><tr><td>Croatia</td><td>0</td></tr><tr><td>Cyprus</td><td>0</td></tr><tr><td>Czechia</td><td>0</td></tr><tr><td>Denmark</td><td>0</td></tr><tr><td>Estonia</td><td>0</td></tr><tr><td>Finland</td><td>0</td></tr><tr><td>France</td><td>0</td></tr><tr><td>Germany</td><td>0</td></tr><tr><td>Greece</td><td>0</td></tr><tr><td>Hungary</td><td>0</td></tr><tr><td>Ireland</td><td>0</td></tr><tr><td>Italy</td><td>0</td></tr><tr><td>Latvia</td><td>0</td></tr><tr><td>Lithuania</td><td>0</td></tr><tr><td>Luxembourg</td><td>0</td></tr><tr><td>Malta</td><td>0</td></tr><tr><td>Netherlands</td><td>0</td></tr><tr><td>Poland</td><td>0</td></tr><tr><td>Portugal</td><td>0</td></tr><tr><td>Romania</td><td>1</td></tr><tr><td>Slovakia</td><td>0</td></tr><tr><td>Slovenia</td><td>0</td></tr><tr><td>Spain</td><td>1</td></tr><tr><td>Sweden</td><td>0</td></tr><tr><td>UK (N. Ireland)</td><td>0</td></tr></table>

<table><tr><td>AT</td><td>0</td></tr><tr><td>BE</td><td>0</td></tr><tr><td>BG</td><td>0.016</td></tr><tr><td>HR</td><td>0</td></tr><tr><td>CY</td><td>0</td></tr><tr><td>CZ</td><td>0</td></tr><tr><td>DK</td><td>0</td></tr><tr><td>EE</td><td>0</td></tr><tr><td>FI</td><td>0</td></tr><tr><td>FR</td><td>0</td></tr><tr><td>DE</td><td>0</td></tr><tr><td>EL</td><td>0</td></tr><tr><td>HU</td><td>0</td></tr><tr><td>IE</td><td>0</td></tr><tr><td>IT</td><td>0</td></tr><tr><td>LV</td><td>0</td></tr><tr><td>LT</td><td>0</td></tr><tr><td>LU</td><td>0</td></tr><tr><td>MT</td><td>0</td></tr><tr><td>NL</td><td>0</td></tr><tr><td>PL</td><td>0</td></tr><tr><td>PT</td><td>0</td></tr><tr><td>RO</td><td>0.005</td></tr><tr><td>SK</td><td>0</td></tr><tr><td>SI</td><td>0</td></tr><tr><td>ES</td><td>0.002</td></tr><tr><td>SE</td><td>0</td></tr><tr><td>XI</td><td>0</td></tr></table>

<table><tr><td>AT</td><td>0</td></tr><tr><td>BE</td><td>0</td></tr><tr><td>BG</td><td>0.016</td></tr><tr><td>HR</td><td>0</td></tr><tr><td>CY</td><td>0</td></tr><tr><td>CZ</td><td>0</td></tr><tr><td>DK</td><td>0</td></tr><tr><td>EE</td><td>0</td></tr><tr><td>FI</td><td>0</td></tr><tr><td>FR</td><td>0</td></tr><tr><td>DE</td><td>0</td></tr><tr><td>EL</td><td>0</td></tr><tr><td>HU</td><td>0</td></tr><tr><td>IE</td><td>0</td></tr><tr><td>IT</td><td>0</td></tr><tr><td>LV</td><td>0</td></tr><tr><td>LT</td><td>0</td></tr><tr><td>LU</td><td>0</td></tr><tr><td>MT</td><td>0</td></tr><tr><td>NL</td><td>0</td></tr><tr><td>PL</td><td>0</td></tr><tr><td>PT</td><td>0</td></tr><tr><td>RO</td><td>0.063</td></tr><tr><td>SK</td><td>0</td></tr><tr><td>SI</td><td>0</td></tr><tr><td>ES</td><td>0.037</td></tr><tr><td>SE</td><td>0</td></tr><tr><td>XI</td><td>0</td></tr></table>

<figure><img src="image_83.png" /></figure>

### Implicated food vehicles (Strong-evidence outbreaks)

#### Top food vehicles

<figure><img src="image_84.png" /></figure>

Pig meat and products thereof

1 Outbreak

<figure><img src="image_85.png" /></figure>

Other or mixed red meat and products thereof

1 Outbreak

<footnote>* The percentages are calculated on the number of cases with information available (for further details see Table 2)</footnote>

<footnote>* The percentages are calculated on the number of cases with information available (for further details see Table 2)</footnote>

<footnote>** Differences among countries shall be interpreted with caution as this indicator depends on several factors including the type of outbreaks under surveillance and does not necessarily reflect the level of food safety in each country.</footnote>

<footnote n="39">³⁹This designation is without prejudice to positions on status, and is in line with UNSCR 1244/1999 and the ICJ Opinion on the Kosovo declaration of independence.</footnote>
The summary data which make up this chapter, as well as additional information on related projects and internet sources, are published for this report on the EFSA Knowledge Junction at Zenodo [here]. Summary statistics on human surveillance data with downloadable files are retrievable using the ECDC Surveillance Atlas of Infectious Diseases available [here].

For additional information about *Trichinella* and for the consultation of data collected, the following interactive tools are available:

Trichinella
▶ DASHBOARD

<figure><img src="image_86.png" /></figure>

Trichinella
▶ STORY MAP

<figure><img src="image_87.png" /></figure>

## 7.1 | Key facts

* In 2023, there were 76 confirmed cases of human trichinellosis, corresponding to a European Union notification rate of 0.02 cases per 100,000 population with an increase of 94.0% compared with 2022 (0.01 cases per 100,000 population).

* The overall notification rate for trichinellosis did not exceed 0.03 cases per 100,000 population in 2019–2023.

* In 2023, no *Trichinella* infections were reported in tested fattening pigs (30 million) or breeding pigs (0.6 million) raised under controlled housing conditions recognised by the competent authorities, in the European Union. This confirms that farming conditions play a crucial role in preventing infection with this zoonosis.

* Among other domestic pigs in the European Union, 46 (0.00003%) out of more than 168 million tested positive for *Trichinella*. Positive domestic pigs were reported by Romania (43), Spain (two) and Croatia<fnref n="40" /> (one).

* As in previous years (2019–2022), no *Trichinella* infections were detected in domestic solipeds within the European Union in 2023.

* In 2023, the proportions of *Trichinella*-positive hunted wild boar and foxes (used as indicator animals) were 0.07% and 1.8%, respectively, compared to 0.08% and 0.95% in 2022.

## 7.2 | Surveillance and monitoring of *Trichinella* in the EU

### 7.2.1 | Humans

For 2023, 26 EU MSs reported information on trichinellosis in humans. The surveillance of *Trichinella* infections is mandatory in all reporting MSs, except in Belgium and France, where the surveillance systems are voluntary. Denmark has no surveillance system for trichinellosis, and the disease is not notifiable or reported at the EU level. Twenty-three MSs used the EU case definition, while other case definitions were used by three MSs. The surveillance systems cover the whole population in all MSs reporting trichinellosis data. All countries reported case-based data except Belgium, Bulgaria, Croatia and the Netherlands, which reported aggregated data.

### 7.2.2 | Animals

**Trichinella monitoring data for domestic pigs, farmed wild boar and solipeds**

In accordance with Commission Implementing Regulation (EU) 2015/1375,<fnref n="41" /> all *Trichinella*-susceptible animals intended for human consumption in the EU, i.e. domestic pigs (both fattening and breeding animals), farmed wild boar and solipeds, should be tested for the presence of *Trichinella* larvae in the muscles unless carcases have undergone a freezing treatment (freezing inactivates the parasite). ISO 18743/2015/Amd 1:2023 (ISO, 2015a) or an equivalent method should be used (Commission Implementing Regulation (EU) 2015/1375). Therefore, data on *Trichinella* infections in these animals are comparable across MSs because the monitoring schemes are harmonised and the data collected and reported to EFSA originate from census sampling (EFSA BIOHAZ Panel, 2013a, 2013b) (Table 1).

Domestic pigs, farmed and hunted wild boar, and other wild animals (e.g. bears) that are not processed to be placed on the EU market (e.g. those intended for own consumption) are exempted from CIR (EU) 2015/1375, and their control falls under national legislation. CIR (EU) 2015/1375 states that the reporting of data for domestic pigs shall, at least, provide specific information related both to the number of animals tested that were raised under controlled housing conditions and

<footnote n="40">⁴⁰Croatia reported only positive results.</footnote>

<footnote n="41">⁴¹Commission Implementing Regulation (EU) 2015/1375 of 10 August 2015 laying down specific rules on official controls for Trichinella in meat (text with EEA relevance). OJ L 212, 11.8.2015, pp. 7–34.</footnote>
to the number of breeding sows, boar and fattening pigs tested. Furthermore, the regulation states that a negligible risk status for a country or region is no longer recognised.

From 2022, for reporting *Trichinella* monitoring results for domestic pigs, MSs have the possibility of specifying whether the pigs were raised under controlled housing conditions officially recognised by the CA or not (Pigs – others). Further voluntary reporting could specify whether these pigs were raised under controlled housing conditions not recognised by the CA or whether they were not raised under controlled housing conditions. When *Trichinella*-positive results are reported, it is mandatory to indicate whether the pigs were raised indoors or outdoors.

## *Trichinella* monitoring data for animals other than domestic pigs, farmed wild boar and solipeds

MSs should monitor the circulation of *Trichinella* in the main natural reservoir hosts (carnivorous and omnivorous animals) to acquire information on the risk of transmission to domestic animals (and from these to humans) and on the introduction of new *Trichinella* species from non-EU countries. However, monitoring data provided by the MSs to EFSA are generated by non-harmonised monitoring schemes across MSs without mandatory reporting requirements. Wild animals are the main reservoir hosts of *Trichinella*, and their biology and ecology vary from one MS to another and from one region or habitat in the same MS to another due to the human and environmental impact on ecosystems, resulting in different transmission patterns and prevalence rates of infection. Therefore, data on *Trichinella* in wild animals are not fully comparable among MSs, as neither harmonised monitoring schemes nor mandatory reporting requirements are in place and the reported findings must be interpreted with caution. These data allow descriptive summaries to be produced at the EU level but preclude any subsequent data analysis, such as assessing temporal and spatial trends (Table 1).

## 7.3 | Results

### 7.3.1 | Overview of key statistics, EU, 2019–2023

Table 41 summarises EU-level statistics on human trichinellosis and *Trichinella* in animals for 2019–2023. More detailed descriptions of these statistics are provided in the subsections below and in the chapter on food-borne outbreaks.

<table><caption>TABLE 41 Summary of *Trichinella* statistics relating to humans (2019–2023), domestic pigs (2022–2023) and other main animal species (2019–2023), EU.</caption><thead><tr><th></th><th>2023</th><th>2022</th><th>2021</th><th>2020</th><th>2019</th><th>Data source</th></tr></thead><tbody><tr><td colspan="7"><strong>Humans</strong></td></tr><tr><td>Total number of confirmed cases</td><td>76</td><td>39</td><td>77</td><td>117</td><td>97</td><td>ECDC</td></tr><tr><td>Total number of confirmed cases/100,000 population (notification rates)</td><td>0.02</td><td>0.01</td><td>0.02</td><td>0.03</td><td>0.02</td><td>ECDC</td></tr><tr><td>Number of reporting MSs</td><td>26</td><td>26</td><td>26</td><td>26</td><td>27</td><td>ECDC</td></tr><tr><td>Infections acquired in the EU</td><td>68</td><td>25</td><td>29</td><td>99</td><td>26</td><td>ECDC</td></tr><tr><td>Infections acquired outside the EU</td><td>6</td><td>1</td><td>2</td><td>2</td><td>2</td><td>ECDC</td></tr><tr><td>Unknown travel status or unknown country of infection</td><td>2</td><td>13</td><td>46</td><td>16</td><td>69</td><td>ECDC</td></tr><tr><td>Number of outbreak-related cases</td><td>31</td><td>68</td><td>2</td><td>119</td><td>44</td><td>EFSA</td></tr><tr><td>Total number of outbreaks</td><td>3</td><td>7</td><td>1</td><td>6</td><td>5</td><td>EFSA</td></tr><tr><td colspan="7"><strong>Animals</strong></td></tr><tr><td colspan="7"><strong>Domestic pigs raised under controlled housing conditions, recognised by the competent authorities</strong></td></tr><tr><td>Number of animals tested</td><td>30,653,165</td><td>34,183,655</td><td>-</td><td>-</td><td>-</td><td>EFSA</td></tr><tr><td>% of positive animals</td><td>0</td><td>0</td><td>-</td><td>-</td><td>-</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>10</td><td>7</td><td>-</td><td>-</td><td>-</td><td>EFSA</td></tr><tr><td colspan="7"><strong>Domestic pigs (other)</strong></td></tr><tr><td colspan="7"><em>Controlled housing conditions not recognised by the competent authorities</em></td></tr><tr><td>Number of animals tested</td><td>17,806,783</td><td>15,644,310</td><td>-</td><td>-</td><td>-</td><td>EFSA</td></tr><tr><td>% of positive animals</td><td>0</td><td>0</td><td>-</td><td>-</td><td>-</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>7</td><td>8</td><td>-</td><td>-</td><td>-</td><td>EFSA</td></tr><tr><td colspan="7"><em>Not controlled housing conditions</em></td></tr><tr><td>Number of animals tested</td><td>133,449,395</td><td>96,748,782</td><td>-</td><td>-</td><td>-</td><td>EFSA</td></tr><tr><td>% of positive animals</td><td>0.00003</td><td>0.00007</td><td>-</td><td>-</td><td>-</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>20</td><td>20</td><td>-</td><td>-</td><td>-</td><td>EFSA</td></tr><tr><td colspan="7"><em>Other, unspecified</em></td></tr><tr><td>Number of animals tested</td><td>17,365,718</td><td>63,084,065</td><td>-</td><td>-</td><td>-</td><td>EFSA</td></tr></tbody></table>

(Continues)
<table><caption>TABLE 41 (Continued)</caption><thead><tr><th></th><th>2023</th><th>2022</th><th>2021</th><th>2020</th><th>2019</th><th>Data source</th></tr></thead><tbody><tr><td>% of positive animals</td><td>0</td><td>0</td><td>-</td><td>-</td><td>-</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>4</td><td>5</td><td>-</td><td>-</td><td>-</td><td>EFSA</td></tr><tr><td><strong>Farmed wild boar</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Number of animals tested</td><td>4726</td><td>5372</td><td>5755</td><td>3922</td><td>7570</td><td>EFSA</td></tr><tr><td>% of positive animals</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>8</td><td>8</td><td>8</td><td>6</td><td>7</td><td>EFSA</td></tr><tr><td><strong>Hunted wild boar<sup>a</sup></strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Number of animals tested</td><td>1,692,182</td><td>1,514,255</td><td>1,786,892</td><td>1,470,830</td><td>1,757,383</td><td>EFSA</td></tr><tr><td>% of positive animals</td><td>0.07</td><td>0.08</td><td>0.07</td><td>0.05</td><td>0.08</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>21</td><td>21</td><td>20</td><td>21</td><td>23</td><td>EFSA</td></tr><tr><td><strong>Foxes</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Number of animals tested</td><td>3731</td><td>6652</td><td>6776</td><td>5764</td><td>6696</td><td>EFSA</td></tr><tr><td>% of positive animals</td><td>1.8</td><td>0.95</td><td>1.6</td><td>0.85</td><td>1.3</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>10</td><td>11</td><td>11</td><td>9</td><td>10</td><td>EFSA</td></tr></tbody></table>

Abbreviations: –, Data not reported; ECDC, European Centre for Disease Prevention and Control; EFSA, European Food Safety Authority; MSs, Member States.

### 7.3.2 | Human trichinellosis

In 2023, 76 confirmed cases of trichinellosis were reported by 11 MSs, which was an increase of 37 cases compared with 2022 (Table 42). The EU notification rate increased by 94.0% from 0.01 per 100,000 in 2022 to 0.02 per 100,000 in 2023. This increase was due to the increment in the number of confirmed human cases reported in 2023 by Romania (+19), Spain (+18), Italy (+8), Austria and Poland (+4 each), Germany (+3) and Croatia, Latvia and Lithuania (+1 each). The number of MSs reporting zero cases in 2023 decreased by 16.7% (N = 15) (Table 42).

In 2023, Latvia and Romania had the highest notification rates in the EU (0.21 and 0.12 cases per 100,000, respectively), followed by Austria (0.07 cases per 100,000) (Table 42).

In 2023, 68 cases (89.5%) of trichinellosis with known travel status and known country of infection were reported as having been acquired in the EU. Three MSs (Austria, Germany and Lithuania) reported seven travel-associated trichinellosis cases, one acquired in Italy and six outside the EU. Travel status was not reported for two cases (2.6%) (Table 41).

<table><caption>TABLE 42 Reported confirmed human cases of trichinellosis and notification rates per 100,000 population in EU MSs and non-MS countries, by country and year, 2019–2023.</caption><thead><tr><th rowspan="3">Country</th><th colspan="2">2023</th><th colspan="2">2022</th><th colspan="2">2021</th><th colspan="2">2020</th><th colspan="2">2019</th></tr><tr><th rowspan="2">National coverage<sup>a</sup></th><th rowspan="2">Data format<sup>a</sup></th><th colspan="2">Confirmed cases and rate</th><th colspan="2">Confirmed cases and rate</th><th colspan="2">Confirmed cases and rate</th><th colspan="2">Confirmed cases and rate</th></tr><tr><th>Cases</th><th>Rate</th><th>Cases</th><th>Rate</th><th>Cases</th><th>Rate</th><th>Cases</th><th>Rate</th></tr></thead><tbody><tr><td>Austria</td><td>Y</td><td>C</td><td>6</td><td>0.07</td><td>2</td><td>0.02</td><td>10</td><td>0.11</td><td>6</td><td>0.07</td><td>1</td><td>0.01</td></tr><tr><td>Belgium<sup>b</sup></td><td>Y</td><td>A</td><td>0</td><td>-</td><td>0</td><td>-</td><td>0</td><td>-</td><td>0</td><td>-</td><td>0</td><td>-</td></tr><tr><td>Bulgaria</td><td>Y</td><td>A</td><td>1</td><td>0.02</td><td>9</td><td>0.13</td><td>29</td><td>0.42</td><td>13</td><td>0.19</td><td>55</td><td>0.79</td></tr><tr><td>Croatia</td><td>Y</td><td>A</td><td>1</td><td>0.03</td><td>0</td><td>0</td><td>17</td><td>0.42</td><td>0</td><td>0.00</td><td>3</td><td>0.07</td></tr><tr><td>Cyprus</td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0.00</td><td>0</td><td>0.00</td><td>0</td><td>0.00</td></tr><tr><td>Czechia</td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0.00</td><td>0</td><td>0.00</td><td>0</td><td>0.00</td></tr><tr><td>Denmark<sup>c</sup></td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td></tr><tr><td>Estonia</td><td>Y</td><td>C</td><td>0</td><td>0</td><td>1</td><td>0.08</td><td>0</td><td>0.00</td><td>0</td><td>0.00</td><td>0</td><td>0.00</td></tr><tr><td>Finland</td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0.00</td><td>0</td><td>0.00</td><td>0</td><td>0.00</td></tr><tr><td>France</td><td>Y</td><td>C</td><td>2</td><td>&lt;0.01</td><td>15</td><td>0.02</td><td>2</td><td>0.00</td><td>1</td><td>0.00</td><td>2</td><td>0.00</td></tr><tr><td>Germany</td><td>Y</td><td>C</td><td>3</td><td>&lt;0.01</td><td>0</td><td>0</td><td>2</td><td>0.00</td><td>1</td><td>0.00</td><td>3</td><td>0.00</td></tr><tr><td>Greece</td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0.00</td><td>0</td><td>0.00</td><td>0</td><td>0.00</td></tr><tr><td>Hungary</td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0.00</td><td>0</td><td>0.00</td><td>0</td><td>0.00</td></tr><tr><td>Ireland</td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0.00</td><td>0</td><td>0.00</td><td>0</td><td>0.00</td></tr><tr><td>Italy</td><td>Y</td><td>C</td><td>12</td><td>0.02</td><td>4</td><td>0.01</td><td>0</td><td>0.00</td><td>79</td><td>0.13</td><td>10</td><td>0.02</td></tr><tr><td>Latvia</td><td>Y</td><td>C</td><td>4</td><td>0.21</td><td>3</td><td>0.16</td><td>7</td><td>0.37</td><td>1</td><td>0.05</td><td>1</td><td>0.05</td></tr><tr><td>Lithuania</td><td>Y</td><td>C</td><td>1</td><td>0.03</td><td>0</td><td>0</td><td>1</td><td>0.04</td><td>0</td><td>0.00</td><td>0</td><td>0.00</td></tr></tbody></table>

<footnote>ªIncluding wild boar without information whether hunted or not.</footnote>
<table><caption>TABLE 42 (Continued)</caption><thead><tr><th rowspan="3">Country</th><th colspan="2">2023</th><th colspan="2">2022</th><th colspan="2">2021</th><th colspan="2">2020</th><th colspan="2">2019</th></tr><tr><th rowspan="2">National coverage<sup>a</sup></th><th rowspan="2">Data format<sup>a</sup></th><th colspan="2">Confirmed cases and rate</th><th colspan="2">Confirmed cases and rate</th><th colspan="2">Confirmed cases and rate</th><th colspan="2">Confirmed cases and rate</th></tr><tr><th>Cases</th><th>Rate</th><th>Cases</th><th>Rate</th><th>Cases</th><th>Rate</th><th>Cases</th><th>Rate</th></tr></thead><tbody><tr><td>Luxembourg</td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0.00</td><td>0</td><td>0.00</td><td>0</td><td>0.00</td></tr><tr><td>Malta</td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0.00</td><td>0</td><td>0.00</td><td>0</td><td>0.00</td></tr><tr><td>Netherlands</td><td>Y</td><td>A</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0.00</td><td>0</td><td>0.00</td><td>1</td><td>0.01</td></tr><tr><td>Poland</td><td>Y</td><td>C</td><td>5</td><td>0.01</td><td>1</td><td>&lt;0.01</td><td>2</td><td>0.01</td><td>11</td><td>0.03</td><td>2</td><td>0.01</td></tr><tr><td>Portugal</td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0.00</td><td>0</td><td>0.00</td><td>1</td><td>0.01</td></tr><tr><td>Romania</td><td>Y</td><td>C</td><td>23</td><td>0.12</td><td>4</td><td>0.02</td><td>6</td><td>0.03</td><td>4</td><td>0.02</td><td>6</td><td>0.03</td></tr><tr><td>Slovakia</td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0.00</td><td>0</td><td>0.00</td><td>0</td><td>0.00</td></tr><tr><td>Slovenia</td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0.00</td><td>0</td><td>0.00</td><td>0</td><td>0.00</td></tr><tr><td>Spain<sup>d</sup></td><td>Y</td><td>C</td><td>18</td><td>0.04</td><td>0</td><td>0</td><td>1</td><td>-</td><td>1</td><td>-</td><td>12</td><td>0.03</td></tr><tr><td>Sweden</td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0.00</td><td>0</td><td>0.00</td><td>0</td><td>0.00</td></tr><tr><td><strong>EU Total 27</strong></td><td></td><td></td><td><strong>76</strong></td><td><strong>0.02</strong></td><td><strong>39</strong></td><td><strong>0.01</strong></td><td><strong>77</strong></td><td><strong>0.02</strong></td><td><strong>117</strong></td><td><strong>0.03</strong></td><td><strong>97</strong></td><td><strong>0.02</strong></td></tr><tr><td>United Kingdom</td><td>Y</td><td>C</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>0</td><td>0.00</td></tr><tr><td><strong>EU Total</strong></td><td></td><td></td><td><strong>76</strong></td><td><strong>0.02</strong></td><td><strong>39</strong></td><td><strong>0.01</strong></td><td><strong>77</strong></td><td><strong>0.02</strong></td><td><strong>117</strong></td><td><strong>0.03</strong></td><td><strong>97</strong></td><td><strong>0.02</strong></td></tr><tr><td>Iceland</td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0.00</td><td>0</td><td>0.00</td><td>0</td><td>0.00</td></tr><tr><td>Norway</td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0.00</td><td>0</td><td>0.00</td><td>0</td><td>0.00</td></tr><tr><td>Liechtenstein</td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0.00</td><td>4</td><td>0.05</td><td>3</td><td>0.03</td></tr><tr><td>Switzerland<sup>e</sup></td><td>Y</td><td>C</td><td>2</td><td>0.02</td><td>4</td><td>0.05</td><td>0</td><td>0.00</td><td></td><td></td><td></td><td></td></tr></tbody></table>

Abbreviation: –, Data not reported.

The number of EU confirmed cases of trichinellosis showed an increase in winter over the period 2019–2023 (Figure 18).

<figure><img src="image_88.png" /><figcaption>**FIGURE 18** Number of confirmed human cases of trichinellosis in the EU by month and year, 2014–2023. Source: Austria, Cyprus, Czechia, Estonia, Finland, Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, Poland, Portugal, Romania, Slovakia, Slovenia and Sweden.</figcaption></figure>

<footnote>ªY: yes; A: aggregated data; C: case-based data.</footnote>

<footnote>ᵇSentinel surveillance changed to comprehensive for trichinellosis for 2023; no rate could be calculated for the country. Before 2023 sentinel surveillance, the disease was not under formal surveillance; notification rates could not be calculated.</footnote>

<footnote>ᶜNo surveillance system.</footnote>

<footnote>ᵈData not complete for 2020–2021. Notification rate could not be calculated.</footnote>

<footnote>ᵉSwitzerland provided data directly to EFSA. The human data for Switzerland include data from Liechtenstein for the years 2019–2020.</footnote>
*Trichinella spiralis* was identified as the causative agent of 34 (44.7%) confirmed human cases reported by five MSs.

In 2023, 31 food-borne outbreak (FBO)-related human trichinellosis cases were reported to EFSA. *Trichinella* was identified in three FBOs reported by three MSs: Bulgaria, Romania and Spain. Two out of three FBOs were reported as strong-evidence FBOs and affected 13 people. One FBO was reported by Spain as a weak-evidence FBO and involved 18 people. The FBO reported as a strong-evidence FBO by Romania was caused by *T. spiralis* whereas the causative agent of the FBO reported by Bulgaria was unknown. One non-MS (Serbia) reported two strong-evidence FBOs, with 12 human cases in which *T. spiralis* was the causative agent identified. More detailed descriptions of these FBOs are provided in the chapter on food-borne outbreaks.

### 7.3.3 | *Trichinella* in food and animals

No MSs reported monitoring data for food for 2023.

In 2023, 31 countries (27 MSs, the United Kingdom (Northern Ireland) and three non-MSs) provided information on *Trichinella* in domestic animals (pigs and/or farmed wild boar). Nine MSs and the United Kingdom (Northern Ireland) reported data on breeding (N=652,504) and/or fattening pigs (N=30,000,661) raised under controlled housing conditions officially recognised by the CA; no positive findings were reported. Seven MSs and one non-MS (Iceland) reported data on breeding and/or fattening pigs raised under controlled housing conditions not recognised by the CA; no positive findings were reported. Nineteen MSs, the United Kingdom (Northern Ireland) and two non-MSs reported data on breeding and/or fattening pigs not raised under controlled housing conditions (Table 41) 46 positive findings were reported (Table 43). Moreover, eight MSs reported monitoring data in farmed wild boar with no positive results reported (Table 41).

<table><caption>**TABLE 43** Positive *Trichinella* monitoring results for domestic pigs not raised under controlled housing conditions, in reporting EU MSs and non-MS countries, 2023.</caption><thead><tr><th rowspan="2">Country</th><th colspan="2">N positive/tested (% positive)</th></tr><tr><th>Fattening pigs</th><th>Breeding pigs</th></tr></thead><tbody><tr><td>Croatia<sup>a</sup></td><td>–</td><td>1/1 (100)<sup>b</sup></td></tr><tr><td>Romania<sup>c</sup></td><td>43/196,620 (0.02)</td><td>–</td></tr><tr><td>Spain<sup>a</sup></td><td>2/6293 (0.03)</td><td>–</td></tr><tr><td>EU Total (27 + XI)</td><td>45/127,455,407<sup>d</sup> (0.00004)</td><td>1/5,993,988<sup>d</sup> (0.0002)</td></tr><tr><td>Total non-EU countries</td><td>0/3,910,961<sup>d</sup> (0)</td><td>0/0 (0)</td></tr><tr><td>Total EU (27+ XI) + non-EU countries</td><td>45/131,366,368<sup>d</sup> (0.00004)</td><td>1/5,993,988<sup>d,e</sup> (0.0002)</td></tr></tbody></table>

Three MSs (Croatia, Romania and Spain) reported positive findings for domestic pigs not raised under controlled housing conditions with a total of 46 (0.000034%) positive out of 133 million animals tested in 27 MSs and the United Kingdom (Northern Ireland). Croatia reported one positive outdoor breeding pig, Romania reported 43 positive indoor fattening pigs and Spain reported two positive outdoor fattening pigs (Table 43). Species identification was reported for 41 (89.1%) of 46 pigs. *T. spiralis* was detected in 32 (78.0%) and *T. britovi* in nine (21.9%) of the 41 pigs for which species identification was reported. As in previous years, these *Trichinella* infections were found in pigs not raised under controlled housing conditions (Romania) or in free-range and backyard pigs reared in rural EU regions (Spain and Croatia).

In 2023, as in the previous 5-year period (2018–2022), positive findings were not reported either in 91,597 domestic solipeds tested in 20 MSs or in 9730 domestic solipeds tested in two non-MSs (Iceland and Switzerland).

<footnote><sup>a</sup>Outdoor pigs.</footnote>

<footnote><sup>b</sup>Sow from a mixed herd. Croatia reported only positive results.</footnote>

<footnote><sup>c</sup>Indoor pigs.</footnote>

<footnote><sup>d</sup>Total N tested includes samples from additional countries not listed in the table, as no positive *Trichinella* monitoring results (N positive) were reported for those countries. However, their data contribute to the overall total number of animals sampled and tested (N tested).</footnote>

<footnote><sup>e</sup>Portugal informed during the last phase of the production of this report of a reporting error and that 2,664 fattening pigs not raised under controlled housing conditions were mistakenly reported as outdoor breeding pigs.</footnote>
<table><caption>TABLE 44 Trichinella monitoring results for hunted wild boar and wild boar with unspecified habitat and foxes, in reporting EU MSs and non-MS countries, 2023.</caption><thead><tr><th rowspan="2">Country</th><th colspan="2">N positive/tested (% positive)</th></tr><tr><th>Hunted or unspecified wild boar</th><th>Foxes</th></tr></thead><tbody><tr><td>Austria</td><td>–</td><td>2/159 (1.3)</td></tr><tr><td>Bulgaria</td><td>128/31,298 (0.41)</td><td>–</td></tr><tr><td>Croatia</td><td>65/49,985 (0.13)</td><td>–</td></tr><tr><td>Czechia</td><td>1/255,657 (&lt; 0.01)</td><td>–</td></tr><tr><td>Estonia</td><td>11/3386 (0.32)</td><td>–</td></tr><tr><td>Finland</td><td>1/595 (0.17)</td><td>53/176 (30.1)</td></tr><tr><td>France</td><td>4/55,035 (&lt; 0.01)</td><td>–</td></tr><tr><td>Germany</td><td>20/416,930 (&lt; 0.01)</td><td>–</td></tr><tr><td>Hungary</td><td>4/33,863 (0.01)</td><td>–</td></tr><tr><td>Italy</td><td>15/213,445 (&lt; 0.01)</td><td>5/2060 (0.24)</td></tr><tr><td>Latvia</td><td>19/8768 (0.22)</td><td>–</td></tr><tr><td>Poland</td><td>242/219,218 (0.11)</td><td>–</td></tr><tr><td>Romania</td><td>29/7245 (0.4)</td><td>–</td></tr><tr><td>Slovakia</td><td>2/9764 (0.02)</td><td>–</td></tr><tr><td>Slovenia</td><td>4/2953 (0.14)</td><td>5/276 (1.8)</td></tr><tr><td>Spain</td><td>556/210,873 (0.26)</td><td>–</td></tr><tr><td>Sweden</td><td>3/98,365 (&lt; 0.01)</td><td>1/88 (1.1)</td></tr><tr><td>EU Total (27 + XI)</td><td>1104/1,692,182<sup>a</sup> (0.07)</td><td>66/3731<sup>a</sup> (1.8)</td></tr><tr><td>Republic of North Macedonia</td><td>17/4850 (0.35)</td><td>–</td></tr><tr><td>Total non-EU countries</td><td>17/13,817<sup>a</sup> (0.12)</td><td>–</td></tr><tr><td>Total EU (27+ XI) + non-EU countries</td><td>1121/1,705,999<sup>a</sup> (0.07)</td><td>66/3731<sup>a</sup> (1.8)</td></tr></tbody></table>

Sixteen MSs reported positive findings for hunted or unspecified wild boar (1104 positive results out of 1,692,182 animals tested (0.07%) (Table 44)). Species identification was provided for 351 wild boar (31.8%), of which 279 (79.5%) were infected with *T. spiralis*, 69 (19.7%) with *T. britovi* and three (< 0.85%) with *T. pseudospiralis*. For 754 (68.3%) animals, species identification was not reported.

Five MSs (Austria, Finland, Italy, Slovenia and Sweden) reported positive findings for *Trichinella* in foxes (*Vulpes vulpes*) with, in total, 66 (1.8%) positive out of 3731 tested animals in 10 MSs and the United Kingdom (Northern Ireland) (Table 44). *T. britovi* was identified in 12 (92.3%) animals and *T. nativa* in one (7.7%) out of 13 positive foxes with species identification provided.

In 2023, the proportion of positive samples from wildlife was higher in raccoon dogs (32.3%), wolves (10.8%) and lynxes (8.6%) than in other animals sampled but their population sizes and distributions in Europe are generally limited to a few countries.

## 7.4 | Discussion

Trichinellosis is a severe but rare human disease reported by 11 EU MSs in 2023. Seventy-six human cases were reported, with an increased EU notification rate (0.02 cases per 100,000 population) compared to 2022 (0.01 cases per 100,000 population). Fifteen of twenty-six MSs reported zero cases, including four MSs (Cyprus, Finland, Luxembourg and Malta) that have never reported any trichinellosis cases to TESSy.

In general, *Trichinella* infections in humans are often linked to FBOs; therefore, the number and size of FBOs have affected the EU trend for trichinellosis. The EU notification rate was not higher than 0.03 per 100,000 population in the last 5 years, from 2019 to 2023, with the highest rate (0.03) reported in 2020. The lowest rate (0.01) was reported in 2022. In 2023, Romania and Spain together accounted for over half (53.9%) of all confirmed trichinellosis cases in the EU. Three FBOs involving 31 human cases were reported by Bulgaria, Romania and Spain. As in previous years, discrepancies between the number of FBO-related human cases (31) reported to EFSA and the confirmed human cases of trichinellosis (76) reported to TESSy arose from differences in case classification between the two reporting databases.

<footnote><sup>a</sup>Total N tested includes samples from additional countries not listed in the table, as no positive *Trichinella* monitoring results (N positive) were reported for those countries. However, their data contribute to the overall total number of animals sampled and tested (N tested).</footnote>
Pigs are the largest livestock category in the EU for which not all MSs or EEA and EFTA countries report data (i.e. Croatia). In 2023, nearly 200 million pigs were tested for *Trichinella* across MSs, out of over 220 million pigs slaughtered (based on pig-meat production data by the EU Directorate-General for Agriculture and Rural Development) (European Commission, 2024). Of those, only 46 animals tested positive, corresponding to approximately 0.21 cases per million slaughtered pigs, and an overall prevalence of just 0.00002%. Only three of 27 MSs - Croatia, Romania and Spain - reported positive findings for *Trichinella* in pigs. Positive cases were exclusively found in pigs not raised under controlled housing conditions. Croatia and Spain reported one and two positive outdoor pigs, respectively, while Romania documented 43 positive indoor pigs from backyard farms. Ten MSs provided data for pigs raised under controlled housing conditions officially recognised by the CA, and seven MSs reported on pigs raised under controlled housing conditions not recognised by the CA, with no positive cases detected in either group. This confirms that controlled housing conditions play a crucial role for preventing infection with this zoonosis. Pigs most at risk are backyard or free-range pigs, typically slaughtered at home where veterinary controls may be circumvented. *Trichinella*-infected pigs are primarily concentrated in five MSs: Bulgaria, Croatia, Poland, Romania and Spain, though sporadic infections have been reported in other MSs (Pozio, 2014). In 2023, species-level identification of *Trichinella* larvae confirmed that *T. spiralis* was more prevalent in pigs than *T. britovi* (78.0% vs. 21.9%) (Pozio et al., 2009), though *T. spiralis* was unevenly distributed. No cases of *T. pseudospiralis* were reported in 2023, in accordance with the low prevalence of this species in Europe, especially in pigs (Pozio, 2016).

Hunted wild boar meat has been a major source of trichinellosis infections in humans since 2015 according to the data reported to TESSy, whereas earlier, pig meat was the main source. Human behaviour can strongly influence sylvatic cycles, both favouring and reducing the transmission of *Trichinella* spp. For example, carcases of *Trichinella*-infected animals left by hunters, or animals that have died in road accidents, may be scavenged by other wild animals, thereby contributing to transmission.

No positive findings were reported for solipeds in 2023. Over the last 15 years, only four horses tested positive, out of more than two million tested (EFSA and ECDC, 2010, 2011, 2012, 2014, 2015a, 2015b, 2016, 2017, 2018, 2019, 2021a, 2021b, 2022). This extremely low (0.000002%) prevalence may have been related to effective control which, according to the EFSA BIOHAZ Panel (EFSA BIOHAZ Panel, 2013b), should be maintained if there is no reliable traceability system in place, especially since meat from solipeds can be eaten raw in some EU countries.

*Trichinella* spp. circulate widely among wild animals across much of Europe; however, the prevalence of infection in these animals can vary among the sampling areas. Negative findings reported by MSs may result from limited surveys, inadequate sample sizes or investigations in areas where environmental conditions do not support the transmission of these zoonotic nematodes among wildlife. In 2023, some MSs - such as Germany, Italy and Slovakia - tested non-susceptible wild animals (e.g. deer) for *Trichinella* infection, which may have further contributed to the absence of positive results in those cases. Apart from horses, some other herbivores, such as beavers, moose, etc., can be considered accidental hosts of *Trichinella* spp. (Kärssin et al., 2021). High endemicity for *Trichinella* in the sylvatic cycles of these countries and/or convenience sampling might justify surveillance in these animals. The large and widespread population of foxes (indicator animals) can be considered as the main natural reservoir of *Trichinella* in Europe. In 2023, the percentage of positive specimens was 1.8%, which was almost double that observed in 2022 (0.95%). In 2023, the number of MSs reporting data from pigs raised under controlled housing conditions officially recognised by the CA increased to 10, vs. seven in 2022. In most MSs, there has been increased control at slaughter of pigs not raised under controlled housing conditions during the last few years. These measures, combined with trichinellosis awareness-raising and farmers' education activities, may have contributed to a reduction in the parasite biomass in domestic habitats and the probability of acquiring an infection for humans.

Farming practices at risk of transmitting *Trichinella* spp. (rearing outdoor, backyard or free-range pigs (Pozio et al., 2021) occur), in general, in disadvantaged and poor areas where veterinary services do not exist or are unable to control many small pig units, or where veterinary supervision can be circumvented (Pozio, 2014). There are examples from the past where countries had suitable controls in place for parasite management in domestic pigs but where changes in pork production affected by socioeconomic conflicts resulted in the re-emergence of trichinellosis as a severe public health problem (Cuperlovic et al., 2005; Djordjevic et al., 2003). The increasing number of wild boar and foxes and the spread of the raccoon dog population from eastern to western Europe and of the jackal population from southeastern to northwestern Europe may increase the prevalence of *Trichinella* circulating among wild animals (Alban et al., 2011; Széll et al., 2013).
## 8 | ECHINOCOCCUS

### Human cases [EU, 2023]
Notification rate
(per 100,000 population) **0.21**

929 Cases of illness

427 Infections acquired in the EU

103 Infections acquired outside the EU

399 Unknown travel status or unknown country of infection

153 Hospitalisations (37.7%)*

3 Deaths (0.53%)*

<figure><img src="image_89.png" /></figure>

ECDC data

The summary data which make up this chapter, and additional information on related projects and internet sources, are published for this report on the EFSA Knowledge Junction at Zenodo [here]. Summary statistics on human surveillance data with downloadable files are retrievable using the ECDC Surveillance Atlas of Infectious Diseases [here].

For additional information about *Echinococcus* and for the consultation of data collected, the following interactive tools are available:

Echinococcus

<figure><img src="image_90.png" /></figure>

DASHBOARD

<figure><img src="image_91.png" /></figure>

Echinococcus

<figure><img src="image_92.png" /></figure>

STORY MAP

<figure><img src="image_93.png" /></figure>

### 8.1 | Key facts

* In 2023, there were 929 confirmed cases of human echinococcosis, corresponding to a European Union notification rate of 0.21 per 100,000 population and an increase of 8.4% compared with 2022 (0.19 per 100,000 population).

* In 2023, *Echinococcus granulosus sensu lato* causing cystic echinococcosis accounted for 67.3% of human cases reported with species information, while *E. multilocularis* causing alveolar echinococcosis accounted for 32.7% of cases.

* In 2023, *E. multilocularis* was detected by nine Member States and one non-Member State in four different animal categories. Most samples that tested positive in the European Union were from foxes (6399), and the proportion of positives was 15.2%. Czechia, France, Germany, Poland and Slovenia reported the largest proportions of infected foxes among those tested, accounting for 22.0%, 15.2%, 19.7%, 31.2% and 17.6% of positive individuals, respectively.

* In 2023, *E. granulosus sensu lato* was detected by 12 Member States and one non-Member State in nine different animal categories. The majority of the samples tested in the European Union were from sheep and goats (11,543,410), cattle (6,794,791) and pigs (55,162,890), and the proportion of positives was 0.66%, 0.28% and < 0.01%, respectively. Italy and Spain accounted for the largest proportions of sheep and goats (49.0% and 43.4%), cattle (27.3% and 65.2%) and pigs (17.3% and 75.8%) that tested positive, respectively.

* Data from Finland, Ireland, Malta, the United Kingdom (Northern Ireland) and mainland Norway confirmed the free status of these countries for *E. multilocularis* in 2023 in accordance with Commission Delegated Regulation (EU) 2018/772.

### 8.2 | Surveillance and monitoring of cystic and alveolar echinococcosis in humans and animals in the EU

#### 8.2.1 | Humans

For 2023, 26 Member States (MSs) reported information on echinococcosis infections in humans. Surveillance is mandatory in 23 MSs and voluntary in 3 (Belgium, France and the Netherlands). Denmark does not have a surveillance system for echinococcosis. The EU case definition was used by 23 countries; Germany and Italy reported cases using a different case definition, and France did not specify which case definition was used. All MSs except Belgium have comprehensive surveillance systems. The surveillance systems for echinococcosis cover the whole population in all MSs where surveillance systems are in place. All countries reported case-based data except Bulgaria, Croatia and the Netherlands, which reported aggregated data.

<footnote>* The percentages are calculated on the number of cases with information available (for further details see Table 2)</footnote>
Alveolar echinococcosis (AE) caused by the tapeworm *E. multilocularis* and cystic echinococcosis (CE) caused by *E. granulosus sensu lato* (s.l.) are listed under the common disease name 'echinococcosis' in the EU case definition, thus making no distinction between these two diseases. Alveolar echinococcosis and CE can be reported by species and, as of 2019 (2018 data), by clinical presentation of the disease in the ECDC TESSy database.

## 8.2.2 | Animals

Surveillance of *E. multilocularis* in Europe is usually carried out voluntarily, except in the reporting countries claiming to be free of this parasite per Commission Delegated Regulation (CDR) (EU) 2018/772.<fnref n="42" /> Surveillance is mainly carried out in red foxes, Europe's main definitive host. In 2023, Finland, Ireland, mainland Norway (Svalbard archipelago excluded) and the United Kingdom (Northern Ireland) demonstrated the absence of *E. multilocularis* through the implementation of an annual surveillance programme in compliance with CDR (EU) 2018/772 (EFSA, 2024c). In accordance with this regulation, Malta is not required to implement a surveillance programme due to the absence of the definitive host (red fox) on its territory. In all other MSs, data on *E. multilocularis* depend on whether findings are notifiable, monitoring is in place or studies on *E. multilocularis* are performed. Data on *E. multilocularis* in animals vary geographically across and within countries and over time, depending on the sampling effort and it is therefore challenging to compare reported cases of *E. multilocularis* within and between countries. According to a meta-analysis based on studies published between 1900 and 2015, *E. multilocularis* has been documented in red foxes from 21 countries (Oksanen et al., 2016). Since 2018, this parasite has also been found in golden jackals and foxes from Bosnia and Herzegovina, Croatia, Hungary, Serbia and Slovenia (Balog et al., 2021; Dušek et al., 2020; Omeragić et al., 2022; Sindičić et al., 2018). Human AE cases have also been detected recently in Croatia, Italy and Serbia (Dušek et al., 2020; Lalošević et al., 2023; Tamarozzi et al., 2024). In accordance with CIR (EU) 2020/2002, disease-free EU MSs must notify outbreaks of infection with *E. multilocularis* in Canidae to the EU ADIS.<fnref n="43" />

Surveillance of *E. granulosus* s.l. is carried out in livestock intermediate hosts during slaughterhouse inspections. Necropsies on sheep livers and lungs are performed to detect the presence of parasitic cysts. In contrast, methods based on polymerase chain reaction (PCR) methods are used to confirm and identify genotype/species belonging to the *Echinococcus* genus (Siles-Lucas et al., 2017). Although CDR (EU) 2018/772 is in force for *E. multilocularis*, no specific EU regulation is in place for detecting *E. granulosus* s.l. in animals or humans. Surveillance of the latter parasite, therefore, depends on national regulations. Approximate geographical distribution of *E. granulosus* s.l. species causing human CE as well as country-based incidences in Europe were reported recently (Casulli et al., 2022; Casulli et al., 2023).

## 8.3 | Results

### 8.3.1 | Overview of key statistics, EU, 2019–2023

Table 45 summarises EU-level statistics aggregated by year for echinococcosis (AE and CE) in humans and *E. granulosus* s.l. and *E. multilocularis* in their most relevant definitive and intermediate animal hosts in 2019–2023. More detailed descriptions of these statistics are provided in the subsections below.

<table><caption>TABLE 45 Summary statistics on echinococcosis caused by *Echinococcus multilocularis* and *Echinococcus granulosus* s.l. in humans and the most relevant definitive and intermediate animal hosts, EU, 2019–2023.</caption><thead><tr><th></th><th>2023</th><th>2022</th><th>2021</th><th>2020</th><th>2019</th><th>Data source</th></tr></thead><tbody><tr><td><strong>Humans</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Total number of confirmed cases</td><td>929</td><td>739</td><td>592</td><td>547</td><td>779</td><td>ECDC</td></tr><tr><td>Total number of confirmed cases/100,000 population (notification rates)</td><td>0.21</td><td>0.19</td><td>0.17</td><td>0.16</td><td>0.17</td><td>ECDC</td></tr><tr><td>Number of reporting MSs</td><td>26</td><td>25</td><td>25</td><td>25</td><td>26</td><td>ECDC</td></tr><tr><td>Infection acquired in the EU</td><td>427</td><td>294</td><td>173</td><td>132</td><td>176</td><td>ECDC</td></tr><tr><td>Infection acquired outside the EU</td><td>103</td><td>105</td><td>85</td><td>77</td><td>96</td><td>ECDC</td></tr><tr><td>Unknown travel status or unknown country of infection</td><td>399</td><td>340</td><td>334</td><td>338</td><td>507</td><td>ECDC</td></tr></tbody></table>

<footnote n="42">⁴²Commission Delegated Regulation (EU) 2018/772 of 21 November 2017 supplementing Regulation (EU) 576/2013 of the European Parliament and of the Council with regard to preventive health measures for the control of *Echinococcus multilocularis* infection in dogs and repealing Delegated Regulation (EU) 1152/2011 C/2017/7619 OJ L 130, 28.5.2018, pp. 1–10.</footnote>

<footnote n="43">⁴³EU Animal Disease Information System (ADIS). More information is available at: https://food.ec.europa.eu/animals/animal-diseases/animal-disease-information-system-adis_en.</footnote>
<table><caption>**TABLE 45** (Continued)</caption><thead><tr><th></th><th>2023</th><th>2022</th><th>2021</th><th>2020</th><th>2019</th><th>Data source</th></tr></thead><tbody><tr><td><strong>Animals</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td><strong>Echinococcus multilocularis in foxes</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Number of animals tested</td><td>6399</td><td>6331</td><td>6318</td><td>5506</td><td>6326</td><td>EFSA</td></tr><tr><td>positive animals</td><td>15.2</td><td>13.2</td><td>17.0</td><td>16.1</td><td>13.7</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>14</td><td>14</td><td>14</td><td>10</td><td>13</td><td>EFSA</td></tr><tr><td><strong>Echinococcus spp. in dogs</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Number of animals tested</td><td>2619</td><td>2502</td><td>2942</td><td>2515</td><td>2113</td><td>EFSA</td></tr><tr><td>positive animals</td><td>0.73</td><td>0.08</td><td>0.07</td><td>0.08</td><td>0.24</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>6</td><td>7</td><td>5</td><td>5</td><td>6</td><td>EFSA</td></tr><tr><td><strong>Echinococcus granulosus s.l. in cattle (bovine animals)</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Number of animals tested</td><td>6,794,791</td><td>7,185,526</td><td>7,065,934</td><td>7,035,066</td><td>10,956,688</td><td>EFSA</td></tr><tr><td>positive animals</td><td>0.28</td><td>0.32</td><td>0.21</td><td>0.21</td><td>0.17</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>17</td><td>16</td><td>16</td><td>15</td><td>16</td><td>EFSA</td></tr><tr><td><strong>Echinococcus granulosus s.l. in sheep and goats</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Number of animals tested</td><td>11,543,410</td><td>12,337,176</td><td>10,806,419</td><td>11,089,043</td><td>36,890,847</td><td>EFSA</td></tr><tr><td>positive animals</td><td>0.66</td><td>0.81</td><td>0.38</td><td>0.96</td><td>0.38</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>14</td><td>13</td><td>14</td><td>12</td><td>15</td><td>EFSA</td></tr></tbody></table>

Abbreviations: ECDC, European Centre for Disease Prevention and Control; EFSA, European Food Safety Authority; MSs, Member States.

### 8.3.2 | Human echinococcosis

In 2023, 929 confirmed echinococcosis cases were recorded by 26 MSs, corresponding to an EU notification rate of 0.21 cases per 100,000 population (Table 46) and an increase of 8.4% compared with 2022 (0.19 per 100,000 population). A mean notification rate of 0.18 per 100,000 population was reported over 2019–2023. In 2023, 22 MSs reported at least one confirmed case; four MSs reported zero cases (Estonia, Finland, Ireland and Malta); and Denmark did not report any data. In 2023, the highest notification rates were observed in Lithuania and Bulgaria, with 3.1 and 1.8 cases per 100,000 population, respectively, followed by Slovenia and Austria with 0.76 and 0.59 cases per 100,000 population, respectively.

In 2023, more than half of the EU echinococcosis cases (59.3%; 551/929) were reported with data on importation and probable country of infection; 71.3% (393/551) of cases reported with such information were domestic, while 28.7% (158/551) were imported.

<table><caption>**TABLE 46** Reported confirmed human cases of cystic and alveolar echinococcosis and notification rates per 100,000 population in EU MSs and non-MSs, by country and year, 2019–2023.</caption><thead><tr><th rowspan="3">Country</th><th colspan="2">2023</th><th colspan="2">2022</th><th colspan="2">2021</th><th colspan="2">2020</th><th colspan="2">2019</th></tr><tr><th rowspan="2">National coverage<sup>a</sup></th><th rowspan="2">Data format<sup>a</sup></th><th colspan="2">Confirmed cases and rate</th><th colspan="2">Confirmed cases and rate</th><th colspan="2">Confirmed cases and rate</th><th colspan="2">Confirmed cases and rate</th></tr><tr><th>Cases</th><th>Rate</th><th>Cases</th><th>Rate</th><th>Cases</th><th>Rate</th><th>Cases</th><th>Rate</th></tr></thead><tbody><tr><td>Austria</td><td>Y</td><td>C</td><td>54</td><td>0.59</td><td>54</td><td>0.60</td><td>42</td><td>0.47</td><td>34</td><td>0.38</td><td>36</td><td>0.41</td></tr><tr><td>Belgium</td><td>Y</td><td>C</td><td>25</td><td>0.21</td><td>23</td><td>0.20</td><td>17</td><td>0.15</td><td>19</td><td>0.16</td><td>22</td><td>0.19</td></tr><tr><td>Bulgaria</td><td>Y</td><td>A</td><td>117</td><td>1.8</td><td>89</td><td>1.3</td><td>89</td><td>1.3</td><td>95</td><td>1.4</td><td>193</td><td>2.8</td></tr><tr><td>Croatia</td><td>Y</td><td>A</td><td>8</td><td>0.21</td><td>5</td><td>0.13</td><td>3</td><td>0.07</td><td>3</td><td>0.07</td><td>3</td><td>0.07</td></tr><tr><td>Cyprus</td><td>Y</td><td>C</td><td>2</td><td>0.22</td><td>0</td><td>0</td><td>0</td><td>0</td><td>1</td><td>0.11</td><td>0</td><td>0</td></tr><tr><td>Czechia</td><td>Y</td><td>C</td><td>13</td><td>0.12</td><td>10</td><td>0.10</td><td>1</td><td>0.01</td><td>4</td><td>0.04</td><td>1</td><td>0.01</td></tr><tr><td>Denmark<sup>b</sup></td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td></tr><tr><td>Estonia</td><td>Y</td><td>C</td><td>0</td><td>0</td><td>1</td><td>0.08</td><td>4</td><td>0.30</td><td>1</td><td>0.08</td><td>2</td><td>0.15</td></tr><tr><td>Finland<sup>c</sup></td><td>Y</td><td>C</td><td>0</td><td>0</td><td>2</td><td>0.04</td><td>6</td><td>0.11</td><td>4</td><td>0.07</td><td>8</td><td>0.14</td></tr><tr><td>France</td><td>Y</td><td>C</td><td>94</td><td>0.14</td><td>79</td><td>0.12</td><td>75</td><td>0.11</td><td>55</td><td>0.08</td><td>55</td><td>0.08</td></tr><tr><td>Germany</td><td>Y</td><td>C</td><td>186</td><td>0.22</td><td>180</td><td>0.22</td><td>163</td><td>0.20</td><td>171</td><td>0.21</td><td>150</td><td>0.18</td></tr><tr><td>Greece</td><td>Y</td><td>C</td><td>10</td><td>0.10</td><td>5</td><td>0.05</td><td>4</td><td>0.04</td><td>7</td><td>0.07</td><td>7</td><td>0.07</td></tr><tr><td>Hungary</td><td>Y</td><td>C</td><td>19</td><td>0.20</td><td>9</td><td>0.09</td><td>7</td><td>0.07</td><td>4</td><td>0.04</td><td>10</td><td>0.10</td></tr><tr><td>Ireland<sup>c</sup></td><td>Y</td><td>C</td><td>0</td><td>0</td><td>1</td><td>0.02</td><td>1</td><td>0.02</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Italy<sup>d</sup></td><td>Y</td><td>C</td><td>15</td><td>0.03</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td></tr></tbody></table>

(Continues)
<table><caption>TABLE 46 (Continued)</caption><thead><tr><th rowspan="3">Country</th><th colspan="2">2023</th><th colspan="2">2022</th><th colspan="2">2021</th><th colspan="2">2020</th><th colspan="2">2019</th></tr><tr><th rowspan="2">National coverage<sup>a</sup></th><th rowspan="2">Data format<sup>a</sup></th><th colspan="2">Confirmed cases and rate</th><th colspan="2">Confirmed cases and rate</th><th colspan="2">Confirmed cases and rate</th><th colspan="2">Confirmed cases and rate</th></tr><tr><th>Cases</th><th>Rate</th><th>Cases</th><th>Rate</th><th>Cases</th><th>Rate</th><th>Cases</th><th>Rate</th></tr></thead><tbody><tr><td>Latvia</td><td>Y</td><td>C</td><td>7</td><td>0.37</td><td>4</td><td>0.21</td><td>6</td><td>0.32</td><td>5</td><td>0.26</td><td>6</td><td>0.31</td></tr><tr><td>Lithuania</td><td>Y</td><td>C</td><td>89</td><td>3.1</td><td>74</td><td>2.6</td><td>20</td><td>0.72</td><td>37</td><td>1.3</td><td>81</td><td>2.9</td></tr><tr><td>Luxembourg</td><td>Y</td><td>C</td><td>3</td><td>0.45</td><td>1</td><td>0.15</td><td>1</td><td>0.16</td><td>3</td><td>0.48</td><td>1</td><td>0.16</td></tr><tr><td>Malta<sup>c</sup></td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Netherlands</td><td>Y</td><td>A</td><td>46</td><td>0.26</td><td>45</td><td>0.26</td><td>53</td><td>0.30</td><td>48</td><td>0.28</td><td>48</td><td>0.28</td></tr><tr><td>Poland</td><td>Y</td><td>C</td><td>66</td><td>0.18</td><td>46</td><td>0.12</td><td>26</td><td>0.07</td><td>18</td><td>0.05</td><td>70</td><td>0.18</td></tr><tr><td>Portugal</td><td>Y</td><td>C</td><td>2</td><td>0.02</td><td>2</td><td>0.02</td><td>2</td><td>0.02</td><td>1</td><td>0.01</td><td>5</td><td>0.05</td></tr><tr><td>Romania</td><td>Y</td><td>C</td><td>38</td><td>0.20</td><td>4</td><td>0.02</td><td>1</td><td>0.01</td><td>0</td><td>0</td><td>1</td><td>0.01</td></tr><tr><td>Slovakia</td><td>Y</td><td>C</td><td>10</td><td>0.18</td><td>6</td><td>0.11</td><td>2</td><td>0.04</td><td>3</td><td>0.05</td><td>11</td><td>0.20</td></tr><tr><td>Slovenia</td><td>Y</td><td>C</td><td>16</td><td>0.76</td><td>5</td><td>0.24</td><td>11</td><td>0.52</td><td>3</td><td>0.14</td><td>6</td><td>0.29</td></tr><tr><td>Spain<sup>e</sup></td><td>Y</td><td>C</td><td>90</td><td>0.19</td><td>72</td><td>0.15</td><td>33</td><td>–</td><td>8</td><td>–</td><td>34</td><td>0.07</td></tr><tr><td>Sweden</td><td>Y</td><td>C</td><td>19</td><td>0.18</td><td>22</td><td>0.21</td><td>25</td><td>0.24</td><td>23</td><td>0.22</td><td>26</td><td>0.25</td></tr><tr><td><strong>EU-27 total</strong></td><td></td><td></td><td><strong>929</strong></td><td><strong>0.21</strong></td><td><strong>739</strong></td><td><strong>0.19</strong></td><td><strong>592</strong></td><td><strong>0.17</strong></td><td><strong>547</strong></td><td><strong>0.16</strong></td><td><strong>776</strong></td><td><strong>0.20</strong></td></tr><tr><td>United Kingdom<sup>c</sup></td><td>Y</td><td>C</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td>3</td><td>&lt; 0.01</td></tr><tr><td><strong>EU total</strong></td><td></td><td></td><td><strong>929</strong></td><td><strong>0.21</strong></td><td><strong>739</strong></td><td><strong>0.19</strong></td><td><strong>592</strong></td><td><strong>0.17</strong></td><td><strong>547</strong></td><td><strong>0.16</strong></td><td><strong>779</strong></td><td><strong>0.17</strong></td></tr><tr><td>Iceland</td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Norway<sup>c</sup></td><td>Y</td><td>C</td><td>12</td><td>0.22</td><td>9</td><td>0.17</td><td>11</td><td>0.20</td><td>6</td><td>0.11</td><td>7</td><td>0.13</td></tr><tr><td>Liechtenstein<sup>b</sup></td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td></tr><tr><td>Switzerland<sup>b</sup></td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td></tr></tbody></table>

Abbreviation: –, data not reported.

<sup>aY</sup>: yes; N: no; A: aggregated data; C: case-based data.

<sup>b</sup>No surveillance system.

<sup>c</sup>Finland, Ireland, Malta, the United Kingdom (Northern Ireland) and mainland Norway have been declared free of *Echinococcus multilocularis*.

<sup>d</sup>No surveillance system before 2023.

<sup>e</sup>Data incomplete for 2020 and 2021, rate not calculated.

In 2023, considering the country of infection for imported cases (N=158), 21.5% (34/158) were from EU countries, while 65.2% (103/158) were from non-EU countries and 13.3% (21/158) were unknown. For imported cases in the EU, the most probable countries of infection were Bulgaria (32.4%; 11/34) and Romania (32.4%; 11/34).

In 2023, *Echinococcus* species information was provided for 624 out of 929 (67.2%) confirmed echinococcosis cases reported by 22 MSs (Table 47). In 2023, human infections caused by *E. multilocularis* accounted for 204 cases (32.7% of cases with known species information). France, Germany, Poland and Lithuania reported the highest numbers of human cases caused by *E. multilocularis*, accounting for 30.9%, 17.6%, 13.2% and 12.7% of all reported AE cases, respectively. Human infections caused by *E. granulosus* s.l. accounted for 420 cases (67.3%) out of the cases with species information available. Bulgaria and Germany reported the highest numbers of human cases caused by *E. granulosus* s.l., accounting for 27.9% and 26.9% of all reported CE cases, respectively.

<table><caption>TABLE 47 Reported human cases of cystic and alveolar echinococcosis in EU MSs and non-MSs by country, year and *Echinococcus* species, 2019–2023.</caption><thead><tr><th rowspan="2">Country</th><th colspan="3">2023</th><th colspan="3">2022</th><th colspan="3">2021</th><th colspan="3">2020</th><th colspan="3">2019</th></tr><tr><th>Total cases</th><th>Eg</th><th>Em</th><th>Total cases</th><th>Eg</th><th>Em</th><th>Total cases</th><th>Eg</th><th>Em</th><th>Total cases</th><th>Eg</th><th>Em</th><th>Total cases</th><th>Eg</th><th>Em</th></tr></thead><tbody><tr><td>Austria</td><td>54</td><td>24</td><td>14</td><td>54</td><td>24</td><td>8</td><td>42</td><td>24</td><td>7</td><td>34</td><td>18</td><td>4</td><td>36</td><td>16</td><td>13</td></tr><tr><td>Belgium</td><td>25</td><td>13</td><td>12</td><td>23</td><td>11</td><td>12</td><td>17</td><td>11</td><td>6</td><td>19</td><td>10</td><td>8</td><td>22</td><td>12</td><td>10</td></tr><tr><td>Bulgaria</td><td>117</td><td>117</td><td>0</td><td>89</td><td>89</td><td>0</td><td>89</td><td>89</td><td>0</td><td>95</td><td>95</td><td>0</td><td>193</td><td>193</td><td>0</td></tr><tr><td>Croatia</td><td>8</td><td>–</td><td>–</td><td>5</td><td>–</td><td>3</td><td>3</td><td>–</td><td>–</td><td>3</td><td>–</td><td>–</td><td>3</td><td>–</td><td>–</td></tr><tr><td>Cyprus</td><td>2</td><td>–</td><td>–</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>1</td><td>–</td><td>–</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Czechia</td><td>13</td><td>1</td><td>7</td><td>10</td><td>3</td><td>4</td><td>1</td><td>0</td><td>1</td><td>4</td><td>1</td><td>2</td><td>1</td><td>–</td><td>–</td></tr><tr><td>Denmark<sup>a</sup></td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td></tr></tbody></table>
<table><caption>TABLE 47 (Continued)</caption><thead><tr><th rowspan="2">Country</th><th colspan="3">2023</th><th colspan="3">2022</th><th colspan="3">2021</th><th colspan="3">2020</th><th colspan="3">2019</th></tr><tr><th>Total cases</th><th>Eg</th><th>Em</th><th>Total cases</th><th>Eg</th><th>Em</th><th>Total cases</th><th>Eg</th><th>Em</th><th>Total cases</th><th>Eg</th><th>Em</th><th>Total cases</th><th>Eg</th><th>Em</th></tr></thead><tbody><tr><td>Estonia</td><td>0</td><td>0</td><td>0</td><td>1</td><td>0</td><td>1</td><td>4</td><td>-</td><td>-</td><td>1</td><td>1</td><td>0</td><td>2</td><td>-</td><td>-</td></tr><tr><td>Finland<sup>b</sup></td><td>0</td><td>0</td><td>0</td><td>2</td><td>2</td><td>0</td><td>6</td><td>5</td><td>-</td><td>4</td><td>3</td><td>-</td><td>8</td><td>8</td><td>0</td></tr><tr><td>France</td><td>94</td><td>31</td><td>63</td><td>79</td><td>25</td><td>54</td><td>75</td><td>22</td><td>53</td><td>55</td><td>13</td><td>42</td><td>55</td><td>20</td><td>35</td></tr><tr><td>Germany</td><td>186</td><td>113</td><td>36</td><td>180</td><td>103</td><td>50</td><td>163</td><td>97</td><td>43</td><td>171</td><td>81</td><td>54</td><td>150</td><td>87</td><td>41</td></tr><tr><td>Greece</td><td>10</td><td>-</td><td>-</td><td>5</td><td>-</td><td>-</td><td>4</td><td>-</td><td>-</td><td>7</td><td>7</td><td>0</td><td>7</td><td>-</td><td>-</td></tr><tr><td>Hungary</td><td>19</td><td>9</td><td>6</td><td>9</td><td>7</td><td>1</td><td>7</td><td>-</td><td>-</td><td>4</td><td>1</td><td>-</td><td>10</td><td>-</td><td>-</td></tr><tr><td>Ireland<sup>b</sup></td><td>0</td><td>0</td><td>0</td><td>1</td><td>-</td><td>-</td><td>1</td><td>1</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Italy<sup>c</sup></td><td>15</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td></tr><tr><td>Latvia</td><td>7</td><td>4</td><td>-</td><td>4</td><td>-</td><td>-</td><td>6</td><td>6</td><td>0</td><td>5</td><td>5</td><td>0</td><td>6</td><td>4</td><td>-</td></tr><tr><td>Lithuania</td><td>89</td><td>24</td><td>26</td><td>74</td><td>5</td><td>28</td><td>20</td><td>2</td><td>14</td><td>37</td><td>0</td><td>0</td><td>81</td><td>30</td><td>21</td></tr><tr><td>Luxembourg</td><td>3</td><td>3</td><td>0</td><td>1</td><td>1</td><td>0</td><td>1</td><td>-</td><td>-</td><td>3</td><td>3</td><td>0</td><td>1</td><td>1</td><td>0</td></tr><tr><td>Malta<sup>b</sup></td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Netherlands</td><td>46</td><td>-</td><td>-</td><td>45</td><td>-</td><td>-</td><td>53</td><td>-</td><td>-</td><td>48</td><td>-</td><td>-</td><td>48</td><td>-</td><td>-</td></tr><tr><td>Poland</td><td>66</td><td>21</td><td>27</td><td>46</td><td>11</td><td>26</td><td>26</td><td>12</td><td>11</td><td>18</td><td>8</td><td>6</td><td>70</td><td>21</td><td>25</td></tr><tr><td>Portugal</td><td>2</td><td>2</td><td>0</td><td>2</td><td>1</td><td>-</td><td>2</td><td>2</td><td>0</td><td>1</td><td>1</td><td>0</td><td>5</td><td>5</td><td>0</td></tr><tr><td>Romania</td><td>38</td><td>26</td><td>-</td><td>4</td><td>-</td><td>-</td><td>1</td><td>-</td><td>-</td><td>0</td><td>0</td><td>0</td><td>1</td><td>-</td><td>-</td></tr><tr><td>Slovakia</td><td>10</td><td>1</td><td>6</td><td>6</td><td>1</td><td>4</td><td>2</td><td>0</td><td>2</td><td>3</td><td>1</td><td>2</td><td>11</td><td>3</td><td>8</td></tr><tr><td>Slovenia</td><td>16</td><td>4</td><td>5</td><td>5</td><td>1</td><td>-</td><td>11</td><td>2</td><td>2</td><td>3</td><td>1</td><td>-</td><td>6</td><td>1</td><td>-</td></tr><tr><td>Spain<sup>d</sup></td><td>90</td><td>19</td><td>1</td><td>72</td><td>11</td><td>-</td><td>33</td><td>1</td><td>-</td><td>8</td><td>1</td><td>-</td><td>34</td><td>6</td><td>-</td></tr><tr><td>Sweden</td><td>19</td><td>8</td><td>1</td><td>22</td><td>11</td><td>2</td><td>25</td><td>12</td><td>-</td><td>23</td><td>8</td><td>3</td><td>26</td><td>17</td><td>2</td></tr><tr><td>EU-27 total</td><td>929</td><td>420</td><td>204</td><td>739</td><td>306</td><td>193</td><td>592</td><td>286</td><td>139</td><td>547</td><td>258</td><td>121</td><td>776</td><td>424</td><td>155</td></tr><tr><td>United Kingdom<sup>b</sup></td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>3</td><td>3</td><td>0</td></tr><tr><td>EU total</td><td>929</td><td>420</td><td>204</td><td>739</td><td>306</td><td>193</td><td>592</td><td>286</td><td>139</td><td>547</td><td>258</td><td>121</td><td>779</td><td>427</td><td>155</td></tr><tr><td>Iceland</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Norway<sup>b</sup></td><td>12</td><td>1</td><td>2</td><td>9</td><td>-</td><td>1</td><td>11</td><td>5</td><td>-</td><td>6</td><td>1</td><td>1</td><td>7</td><td>2</td><td>-</td></tr><tr><td>Liechtenstein<sup>a</sup></td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td></tr><tr><td>Switzerland<sup>a</sup></td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td></tr></tbody></table>

Abbreviations: -, data not reported; Eg, Echinococcus granulosus sensu lato; Em, Echinococcus multilocularis.

### 8.3.3 | Echinococcus spp. in animals and food

#### Monitoring data for Echinococcus multilocularis

Table 48 shows *Echinococcus multilocularis* positive monitoring results in wild and domestic animals in reporting EU MSs and non-MSs in 2023. In 2023, a total of 13 MSs, the United Kingdom (Northern Ireland) and 2 non-MSs (Norway and Switzerland) reported monitoring data from 6399 and 513 foxes examined for *E. multilocularis*, respectively. Nine MSs (Austria, Czechia, Denmark, France, Germany, Luxembourg, Poland, Slovenia and Sweden) and one non-MS (Switzerland) reported 14.1% positive samples. Czechia, France, Germany, Poland and Slovenia reported the largest numbers of infected foxes in Europe, accounting for 22.0%, 15.2%, 19.7%, 31.2% and 17.6% of positive individuals, respectively.

In addition to its presence in foxes, *E. multilocularis* was reported in 15 other wild species (three wolves in France and three wild boars, two beavers and seven coypus in Germany), 10 pigs (Poland and Switzerland) and 16 dogs (Switzerland). Moreover, 26 pigs tested positive for *Echinococcus* spp. (unspecified) in Slovakia, where circulation of both *E. multilocularis* and *E. granulosus* s.l. is known, meaning that the positive samples could potentially be from animals infected with *E. multilocularis*.

<footnote>aNo surveillance system.</footnote>

<footnote>bFinland, Ireland, Malta, the United Kingdom (Northern Ireland) and mainland Norway have been declared free of E. multilocularis.</footnote>

<footnote>cNo surveillance system before 2023.</footnote>

<footnote>dData not complete for 2020 and 2021.</footnote>
<table><caption>TABLE 48 *Echinococcus multilocularis* positive monitoring results in wild and domestic animals in reporting EU MSs and non-MSs, 2023.</caption><thead><tr><th rowspan="2">Country</th><th rowspan="2">Presence of Em/Eg<sup>a</sup></th><th colspan="3">N positive/N tested (% positive)</th></tr><tr><th>Dogs</th><th>Foxes</th><th>Other wild species<sup>b</sup></th></tr></thead><tbody><tr><td>Austria</td><td>Em</td><td></td><td>18/144 (12.5)</td><td></td></tr><tr><td>Czechia</td><td>Em/Eg</td><td></td><td>552/2511 (22.0)</td><td></td></tr><tr><td>Denmark</td><td>Em</td><td></td><td>6/157 (3.8)</td><td></td></tr><tr><td>France</td><td>Em/Eg</td><td></td><td>25/165 (15.2)</td><td>3/218 (1.4)</td></tr><tr><td>Germany</td><td>Em</td><td></td><td>119/604 (19.7)</td><td>12/69<sup>c</sup> (5.0)</td></tr><tr><td>Luxembourg</td><td>Em</td><td></td><td>4/41 (9.8)</td><td></td></tr><tr><td>Poland</td><td>Em/Eg</td><td></td><td>212/680 (31.2)</td><td></td></tr><tr><td>Slovenia</td><td>Em/Eg</td><td></td><td>33/188 (17.6)</td><td></td></tr><tr><td>Sweden</td><td>Em/Eg</td><td></td><td>3/393 (0.76)</td><td></td></tr><tr><td><strong>EU total (27+XI)</strong></td><td></td><td><strong>0/2619 (0)<sup>d</sup></strong></td><td><strong>972/6399 (15.2)<sup>d</sup></strong></td><td><strong>15/14,058 (0.11)<sup>d,e</sup></strong></td></tr><tr><td>Switzerland</td><td>Em</td><td>16/38 (42.1)</td><td>1/1 (100)</td><td>2/7 (28.6)</td></tr><tr><td><strong>Total non-EU countries</strong></td><td></td><td><strong>16/38 (42.1)</strong></td><td><strong>1/513 (0.19)<sup>d</sup></strong></td><td><strong>2/7 (28.6)</strong></td></tr><tr><td><strong>Total EU (27+XI) + non-EU countries</strong></td><td></td><td><strong>16/2657 (0.60)<sup>d</sup></strong></td><td><strong>973/6912 (14.1)<sup>d</sup></strong></td><td><strong>17/14,065 (0.06)<sup>d,e</sup></strong></td></tr></tbody></table>

Abbreviations: Em, *Echinococcus multilocularis*; Eg, *Echinococcus granulosus* sensu lato.

<sup>a</sup>Presence in the country of *Echinococcus multilocularis* (Em) and/or *Echinococcus granulosus* sensu lato (Eg).

<sup>b</sup>Includes beavers, coypus, jackals, raccoons, raccoon dogs, wolves and wild boars, with positive observed only among wolves and wild boars, and farmed and zoo animals excluded from the total number of animals tested (i.e. N tested).

<sup>c</sup>One positive sample from wild boar, reported without *Echinococcus* species information, was mentioned in the table given the known circulation of *E. multilocularis* in the reporting country.

<sup>d</sup>Total N tested includes samples from additional countries not listed in the table, as no positive monitoring results (N positive) were reported for those countries. However, their data contribute to the overall total number of animals sampled and tested (N tested).

<sup>e</sup>The percentage of positive cases was calculated based on the total number of samples (i.e. N tested) from suitable hosts in countries where *E. multilocularis* is known to circulate.

## Monitoring data for *Echinococcus granulosus* sensu lato

Table 49 shows *Echinococcus granulosus* s.l. positive monitoring results in relevant definitive and intermediate hosts in reporting EU MSs and non-MSs in 2023. In 2023, 20 MSs and two non-MSs (Norway and Switzerland) reported monitoring data for *E. granulosus* s.l. The data reported were from approximately 74 million domestic and wild animals tested for *E. granulosus* s.l., more than 99% of which were domestic animals (sheep, cattle, goats, pigs, horses, water buffalos and dogs). Most of these data were obtained from livestock during meat inspections at the slaughterhouse. Wild animals tested included deer, moose, mouflons, mountain goats, reindeers, wolves and wild boars. A total of 97,327 (0.13%) positive samples were reported by 12 MSs and one non-MS, mainly from domestic animals. These positive samples came primarily from small ruminants (sheep and goats; N = 76,163), accounting for 78.3% of positive results. Positive tests in small ruminants were mainly reported by Italy and Spain, accounting for 49.0% and 43.4% of positive animals, respectively, followed by Bulgaria, Greece and Slovakia. A total of 18,750 cattle tested positive (19.3% of animals positive for *E. granulosus* s.l.), mainly reported by Spain (65.2%) and Italy (27.3%), followed by Bulgaria and Greece. A total of 2314 pigs tested positive (2.4% of animals positive for *E. granulosus* s.l.), of which Spain reported 75.8%.

During the last 5 years (2019–2023), small ruminants accounted for 77.8% of all positive samples for *E. granulosus* s.l. and were mainly reported by a small number of countries (Italy, Spain, Greece and Bulgaria) with large animal populations. During the same period, cattle and pigs accounted for 15.0% and 7.1% of all positive samples for *E. granulosus* s.l., respectively, and were mainly reported by a small number of countries (Italy and Spain for cattle; Poland and Spain for pigs).
<table><caption>TABLE 49 *Echinococcus granulosus* sensu lato positive monitoring results in wild and domestic animals in reporting EU MSs and non-MSs, 2023.</caption><thead><tr><th rowspan="2">Country</th><th rowspan="2">Presence of Em/Eg<sup>a</sup></th><th colspan="6">N positive / N tested (% positive)</th><th rowspan="2">Sheep and goats</th><th rowspan="2">Solipeds, domestic</th><th rowspan="2">Wild species<sup>b</sup></th></tr><tr><th>Buffalos</th><th>Cattle (bovine animals)</th><th>Dogs</th><th>Pigs</th><th>Goats</th><th>Sheep</th></tr></thead><tbody><tr><td>Belgium</td><td>Em</td><td></td><td></td><td></td><td></td><td></td><td>3/75,479 (&lt; 0.01)</td><td></td><td></td><td></td></tr><tr><td>Bulgaria</td><td>Eg</td><td>1268/36,177 (3.5)</td><td></td><td></td><td>130/1,200,664 (0.01)</td><td></td><td></td><td>4366/157,113 (2.8)</td><td></td><td></td></tr><tr><td>Cyprus</td><td>Eg</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td>2/58 (3.4)</td></tr><tr><td>Finland</td><td>Eg</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td>5/63,412 (0.01)</td></tr><tr><td>France</td><td>Em/Eg</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td>3/218 (1.4)</td></tr><tr><td>Greece</td><td>Eg</td><td>8/594 (1.3)</td><td>113/39,924 (0.28)</td><td></td><td></td><td>2/219,449 (&lt; 0.01)</td><td>18/150,646 (0.01)</td><td>800/758,781 (0.11)</td><td></td><td></td></tr><tr><td>Hungary</td><td>Eg</td><td>2/2 (100)</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Italy</td><td>Em/Eg</td><td>3/6082 (0.05)</td><td>5122/1,882,256 (0.27)</td><td>19/238 (8.0)</td><td>400/4,202,000 (0.01)</td><td>496/62,614 (0.79)</td><td>36,817/1,034,031 (3.6)</td><td></td><td></td><td>53/41,508 (0.13)</td></tr><tr><td>Portugal</td><td>Eg</td><td></td><td>7/403,247 (&lt; 0.01)</td><td></td><td>2/5,282,049 (&lt; 0.01)</td><td></td><td>8/598,976 (&lt; 0.01)</td><td></td><td></td><td></td></tr><tr><td>Romania</td><td>Em/Eg</td><td>13/26 (50.0)</td><td></td><td></td><td></td><td></td><td></td><td>3/30 (10.0)</td><td></td><td></td></tr><tr><td>Slovakia</td><td>Em/Eg</td><td>2/30,620 (0.01)</td><td></td><td></td><td>26/517,310 (0.01)<sup>c</sup></td><td></td><td>564/374,039 (0.15)</td><td></td><td></td><td></td></tr><tr><td>Spain</td><td>Eg</td><td>12,223/2,275,285 (0.54)</td><td></td><td></td><td>1754/38,284,434 (&lt; 0.01)</td><td>3581/1,130,562 (0.32)</td><td>29,507/6,789,618 (0.43)</td><td></td><td>1/10,391 (0.01)</td><td>6/408,650 (&lt; 0.01)</td></tr><tr><td>EU total (27 + XI)</td><td></td><td>11/6676 (0.16)</td><td>18,750/6,794,791 (0.28)<sup>d</sup></td><td>19/2612 (0.73)<sup>d,e</sup></td><td>2314/55,162,890 (&lt; 0.01)<sup>d,e</sup></td><td>4095/1,441,844 (0.28)<sup>d</sup></td><td>67,702/9,944,453 (0.68)<sup>d</sup></td><td>4366/157,113 (2.8)</td><td>1/14,171 (0.01)<sup>d</sup></td><td>69/577,605 (0.01)<sup>d,e</sup></td></tr><tr><td>Norway</td><td>Eg</td><td>0/0 (0)</td><td>0/302,000 (0)<sup>d</sup></td><td>0/0 (0)</td><td>0/1,600,000 (0)<sup>d,e</sup></td><td>0/26,000 (0)<sup>d</sup></td><td>0/1,100,000 (0)<sup>d</sup></td><td>0/0 (0)</td><td>0/0 (0)</td><td>4/9 (44.4)</td></tr><tr><td>Total non-EU countries</td><td></td><td>11/6676 (0.16)</td><td>18,750/7,096,791 (0.26)<sup>d</sup></td><td>19/2612 (0.73)<sup>d,e</sup></td><td>2314/56,762,890 (&lt; 0.01)<sup>d,e</sup></td><td>4095/1,467,844 (0.28)<sup>d</sup></td><td>67,702/11,044,453 (0.61)<sup>d</sup></td><td>4366/157,113 (2.8)</td><td>1/14,171 (0.01)<sup>d</sup></td><td>73/577,614 (0.01)<sup>d,e</sup></td></tr><tr><td>Total EU (27+ XI) + non-EU countries</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr></tbody></table>

Abbreviations: Em, *Echinococcus multilocularis*; Eg, *Echinococcus granulosus sensu lato*.

<sup>a</sup>Presence in the country of *E. multilocularis* (Em) and/or *E. granulosus sensu lato* (Eg).

<sup>b</sup>Includes deer, moose, mouflons, mountain goats, reindeers, wolves and wild boars, with farmed and zoo animals excluded from the total number of animals tested (i.e. N tested).

<sup>c</sup>Positive samples with unspecified *Echinococcus* species.

<sup>d</sup>Total N tested includes samples from additional countries not listed in the table, as no positive monitoring results (N positive) were reported for those countries. However, their data contribute to the overall total number of animals sampled and tested (N tested).

<sup>e</sup>The percentage of positive cases was calculated based on the total number of samples (i.e. N tested) from suitable hosts in countries where *E. granulosus sensu lato* is known to circulate.
## 8.4 | Discussion

In 2023, the EU notification rate of confirmed human echinococcosis cases increased when compared with previous data reported from 2019 to 2022. This peak, corresponding to the highest number of confirmed human cases (N=929) in the last 15 years, may be explained by increased human surveillance activities and improved notification systems for these diseases. For instance, Italy notified cases for the first time in 2023, reporting 15 cases of echinococcosis to the ECDC TESSy database. Increased awareness about the diseases among clinicians, as well as immigration from endemic countries, may also have influenced the numbers of CE and AE diagnosed cases in some non-endemic countries in Northern Europe (Scandinavia) and Western Europe (Casulli et al., 2022; Casulli et al., 2023; Richter et al., 2019). The recent discovery of AE in other countries such as Croatia, Italy and Serbia points to a geographical spread of the parasite (Balen et al., 2023; Lalošević et al., 2023; Tamarozzi et al., 2024). It should be emphasised that the true proportion of positive samples of these diseases is extremely difficult to estimate due to the long incubation period (years), high proportion of asymptomatic or paucisymp- tomatic carriers who never seek medical attention, non-specific symptoms and under-reported or misdiagnosed CE and AE cases. The factors mentioned above contribute to underestimation of the burden of these diseases (Casulli, 2020). For these reasons, the patchy data reported by MSs on the number of people with echinococcosis currently represent the ‘tip of the iceberg’ for infections, with asymptomatic carriers and misdiagnosed cases of CE and AE making up the invisible portion. For instance, it has been estimated that the official figures from hospital records should be far higher, with true values 10 and 700 times greater for Bulgaria and Romania in 2015–2016, respectively (Tamarozzi et al., 2018). More recently, a multicentred retrospective study to lower uncertainty limits on the impact of human CE identified around 65,000 human cases in Europe in 1997–2021 (Casulli et al., 2023). Using different data sources, this study also identified a total number of CE cases fourfold greater than ECDC data in 2017–2019 (Casulli et al., 2023).

In 2023, 25 MSs, the United Kingdom (Northern Ireland) and two non-MSs (Norway and Switzerland) reported moni- toring data on *E. granulosus* s.l. and *E. multilocularis* in animals. No data were reported by Croatia, Iceland or Lithuania. As for 2022, in 2023 the highest numbers of animals infected with *E. granulosus* s.l. were reported in Italy and Spain, followed by Bulgaria and Greece. Infections were mainly observed in sheep intermediate hosts and, to a lesser extent, in cattle and goats. Regarding *E. multilocularis*, similarly to data reported in 2022, in 2023 most of the infected animals (primarily red foxes) were reported by Czechia, followed by Poland and Germany. The surveillance of *E. multilocularis* in foxes is important for assessing the proportion of positive samples of AE in Europe, given that its geographical distribution seems to have widened in recent decades. It is difficult to establish whether the increased geographical distribution of *E. multilocularis* is due to a growing fox population in Europe (Deplazes et al., 2004) or whether it reflects greater surveillance efforts, as there is a general lack of baseline data and standardised detection methods. One growing concern is the detection in recent years of *E. multilocularis* in golden jackals, which are extending their geographical range from southeastern to northwestern Europe, and therefore contributing to the dispersion of this parasite over long distances (Balog et al., 2021; Dušek et al., 2020). In this context, *E. multilocularis* was detected for the first time in Serbia (in golden jackals and foxes) and in Bosnia and Herzegovina (in foxes) (Marinković et al., 2022; Miljević et al., 2021; Omeragić et al., 2022).

Moreover, in animals, notification is necessary to obtain reliable data, and information on parasite speciation is essential to risk management efforts, since *E. granulosus* s.l. and *E. multilocularis* have different epidemiologies and pose different health risks for humans (Conraths et al., 2017; Possenti et al., 2016). For *E. granulosus* s.l., requiring notification would ensure that comparable data between MSs are obtained from meat inspections of food-producing animals. For *E. multilocularis*, while the need for general notification by all MSs may raise questions, it is nevertheless required in countries free from this parasite, per CDR (EU) 2018/772.
# FOOD-BORNE OUTBREAKS (IN ACCORDANCE WITH DIRECTIVE 2003/99/EC)

The summary data which make up this chapter, as well as additional information on related projects and internet sources, are published for this report on the EFSA Knowledge Junction at Zenodo here.

For additional information about food-borne outbreaks and for the consultation of data collected, the following interactive tools are available:

Foodborne outbreaks

<figure><img src="image_94.png" /></figure>

DASHBOARD

<figure><img src="image_95.png" /></figure>

Foodborne outbreaks

<figure><img src="image_96.png" /></figure>

STORY MAP

<figure><img src="image_97.png" /></figure>

## 1 | KEY FACTS

* In 2023, 27 European Union Member States and the United Kingdom (Northern Ireland) reported 5691 food-borne outbreaks, 52,127 human cases, 2894 hospitalisations and 65 deaths. The number of deaths in 2023 was similar to that reported in 2022 (one more death in 2023) and was the highest value reported in the last 10 years. A total of 100 food-borne outbreaks, 1158 cases of illness, 125 hospitalisations and eight deaths were reported by seven non-Member States.

* Food-borne outbreaks in the European Union decreased slightly by 1.2% in 2023 compared with the previous year (5763 in 2022). Conversely, the number of human cases and hospitalisations increased, by 7.2% (48,605 cases in 2022) and 4.0% (2783 hospitalisations in 2022), respectively. The number of deaths also increased in 2023, by 1.6% (64 deaths in 2022).

* The food-borne outbreak reporting rate was 1.3 per 100,000 population, an increase of 26.2% compared with the mean annual rate for the period 2019–2022 (1.0 per 100,000 population). The case reporting rate rose to 11.6 cases per 100,000 population, an increase of 41.8% compared with the mean annual rate for the 2019–2022 period (8.2 per 100,000 population).

* *Salmonella* was identified in the most food-borne outbreaks with known causative agents (N=1115) and it was associated with the highest number of human cases (N=9210), hospitalisations (N=1726) and deaths (N=16). S. Enteritidis was the most frequently reported serovar (542 food-borne outbreaks; 81.5% of *Salmonella* outbreaks with serovar information available). *Salmonella* was also the causative agent associated with the most multi-country food-borne outbreaks reported in the European Union in 2023 (17 food-borne outbreaks; 81.0% of the total for multi-country food-borne outbreaks).

* *Listeria monocytogenes* caused 11 deaths, which is a high number since this agent caused only a small number of food-borne outbreaks (N=19), confirming its high health impact in terms of case fatality rate (8.3% of cases) and proportion of hospitalisations (63.2% of cases).

* The proportion of food-borne outbreaks of unknown aetiology accounted for 48.4% of total reported food-borne outbreaks and was the highest value reported since 2014. The Netherlands, France and Belgium contributed most to this reporting.

* A total of 51 very large food-borne outbreaks (≥ 100 cases each) were reported. They were mainly caused by *Salmonella*, norovirus and other calicivirus, and bacterial toxins (i.e. *Bacillus cereus*, *Clostridium perfringens* and *Staphylococcus aureus* toxins), followed by *Cryptosporidium*, enteroinvasive *E. coli* (EIEC), *Campylobacter*, enterotoxigenic *E. coli* (ETEC), atropine and histamine.

* A total of 578 strong-evidence outbreaks were reported in 2023 (10.2% of all food-borne outbreaks), causing 11,160 human cases, 944 hospitalisations and 18 deaths.

* Foodstuffs belonging to the group 'composite foods, multi-ingredient foods and other foods' were implicated in most of these food-borne outbreaks (179 strong-evidence food-borne outbreaks; 31.0% of strong-evidence food-borne outbreaks) with an increase of 26.1% over 2022 (142 strong-evidence outbreaks in 2022), causing most cases (30.5% of cases in strong-evidence outbreaks) and hospitalisations (35.8% of hospitalisations in strong-evidence food-borne outbreaks). Foods of animal origin had a major impact. 'Eggs and egg products' was the second most frequently reported food vehicle group in strong-evidence food-borne outbreaks. The numbers of strong-evidence food-borne outbreaks (N=95) and hospitalisations (N=125) associated with the consumption of these products were rather stable in 2023, but cases (N=1223) increased by 33.1% (304 more cases than in 2022). 'Broiler meat (G. gallus) and products thereof' and 'fish and fish products' caused 52 and 43 strong-evidence outbreaks, respectively, and ranked third and fourth as implicated foods in strong-evidence food-borne outbreaks. Consumption of 'fish and fish products' was associated with the highest number of deaths among cases in strong-evidence outbreaks (seven deaths).

* Most strong-evidence food-borne outbreaks took place on domestic premises (196 outbreaks; 33.9% of all strong-evidence outbreaks). However, approximately one in four cases and one in four hospitalisations were associated with consumption of food in a 'restaurant or cafe or pub or bar or hotel or catering service' (2608 cases; 23.4% of all strong-evidence outbreak-related cases and 270 hospitalisations; 28.6% of all hospitalisations in strong-evidence outbreaks). In the latter setting, strong-evidence outbreaks increased by 35.1% (134 strong-evidence outbreaks in 2022), with cases
increasing by 47.8% (1764 cases in strong-evidence outbreaks in 2022) and hospitalisations by 101.5% (134 hospitalisations in strong-evidence outbreaks in 2022).

* 'Infected food handler' ranked first among the contributory factors for outbreaks taking place in a 'restaurant, pub, street vendors, take away, etc.' (24 outbreaks, 28.6% of all strong-evidence outbreaks with information on risk factors available). The most frequent factor contributing to strong-evidence outbreaks occurring in 'domestic premises' was 'inadequate heat treatment' (24 outbreaks, 61.5% of all strong-evidence outbreaks with information on risk factors available).

## 2 | SURVEILLANCE AND MONITORING OF FOOD-BORNE OUTBREAKS IN THE EU

Every year, EU Member States (MSs) and non-MSs report to EFSA concerning the food-borne outbreaks (FBOs) occurring in their country, in compliance with Directive 2003/99/EC. The reporting of FBO data is mandatory for EU MSs and based on the standard set out in the guidance document, published annually by EFSA (EFSA, 2024a, 2024b). The key findings are summarised in this report.

EFSA is assigned the task of describing the causative agents and foodstuffs implicated in FBOs, the place of exposure and contributing factors, along with their time trends. The aim is to assess the health impact of FBOs in Europe and to characterise the food vehicles most frequently implicated. Outbreaks are categorised as 'strong evidence' or 'weak evidence' based on the strength of evidence implicating a suspected food vehicle as the cause of the outbreak (EFSA, 2014). The analysis takes account of uncertainty around the evidence implicating a given food as the vehicle of the outbreak, by limiting the description of certain findings (i.e. implicated food vehicles, place of exposure and contributory factors) to strong-evidence outbreaks.

The current data reporting system is known as the European Union Foodborne Outbreak Reporting System (EU-FORS) (EFSA, 2014). It applies to FBOs caused by bacteria, viruses, parasites, fungi and their products, such as toxins and biological amines (e.g. histamine), whether typical food-borne agents or agents for which food-borne transmission is usually accidental. Outbreaks caused by the ingestion of drinking water are also considered in FBO reporting, since drinking water is defined as a food in Regulation (EC) No 178/2002.<fnref n="44" />

A description of the national systems in place for FBO surveillance and reporting can be found in the national zoonoses reports submitted in accordance with Directive 2003/99/EC and published on the EFSA website, together with the EU One Health Zoonoses Report, both available online here.

Information on the surveillance and monitoring of food-borne outbreaks in the EU is also summarised in the EFSA story map (here see story map sections on 'What food-borne outbreaks are and how they are classified', 'Who investigates food-borne outbreaks' and 'EU regulatory framework and the role of EFSA').

## 3 | DATA ANALYSES

Key statistics on FBOs described in this chapter refer to the EU level for 2023, unless specified otherwise. Basic indicators used to describe the impact of FBOs on human health include the total number of outbreaks, cases, the number and proportion of cases (%) leading to hospitalisations or deaths, the mean outbreak size (N cases per outbreak) and its range (minimum and maximum). Outbreak size was categorised as very small (< 10 cases), small (≥10 and < 25 cases), medium (≥ 25 and < 50 cases), large (≥ 50 and < 100 cases) and very large (100 ≥ cases). Outbreak and case reporting rates (per 100,000 population) are used as relative measures of occurrence in the population, allowing a direct comparison among MSs, independently of the size of the population and its variation over time. However, due to the lack of full harmonisation of FBO surveillance among MSs, any direct comparison of findings between countries should be interpreted with caution. Counts of hospitalisations and deaths and the proportion (%) of hospitalisations and deaths among outbreak cases are used as indicators for outbreak severity. However, since the total number of hospitalisations and deaths can be reported as 'unknown' by MSs, these values might be underestimated and should be interpreted with caution.

The causative agents in FBOs in 2023 have been grouped in accordance with the following criteria (see also Section 1 of the FBO addendum for further details on the EFSA Knowledge Junction at Zenodo here):

- 'E. coli' other than STEC' includes any pathogenic *Escherichia coli* other than 'Shiga Toxin-producing *E. coli* (STEC)'. In 2023, this group included 'enteroaggregative *E. coli* (EAEC)', 'enteroinvasive *E. coli* (EIEC)', 'enteropathogenic *E. coli* (EPEC)', 'enterotoxigenic *E. coli* (ETEC)' and 'E. coli', unspecified'.

- 'Bacillus cereus' toxins' includes 'B. cereus' and 'B. cereus' enterotoxins'.

- 'Staphylococcus aureus' toxins' includes 'S. aureus', 'Staphylococcus', unspecified' and 'staphylococcal enterotoxins'.

- 'Norovirus' (and other calicivirus)' includes 'calicivirus, unspecified', 'norovirus' (Norwalk-like virus) and 'sapovirus' (Sapporo-like virus).

<footnote n="44">⁴⁴Regulation (EC) No 178/2002 of the European Parliament and of the Council of 28 January 2002 laying down the general principles and requirements of food law, establishing the European Food Safety Authority and laying down procedures in matters of food safety.</footnote>
Food vehicles have been grouped according to the general criteria (see section 2 of the FBO addendum for further details on the EFSA Knowledge Junction at Zenodo [here] set out in the EFSA data catalogues (EFSA, 2024d). Places of exposure have been grouped according to the general characteristics and level of risk associated with the setting, as well as the process behind food preparation (see section 3 of the FBO addendum for further details on the EFSA Knowledge Junction at Zenodo [here]).

Eurostat data on the resident population (on 1 January 2024) were used to calculate reporting rates at national and EU level. Data from the NISRA<fnref n="45" /> from 2021 were used for the United Kingdom (Northern Ireland).

Short-term variations over time were described using the same metrics (annual mean) by comparison with 2022 and 2019-2022. Long-term variations were also described, taking 2014-2023 as the reference time period. Frequency distributions are shown at EU level. Trends were analysed only at MS level, according to the rationale described in Boelaert et al. (2016) for data quality. Time trends were tested for statistical significance over the period 2014-2023 using the Cox-Stuart sign test, a non-parametric test appropriate for limited numbers of observations. A p-value of < 0.05 was considered to identify a statistically significant trend, beyond chance. Significant long-term trends 2014-2023 may not fully reflect short-term trend fluctuations. The detection of significant trends at national level should be interpreted with caution, following changes in the reporting specifications for FBOs, introduced in 2014 (EFSA, 2014).

Key statistics on FBOs for 2022 and previous years may differ from those published in the European Union One Health 2022 Zoonoses Report, as MSs may have updated their historical data.

# 4 | RESULTS AND DISCUSSION

## 4.1 | Overview of countries reporting food-borne outbreak data, in 2023

In 2023, 27 MSs and the United Kingdom (Northern Ireland) reported a total of 5691 food-borne outbreaks (FBOs), with 52,127 human cases, 2894 hospitalisations and 65 deaths. Luxembourg reported no FBOs occurring in 2023.<fnref n="46" /> In addition, seven non-MSs reported 100 FBOs, 1158 cases, 125 hospitalisations and 8 deaths (Table 50).

The number of FBOs and cases reported by each MS varied considerably across countries. Most outbreaks (4694 outbreaks; 82.5%) and cases (39,185 cases; 75.2%) were limited to a few countries (Belgium, France, Netherlands, Poland and Spain). France was the main contributor, accounting for 35.8% of all FBOs and 38% of all cases reported in 2023, which is consistent with observations from previous years. Most hospitalisations (2140 hospitalisations; 73.9%) and deaths (55 deaths; 84.6%) were also reported by five MSs (France, Germany, Italy, Poland and Spain) only. The outbreak reporting rates and case reporting rates (Table 50), show how frequently FBOs and cases were reported, regardless of the country population size. In 2023, there was an increase of 26.2% in the outbreak reporting rate and of 41.8% in the case reporting rate compared with the respective mean annual rates for the 2019-2022 period. There was enormous variation in these values among MSs. The 'outbreak reporting rate' ranged from 0.03 (Bulgaria) to 6.1 (Belgium), while the 'case reporting rate' ranged from 0.06 (Bulgaria) to 29.7 (Denmark). Considerable variations among MSs were also observed in the 'mean outbreak size' (Table 50). All these indicators provide evidence on the considerable variability in the sensitivity of the surveillance and the types of FBOs monitored across MSs.

Although the number of FBOs reported by MSs and the United Kingdom (Northern Ireland) decreased slightly in 2023 (72 fewer FBOs 1.2% decrease, compared with 2022), a 7.2% increase in the number of human cases was observed (3522 more cases than in 2022), while the overall health impact of FBOs in the EU did not change substantially. A total of 111 more hospitalisations (4.0% increase) and one more death were reported than in 2022. The number of deaths was the highest reported to EFSA since 2014.

At the country level, the relative variation in the number of FBOs and the outbreak-related cases reported in 2023 compared with 2022, are shown in Figure 19 (left panel and right panel, respectively). An increase in the number of FBOs was observed for 16 MSs and the United Kingdom (Northern Ireland), while for nine MSs (Belgium, Czechia, Finland, Germany, Italy, Luxembourg, Netherlands, Slovenia and Sweden) the number of FBOs decreased. For Cyprus and Malta, the number of FBOs reported in 2023 was stable. A similar pattern was observed for outbreak-related cases, with 15 MSs reporting more cases in 2023 and 11 MSs fewer cases.

Information on the type of outbreak was reported for 3866 FBOs (67.9%). All MSs except Bulgaria and the United Kingdom (Northern Ireland), reported 'general' outbreaks (2560 FBOs). For five MSs (Cyprus, Finland, Hungary, Portugal and Slovenia) and the United Kingdom (Northern Ireland), this was the only type of outbreak reported. 'General' outbreaks involve human cases from more than one household, while 'household' outbreaks, which are usually smaller, are outbreaks where all cases live in a single household. Eighteen MSs provided information on household outbreaks (1283 FBOs), and this was the most frequently reported type of outbreak for nine MSs (Austria, Croatia, Estonia, Greece, Ireland, Italy, Lithuania, Malta and Poland). No 'household' outbreaks were reported by Bulgaria, Cyprus, Denmark, Finland, Germany, Hungary, Portugal, Slovenia and the United Kingdom (Northern Ireland). In general, MSs with the highest 'mean outbreak size' were those that reported predominantly or exclusively 'general' outbreaks. A similar pattern on the type of outbreak

<footnote n="45">⁴⁵Northern Ireland Statistics and Research Agency (NISRA) https://www.nisra.gov.uk/</footnote>

<footnote n="46">⁴⁶Since Luxembourg reported no outbreaks in 2023, it will not be mentioned again in this chapter.</footnote>
was observed in non-MSs, with most outbreaks (57 FBOs) reported as 'general outbreaks' by all non-MSs reporting data to EFSA in 2023, followed by 'household outbreaks' (22 FBOs).

Five MSs (Austria, Belgium, Denmark, France, Italy and Sweden) reported 21 general FBOs as part of multi-country outbreaks in 2023, resulting in 275 cases, 39 hospitalisations and 2 deaths. Three FBOs were reported by Norway as part of a multi-country outbreak. Among MSs, the number of reported FBOs, cases and hospitalisations linked to multi-country outbreaks decreased by 32.3% (10 fewer FBOs than 2022), 66.0% (533 fewer human cases than 2022) and 68.8% (86 fewer hospitalisations than 2022), respectively, compared with 2022. Most multi-country FBOs were caused by *Salmonella* (17 FBOs), followed by *Listeria monocytogenes* (two FBOs), *Bacillus cereus* toxins and *Cryptosporidium* (one FBO each). Rapid information exchange systems, such as the Early Warning Response System (EWRS), EpiPulse and the Rapid Alert System for Food and Feed (RASFF), play a crucial role in real-time alert dissemination across European countries, significantly supporting the investigation of multi-country FBOs.

In 2023, MSs and non-MSs reported a total of 51 and two very large FBOs (≥ 100 cases each), respectively. Overall, the numbers of cases included in these outbreaks were 9898 and 330, respectively.

For a more interactive look at FBO data by reporting countries, visit the dedicated page in the EFSA's dashboard on FBO [here](#).
<table><caption>TABLE 50 Number of food-borne outbreaks, human cases, hospitalisations and deaths, in reporting EU MSs and non-MS countries, 2023.</caption><thead><tr><th rowspan="3">Country</th><th colspan="2">Outbreaks</th><th colspan="4">Cases</th><th colspan="2">Hospitalised</th><th colspan="2">Deaths</th></tr><tr><th rowspan="2">Total (strong-evidence)</th><th rowspan="2">% of total</th><th colspan="2">Outbreaks per 100,000</th><th rowspan="2">N</th><th rowspan="2">% of total</th><th rowspan="2">Mean outbreak size (N) and range (min-max)</th><th colspan="2">Cases per 100,000</th><th rowspan="2">N</th><th rowspan="2">% of total</th><th rowspan="2">N</th><th rowspan="2">% of total</th></tr><tr><th>2023</th><th>2019-2022</th><th>2023</th><th>2019-2022</th></tr></thead><tbody><tr><td>Austria</td><td>42 (12)</td><td>0.74</td><td>0.46</td><td>0.33</td><td>222</td><td>0.43</td><td>5.3 (1-32)</td><td>2.4</td><td>3.1</td><td>38</td><td>1.3</td><td>1</td><td>1.5</td></tr><tr><td>Belgium</td><td>722 (6)</td><td>12.7</td><td>6.1</td><td>4.9</td><td>3188</td><td>6.1</td><td>4.4 (2-124)</td><td>27.1</td><td>21.7</td><td>76</td><td>2.6</td><td>1</td><td>1.5</td></tr><tr><td>Bulgaria</td><td>2 (2)</td><td>0.04</td><td>0.03</td><td>0.08</td><td>4</td><td>0.01</td><td>2.0 (1-3)</td><td>0.06</td><td>1.1</td><td>3</td><td>0.10</td><td>0</td><td>0</td></tr><tr><td>Croatia</td><td>38 (3)</td><td>0.67</td><td>0.99</td><td>0.59</td><td>277</td><td>0.53</td><td>7.3 (2-41)</td><td>7.2</td><td>10.3</td><td>19</td><td>0.66</td><td>1</td><td>1.5</td></tr><tr><td>Cyprus</td><td>1 (0)</td><td>0.02</td><td>0.11</td><td>0.11</td><td>63</td><td>0.12</td><td>63.0 (-)</td><td>6.8</td><td>1.6</td><td>5</td><td>0.17</td><td>0</td><td>0</td></tr><tr><td>Czechia</td><td>31 (9)</td><td>0.54</td><td>0.29</td><td>0.32</td><td>961</td><td>1.8</td><td>31.0 (5-141)</td><td>8.9</td><td>12.5</td><td>52</td><td>1.80</td><td>2</td><td>3.1</td></tr><tr><td>Denmark</td><td>64 (18)</td><td>1.1</td><td>1.1</td><td>0.91</td><td>1760</td><td>3.4</td><td>27.5 (2-323)</td><td>29.7</td><td>25.5</td><td>47</td><td>1.62</td><td>0</td><td>0</td></tr><tr><td>Estonia</td><td>7 (2)</td><td>0.12</td><td>0.51</td><td>0.77</td><td>39</td><td>0.07</td><td>5.6 (2-15)</td><td>2.9</td><td>2.3</td><td>11</td><td>0.38</td><td>0</td><td>0</td></tr><tr><td>Finland</td><td>45 (20)</td><td>0.79</td><td>0.81</td><td>0.87</td><td>980</td><td>1.9</td><td>21.8 (2-150)</td><td>17.6</td><td>16.1</td><td>3</td><td>0.10</td><td>0</td><td>0</td></tr><tr><td>France</td><td>2038 (74)</td><td>35.8</td><td>3.0</td><td>2.2</td><td>19,823</td><td>38.0</td><td>9.7 (2-740)</td><td>29.1</td><td>18.3</td><td>528</td><td>18.2</td><td>23</td><td>35.4</td></tr><tr><td>Germany</td><td>190 (18)</td><td>3.3</td><td>0.23</td><td>0.29</td><td>2248</td><td>4.3</td><td>11.8 (2-538)</td><td>2.7</td><td>1.7</td><td>283</td><td>9.8</td><td>13</td><td>20.0</td></tr><tr><td>Greece</td><td>58 (2)</td><td>1.0</td><td>0.56</td><td>0.12</td><td>359</td><td>0.69</td><td>6.2 (2-69)</td><td>3.4</td><td>3.4</td><td>81</td><td>2.8</td><td>1</td><td>1.5</td></tr><tr><td>Hungary</td><td>32 (12)</td><td>0.56</td><td>0.33</td><td>0.21</td><td>1554</td><td>3.0</td><td>48.6 (2-300)</td><td>16.2</td><td>8.1</td><td>88</td><td>3.0</td><td>0</td><td>0</td></tr><tr><td>Ireland</td><td>31 (0)</td><td>0.54</td><td>0.59</td><td>0.39</td><td>125</td><td>0.24</td><td>4.0 (2-13)</td><td>2.4</td><td>2.1</td><td>8</td><td>0.28</td><td>0</td><td>0</td></tr><tr><td>Italy</td><td>171 (41)</td><td>3.0</td><td>0.29</td><td>0.20</td><td>1271</td><td>2.4</td><td>7.4 (2-107)</td><td>2.2</td><td>2.0</td><td>349</td><td>12.1</td><td>3</td><td>4.6</td></tr><tr><td>Latvia</td><td>11 (0)</td><td>0.19</td><td>0.58</td><td>0.88</td><td>426</td><td>0.82</td><td>38.7 (5-61.2)</td><td>22.6</td><td>16.9</td><td>15</td><td>0.52</td><td>0</td><td>0</td></tr><tr><td>Lithuania</td><td>10 (10)</td><td>0.18</td><td>0.35</td><td>0.68</td><td>31</td><td>0.06</td><td>3.1 (2-8)</td><td>1.1</td><td>4.1</td><td>25</td><td>0.86</td><td>0</td><td>0</td></tr><tr><td>Luxembourg</td><td>0 (0)</td><td>0</td><td>0</td><td>0.16</td><td>-</td><td>-</td><td>-</td><td>0</td><td>2.6</td><td>-</td><td>-</td><td>-</td><td>-</td></tr><tr><td>Malta</td><td>29 (1)</td><td>0.51</td><td>5.4</td><td>6.1</td><td>88</td><td>0.17</td><td>3.0 (2-156)</td><td>16.2</td><td>25.2</td><td>8</td><td>0.28</td><td>0</td><td>0</td></tr><tr><td>Netherlands</td><td>911 (3)</td><td>16.0</td><td>5.1</td><td>4.7</td><td>3500</td><td>6.7</td><td>3.8 (2-184)</td><td>19.7</td><td>18.5</td><td>13</td><td>0.45</td><td>1</td><td>1.5</td></tr><tr><td>Poland</td><td>409 (89)</td><td>7.2</td><td>1.1</td><td>0.81</td><td>4089</td><td>7.8</td><td>10.0 (8-209)</td><td>11.1</td><td>9.2</td><td>669</td><td>23.1</td><td>7</td><td>10.8</td></tr><tr><td>Portugal</td><td>13 (6)</td><td>0.23</td><td>0.12</td><td>0.11</td><td>819</td><td>1.6</td><td>63.0 (3-40)</td><td>7.8</td><td>6.3</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Romania</td><td>16 (14)</td><td>0.28</td><td>0.08</td><td>0.03</td><td>250</td><td>0.48</td><td>15.6 (2-69)</td><td>1.3</td><td>0.66</td><td>97</td><td>3.4</td><td>3</td><td>4.6</td></tr><tr><td>Slovakia</td><td>141 (21)</td><td>2.5</td><td>2.6</td><td>6.0</td><td>663</td><td>1.3</td><td>4.7 (20-20)</td><td>12.2</td><td>19.7</td><td>157</td><td>5.4</td><td>0</td><td>0</td></tr><tr><td>Slovenia</td><td>1 (1)</td><td>0.02</td><td>0.05</td><td>0.08</td><td>20</td><td>0.04</td><td>20.0 (2-580)</td><td>0.94</td><td>4.5</td><td>2</td><td>0.07</td><td>0</td><td>0</td></tr><tr><td>Spain</td><td>614 (201)</td><td>10.8</td><td>1.3</td><td>0.78</td><td>8585</td><td>16.5</td><td>14.0 (2-154)</td><td>17.9</td><td>8.8</td><td>311</td><td>10.7</td><td>9</td><td>13.8</td></tr><tr><td>Sweden</td><td>61 (12)</td><td>1.1</td><td>0.58</td><td>0.61</td><td>772</td><td>1.5</td><td>12.7 (2-5)</td><td>7.3</td><td>11.5</td><td>3</td><td>0.10</td><td>0</td><td>0</td></tr><tr><td>United Kingdom (Northern Ireland)</td><td>3 (1)</td><td>0.05</td><td>0.16</td><td>0.10</td><td>10</td><td>0.02</td><td>3.3 (-)</td><td>0.52</td><td>0.94</td><td>3</td><td>0.10</td><td>0</td><td>0</td></tr></tbody><tfoot><tr><td>EU Total (27 + XI)</td><td>5691 (578)</td><td>100</td><td>1.3</td><td>1.0</td><td>52,127</td><td>100</td><td>9.2 (1-740)</td><td>11.6</td><td>8.2</td><td>2894</td><td>100</td><td>65</td><td>100</td></tr></tfoot></table>

(Continues)
<table><caption>TABLE 50 (Continued)</caption><thead><tr><th rowspan="3">Country</th><th colspan="2">Outbreaks</th><th colspan="4">Cases</th><th colspan="2">Hospitalised</th><th colspan="2">Deaths</th></tr><tr><th rowspan="2">Total (strong-evidence)<br>N</th><th rowspan="2">% of total</th><th colspan="2">Outbreaks per 100,000</th><th rowspan="2">N</th><th rowspan="2">% of total</th><th rowspan="2">Mean outbreak size (N) and range (min-max)</th><th colspan="2">Cases per 100,000</th><th rowspan="2">N</th><th rowspan="2">% of total</th><th rowspan="2">N</th><th rowspan="2">% of total</th></tr><tr><th>2023</th><th>2019-2022</th><th>2023</th><th>2019-2022</th></tr></thead><tbody><tr><td>Albania</td><td>1 (0)</td><td>-</td><td>0.04</td><td>0</td><td>22</td><td>-</td><td>-</td><td>0.80</td><td>0</td><td>3</td><td>-</td><td>0</td><td>-</td></tr><tr><td>Iceland</td><td>4 (0)</td><td>-</td><td>1.0</td><td>0.82</td><td>220</td><td>-</td><td>55.0 (3-19)</td><td>56.7</td><td>15.8</td><td>5</td><td>-</td><td>1</td><td>-</td></tr><tr><td>Montenegro</td><td>4 (0)</td><td>-</td><td>0.65</td><td>0.64</td><td>32</td><td>-</td><td>8.0 (2-140)</td><td>5.2</td><td>11.7</td><td>3</td><td>-</td><td>0</td><td>-</td></tr><tr><td>Norway</td><td>20 (13)</td><td>-</td><td>0.36</td><td>0.61</td><td>382</td><td>-</td><td>19.1 (3-15)</td><td>7.0</td><td>19.4</td><td>4</td><td>-</td><td>0</td><td>-</td></tr><tr><td>Republic of North<br>Macedonia</td><td>9 (3)</td><td>-</td><td>0.49</td><td>0.15</td><td>69</td><td>-</td><td>7.7 (2-19)</td><td>3.8</td><td>4.6</td><td>16</td><td>-</td><td>0</td><td>-</td></tr><tr><td>Serbia</td><td>22 (18)</td><td>-</td><td>0.33</td><td>0.25</td><td>184</td><td>-</td><td>8.4 (2-26)</td><td>2.8</td><td>3.7</td><td>59</td><td>-</td><td>1</td><td>-</td></tr><tr><td>Switzerland<sup>a</sup></td><td>40 (2)</td><td>-</td><td>0.45</td><td>0.33</td><td>249</td><td>-</td><td>6.6 (-)</td><td>2.8</td><td>5.3</td><td>35</td><td>-</td><td>6</td><td>-</td></tr></tbody></table>

<footnote>a For two outbreaks, information on cases was not available. These outbreaks were excluded from the calculation of the mean outbreak size.</footnote>
<figure><img src="image_98.png" /><figcaption>**FIGURE 19** Relative variation (%) in food-borne outbreaks and outbreak-related cases reported in 2023 compared with 2022, by reporting country.</figcaption></figure>

A total of 578 strong-evidence FBOs were identified by 23 MSs (all MSs except Cyprus, Ireland and Latvia) and the United Kingdom (Northern Ireland). This reporting accounted for 10.2% of all FBOs. In 2022, strong-evidence outbreaks accounted for 8.4%. Most strong-evidence FBOs were reported by four MSs (France, Italy, Poland and Spain), which alone accounted for 70.1% of the reporting (405 strong-evidence FBOs).

For the period 2014–2023, the country-level distribution of FBOs by strength of evidence and the outbreak reporting rate (per 100,000 population) in the EU MSs and non-MSs is presented in **Figure 20**. Overall, the number of FBOs observed over the last 10 years has decreased significantly for seven MSs (Austria, Germany, Hungary, Latvia, Lithuania, Romania and Sweden), and increased for two MSs (Italy and Netherlands) and Switzerland. These trends should be interpreted with caution since annual variations may be influenced by changes in the FBO surveillance of MSs, including changes in the procedures for outbreak detection and investigation.

In 2023, there were 20 FBOs involving travel-associated cases, which is the highest value ever reported to EFSA. These FBOs involved 96 cases, 19 hospitalisations but no deaths.
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<figure><img src="image_117.png" /><figcaption>**FIGURE 20** Trends in the number of strong-evidence and weak-evidence outbreaks (left axis) and outbreak reporting rate (per 100,000 population) (right axis) in the EU and reporting EU MSs and non-MSs, 2014–2023. \*Indicates countries with a statistically significant trend (p < 0.05) over the period. Dark red and light red show strong- and weak-evidence outbreaks, respectively. Black dots and lines show FBO reporting rates. The dots, lines and secondary Y-axis in blue or green showing the outbreak reporting rates have been used for Belgium, Latvia, Lithuania, Malta, Netherlands and Slovakia, in order to draw attention to a scale that is different to that of the other countries.</figcaption></figure>