## 4.2 | Overview of causative agents in food-borne outbreaks in 2023

In 2023, a causative agent was identified in 2934 FBOs (51.6% of all FBOs reported in the EU). These outbreaks were responsible for 32,273 cases, 2491 hospitalisations and 43 deaths. Table 51 provides a detailed overview of the causative agents responsible for FBOs in the EU in 2023.

The proportion of FBOs of unknown aetiology (48.4%) was the highest reported by MSs since 2014. The Netherlands (880 FBOs), France (759 FBOs) and Belgium (661 FBOs) contributed most to the reporting of FBOs of unknown aetiology (2300 FBOs; 83.4%).

Sixty-two FBOs with known causative agent (62.0%) and thirty-eight with unknown aetiology (38.0%) were also reported by seven and five non-MSs, respectively. FBOs with unknown causative agents were mostly reported by Switzerland (28 outbreaks).

Among outbreaks with known causative agents, bacteria were reported to have caused most FBOs, followed by bacterial toxins, viruses, 'other' causative agents and parasites. The same ranking was observed for number of cases, hospitalisations and deaths (no deaths were caused by parasites or 'other' causative agents). Among the causative agents, *Salmonella* was responsible for the highest number of FBOs, cases, hospitalisations and deaths. *Listeria monocytogenes* had the most severe health impact in relative terms, i.e. proportion of hospitalisations and case fatality rate, together with *Clostridium botulinum* toxins (Table 51).

The range of causative agents reported in FBOs by MSs and non-MSs was very variable in 2023. This finding likely reflects the differences in the monitoring of FBOs across European countries. A high number of causative agents (more than 10) was reported by six MSs (Belgium, France, Germany, Italy, Poland and Spain) while eight MSs (Bulgaria, Czechia, Estonia, Greece, Hungary, Latvia, Lithuania and Slovenia) and the United Kingdom (Northern Ireland) reported three or less causative agents.

Among travel-related outbreaks, *Salmonella* was the most frequently reported causative agent (11 FBOs), followed by *Campylobacter* (seven FBOs), hepatitis A virus and toxigenic *Vibrio cholerae* (one outbreak each).

In the very large outbreaks (≥ 100 cases, each) reported by MSs in 2023, *Salmonella* and norovirus (and other calicivirus) (eight FBOs each) prevailed followed by bacterial toxins (i.e. *Bacillus cereus*, *Clostridium perfringens* and *Staphylococcus aureus* toxins) (nine FBOs), *Cryptosporidium* (two FBOs), enteroinvasive *E. coli* (EIEC) (two FBOs) and atropine, *Campylobacter*, enterotoxigenic *E. coli* (ETEC) and histamine (one FBO each). For 16 very large FBOs the causative agent was unknown. In non-MSs, one very large FBO was associated with norovirus and one with unknown aetiology.

For a more interactive look at FBO data by causative agents, visit the dedicated page in the EFSA's dashboard on FBO (here).

### 4.2.1 | Bacteria

All MSs, except Bulgaria, Cyprus and the United Kingdom (Northern Ireland), and all non-MSs reported FBOs caused by bacteria. Key statistics on FBOs associated with this agent group are available in Table 51.

#### *Salmonella*

In 2023, FBOs caused by *Salmonella* (1115 FBOs) were reported by most MSs (all except Bulgaria, Cyprus and Portugal) and the United Kingdom (Northern Ireland) as well as by seven non-MSs (26 FBOs). Details on FBOs caused by *Salmonella* are shown in Table 51.

Most FBOs associated with this causative agent were reported by four MSs, i.e. Poland (269 FBOs), Spain (252 FBOs), France (143 FBOs) and Slovakia (120 FBOs), accounting altogether for 70.3% of all *Salmonella* outbreaks in the EU. In 14 MSs (Austria, Croatia, Czechia, Denmark, Estonia, Germany, Greece, Italy, Latvia, Lithuania, Poland, Slovakia, Slovenia and Spain) and 3 non-MSs (Albania, Montenegro and Serbia), *Salmonella* was the leading cause of FBOs.

FBOs caused by *Salmonella* increased moderately, with 101 more FBOs than 2022 (a 10.0% relative increase). The number of *Salmonella* FBOs remained fairly consistent with what has been observed in the last 10 years, excluding the COVID-19 pandemic period (i.e. 2020–2021). Conversely, compared with 2022, cases, hospitalisations and deaths involved in *Salmonella* outbreaks increased sharply in 2023 with 2578 more cases (a 38.9% increase), 320 more hospitalisations (a 22.8% increase) and 8 more deaths (a 100% increase). This increasing pattern was mainly due to the reporting of more FBOs due to **S. Enteritidis**, as described below.

Information on the serovar was available for 59.6% of the FBOs caused by *Salmonella* in the EU (665 FBOs). S. Enteritidis was the most frequently reported serovar (542 FBOs; 81.5% of *Salmonella* FBOs with known serovar), followed by **S. Typhimurium** (50 FBOs) and **monophasic S. Typhimurium** (20 FBOs).

The number of FBOs caused by S. Enteritidis increased compared with 2022, by 37.2% (147 more FBOs than 2022). At country level, there was a similar increase in most MSs (see section 4 of the FBO addendum for further details on the EFSA Knowledge Junction at Zenodo here). The health impact of this serovar was high in the EU. S. Enteritidis caused 5323 cases (2877 more cases than in 2022; a 117.6% increase), 1040 hospitalisations (471 more hospitalisations; an 82.8% increase) and 9 deaths (six more deaths; a 200.0% increase). The increase was attributed to the reporting of more FBOs linked to 'broiler meat (Gallus gallus) and products thereof' and 'mixed foods' as the implicated or suspected food vehicle. S. Enteritidis was responsible for a multi-country outbreak in 2023, probably associated with the consumption of 'chicken meat' and 'chicken meat products'. Five MSs (Austria, Denmark, France, Italy and Sweden) reported data on this multi-country outbreak to EFSA as separate individual outbreaks.
Compared with 2022, the number of FBOs caused by S. Typhimurium and monophasic S. Typhimurium decreased in 2023, by 12.3% (seven fewer FBOs) and 4.8% (one fewer FBO), respectively. Fewer cases than in 2022 resulted also from FBOs caused by either S. Typhimurium (189 fewer cases; a 37.1% decrease) or monophasic S. Typhimurium (132 fewer cases; a 41.6% decrease). There was also a reduction in the number of hospitalisations (nine fewer hospitalisations for S. Typhimurium; an 8.7% decrease and 76 fewer hospitalisations for monophasic S. Typhimurium; a 64.4% decrease).

Among non-typhoidal *Salmonella*, the other serovars identified in FBOs in 2023 accounted overall for 7.8% (52 FBOs) of the total number of *Salmonella* outbreaks with known serovars. They included **S. Adelaide**, **S. Agama**, **S. Ajiobo**, **S. Anatum**, **S. Bareilly**, **S. Brandenburg**, **S. Bredeney**, **S. Chester**, **S. Coeln**, **S. Derby**, **S. Give**, **S. Infantis**, **S. Kentucky**, **S. London**, **S. Mbandaka**, **S. Mikawasima**, **S. Montevideo**, **S. Muenchen**, **S. Newport**, **S. Oranienburg**, **S. Panama**, **S. Rissen**, **S. Saintpaul**, **S. Senftenberg**, **S. Stanley**, **S. Stanleyville**, **S. Strathcona**, **S. Thompson** and **S. Virchow**. S. Montevideo, S. Strathcona and S. Senftenberg were reported by MSs as causative agents associated with four multi-country outbreaks.

Five weak-evidence outbreaks associated with paratyphoid *Salmonella* were reported by three MSs (Belgium, Slovakia and Croatia) in 2023, causing 23 cases and two hospitalisations. Four outbreaks were caused by **S. Paratyphi B** and in one FBO the variant Java was reported. For two FBOs, both weak-evidence FBOs, the suspected food vehicles were 'broiler meat and products thereof' and 'mixed foods'. For one outbreak only **S. Paratyphi** was reported, without specification of the serovar. The suspected food vehicle was 'Pig meat and products thereof'.

### Campylobacter

**Campylobacter** ranked second in 2023 among bacterial causative agents and fourth among all known causative agents in the EU. Compared with 2022, in 2023 the number of FBOs caused by *Campylobacter* (229 FBOs) decreased by 10.2% (26 fewer FBOs) while the number of cases and hospitalisations remained fairly stable, with 77 more cases and seven more hospitalisations than 2022.

Sixteen MSs (Austria, Belgium, Croatia, Denmark, Estonia, France, Germany, Greece, Italy, Lithuania, Malta, Netherlands, Poland, Slovakia, Spain and Sweden) and two non-MSs (Norway and Switzerland) reported FBOs caused by *Campylobacter*. France, Germany and Spain alone accounted for 58.5% of total reporting in the EU. In Malta, *Campylobacter* was the main causative agent of FBOs.

In most FBOs, the *Campylobacter* species involved was unknown (161 FBOs; 70.3% of FBOs caused by *Campylobacter*). Among the FBOs with known species, **C. jejuni** and **C. coli** were identified in 63 and five outbreaks, respectively. No hospitalisations and deaths were reported.

### Shiga toxin-producing E. coli (STEC)

In 2023, **Shiga toxin-producing E. coli (STEC)** was reported as the causative agent of 66 FBOs in the EU, a decrease of 7.0% compared with 2022 (five fewer outbreaks). The number of cases and hospitalisations decreased by 33.8% (138 fewer cases than 2022) and 23.8% (15 fewer hospitalisations). The number of deaths remained stable, with one death reported in 2023.

Ten MSs (Austria, Belgium, Denmark, France, Germany, Ireland, Malta, Netherlands, Poland and Sweden), the United Kingdom (Northern Ireland) and Norway reported FBOs caused by STEC. This agent ranked first in FBOs in Ireland and the United Kingdom (Northern Ireland).

Information on the STEC serogroup was available for 22 outbreaks (33.3% of FBOs caused by STEC in the EU). STEC **O157** was identified in nine FBOs. Among non-O157 STEC, serogroup **O26** (five FBOs) prevailed over **O145** (three FBOs), **O103** (two FBOs), **O146** (two FBOs) and **O63** (one FBO).

### Listeria monocytogenes

In 2023, **L. monocytogenes** was reported as the causative agent of 19 FBOs in the EU. The health impact of FBOs caused by *L. monocytogenes* remained high in 2023 although not comparable to that observed in 2022, which was particularly high due to large listeriosis outbreaks reported from Italy (EFSA and ECDC, 2023). In particular, in 2023 the number of hospitalisations and deaths decreased sharply by 65.3% and 60.7% (158 fewer hospitalisations and 17 fewer deaths), respectively. The number of FBOs and cases decreased by 45.7% and 55.1% (16 fewer FBOs and 163 fewer cases), respectively. *L. monocytogenes* was the causative agent associated with the highest case fatality rate among all causative agents detected in FBOs in 2023.

Overall, eight MSs (Austria, Belgium, Denmark, France, Germany, Hungary, Italy and Sweden) and two non-MSs (Norway and Switzerland) reported FBOs caused by *L. monocytogenes*.

Interestingly, one large strong-evidence outbreak caused by *L. monocytogenes* serotype 4b was reported by Italy. It was responsible for 38 cases, all hospitalised and two deaths. The implicated food vehicle was 'table olives'.

### Other bacteria

In total, 24 FBOs caused by **Shigella** were reported by seven MSs (Belgium, Croatia, France, Ireland, Poland, Slovakia and Spain) in similar numbers compared with 2022. **S. sonnei** and **S. flexneri** were identified in eight and four FBOs, respectively. For 12 outbreaks the species was not specified.
**Escherichia coli other than STEC** were identified in 20 FBOs (five more FBOs than 2022) from eight MSs (Denmark, Finland, France, Ireland, Italy, Romania, Spain and Sweden). Three FBOs were also reported by two non-MSs (Norway and Switzerland). **Enterotoxigenic E. coli (ETEC)** caused two FBOs while **enteropathogenic E. coli (EPEC)**, **enteroinvasive E. coli (EIEC)** and **enteroaggregative E. coli (EAEC)** caused one FBO each. For 10 FBOs the *E. coli* pathogroup was unknown. Denmark and Sweden reported two very large strong-evidence outbreaks. The first involved 197 cases and was associated with EIEC, with 'mixed foods' identified as the implicated food vehicle. The second outbreak, caused by ETEC, involved 154 cases and was linked to parsley as the implicated food. Denmark also reported another very large weak-evidence outbreak caused by EIEC with 114 cases involved.

A total of 17 FBOs caused by **Yersinia** (three more FBOs than in 2022) were reported from seven MSs (Austria, France, Germany, Poland, Slovakia, Spain and Sweden). **Yersinia enterocolitica** was identified in 16 FBOs while for one FBO the *Yersinia* species was unspecified. One FBO caused by *Yersinia* was also reported by one non-MS (Switzerland).

**Vibrio parahaemolyticus** was identified in seven FBOs reported from three MSs (France, Portugal and Spain).

In 2023, for the first time since EFSA began collecting data on FBOs, weak-evidence FBOs caused by **Mycobacterium spp.** and **toxigenic Vibrio cholerae** (one FBO each) were reported. The former outbreak occurred in Ireland and involved a total of three cases living in the same household. Consumption of raw cow's milk was the suspected source of infection. No information was available on the *Mycobacterium* species. The latter was a travel-associated outbreak caused by toxigenic *Vibrio cholerae* and involved three cases reported by Germany. Details on the suspect food vehicle, type of outbreak and place of exposure were not available.

### 4.2.2 | Bacterial toxins

In 2023, FBOs caused by bacterial toxins were reported by 16 MSs (Belgium, Bulgaria, Croatia, Czechia, Denmark, Finland, France, Germany, Hungary, Italy, Poland, Portugal, Romania, Slovakia, Spain and Sweden) and 3 non-MSs (Norway, Republic of North Macedonia and Serbia). France was the main contributor, alone accounting for 86.1% of the reporting (769 FBOs). More information on the outbreaks caused by bacterial toxins in the EU is available in Table 51.

**Bacillus cereus** toxins were the most reported agents in this group, followed by *Staphylococcus aureus* toxins and *Clostridium perfringens* toxins. Outbreaks caused by these pathogens increased by 54.9% (168 more FBOs than in 2022), 51.1% (70 more FBOs) and 154.5% (85 more FBOs), respectively. Conversely, the number of FBOs due to unspecified bacterial toxins decreased significantly, by 89.5% compared with 2022 (569 fewer FBOs).

**Bacillus cereus** toxins ranked second among known causative agents of FBOs in 2023, totalling 474 FBOs, behind only *Salmonella*. Eight MSs (Belgium, Finland, France, Germany, Italy, Portugal, Spain and Sweden) contributed to this reporting. One non-MS (Norway) reported one FBO caused by this agent in 2023. Four deaths were reported among cases involved in FBOs caused by *B. cereus* toxins and were all associated with outbreaks occurring in 'health care and residential facilities', namely in a 'residential institution (prison or boarding school)' (three deaths) and a 'nursing home' (one death).

**Staphylococcus aureus** toxins, reported in 207 FBOs, caused the highest number of hospitalisations among cases involved in FBOs caused by bacterial toxins. Thirteen MSs (Belgium, Croatia, Czechia, Finland, France, Germany, Hungary, Italy, Poland, Portugal, Romania, Slovakia and Spain) and two non-MSs (Republic of North Macedonia and Serbia) reported FBOs linked to *S. aureus* toxins. In Portugal and Romania, *S. aureus* toxins were the leading causative agents of FBOs.

**Clostridium perfringens** toxins were associated with the highest number of cases and deaths. In total, 140 FBOs caused by *C. perfringens* toxins were reported by nine MSs (Belgium, Croatia, Denmark, Finland, France, Germany, Italy, Portugal and Spain). Seven deaths associated with *C. perfringens* toxins were reported from FBOs occurring in a 'residential institution (prison or boarding school)'.

**Clostridium botulinum** toxins were responsible for five FBOs (two fewer outbreaks than in 2022) reported by four MSs (Bulgaria, Italy, Romania and Spain) and three FBOs in two non-MSs (Norway and Serbia). *C. botulinum* toxins were among the causative agents with the highest relative impact on health in 2023, in terms of proportion of hospitalisations and case fatality. All FBOs caused by this agent were very small in size and occurred mainly in 'domestic premises' (four FBOs). One death was reported from Italy, among the cases of botulism notified in 2023. The patient was involved in an outbreak caused by a food belonging to the 'fish and fishery products' vehicle group.
<table><caption>TABLE 51 Number of food-borne outbreaks, human cases, hospitalisations and deaths, by causative agent, in reporting EU MSs, 2023.</caption><thead><tr><th rowspan="3">Type of agent</th><th rowspan="3">Total (strong- evidence)</th><th colspan="3">Outbreaks</th><th colspan="4">Cases of illness</th><th colspan="2">Hospitalisations</th><th colspan="2">Deaths</th></tr><tr><th rowspan="2">N</th><th rowspan="2">% of total<sup>a</sup></th><th colspan="2">Reporting rate per 100,000</th><th colspan="2">Human cases</th><th rowspan="2">Mean outbreak size (cases) and range (min-max)</th><th colspan="2">N</th><th rowspan="2">% of cases<sup>b</sup></th><th rowspan="2">N</th><th rowspan="2">% of cases<sup>b</sup></th></tr><tr><th>2023</th><th>2019-2022</th><th>N</th><th>% of total<sup>a</sup></th><th>% of total</th><th></th><th></th></tr></thead><tbody><tr><td rowspan="10">Bacteria</td><td>Campylobacter</td><td>229 (27)</td><td>4.0</td><td>0.05</td><td>0.07</td><td>1174</td><td>2.3</td><td>5.1 (2-112)</td><td>90</td><td>7.7</td><td>0</td><td>0</td></tr><tr><td>Escherichia coli other than STEC<sup>c</sup></td><td>20 (6)</td><td>0.35</td><td>&lt;0.01</td><td>&lt;0.01</td><td>683</td><td>1.3</td><td>34.2 (2-197)</td><td>3</td><td>0.44</td><td>0</td><td>0</td></tr><tr><td>Listeria monocytogenes</td><td>19 (8)</td><td>0.33</td><td>&lt;0.01</td><td>0.01</td><td>133</td><td>0.26</td><td>7.0 (2-38)</td><td>84</td><td>63.2</td><td>11</td><td>8.3</td></tr><tr><td>Mycobacterium spp.</td><td>1 (0)</td><td>0.02</td><td>&lt;0.01</td><td>0</td><td>3</td><td>0.01</td><td>3.0 (-)</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Salmonella</td><td>1115 (258)</td><td>19.6</td><td>0.25</td><td>0.20</td><td>9210</td><td>17.7</td><td>8.3 (1-300)</td><td>1726</td><td>18.7</td><td>16</td><td>0.17</td></tr><tr><td>Shiga toxin-producing E. coli (STEC)</td><td>66 (6)</td><td>1.2</td><td>0.01</td><td>0.01</td><td>270</td><td>0.52</td><td>4.1 (2-36)</td><td>48</td><td>17.8</td><td>1</td><td>0.37</td></tr><tr><td>Shigella</td><td>24 (2)</td><td>0.42</td><td>0.01</td><td>&lt;0.01</td><td>123</td><td>0.24</td><td>5.1 (2-24)</td><td>24</td><td>19.5</td><td>0</td><td>0</td></tr><tr><td>Vibrio cholerae (toxigenic)</td><td>1 (0)</td><td>0.02</td><td>&lt;0.01</td><td>0</td><td>3</td><td>0.01</td><td>3.0 (-)</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Vibrio parahaemolyticus</td><td>9 (1)</td><td>0.16</td><td>&lt;0.01</td><td>&lt;0.01</td><td>43</td><td>0.08</td><td>4.8 (2-14)</td><td>8</td><td>18.6</td><td>0</td><td>0</td></tr><tr><td>Yersinia</td><td>17 (2)</td><td>0.3</td><td>&lt;0.01</td><td>&lt;0.01</td><td>73</td><td>0.14</td><td>4.3 (2-20)</td><td>9</td><td>12.3</td><td>0</td><td>0</td></tr><tr><td colspan="2"><strong>Subtotal</strong></td><td><strong>1501 (310)</strong></td><td><strong>26.4</strong></td><td><strong>0.33</strong></td><td><strong>0.30</strong></td><td><strong>11,715</strong></td><td><strong>22.5</strong></td><td><strong>7.8 (1-300)</strong></td><td><strong>1992</strong></td><td><strong>17.0</strong></td><td><strong>28</strong></td><td><strong>0.24</strong></td></tr><tr><td rowspan="6">Bacterial toxins</td><td>Bacillus cereus toxins</td><td>474 (19)</td><td>8.3</td><td>0.11</td><td>0.03</td><td>4665</td><td>8.9</td><td>9.8 (2-251)</td><td>101</td><td>2.2</td><td>4</td><td>0.09</td></tr><tr><td>Clostridium botulinum toxins</td><td>5 (3)</td><td>0.09</td><td>&lt;0.01</td><td>&lt;0.01</td><td>14</td><td>0.03</td><td>2.8 (2-4)</td><td>10</td><td>71.4</td><td>1</td><td>7.1</td></tr><tr><td>Clostridium perfringens toxins</td><td>140 (30)</td><td>2.5</td><td>0.03</td><td>0.01</td><td>3342</td><td>6.4</td><td>23.9 (2-426)</td><td>20</td><td>0.60</td><td>8</td><td>0.24</td></tr><tr><td>Staphylococcus aureus toxins</td><td>207 (32)</td><td>3.6</td><td>0.05</td><td>0.02</td><td>2268</td><td>4.4</td><td>11.0 (2-123)</td><td>113</td><td>5.0</td><td>1</td><td>0.04</td></tr><tr><td>Bacterial toxins, unspecified</td><td>67 (4)</td><td>1.2</td><td>0.01</td><td>0.12</td><td>372</td><td>0.71</td><td>5.6 (2-43)</td><td>6</td><td>1.6</td><td>0</td><td>0</td></tr><tr><td colspan="2"><strong>Subtotal</strong></td><td><strong>893 (88)</strong></td><td><strong>15.7</strong></td><td><strong>0.20</strong></td><td><strong>0.18</strong></td><td><strong>10,661</strong></td><td><strong>20.5</strong></td><td><strong>11.9 (2-426)</strong></td><td><strong>250</strong></td><td><strong>2.3</strong></td><td><strong>14</strong></td><td><strong>0.13</strong></td></tr><tr><td rowspan="5">Viruses</td><td>Adenovirus</td><td>3 (0)</td><td>0.05</td><td>&lt;0.01</td><td>&lt;0.01</td><td>13</td><td>0.02</td><td>4.3 (2-8)</td><td>2</td><td>15.4</td><td>0</td><td>0</td></tr><tr><td>Flavivirus (incl. tick-borne encephalitis virus)</td><td>3 (3)</td><td>0.05</td><td>&lt;0.01</td><td>&lt;0.01</td><td>36</td><td>0.07</td><td>12.0 (2-28)</td><td>34</td><td>94.4</td><td>0</td><td>0</td></tr><tr><td>Hepatitis A virus</td><td>11 (2)</td><td>0.19</td><td>&lt;0.01</td><td>&lt;0.01</td><td>46</td><td>0.09</td><td>4.2 (2-13)</td><td>36</td><td>78.3</td><td>0</td><td>0</td></tr><tr><td>Hepatitis E virus</td><td>3 (0)</td><td>0.05</td><td>&lt;0.01</td><td>&lt;0.01</td><td>6</td><td>0.01</td><td>2.0 (-)</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Norovirus and other calicivirus<sup>d</sup></td><td>359 (65)</td><td>6.3</td><td>0.08</td><td>0.06</td><td>8149</td><td>15.6</td><td>22.7 (2-580)</td><td>99</td><td>1.2</td><td>1</td><td>0.01</td></tr><tr><td colspan="2">Rotavirus</td><td>2 (0)</td><td>0.04</td><td>&lt;0.01</td><td>&lt;0.01</td><td>18</td><td>0.03</td><td>9 (5-13)</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td colspan="2"><strong>Subtotal</strong></td><td><strong>381 (70)</strong></td><td><strong>6.7</strong></td><td><strong>0.08</strong></td><td><strong>0.07</strong></td><td><strong>8268</strong></td><td><strong>15.9</strong></td><td><strong>21.7 (2-580)</strong></td><td><strong>171</strong></td><td><strong>2.1</strong></td><td><strong>1</strong></td><td><strong>0.01</strong></td></tr><tr><td rowspan="4">Parasites</td><td>Anisakis</td><td>5 (0)</td><td>0.09</td><td>&lt;0.01</td><td>&lt;0.01</td><td>31</td><td>0.06</td><td>6.2 (3-10)</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Cryptosporidium</td><td>18 (4)</td><td>0.32</td><td>&lt;0.01</td><td>&lt;0.01</td><td>684</td><td>1.3</td><td>38.0 (2-225)</td><td>4</td><td>0.58</td><td>0</td><td>0</td></tr><tr><td>Giardia</td><td>9 (0)</td><td>0.16</td><td>&lt;0.01</td><td>&lt;0.01</td><td>31</td><td>0.06</td><td>3.4 (2-8)</td><td>1</td><td>3.2</td><td>0</td><td>0</td></tr><tr><td>Trichinella</td><td>3 (2)</td><td>0.05</td><td>&lt;0.01</td><td>&lt;0.01</td><td>31</td><td>0.06</td><td>10.3 (1-18)</td><td>5</td><td>16.1</td><td>0</td><td>0</td></tr><tr><td colspan="2"><strong>Subtotal</strong></td><td><strong>35 (6)</strong></td><td><strong>0.62</strong></td><td><strong>0.01</strong></td><td><strong>&lt;0.01</strong></td><td><strong>777</strong></td><td><strong>1.5</strong></td><td><strong>22.2 (1-225)</strong></td><td><strong>10</strong></td><td><strong>1.3</strong></td><td><strong>0</strong></td><td><strong>0</strong></td></tr></tbody></table>

(Continues)
<table><caption>TABLE 51 (Continued)</caption><thead><tr><th rowspan="3">Type of agent</th><th rowspan="3">Other causative agents</th><th rowspan="3">Total (strong- evidence)</th><th colspan="2">Outbreaks</th><th colspan="4">Cases of illness</th><th colspan="2">Hospitalisations</th><th colspan="2">Deaths</th></tr><tr><th rowspan="2">N</th><th rowspan="2">% of total<sup>a</sup></th><th colspan="2">Reporting rate per 100,000</th><th colspan="2">Human cases</th><th rowspan="2">Mean outbreak size (cases) and range (min-max)</th><th colspan="2">N</th><th rowspan="2">% of cases<sup>b</sup></th><th rowspan="2">N</th><th rowspan="2">% of cases<sup>b</sup></th></tr><tr><th>2023</th><th>2019-2022</th><th>N</th><th>% of total<sup>a</sup></th><th>2018</th><th>2017</th></tr></thead><tbody><tr><td rowspan="5"></td><td>Histamine and scombrotoxin</td><td>66 (15)</td><td>1.2</td><td>0.01</td><td>0.02</td><td>414</td><td>0.79</td><td>6.3 (2-154)</td><td>18</td><td>4.3</td><td>0</td><td>0</td></tr><tr><td>Marine biotoxins<sup>e</sup></td><td>38 (11)</td><td>0.67</td><td>0.01</td><td>0.01</td><td>162</td><td>0.31</td><td>4.3 (2-26)</td><td>4</td><td>2.5</td><td>0</td><td>0</td></tr><tr><td>Mushroom toxins</td><td>18 (15)</td><td>0.32</td><td>&lt;0.01</td><td>&lt;0.01</td><td>57</td><td>0.11</td><td>3.2 (2-8)</td><td>46</td><td>80.7</td><td>0</td><td>0</td></tr><tr><td>Other agents (incl. unspecified)<sup>f</sup></td><td>2 (1)</td><td>0.04</td><td>&lt;0.01</td><td>&lt;0.01</td><td>219</td><td>0.42</td><td>109.5 (10-209)</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td><strong>Subtotal</strong></td><td><strong>124 (42)</strong></td><td><strong>2.2</strong></td><td><strong>0.03</strong></td><td><strong>0.02</strong></td><td><strong>852</strong></td><td><strong>1.6</strong></td><td><strong>6.9 (2-209)</strong></td><td><strong>68</strong></td><td><strong>8.0</strong></td><td><strong>0</strong></td><td><strong>0</strong></td></tr><tr><td>Unknown</td><td>Unknown / Unspecified</td><td>2757 (62)</td><td>48.4</td><td>0.61</td><td>0.42</td><td>19,854</td><td>38.1</td><td>7.2 (2-740)</td><td>403</td><td>2.0</td><td>22</td><td>0.11</td></tr><tr><td><strong>EU Total</strong></td><td></td><td><strong>5691 (578)</strong></td><td><strong>100</strong></td><td><strong>1.3</strong></td><td><strong>1.0</strong></td><td><strong>52,127</strong></td><td><strong>100</strong></td><td><strong>9.2 (1-740)</strong></td><td><strong>2894</strong></td><td><strong>5.6</strong></td><td><strong>65</strong></td><td><strong>0.12</strong></td></tr></tbody></table>

<footnote><sup>a</sup>Percentage of the total number of cases reported in the EU.</footnote>

<footnote><sup>b</sup>Percentage of the total number of cases caused by the causative agent.</footnote>

<footnote><sup>c</sup>'Escherichia coli' other than STEC' includes 'enteropathogenic E. coli' (EPEC)' (6), 'enteroinvasive E. coli' (EIEC)' (4), 'enteroaggregative E. coli' (EAEC)' (1) and other unspecified 'Escherichia coli' (1).</footnote>

<footnote><sup>d</sup>'Norovirus' and other calicivirus' includes 'norovirus' (317), 'sapovirus' (1) and other unspecified 'calicivirus' (41).</footnote>

<footnote><sup>e</sup>'Marine biotoxins' includes 'ciguatoxin' (8) and other unspecified toxins (30).</footnote>

<footnote><sup>f</sup>'Other agents' includes 'atropine' (1) and 'lectins' (1).</footnote>
### 4.2.3 | Viruses

During 2023, 17 MSs (Austria, Belgium, Czechia, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Latvia, Netherlands, Poland, Portugal, Slovakia, Spain and Sweden) reported 381 FBOs caused by viruses. Ten FBOs involving viruses were also reported by three non-MSs. Key statistics on FBOs associated with viruses are available in Table 51.

#### Norovirus (and other calicivirus)

Outbreaks caused by **norovirus (and other calicivirus)** were reported by 16 MSs (Austria, Belgium, Czechia, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Latvia, Netherlands, Poland, Portugal, Spain and Sweden) and 3 non-MSs (Iceland, Norway and Switzerland).

Norovirus (and other calicivirus) was the third most frequently implicated agent in FBOs in 2023 (with 359 FBOs), ranking second for number of cases involved. In Finland, Iceland and Norway, norovirus (and other calicivirus) was the leading causative agent of FBOs. The number of FBOs due to this causative agent increased by 8.1% compared with 2022 (27 more FBOs). The mean size of outbreaks associated with this agent group was among the largest observed in 2023 and many outbreaks were large (27 outbreaks included ≥ 50 and < 100 cases each) or very large in size (8 outbreaks included ≥ 100 cases each). The largest ones involved more than 500 cases each and were reported by Spain and Germany. The implicated food vehicles were 'tap water, including well water' and a dairy dessert, precisely a quark dessert with mixed berries. FBOs caused by norovirus (and other calicivirus) were mostly reported as 'general outbreaks' (66.9%) and most strong-evidence outbreaks occurred in a 'restaurant, pub, street vendors, take away, etc.' (44.4%) or 'domestic premises' (23.8%).

#### Hepatitis A

Outbreaks caused by **hepatitis A virus** were reported by three MSs (Germany, Italy and Poland), resulting in three more FBOs than 2022 in the EU (11 FBOs in total). In the two hepatitis A strong-evidence outbreaks, reported by Italy and Poland, the implicated food vehicles were 'fruit, berries and juices and other products thereof'. They occurred in a 'restaurant or cafe or pub or bar or hotel or catering service' and 'domestic premises', respectively.

#### Other viruses

Three strong-evidence outbreaks caused by **tick-borne encephalitis virus (TBE)** were reported by Slovakia. All outbreaks were associated with the consumption of 'fresh cheeses made from sheep's milk' and occurred mainly in 'domestic premises' (two FBOs). Other reported viruses causing FBOs in the EU in 2023 were **adenovirus**, **hepatitis E virus** and **rotavirus**. All were reported as weak-evidence outbreaks.

### 4.2.4 | Parasites

Outbreaks caused by parasites were reported by 12 MSs (Belgium, Bulgaria, Denmark, France, Germany, Ireland, Italy, Malta, Poland, Romania, Spain and Sweden) and by 3 non-MSs (Norway, Serbia and Switzerland). Details on the FBOs caused by parasites are available in Table 51.

#### Cryptosporidium

Among parasites, **Cryptosporidium** was the leading causative agent of FBOs and cases in the EU in 2023, responsible for 18 FBOs. A total of seven MSs (Denmark, Germany, Ireland, Italy, Malta, Spain and Sweden) contributed to this reporting. Three more FBOs caused by **Cryptosporidium** were reported compared with 2022. Another two outbreaks were reported by one non-MS (Norway).

**Cryptosporidium** was associated with one of the highest mean outbreak sizes among all causative agents. **Cryptosporidium parvum** was involved in three FBOs. For the remaining FBOs (15 outbreaks) information on the **Cryptosporidium** species was not available. 'Tap water, including well water' was frequently implicated in three strong-evidence FBOs, while 'cheeses made from goats' milk' was identified in one strong-evidence FBO. Two very large strong-evidence outbreaks including 225 and 119 cases, reported by Spain, were caused by contaminated 'tap water, including well water', a source frequently documented in *Cryptosporidium* outbreaks.

#### Trichinella

Outbreaks caused by *Trichinella* (three FBOs) were reported by three MSs (Bulgaria, Romania and Spain) in smaller numbers compared with 2022 (four fewer FBOs). *T. spiralis* was involved in two of the three (for one FBO the information on the species was not reported). In all outbreaks, 'meat and meat products' was the implicated or suspected food vehicle. The two largest outbreaks were caused by *T. spiralis* and involved 18 and 12 human cases, with one and four hospitalisations, respectively. The first outbreak was reported as a weak-evidence FBO by Spain, with 'unspecified meat and meat products' as the suspected food vehicle. The second FBO occurred in Romania and was likely associated with the consumption of
‘other or mixed red meat and products thereof’, with strong evidence. Two strong-evidence FBOs due to *T. spiralis* were also reported by one non-MS (Serbia) and were linked with the consumption of ‘pig meat and products thereof’.

## Other parasites

The other reported parasites causing FBOs were **Giardia** and **Anisakis**, both causing only weak-evidence outbreaks. FBOs caused by *Giardia* were reported by five MSs (Belgium, Germany, Ireland, Italy and Poland). **G. intestinalis** was implicated in two FBOs, while no information on the species was reported for seven other FBOs. All outbreaks were very small in size.

Five outbreaks (all weak evidence) caused by *Anisakis* were reported by France. Consumption of ‘fish and fish products’ was the suspected food vehicle implicated in these FBOs. The suspected place of exposure for four FBOs involving 28 cases was ‘school and kindergarten’, i.e. a public catering setting. No hospitalisations or deaths were reported.

### 4.2.5 | Other causative agents

Nine MSs (Belgium, Denmark, France, Italy, Malta, Poland, Portugal, Spain and Sweden) reported a total of 124 FBOs caused by causative agents other than the ones mentioned above. One FBO was reported by one non-MS (Switzerland). These causative agents are not routinely monitored by national surveillance programmes. As a result, the total number of FBOs reported in the EU may be underestimated and direct comparison among MSs, even when using population-based indicators (e.g. FBO reporting rate), is likely highly biased. Key statistics on FBOs associated with other causative agents are available in Table 51.

**'Histamine and scombrotoxin'** were the most frequent agents reported in this group (53.2%) with six MSs (Belgium, France, Italy, Malta, Spain and Sweden) providing information on such outbreaks. In 2023, the number of FBOs (66 FBOs) decreased by 34.0% compared with the number of outbreaks of 'histamine and scombrotoxin' reported in 2022 (34 fewer FBOs). Almost all these FBOs were due to **histamine** (65 FBOs; 98.5%), while only one outbreak was caused by **scombrotoxin**. 'Histamine and scombrotoxin' poisoning outbreaks were mostly very small in size, involving fewer than 10 human cases and occurred mainly in a 'restaurant, pub, street vendors, take away, etc.' (seven strong-evidence FBOs), followed by 'domestic premises' (three strong-evidence FBOs). All but one of the reported strong-evidence FBOs caused by histamine were linked or suspected to be linked to the consumption of 'fish and fishery products' (14 FBOs). One strong-evidence FBO was associated with the consumption of a canned fish product (one FBO). For the first time since the start of FBO data collection, one very large weak-evidence outbreak involving 154 human cases, was reported by Spain. This weak-evidence outbreak was linked to a 'canteen or workplace catering' setting and was suspected to be associated with the consumption of 'fish and fish products'. No hospitalisations and deaths were reported.

**Marine biotoxins** were responsible for 38 FBOs reported by France and Spain, with seven more outbreaks than in 2022 (an increase of 22.6%). France accounted for most of these FBOs (28 FBOs; 73.7%). **Ciguatoxins** were implicated in eight FBOs while in the other FBOs the specific marine biotoxins were not specified.

Four MSs (France, Italy, Poland and Spain) reported 18 FBOs caused by **mushroom toxins** (11 more FBOs than 2022). Italy contributed the most to this reporting (14 FBOs; 77.8%). Overall, mushroom toxins were associated with very small outbreaks (mean outbreak size of 3.2 cases).

**Atropine and lectins** were associated with two FBOs in 2023, as reported by Portugal and Denmark, respectively. The first FBO was a very large strong-evidence outbreak, which involved a total of 209 cases. The food vehicle implicated was a 'bakery product', specifically a cornbread made from a mixture of cereal flours. Both atropine and scopolamine were identified as the causative agents, found in both the cornbread and the corn flour. No hospitalisations or deaths were reported.

### 4.2.6 | Outbreaks caused by unknown/unspecified agents

In 2023, the number of FBOs with unknown aetiology or unspecified causative agents increased slightly, by 3.7%, resulting in 98 more FBOs than in 2022, bringing the total to 2757. Key statistics on FBOs caused by unknown causative agents are available in Table 51.

Eighteen MSs (Belgium, Croatia, Cyprus, Czechia, Denmark, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Netherlands, Poland, Portugal, Romania, Spain and Sweden) contributed to reporting these data. Outbreaks with unknown causative agents were also reported by five non-MSs (Montenegro, Norway, Republic of North Macedonia, Serbia and Switzerland). Countries with the most reported outbreaks with an unknown or unspecified causative agent were Belgium, Cyprus, France, Hungary, the Netherlands and Sweden, and among non-MSs Montenegro, Republic of North Macedonia and Switzerland. In each of the following three MSs – Belgium, Cyprus and the Netherlands – the reporting of FBOs with unknown aetiology accounted for more than 90.0% of all reported FBOs.

Most outbreaks were very small (< 10 cases) in size (2436 FBOs; 88.4%). This finding suggests that in very small outbreaks, occurring in a confined environment, it is relatively easier to find a link among cases, although identification of the causative agent may be challenging. However, in 2023, various very large outbreaks with unknown causative agents were also reported. The largest one was a weak-evidence outbreak reported by France in a site categorised as a 'canteen or workplace catering' setting, which involved a total of 740 cases. Consumption of 'milk or milk products' was the suspected implicated food vehicle.
## 4.3 Overview of food vehicles implicated in food-borne outbreaks in 2023

The following sections provide information on the food vehicles implicated in FBOs in 2023. Only strong-evidence outbreaks are considered for this purpose since the body of evidence (i.e. the proof) linking a food vehicle and the human cases means that the association is highly likely and the level of uncertainty around this association is low.

For a more interactive look at FBO data by food vehicles, visit the dedicated page in EFSA's dashboard on FBO [here](#).

### 4.3.1 | Food vehicles in strong-evidence outbreaks

Twenty-three MSs (all except Cyprus, Ireland and Latvia) and the United Kingdom (Northern Ireland) provided information on 578 strong-evidence FBOs (10.2% of all FBOs reported in the EU in 2023), an increase of 18.9% over 2022 (92 more FBOs than in 2022). Spain was by far the main contributor of strong-evidence FBOs (34.8%), followed by Poland (15.4%) and France (12.8%). Table 52 describes the food vehicles implicated in strong-evidence FBOs in 2023 in the EU. In addition, information on a total of 36 strong-evidence FBOs was also reported by four non-MSs (Norway, Republic of North Macedonia, Serbia and Switzerland).

#### Composite foods, multi-ingredient foods and other foods

In 2023 foodstuffs belonging to the group 'composite foods, multi-ingredient foods and other foods' ranked first among the food vehicles implicated in strong-evidence FBOs, similarly to 2022 and 2021.

Nineteen MSs (all MSs reporting strong-evidence FBOs except for Greece, Lithuania, Malta and Netherlands) and three non-MSs (Republic of North Macedonia, Serbia and Switzerland) reported a total of 179 and nine strong-evidence FBOs linked to this food group, respectively (Table 52). At the EU level the increase over 2022 was 26.1% (37 more FBOs than 2022). A complete description of the food vehicles included in this category is available as a footnote in Table 52.

Within this big group, the foodstuffs classified under the 'mixed foods' category caused the highest number of strong-evidence FBOs, cases and hospitalisations among all foods implicated in strong-evidence FBOs in 2023. Approximately one in four strong-evidence FBOs, cases and hospitalisations were due to the consumption of 'mixed foods'. Seventeen MSs (Belgium, Bulgaria, Croatia, Czechia, Denmark, Estonia, Finland, France, Germany, Hungary, Italy, Poland, Portugal, Romania, Slovakia, Spain and Sweden) and three non-MSs (Republic of North Macedonia, Serbia and Switzerland) reported strong-evidence FBOs caused by this type of food. Compared with 2022, strong-evidence FBOs, cases and hospitalisations caused by consumption of 'mixed foods' increased in the EU by 52.7%, 42.1% and 49.7%, respectively (49 more strong-evidence FBOs, 826 more cases and 81 more hospitalisations). One reason for this increase was the rise in the number of very large strong-evidence FBOs (≥ 100 cases each), which accounted for seven FBOs in 2023 while there were only two in 2022. Two very large strong-evidence FBOs were caused by *Salmonella* (S. Enteritidis and S. Thompson), one was associated with *Staphylococcus aureus* toxins, one with enteroinvasive *E. coli* (EIEC), while for three FBOs the aetiology was unknown.

Almost half of strong-evidence FBOs due to consumption of 'mixed foods' were caused by *Salmonella* (65 outbreaks) and in particular by S. Enteritidis (28 outbreaks), S. Virchow (two outbreaks), S. Infantis, S. London, S. Newport, S. Oranienburg, S. Thompson and S. Typhimurium (one outbreak each). For 29 strong-evidence *Salmonella* FBOs the serovar was not specified. Overall, strong-evidence outbreaks caused by *Salmonella* associated with 'mixed foods' increased sharply in 2023 (41 more outbreaks than in 2022, corresponding to a 170.8% increase) making this pathogen/food combination the second most frequently reported combination in strong-evidence FBOs in the EU (Table 53). Among the other strong-evidence FBOs implicating this food group, 33 outbreaks were caused by bacterial toxins (i.e. *Bacillus cereus* toxins, *Clostridium botulinum* toxins, *Clostridium perfringens* toxins and *Staphylococcus aureus* toxins), 14 outbreaks were caused by mushroom toxins, 13 outbreaks were caused by norovirus (and other calicivirus) and 3 by bacteria (*Campylobacter*, EIEC and *Vibrio parahaemolyticus*). For 13 strong-evidence FBOs, the causative agent was not identified.

'Bakery products' were reported as the implicated food from nine MSs (Czechia, France, Germany, Italy, Poland, Portugal, Slovakia, Slovenia and Spain) and one non-MS (Serbia). Strong-evidence FBOs (N=25), cases (N=479) and hospitalisations (N=82) caused by this food group (Table 52) also increased compared with 2022 (8 more strong-evidence outbreaks, 217 more cases and 22 more hospitalisations). S. Enteritidis was identified in 17 of all strong-evidence FBOs caused by this food group (68.0%), including one very large outbreak involving 109 cases, reported from Poland. Other causative agents associated with 'bakery products' included atropine, which was responsible for a single FBO involving 209 cases, *Bacillus cereus* toxins, norovirus and *Staphylococcus aureus* toxins (one strong-evidence FBO each). In four strong-evidence FBOs the causative agent was unknown.

S. Enteritidis was also responsible for two strong-evidence FBOs due to 'buffet meals' and one single strong-evidence FBO associated with 'sweets and chocolate'. No substantial variations compared with recent years were observed for 'buffet meals' and 'canned food products' while strong-evidence FBOs and cases implicating 'other foods' decreased sharply (nine fewer outbreaks and 510 fewer cases than in 2022).
<table><caption>TABLE 52 Frequency distribution of strong-evidence food-borne outbreaks, by food vehicle, in reporting EU MSs, in 2023.</caption><thead><tr><th rowspan="3">Type of vehicle</th><th colspan="4">Strong-evidence outbreaks</th><th colspan="4">Deaths</th><th colspan="2">Reporting rate per 100,000</th><th colspan="2">Rank</th></tr><tr><th colspan="2">Outbreaks</th><th colspan="2">Cases</th><th colspan="2">Hospitalisations</th><th colspan="2">N</th><th rowspan="2">2023</th><th rowspan="2">2019-2022</th><th rowspan="2">2023</th><th rowspan="2">2019-2022</th></tr><tr><th>N</th><th>% of total</th><th>N</th><th>% of total</th><th>N</th><th>% of total</th><th>N</th><th>% of total</th></tr></thead><tbody><tr><td colspan="14"><strong>Composite foods, multi-ingredient foods and other foods</strong></td></tr><tr><td>Mixed foods<sup>a</sup></td><td>142</td><td>24.6</td><td>2786</td><td>25.0</td><td>244</td><td>25.8</td><td>2</td><td>11.1</td><td>0.032</td><td>0.015</td><td>1</td><td>2</td></tr><tr><td>Bakery products<sup>b</sup></td><td>25</td><td>4.3</td><td>479</td><td>4.3</td><td>82</td><td>8.7</td><td>0</td><td>0</td><td>0.006</td><td>0.004</td><td>7</td><td>7</td></tr><tr><td>Buffet meals</td><td>8</td><td>1.4</td><td>125</td><td>1.1</td><td>7</td><td>0.74</td><td>0</td><td>0</td><td>0.002</td><td>0.002</td><td>13</td><td>15</td></tr><tr><td>Sweets and chocolate</td><td>2</td><td>0.35</td><td>15</td><td>0.13</td><td>4</td><td>0.42</td><td>0</td><td>0</td><td>&lt;0.001</td><td>0.001</td><td>17</td><td>16</td></tr><tr><td>Canned food products<sup>c</sup></td><td>1</td><td>0.17</td><td>2</td><td>0.02</td><td>1</td><td>0.11</td><td>0</td><td>0</td><td>&lt;0.001</td><td>&lt;0.001</td><td>18</td><td>22</td></tr><tr><td>Other foods</td><td>1</td><td>0.17</td><td>2</td><td>0.02</td><td>0</td><td>0</td><td>0</td><td>0</td><td>&lt;0.001</td><td>0.002</td><td>18</td><td>12</td></tr><tr><td><strong>Subtotal</strong></td><td><strong>179</strong></td><td><strong>31.0</strong></td><td><strong>3409</strong></td><td><strong>30.5</strong></td><td><strong>338</strong></td><td><strong>35.8</strong></td><td><strong>2</strong></td><td><strong>11.1</strong></td><td><strong>0.040</strong></td><td><strong>0.025</strong></td><td>-</td><td>-</td></tr><tr><td colspan="14"><strong>Meat and meat products</strong></td></tr><tr><td>Broiler meat (Gallus gallus) and products thereof<sup>d</sup></td><td>52</td><td>9.0</td><td>658</td><td>5.9</td><td>86</td><td>9.1</td><td>2</td><td>11.1</td><td>0.012</td><td>0.004</td><td>3</td><td>9</td></tr><tr><td>Meat and meat products, unspecified</td><td>27</td><td>4.7</td><td>1098</td><td>9.8</td><td>24</td><td>2.5</td><td>1</td><td>5.6</td><td>0.006</td><td>0.004</td><td>6</td><td>8</td></tr><tr><td>Pig meat and products thereof<sup>e</sup></td><td>23</td><td>4.0</td><td>454</td><td>4.1</td><td>118</td><td>12.5</td><td>3</td><td>16.7</td><td>0.005</td><td>0.006</td><td>8</td><td>5</td></tr><tr><td>Bovine meat and products thereof<sup>f</sup></td><td>6</td><td>1.0</td><td>90</td><td>0.81</td><td>13</td><td>1.4</td><td>0</td><td>0</td><td>0.001</td><td>0.002</td><td>14</td><td>10</td></tr><tr><td>Turkey meat and products thereof<sup>f</sup></td><td>2</td><td>0.35</td><td>6</td><td>0.05</td><td>4</td><td>0.42</td><td>0</td><td>0</td><td>&lt;0.001</td><td>&lt;0.001</td><td>17</td><td>21</td></tr><tr><td>Other or mixed red meat and products thereof<sup>h</sup></td><td>13</td><td>2.2</td><td>132</td><td>1.2</td><td>9</td><td>0.95</td><td>1</td><td>5.6</td><td>0.003</td><td>0.002</td><td>11</td><td>14</td></tr><tr><td>Other, mixed or unspecified poultry meat and products thereof<sup>f</sup></td><td>10</td><td>1.7</td><td>140</td><td>1.3</td><td>3</td><td>0.32</td><td>0</td><td>0</td><td>0.002</td><td>0.001</td><td>12</td><td>18</td></tr><tr><td><strong>Subtotal</strong></td><td><strong>133</strong></td><td><strong>23.0</strong></td><td><strong>2578</strong></td><td><strong>23.1</strong></td><td><strong>257</strong></td><td><strong>27.2</strong></td><td><strong>7</strong></td><td><strong>38.9</strong></td><td><strong>0.030</strong></td><td><strong>0.020</strong></td><td>-</td><td>-</td></tr><tr><td><strong>Eggs and egg products<sup>i</sup></strong></td><td><strong>95</strong></td><td><strong>16.4</strong></td><td><strong>1223</strong></td><td><strong>11.0</strong></td><td><strong>125</strong></td><td><strong>13.2</strong></td><td><strong>0</strong></td><td><strong>0</strong></td><td><strong>0.021</strong></td><td><strong>0.016</strong></td><td><strong>2</strong></td><td><strong>1</strong></td></tr><tr><td colspan="14"><strong>Fish and fishery products</strong></td></tr><tr><td>Fish and fish products<sup>k</sup></td><td>43</td><td>7.4</td><td>355</td><td>3.2</td><td>57</td><td>6.0</td><td>7</td><td>38.9</td><td>0.010</td><td>0.008</td><td>4</td><td>4</td></tr><tr><td>Crustaceans, shellfish, molluscs and products thereof<sup>f</sup></td><td>40</td><td>6.9</td><td>472</td><td>4.2</td><td>1</td><td>0.11</td><td>0</td><td>0</td><td>0.009</td><td>0.012</td><td>5</td><td>3</td></tr><tr><td><strong>Subtotal</strong></td><td><strong>83</strong></td><td><strong>14.4</strong></td><td><strong>827</strong></td><td><strong>7.4</strong></td><td><strong>58</strong></td><td><strong>6.1</strong></td><td><strong>7</strong></td><td><strong>38.9</strong></td><td><strong>0.018</strong></td><td><strong>0.020</strong></td><td>-</td><td>-</td></tr></tbody></table>
<table><caption>TABLE 52 (Continued)</caption><thead><tr><th rowspan="3">Type of vehicle</th><th colspan="4">Strong-evidence outbreaks</th><th colspan="4">Deaths</th><th colspan="2">Reporting rate per 100,000</th><th colspan="2">Rank</th></tr><tr><th colspan="2">Outbreaks</th><th colspan="2">Cases</th><th colspan="2">Hospitalisations</th><th colspan="2">N</th><th rowspan="2">2023</th><th rowspan="2">2019-2022</th><th rowspan="2">2023</th><th rowspan="2">2019-2022</th></tr><tr><th>N</th><th>% of total</th><th>N</th><th>% of total</th><th>N</th><th>% of total</th><th>N</th><th>% of total</th></tr></thead><tbody><tr><td colspan="13"><strong>Foods of non-animal origin</strong></td></tr><tr><td>Vegetables and juices and other products thereof<sup>a</sup></td><td>25</td><td>4.3</td><td>435</td><td>3.9</td><td>60</td><td>6.4</td><td>2</td><td>11.1</td><td>0.006</td><td>0.005</td><td>7</td><td>6</td></tr><tr><td>Fruit, berries and juices and other products thereof</td><td>8</td><td>1.4</td><td>120</td><td>1.1</td><td>20</td><td>2.1</td><td>0</td><td>0</td><td>0.002</td><td>0.001</td><td>13</td><td>20</td></tr><tr><td>Cereal products including rice and seeds/pulses (nuts, almonds)<sup>b</sup></td><td>5</td><td>0.87</td><td>101</td><td>0.91</td><td>2</td><td>0.21</td><td>0</td><td>0</td><td>0.001</td><td>0.001</td><td>15</td><td>19</td></tr><tr><td>Herbs and spices<sup>c</sup></td><td>2</td><td>0.35</td><td>184</td><td>1.6</td><td>0</td><td>0</td><td>0</td><td>0</td><td>&lt;0.001</td><td>&lt;0.001</td><td>17</td><td>23</td></tr><tr><td><strong>Subtotal</strong></td><td><strong>40</strong></td><td><strong>6.9</strong></td><td><strong>840</strong></td><td><strong>7.5</strong></td><td><strong>82</strong></td><td><strong>8.7</strong></td><td><strong>2</strong></td><td><strong>11.1</strong></td><td><strong>0.009</strong></td><td><strong>0.008</strong></td><td>-</td><td>-</td></tr><tr><td colspan="13"><strong>Milk and milk products</strong></td></tr><tr><td>Cheese<sup>d</sup></td><td>20</td><td>3.5</td><td>183</td><td>1.6</td><td>57</td><td>6.0</td><td>0</td><td>0</td><td>0.004</td><td>0.002</td><td>9</td><td>11</td></tr><tr><td>Dairy products (other than cheeses)<sup>e</sup></td><td>15</td><td>2.6</td><td>664</td><td>5.9</td><td>20</td><td>2.1</td><td>0</td><td>0</td><td>0.003</td><td>0.001</td><td>10</td><td>17</td></tr><tr><td>Milk<sup>f</sup></td><td>3</td><td>0.52</td><td>11</td><td>0.10</td><td>5</td><td>0.53</td><td>0</td><td>0</td><td>0.001</td><td>0.002</td><td>16</td><td>14</td></tr><tr><td><strong>Subtotal</strong></td><td><strong>38</strong></td><td><strong>6.6</strong></td><td><strong>858</strong></td><td><strong>7.7</strong></td><td><strong>82</strong></td><td><strong>8.7</strong></td><td><strong>0</strong></td><td><strong>0</strong></td><td><strong>0.008</strong></td><td><strong>0.005</strong></td><td>-</td><td>-</td></tr><tr><td>Water (and other beverages)<sup>g</sup></td><td>10</td><td>1.7</td><td>1425</td><td>12.8</td><td>2</td><td>0.21</td><td>0</td><td>0</td><td>0.002</td><td>0.002</td><td>12</td><td>13</td></tr><tr><td><strong>EU Total</strong></td><td><strong>578</strong></td><td><strong>100</strong></td><td><strong>11,160</strong></td><td><strong>100</strong></td><td><strong>944</strong></td><td><strong>100</strong></td><td><strong>18</strong></td><td><strong>100</strong></td><td><strong>0.128</strong></td><td><strong>0.098</strong></td><td>-</td><td>-</td></tr></tbody></table>

Notes: Single food items are consolidated into major groups according to their origin. The 'outbreak reporting rate' columns include the mean outbreak reporting rate per 100,000 for 2023 and for the previous years (2019-2022) for trend watching. The ranking of each food item provides a visual demonstration of the relative importance of the item, among all food vehicles implicated in food-borne outbreaks, for the same year and period.

<footnote>a Mixed foods includes 'mixed foods' (83), other processed food products and prepared dishes (20), 'other processed food products and prepared dishes - mushroom based dishes' (14), 'other processed food products and prepared dishes - meat based dishes' (8), other processed food products and prepared dishes - pizza and pizza-like dishes' (2), 'other processed food products and prepared dishes - sushi' (2), 'other processed food products and prepared dishes - vegetable-based dishes' (2), 'sauce and dressings' (2), 'sauce and dressings - mayonnaise' (2), 'bean curd sauce' (1), 'other processed food products and prepared dishes - fish and seafood based dishes' (1), 'other processed food products and prepared dishes - pasta - simple pasta' (1), 'other processed food products and prepared dishes - pasta based dishes' (1), 'other processed food products and prepared dishes - rice based dishes' (1), 'soups - ready-to-eat' (1), 'vegetable-based cooked sauce' (1).</footnote>

<footnote>b 'Bakery products' includes 'bakery products' (15), 'bakery products - desserts - containing raw eggs' (4), 'bakery products - pastry - made with raw eggs' (2), 'bakery products - bread' (1), 'bakery products - cakes - containing heat-treated cream' (1), 'bakery products - desserts' (1).</footnote>

<footnote>c 'Canned food products' includes 'fish - canned' (1).</footnote>

<footnote>d 'Broiler meat (Gallus gallus) and products thereof' includes 'broiler meat (Gallus gallus)' (1), 'meat from broilers (Gallus gallus)' (1), 'meat from broilers (Gallus gallus)' - fresh - skinned' (1), 'meat from broilers (Gallus gallus)' - meat products' (1).</footnote>

<footnote>e 'Pig meat and products thereof' includes 'pig meat and products thereof' (9), 'meat from pig - fresh' (4), 'meat from pig - meat products - meat specialities' (3), 'meat from pig - meat products - ready-to-eat' (2), 'meat from pig - meat preparation' (1), 'meat from pig - meat products - cooked ham' (1), 'meat from pig - meat products - raw and intended to be eaten raw' (1), 'meat from pig - minced meat' (1), 'meat from pig - minced meat - intended to be eaten raw' (1).</footnote>

<footnote>f 'Bovine meat and products thereof' includes 'bovine meat and products thereof' (3), 'meat from bovine animals - meat products' (2), 'meat from bovine animals - meat products - raw and intended to be eaten raw' (1).</footnote>

<footnote>g 'Turkey meat and products thereof' includes 'meat from turkey - fresh' (2).</footnote>

<footnote>h 'Other, mixed red meat and products thereof' includes 'other or mixed red meat and products thereof' (7), 'meat from farmed game - land mammals - meat products' (1), 'meat from rabbit - meat preparation' (1), 'meat from wild boar' (1), 'meat, mixed, meat - meat products' (1), 'meat, mixed meat - meat products - ready-to-eat' (1).</footnote>

<footnote>i 'Other, mixed or unspecified poultry meat and products thereof' includes 'other mixed or unspecified poultry meat and products thereof' (8), 'meat from poultry, unspecified - meat preparation' (1), 'meat from poultry, unspecified - meat products' (1).</footnote>

<footnote>j 'Eggs and egg products' includes 'eggs and egg products' (88), 'eggs' (7).</footnote>

<footnote>(Continues)</footnote>
<table><caption>**TABLE 52** (Continued)</caption><tr><td><sup>a</sup>Fish and fish products' includes 'fish and fish products' (39), 'fish' (1), 'fish – cooked' (1), 'fish – fishery products from fish species associated with a high amount of histidine – not enzyme matured' (1), 'fish – gravad' /slightly salted' (1).</td></tr><tr><td><sup>b</sup>'Crustaceans, shellfish, molluscs and products thereof' includes 'live bivalve molluscs – oysters' (25), 'crustaceans, shellfish, molluscs and products thereof' (9), 'live bivalve molluscs – mussels' (5), 'bivalve molluscs' (1).</td></tr><tr><td><sup>c</sup>'Vegetables and juices and other products thereof' includes 'vegetables and juices and other products thereof' (13), 'potatoes' (2), 'cherry tomato' (1), 'lettuce' (1), 'lettuce, leaf' (1), 'sprouts' (1), 'sprouts ready-to-eat' (1), 'table olives' (1), 'vegetables' (1), 'vegetables – products – cooked' (1).</td></tr><tr><td><sup>d</sup>'Cereal products including rice and seeds/pulses (nuts, almonds)' includes 'cereal products including rice and seeds/pulses (nuts, almonds)' (3), 'rice' (1), 'sesame paste ( tahini) (Sesamum indicum)' (1).</td></tr><tr><td><sup>e</sup>'Herbs and spices' includes 'herbs and spices' (1), 'parsley' (1).</td></tr><tr><td><sup>f</sup>'Cheese' includes 'cheese' (10), 'cheeses made from cows' milk' (4), 'cheeses made from sheep's milk – fresh' (3), 'cheese made from raw or low heat-treated milk' (1), 'cheeses made from cows' milk – fresh' (1), 'cheeses made from goats' milk' (1).</td></tr><tr><td><sup>g</sup>'Dairy products (other than cheeses)' includes 'dairy products (other than cheeses)' (9), 'dairy products (excluding cheeses) – cream' (2), 'dairy products (excluding cheeses) – buttermilk' (1), 'dairy products (excluding cheeses) – dairy desserts' (1), 'dairy products (excluding cheeses)' – 'cream' (1).</td></tr><tr><td><sup>h</sup>'Milk' includes 'milk' (1), 'milk, cows' (1), 'milk, cows' – 'raw milk' (1).</td></tr><tr><td><sup>i</sup>'Water (and other beverages)' includes 'tap water, including well water' (8), 'water – potable water' (2).</td></tr></table>
## Foods of animal origin

Foods of animal origin includes 'eggs and egg products', 'meat and meat products', 'fish and fishery products' and 'milk and milk products'. Altogether these vehicles caused 349 strong-evidence FBOs (60.4% of all strong-evidence FBOs), 5486 cases (49.2% of all cases in strong-evidence FBOs), 522 hospitalisations (55.3% of all hospitalisations in strong-evidence FBOs) and 14 deaths (77.8% of all deaths in strong-evidence FBOs). All MSs but two (Croatia and Slovenia) and the United Kingdom (Northern Ireland), as well as four non-MSs (Norway, Republic of North Macedonia, Serbia and Switzerland), provided information on FBOs associated with foods of animal origin.

'Meat and meat products' was the food vehicle group reported most frequently by MSs. However, despite the increase observed in 2023 in the number of strong-evidence FBOs (133 outbreaks in total, 33 more than in 2022; 33.0% increase), the number of cases, hospitalisations and deaths associated with this food group decreased by 17.9% (563 fewer cases), 20.7% (67 fewer hospitalisations) and 22.2% (two fewer deaths), respectively, compared with 2022.

The drop in the number of cases and hospitalisations was mainly attributable to fewer FBOs caused by 'bovine meat and products thereof' (251 fewer cases and 36 fewer hospitalisations), 'pig meat and products thereof' (276 fewer cases and 10 fewer hospitalisations) or 'other or mixed red meat and products thereof' (870 fewer cases and two fewer hospitalisations). Conversely, more FBOs and cases were reported in strong-evidence FBOs caused by 'broiler meat (Gallus gallus) and products thereof' (31 more FBOs and 272 more cases) and 'meat and meat products, unspecified' (11 more FBOs and 642 more cases).

Salmonella was the causative agent associated with the largest number of strong-evidence FBOs (59 outbreaks; 44.4%), hospitalisations (N=213; 82.9%) and deaths (N=3; 42.9%) caused by the consumption of 'meat and meat products', while Clostridium perfringens toxins caused the largest number of cases (N=957; 37.1%). In Spain, consumption of 'meat and meat products' contaminated with C. perfringens toxins caused two very large strong-evidence FBOs (426 and 165 cases, respectively). The largest one involved cases in 'school or kindergarten'. In Poland, S. Enteritidis in 'meat and meat products' was responsible for 184 cases in a single strong-evidence FBO. Salmonella serovars associated with the 'meat and meat products' vehicle included S. Enteritidis (29 strong-evidence FBOs), monophasic S. Typhimurium (seven strong-evidence FBOs), S. Infantis (three strong-evidence FBOs) and S. Brandenburg, S. Stanley and S. Typhimurium (one FBO each).

'Eggs and egg products' was the second most frequently reported food vehicle group in strong-evidence FBOs (95 FBOs). The number of outbreaks and hospitalisations linked to this food remained rather stable in 2023 (eight fewer outbreaks and 17 fewer hospitalisations than 2022) despite an increase in the number of cases (304 more cases; 33.1% increase). There was also a decrease in deaths (four fewer deaths). Twelve MSs (Austria, Czechia, France, Hungary, Italy, Lithuania, Malta, Netherlands, Poland, Slovakia, Spain and Sweden) reported strong-evidence FBOs caused by 'eggs and egg products', with two of these countries (Poland and Spain) contributing the most to these FBOs (81 outbreaks; 85.3%). Five strong-evidence FBOs caused by 'eggs and egg products' were also reported by one non-MS (Serbia).

As with 2022, Salmonella was the main agent involved in strong-evidence FBOs associated with the consumption of 'eggs and egg products' (83 outbreaks; 87.4%), including S. Enteritidis (38 outbreaks), S. Typhimurium and S. Kentucky (1 outbreak each) and other unspecified Salmonella serovars (43 outbreaks). Two very large strong-evidence FBOs caused by the consumption of 'eggs and egg products' contaminated with S. Enteritidis were reported by Hungary (300 cases in a 'school or kindergarten') and the Netherlands (156 cases exposed in 'multiple places of exposure in one country').

A total of 83 strong-evidence FBOs caused by the consumption of food items belonging to the 'fish and fishery products' group were reported by 12 MSs (Belgium, Denmark, Estonia, Finland, France, Germany, Italy, Poland, Romania, Slovakia, Spain and Sweden). Two strong-evidence FBOs linked to these foodstuffs were reported by two non-MSs (Norway and Switzerland). In 2023, strong-evidence FBOs linked to consumption of 'fish and fishery products' increased by 20.3% (14 more outbreaks) compared to 2022. Moreover, the health impact associated with these outbreaks was much higher than in the previous year, with an increase of 39.2% in the number of cases (233 more cases), 56.8% in the number of hospitalisations (21 more hospitalisations) and, most critically, 250% in the number of deaths (five more deaths). In particular, the increase in hospitalisations and deaths was mostly due to strong-evidence FBOs caused by 'fish and fish products' (28 more hospitalisations and 5 more deaths than in 2022).

A wide range of causative agents was associated with 'fish and fish products' including in decreasing order histamine and scombrotoxin, Salmonella, marine biotoxins, Bacillus cereus toxins, norovirus (and other calicivirus), Listeria monocytogenes, Staphylococcus aureus toxins, Campylobacter, Shigella, Clostridium perfringens toxins and Clostridium botulinum toxins. In four strong-evidence FBOs causing 29 hospitalisations and three deaths, the implicated agent was unknown. In 'crustaceans, shellfish, molluscs and products thereof' the most frequently reported causative agent was by far norovirus, which was reported in 30 strong-evidence FBOs (75.0% of all strong-evidence FBOs caused by this vehicle group) totalling 414 cases (87.7% of cases). Among these strong-evidence FBOs, Finland reported a single strong-evidence FBO associated with oysters, causing 150 cases.

In the 'milk and milk products' group, strong-evidence FBOs associated with the consumption of either 'cheese', 'dairy products (other than cheeses)' or 'milk' were reported by 12 MSs (Belgium, Finland, France, Germany, Hungary, Italy, Lithuania, Poland, Romania, Slovakia, Spain and Sweden) and two non-MSs (Republic of North Macedonia and Serbia) totalling 38 FBOs. The health impact of strong-evidence FBOs linked to this food group was lower than in 2022 in terms of deaths (no deaths in 2023, there were seven in 2022) but not in terms of cases (392 more cases; 84.1% increase) and hospitalisations (30 more cases; 57.7% increase).
The causative agents linked to strong-evidence FBOs associated with 'milk and milk products' included bacteria (19 FBOs caused by *Campylobacter*, *Listeria monocytogenes*, *Salmonella*, Shiga toxin-producing *E. coli* (STEC)), bacterial toxins (eight outbreaks caused by *Staphylococcus aureus* toxins), viruses (five outbreaks caused by tick-borne encephalitis virus, norovirus) and parasites (one outbreak caused by *Cryptosporidium*). The second largest strong-evidence FBO in this group was reported by Germany and was associated with the consumption of a quark dessert with mixed berries contaminated with norovirus. The outbreak involved a total of 538 cases and was linked to a 'canteen or workplace catering' as the place of exposure.

## Foods of non-animal origin

Strong-evidence FBOs linked to foods of non-animal origin were reported by 10 MSs (Austria, Belgium, Croatia, Finland, France, Germany, Italy, Poland, Spain and Sweden) and 1 non-MS (Norway). In total 40 FBOs were reported in the EU. The health impact of foods of non-animal origin fell approximately within the same range observed in the last 5 years regarding the total number of outbreaks, cases and hospitalisations, although there were specific annual variations. The number of deaths linked to strong-evidence FBOs associated with the consumption of foods of non-animal origin decreased sharply over 2022 (four fewer deaths). The largest FBO linked to foods of non-animal origin was reported by Sweden and was caused by enterotoxigenic *E. coli* (ETEC) and involved a total of 154 cases. It was the second largest strong-evidence FBO caused by 'herbs and spices' reported in the EU in the last 10 years. The implicated food was parsley imported from Italy.

A wide variety of causative agents were reported in strong-evidence FBOs associated with foods of non-animal origin. In the 25 strong-evidence FBOs caused by 'vegetables and juices and other products thereof', *Salmonella* (7 FBOs, 132 cases and 19 hospitalisations) and norovirus (and other calicivirus) (5 FBOs and 138 cases) prevailed ahead of the other causative agents (*Bacillus cereus* toxins, *Clostridium perfringens* toxins, *Escherichia coli* other than STEC, *Listeria monocytogenes*, mushroom toxins, *Staphylococcus aureus* toxins, *Yersinia* and unknown agents), which altogether caused 13 FBOs, 165 cases, 41 hospitalisations and two deaths (both associated with *Listeria monocytogenes*). S. Adelaide, S. Enteritidis, S. Senftenberg and S. Strathcona were the *Salmonella* serovars associated with this foodstuff group. In the eight strong-evidence FBOs caused by 'fruit, berries and juices and other products thereof', the causative agents included norovirus, hepatitis A virus, *Shigella*, *Salmonella* and unknown agents. *Bacillus cereus* toxins, unspecified bacterial toxins and S. Senftenberg were the causative agents reported in the five strong-evidence FBOs associated with 'cereal products including rice and seeds/pulses (nuts, almonds) products'.

### 4.3.2 | Suspect foods in weak-evidence outbreaks

In 2023, 21 MSs (all MSs reporting weak-evidence FBOs except Cyprus, Germany) and 5 non-MSs (Iceland, Montenegro, Republic of North Macedonia, Serbia and Switzerland) described the suspect foods in weak-evidence FBOs. The information was available for a total of 3107 weak-evidence FBOs reported in the EU (60.8% of all weak-evidence FBOs).

The pattern of food vehicles implicated in weak-evidence FBOs with information available was generally consistent with that observed in strong-evidence outbreaks, with a few exceptions. Consistencies were observed for 'composite foods, multi-ingredient foods and other foods' and 'meat and meat products', which ranked first and second, respectively in both strong-evidence and weak-evidence outbreak groups as well as for 'foods of non-animal origin', 'milk and milk products' and 'water (and other beverages)', which ranked fifth, sixth and seventh. In contrast, 'eggs and egg products' ranked third in strong-evidence FBOs but fourth in weak-evidence FBOs since this food group was much more frequently reported in strong-evidence FBOs (Table 52) than in weak-evidence FBOs (235 outbreaks; 7.6% of total weak-evidence FBOs). The opposite ranking was observed for 'fish and fishery products'. This food group ranked fourth in strong-evidence FBOs (Table 52) and third in weak-evidence FBOs (559 outbreaks, 18.0% of total weak-evidence FBOs) mainly due to a more frequent reporting of 'crustaceans, shellfish, molluscs and products thereof' in weak-evidence FBOs (315 outbreaks; 10.1%) than in strong-evidence FBOs (Table 52). Other noteworthy differences concern 'cheese', which was suspected less frequently in weak-evidence FBOs (five outbreaks, 0.16% of total weak-evidence FBOs) as well as 'fruit, berries and juices and other products thereof' (four outbreaks, 0.13% of total weak-evidence FBOs).

### 4.3.3 | Top-10 agent/food pairs in strong-evidence outbreaks associated with the highest impact on health in the EU

The top-10 pairs of causative agents and food vehicles in strong-evidence FBOs with the highest health impact in 2023 in the EU, in terms of number of FBOs, cases, hospitalisations and deaths, are shown in Tables 53–56. These tables include details on the number of MSs reporting FBOs for the related food/agent pair in 2023, as well as for the period 2019–2022, for trend watching purposes. Regarding food vehicles, details were provided in the table footnotes, if available.

Overall, *Salmonella* paired with either 'mixed foods' or 'broiler meat (*Gallus gallus*) and products thereof' ranked among the top 10 in all the classifications. In combination with 'eggs and egg products' *Salmonella* was the most frequent pair for total number of outbreaks and cases and was second for total number of hospitalisations. *Salmonella*, in combination with other types of food (i.e. 'pig meat and products thereof', 'bakery products' and 'fish and fish products'), was also frequently
reported among the top-10 pairs for hospitalisations and deaths. These findings confirm the high health burden of this food-borne pathogen in the EU in 2023.

Interestingly, the reporting of single FBOs with an uncommonly very large number of either cases or hospitalisations, or even deaths, in 2023 is the main explanation for variations > 50% in the number of either cases, hospitalisations or deaths compared with previous years (Tables 53–55). Such fluctuations due to single sporadic events or even to the reporting of new agent/food combinations deserve attention since they potentially represent early signals of possible changes in the epidemiology of food-borne pathogens, in the EU horizon. An example is given by the top-two pairs causing the highest number of deaths in 2023. Aside from ‘meat from pig – meat products – ready-to-eat’, which is a well-known food vehicle implicated in the transmission of *Listeria monocytogenes* to humans, the food matrix ‘table olives’ has rarely been reported before in the literature as a source of *L. monocytogenes*. The reporting of this severe FBO shed light on the risk connected to this food of non-animal origin.
<table><caption>TABLE 53 Top-10 pathogen/food vehicle pairs causing the highest number of strong-evidence outbreaks in reporting EU MSs, in 2023.</caption><thead><tr><th rowspan="2">Rank<sup>a</sup></th><th rowspan="2">Causative agent</th><th rowspan="2">Food vehicle</th><th rowspan="2">Outbreaks (N)</th><th rowspan="2">Reporting MS (N outbreaks)</th><th colspan="3">2019-2022</th><th colspan="2">Evaluation</th></tr><tr><th>Rank<sup>a</sup></th><th>Outbreaks (N/year) (range)</th><th>Reporting MS (N/year)</th><th>2023 vs 2019-2022<sup>b</sup></th></tr></thead><tbody><tr><td>1</td><td>Salmonella</td><td>Eggs and egg products<sup>c</sup></td><td>83</td><td>Spain (44), Poland (25), Slovakia (3), Austria (2), Hungary (2), Czechia (1), France (1), Italy (1), Lithuania (1), Malta (1), Netherlands (1), Sweden (1)</td><td>1</td><td>70.0 (37-118)</td><td>8.3</td><td>-</td><td>-</td></tr><tr><td>2</td><td>Salmonella</td><td>Mixed foods<sup>d</sup></td><td>65</td><td>Spain (23), Poland (18), Slovakia (6), Hungary (4), Romania (4), Germany (3), Czechia (2), France (2), Italy (2), Estonia (1)</td><td>3</td><td>19.0 (3-25)</td><td>7.0</td><td>↑↑</td><td>↑↑</td></tr><tr><td>3</td><td>Norovirus and other calicivirus</td><td>Crustaceans, shellfish, molluscs and products thereof<sup>e</sup></td><td>30</td><td>France (19), Denmark (3), Sweden (3), Belgium (2), Spain (2), Finland (1)</td><td>2</td><td>50.3 (10-144)</td><td>5.5</td><td>↓</td><td>↓</td></tr><tr><td>3</td><td>Salmonella</td><td>Broiler meat (Gallus gallus) and products thereof<sup>f</sup></td><td>30</td><td>Lithuania (6), Spain (6), Austria (5), France (3), Hungary (3), Poland (3), Denmark (1), Greece (1), Romania (1), Slovakia (1)</td><td>8</td><td>8.5 (2-14)</td><td>5.3</td><td>↑↑</td><td>↑↑</td></tr><tr><td>4</td><td>Salmonella</td><td>Bakery products<sup>g</sup></td><td>17</td><td>Poland (10), Czechia (2), Italy (2), Slovakia (2), Slovenia (1)</td><td>6</td><td>16.8 (9-32)</td><td>4.3</td><td>-</td><td>-</td></tr><tr><td>5</td><td>Campylobacter</td><td>Broiler meat (Gallus gallus) and products thereof</td><td>15</td><td>Denmark (8), France (2), Lithuania (2), Spain (2), Poland (1)</td><td>11</td><td>7.5 (4-10)</td><td>4.3</td><td>↑↑</td><td>↑↑</td></tr><tr><td>6</td><td>Histamine and scombrotoxin</td><td>Fish and fish products<sup>h</sup></td><td>14</td><td>Spain (11), France (1), Italy (1), Sweden (1)</td><td>4</td><td>18.3 (14-24)</td><td>5.0</td><td>-</td><td>-</td></tr><tr><td>6</td><td>Mushroom toxins</td><td>Mixed foods<sup>i</sup></td><td>14</td><td>Italy (14)</td><td>NA</td><td>0</td><td>0</td><td>NA</td><td>NA</td></tr><tr><td>7</td><td>Norovirus and other calicivirus</td><td>Mixed foods</td><td>13</td><td>Finland (5), Spain (5), Denmark (2), Belgium (1)</td><td>7</td><td>10.8 (5-16)</td><td>5.5</td><td>-</td><td>-</td></tr><tr><td>7</td><td>Staphylococcus aureus toxins</td><td>Mixed foods<sup>j</sup></td><td>13</td><td>Romania (3), France (2), Portugal (2), Spain (2), Czechia (1), Hungary (1), Poland (1), Slovakia (1)</td><td>13</td><td>6.0 (1-12)</td><td>3.5</td><td>↑↑</td><td>↑↑</td></tr></tbody></table>

Abbreviation: NA, not applicable.

<footnote><sup>a</sup>Ranking of the food vehicle based on the number of strong-evidence FBOs in which the combination (causative agent/food vehicle) was implicated (rank 1 is the highest rank meaning the most commonly implicated). Strong-evidence outbreaks with unknown causative agents are not included.</footnote>

<footnote><sup>b</sup>A single arrow indicates variations between -25% and -50% in the number of outbreaks; double arrows indicate variations > ±50%; a 'stable' value indicates variations of between -25% and +25%.</footnote>

<footnote><sup>c</sup>In 2023, 'eggs and egg products' includes 'eggs and egg products' (76), 'eggs' (7).</footnote>

<footnote><sup>d</sup>In 2023, 'mixed foods' includes 'mixed foods' (50), 'other processed food products and prepared dishes - meat based dishes' (6), 'other processed food products and prepared dishes - pizza and seafood based dishes' (1), 'other processed food products and prepared dishes - fish and seafood based dishes' (1), 'other processed food products and prepared dishes - pizza and pizza-like dishes' (1), 'other processed food products and prepared dishes - sushi' (1), 'sauce and dressings' (1).</footnote>

<footnote><sup>e</sup>In 2023, 'crustaceans, shellfish, molluscs and products thereof' includes 'live bivalve molluscs - oysters' (25), 'crustaceans, shellfish, molluscs and products thereof' (4), 'bivalve molluscs' (1).</footnote>

<footnote><sup>f</sup>In 2023, 'broiler meat (Gallus gallus) and products thereof' includes 'broiler meat (Gallus gallus) and products thereof' (27), 'meat from broilers (Gallus gallus)' (1), 'meat from broilers (Gallus gallus)' (1), 'meat from broilers (Gallus gallus)' - fresh - skinned' (1), 'meat from broilers (Gallus gallus)' - meat products' (1).</footnote>

<footnote><sup>g</sup>In 2023, 'bakery products' includes 'bakery products - desserts - containing raw eggs' (4), 'bakery products - pastry - made with raw eggs' (2), 'bakery products - cakes - containing heat-treated cream' (1).</footnote>

<footnote><sup>h</sup>In 2023, 'fish and fish products' includes 'fish and fish products' (13), 'fish - fishery products from fish species associated with a high amount of histidine - not enzyme matured' (1).</footnote>

<footnote><sup>i</sup>In 2023, 'mixed foods' includes 'other processed food products and prepared dishes - mushroom based dishes' (14).</footnote>

<footnote><sup>j</sup>In 2023, 'mixed foods' includes 'mixed foods' (5), 'other processed food products and prepared dishes - meat based dishes' (1), 'other processed food products and prepared dishes - pasta based dishes' (1), 'other processed food products and prepared dishes - pizza and pizza-like dishes' (1).</footnote>
<table><caption>TABLE 54 Top-10 pathogen/food vehicle pairs causing the highest number of cases in strong-evidence outbreaks in reporting EU MSs, in 2023.</caption><thead><tr><th rowspan="2">Rank<sup>a</sup></th><th rowspan="2">Causative agent</th><th rowspan="2">Food vehicle</th><th rowspan="2">Cases (N)</th><th rowspan="2">Reporting MS (N cases)</th><th rowspan="2">Rank<sup>a</sup></th><th colspan="2">2019-2022</th><th colspan="2">Evaluation</th></tr><tr><th>Cases (N/year) (range)</th><th>Reporting MS (N/year)</th><th>2023 vs 2019-2022<sup>b</sup></th></tr></thead><tbody><tr><td>1</td><td>Salmonella</td><td>Eggs and egg products<sup>c</sup></td><td>1101</td><td>Spain (336), Hungary (312), Netherlands (156), Poland (154), Sweden (82), Slovakia (20), Austria (19), Czechia (12), France (4), Italy (2), Lithuania (2), Malta (2)</td><td>1</td><td>630.3 (303-1307)</td><td>8.3</td><td>↑↑</td><td>↑↑</td></tr><tr><td>2</td><td>Salmonella</td><td>Mixed foods<sup>d</sup></td><td>839</td><td>Spain (211), Czechia (180), Poland (156), Slovakia (112), Hungary (52), Romania (50), Germany (42), Italy (16), Estonia (14), France (6)</td><td>2</td><td>604.5 (91-1595)</td><td>7.0</td><td>↑</td><td>↑</td></tr><tr><td>3</td><td>Norovirus and other calicivirus</td><td>Water<sup>e</sup></td><td>751</td><td>Spain (650), Finland (62), Greece (39)</td><td>5</td><td>355.0 (8-984)</td><td>2.8</td><td>↑↑</td><td>↑↑</td></tr><tr><td>4</td><td>Clostridium perfringens toxins</td><td>Meat and meat products, unspecified</td><td>616</td><td>Spain (616)</td><td>16</td><td>148.0 (23-368)</td><td>2.0</td><td>↑↑</td><td>↑↑</td></tr><tr><td>5</td><td>Norovirus and other calicivirus</td><td>Dairy products (other than cheeses)<sup>f</sup></td><td>603</td><td>Germany (603)</td><td>48</td><td>30.5 (0-122)</td><td>0.50</td><td>↑↑</td><td>↑↑</td></tr><tr><td>6</td><td>Cryptosporidium</td><td>Water<sup>g</sup></td><td>569</td><td>Spain (569)</td><td>67</td><td>18.3 (0-73)</td><td>0.25</td><td>↑↑</td><td>↑↑</td></tr><tr><td>7</td><td>Norovirus and other calicivirus</td><td>Crustaceans, shellfish, molluscs and products thereof<sup>h</sup></td><td>414</td><td>Finland (150), France (120), Denmark (100), Sweden (22), Belgium (14), Spain (8)</td><td>3</td><td>521.8 (147-1152)</td><td>5.5</td><td>–</td><td>–</td></tr><tr><td>8</td><td>Salmonella</td><td>Broiler meat (Gallus gallus) and products thereof<sup>i</sup></td><td>359</td><td>Greece (69), Hungary (56), Austria (54), Spain (49), France (46), Denmark (28), Lithuania (23), Romania (19), Slovakia (9), Poland (6)</td><td>19</td><td>100.8 (16-240)</td><td>5.3</td><td>↑↑</td><td>↑↑</td></tr><tr><td>9</td><td>Staphylococcus aureus toxins</td><td>Mixed foods<sup>j</sup></td><td>358</td><td>Portugal (172), Slovakia (60), Romania (34), Spain (33), Czechia (30), France (12), Poland (11), Hungary (6)</td><td>13</td><td>189.8 (3-466)</td><td>3.5</td><td>↑↑</td><td>↑↑</td></tr><tr><td>10</td><td>Norovirus and other calicivirus</td><td>Mixed foods</td><td>335</td><td>Spain (148), Finland (130), Denmark (42), Belgium (15)</td><td>6</td><td>354.8 (223-487)</td><td>5.5</td><td>–</td><td>–</td></tr></tbody></table>

<footnote><sup>a</sup>Ranking of the food vehicle based on the number of cases of illness in strong-evidence FBOs in which the combination (causative agent/food vehicle) was implicated (rank 1 is the highest rank meaning the most commonly implicated). Strong-evidence outbreaks with unknown causative agents are not included.</footnote>

<footnote><sup>b</sup>A single arrow indicates variations between +25% and +50% in the number of outbreaks; double arrows indicate variations > +50%; a 'stable' value indicates variations of between -25% and +25%.</footnote>

<footnote><sup>c</sup>In 2023, 'eggs and egg products' includes 'eggs and egg products' (837), 'eggs' (264).</footnote>

<footnote><sup>d</sup>In 2023, 'mixed foods' includes 'mixed foods' (689), 'other processed food products and prepared dishes - meat based dishes' (73), 'other processed food products and prepared dishes - fish and seafood based dishes' (19), 'sauce and dressings - mayonnaise' (18), 'sauce and dressings' (14), 'other processed food products and prepared dishes - sushi' (12), 'other processed food products and prepared dishes - pizza and pizza-like dishes' (4).</footnote>

<footnote><sup>e</sup>In 2023, 'water' includes 'tap water, including well water' (689), 'water - potable water' (62).</footnote>

<footnote><sup>f</sup>In 2023, 'dairy products (other than cheeses)' includes 'dairy products (excluding cheeses) - dairy desserts' (538), 'dairy products (excluding cheeses) - yoghurt' (65).</footnote>

<footnote><sup>g</sup>In 2023, 'water' includes 'tap water, including well water' (569).</footnote>

<footnote><sup>h</sup>In 2023, 'crustaceans, shellfish, molluscs and products thereof' includes 'live bivalve molluscs - oysters' (379), 'crustaceans, shellfish, molluscs and products thereof' (22), 'bivalve molluscs' (13).</footnote>

<footnote><sup>i</sup>In 2023, 'broiler meat (Gallus gallus) and products thereof' includes 'broiler meat (Gallus gallus) and products thereof' (262), 'meat from broilers (Gallus gallus) - meat products' (69), 'meat from broilers (Gallus gallus) - fresh - skinned' (19), 'meat from broilers (Gallus gallus)' (9).</footnote>

<footnote><sup>j</sup>In 2023, 'mixed foods' includes 'other processed food products and prepared dishes' (190), 'mixed foods' (129), 'other processed food products and prepared dishes - meat based dishes' (23), 'other processed food products and prepared dishes - pasta based dishes' (11), 'other processed food products and prepared dishes - pizza and pizza-like dishes' (5).</footnote>
<table><caption>TABLE 55 Top-10 pathogen/food vehicle pairs causing the highest number of hospitalisations in strong-evidence outbreaks in reporting EU MSs, in 2023.</caption><thead><tr><th rowspan="2">Rank<sup>a</sup></th><th rowspan="2">Causative agent</th><th rowspan="2">Food vehicle</th><th rowspan="2">Hospitalisations (N)</th><th rowspan="2">Reporting MS (N hospitalisations)</th><th colspan="3">2019-2022</th><th colspan="2">Evaluation</th></tr><tr><th>Rank<sup>a</sup></th><th>Hospitalisations (N/year) (range)</th><th>Reporting MS (N/year)</th><th>2023 versus 2019-2022<sup>b</sup></th><th>↑↑</th></tr></thead><tbody><tr><td>1</td><td>Salmonella</td><td>Mixed foods<sup>c</sup></td><td>149</td><td>Poland (32), Hungary (23), Spain (23), Slovakia (19), Romania (17), Germany (14), Czechia (13), Italy (6), Estonia (1), France (1)</td><td>2</td><td>88.0 (11-198)</td><td>6.0</td><td>↑↑</td><td></td></tr><tr><td>2</td><td>Salmonella</td><td>Eggs and egg products<sup>d</sup></td><td>123</td><td>Spain (55), Poland (50), Austria (4), France (3), Slovakia (3), Czechia (2), Italy (2), Lithuania (2), Hungary (1), Malta (1)</td><td>1</td><td>157.8 (46-382)</td><td>6.5</td><td>–</td><td></td></tr><tr><td>3</td><td>Salmonella</td><td>Pig meat and products thereof<sup>e</sup></td><td>94</td><td>Germany (40), Italy (50), France (4)</td><td>4</td><td>42.5 (22-57)</td><td>4.5</td><td>↑↑</td><td></td></tr><tr><td>4</td><td>Salmonella</td><td>Bakery products<sup>f</sup></td><td>82</td><td>Poland (69), Slovakia (7), Czechia (3), Slovenia (2), Italy (1)</td><td>3</td><td>55.8 (21-94)</td><td>4.0</td><td>↑</td><td></td></tr><tr><td>5</td><td>Salmonella</td><td>Broiler meat (Gallus gallus) and products thereof<sup>g</sup></td><td>79</td><td>Lithuania (18), Austria (16), Hungary (16), Greece (11), Denmark (8), Poland (5), France (3), Slovakia (1), Spain (1)</td><td>9</td><td>23.3 (3-73)</td><td>3.3</td><td>↑↑</td><td></td></tr><tr><td>6</td><td>Staphylococcus aureus toxins</td><td>Mixed foods<sup>h</sup></td><td>41</td><td>Romania (28), Hungary (6), Slovakia (6), Czechia (1)</td><td>5</td><td>33.0 (0-58)</td><td>1.8</td><td>–</td><td></td></tr><tr><td>7</td><td>Mushroom toxins</td><td>Mixed foods<sup>i</sup></td><td>39</td><td>Italy (39)</td><td>NA</td><td>0</td><td>0</td><td>NA</td><td></td></tr><tr><td>8</td><td>Listeria monocytogenes</td><td>Vegetables and juices and other products thereof<sup>j</sup></td><td>38</td><td>Italy (38)</td><td>28</td><td>3.8 (0-13)</td><td>0.50</td><td>↑↑</td><td></td></tr><tr><td>9</td><td>Flavivirus (incl. tick-borne encephalitis virus)</td><td>Cheese<sup>k</sup></td><td>34</td><td>Slovakia (34)</td><td>39</td><td>1.0 (0-4)</td><td>0.25</td><td>↑↑</td><td></td></tr><tr><td>10</td><td>Salmonella</td><td>Fish and fish products<sup>l</sup></td><td>24</td><td>Poland (18), Estonia (3), France (2), Spain (1)</td><td>36</td><td>1.8 (0-5)</td><td>0.75</td><td>↑↑</td><td></td></tr></tbody></table>

Abbreviation: NA, not applicable.

<footnote><sup>a</sup>Ranking of the food vehicle based on the number of hospitalisations in strong-evidence FBOs in which the combination (causative agent/food vehicle) was implicated (rank 1 is the highest rank meaning the most commonly implicated). Strong-evidence outbreaks with unknown causative agents are not included.</footnote>

<footnote><sup>b</sup>A single arrow indicates variations between +25% and +50% in the number of outbreaks; double arrows indicate variations > +50%; a 'stable' value indicates variations of between -25% and +25%.</footnote>

<footnote><sup>c</sup>In 2023, 'mixed foods' includes 'mixed foods' (107), 'other processed food products and prepared dishes - meat based dishes' (28), 'other processed food products and prepared dishes - sushi' (4), 'sauce and dressings - mayonnaise' (3), 'other processed food products and prepared dishes' (3), 'other processed food products and prepared dishes - fish and seafood based dishes' (3), 'sauce and dressings' (1).</footnote>

<footnote><sup>d</sup>In 2023, 'eggs and egg products' includes 'eggs and egg products' (115), 'eggs' (8).</footnote>

<footnote><sup>e</sup>In 2023, 'pig meat and product thereof' includes 'pig meat and products thereof' (50), 'meat from pig - minced meat - intended to be eaten raw' (14), 'meat from pig - minced meat - intended to be eaten raw' (13), 'meat from pig - fresh' (4).</footnote>

<footnote><sup>f</sup>In 2023, 'bakery products' includes 'bakery products' (69), 'bakery products - desserts - containing raw eggs' (10), 'bakery products - cakes - containing heat-treated cream' (2), 'bakery products - pastry - made with raw eggs' (1).</footnote>

<footnote><sup>g</sup>In 2023, 'broiler meat (Gallus gallus)' and products thereof' includes 'broiler meat (Gallus gallus)' and products thereof' (67), 'meat from broilers (Gallus gallus)' - meat products' (11), 'meat from broilers (Gallus gallus)' (1).</footnote>

<footnote><sup>h</sup>In 2023, 'mixed foods' includes 'other processed food products and prepared dishes - meat based dishes' (23), 'mixed foods' (13), 'other processed food products and prepared dishes' (5).</footnote>

<footnote><sup>i</sup>In 2023, 'mixed foods' includes 'other processed food products and prepared dishes - mushroom based dishes' (39).</footnote>

<footnote><sup>j</sup>In 2023 'vegetables and juices and other products thereof' includes 'table olives' (38).</footnote>

<footnote><sup>k</sup>In 2023, 'cheese' includes 'cheeses made from sheep's milk - fresh' (34).</footnote>

<footnote><sup>l</sup>In 2023, 'fish and fish products' includes 'fish and fish products' (21), 'fish - gravad /slightly salted' (3).</footnote>
<table><caption>TABLE 56 Top-10 pathogen/food vehicle pairs causing the highest number of deaths in strong-evidence outbreaks in reporting EU MSs, in 2023.</caption><thead><tr><th colspan="2">2023</th><th colspan="4">2019-2022</th><th colspan="2">Evaluation</th></tr><tr><th>Rank<sup>a</sup></th><th>Causative agent</th><th>Food vehicle</th><th>Deaths (N)</th><th>Reporting MS (N deaths)</th><th>Rank<sup>a</sup></th><th>Deaths (N/year) (range)</th><th>Reporting MS (N/year)</th><th>2023 vs 2019-2022<sup>b</sup></th></tr></thead><tbody><tr><td>1</td><td>Listeria monocytogenes</td><td>Pig meat and products thereof<sup>c</sup></td><td>2</td><td>Germany (2)</td><td>5</td><td>1.3 (0-3)</td><td>1.0</td><td>↑↑</td></tr><tr><td>1</td><td>Listeria monocytogenes</td><td>Vegetables and juices and other products thereof<sup>d</sup></td><td>2</td><td>Italy (2)</td><td>5</td><td>1.3 (0-5)</td><td>0.25</td><td>↑↑</td></tr><tr><td>1</td><td>Salmonella</td><td>Mixed foods</td><td>2</td><td>Spain (2)</td><td>9</td><td>0.25 (0-1)</td><td>0.25</td><td>↑↑</td></tr><tr><td>2</td><td>Bacillus cereus toxins</td><td>Fish and fish products</td><td>1</td><td>Spain (1)</td><td>NA</td><td>0</td><td>0</td><td>NA</td></tr><tr><td>2</td><td>Clostridium botulinum toxins</td><td>Fish and fish products</td><td>1</td><td>Italy (1)</td><td>NA</td><td>0</td><td>0</td><td>NA</td></tr><tr><td>2</td><td>Clostridium perfringens toxins</td><td>Broiler meat (Gallus gallus) and products thereof</td><td>1</td><td>France (1)</td><td>NA</td><td>0</td><td>0</td><td>NA</td></tr><tr><td>2</td><td>Clostridium perfringens toxins</td><td>Fish and fish products</td><td>1</td><td>Spain (1)</td><td>NA</td><td>0</td><td>0</td><td>NA</td></tr><tr><td>2</td><td>Salmonella</td><td>Broiler meat (Gallus gallus) and products thereof</td><td>1</td><td>Austria (1)</td><td>NA</td><td>0</td><td>0</td><td>NA</td></tr><tr><td>2</td><td>Salmonella</td><td>Fish and fish products</td><td>1</td><td>Spain (1)</td><td>NA</td><td>0</td><td>0</td><td>NA</td></tr><tr><td>2</td><td>Salmonella</td><td>Meat and meat products, unspecified</td><td>1</td><td>Poland (1)</td><td>9</td><td>0.25 (0-1)</td><td>0.25</td><td>↑↑</td></tr><tr><td>2</td><td>Salmonella</td><td>Pig meat and products thereof</td><td>1</td><td>Germany (1)</td><td>9</td><td>0.25 (0-1)</td><td>0.25</td><td>↑↑</td></tr></tbody></table>

Abbreviation: NA, Not Applicable.

<footnote><sup>a</sup>Ranking of the food vehicle based on the number of deaths in strong-evidence FBOs in which the combination (causative agent/food vehicle) was implicated (rank 1 is the highest rank meaning the most commonly implicated). Strong-evidence outbreaks with unknown causative agents are not included.</footnote>

<footnote><sup>b</sup>Double arrows indicate variations > ±50%. footnote "b" in Table 56.</footnote>

<footnote><sup>c</sup>In 2023, 'pig meat and products thereof' includes 'meat from pig - meat products - ready-to-eat' (2).</footnote>

<footnote><sup>d</sup>In 2023, 'vegetables and juices and other products thereof' includes 'table olives' (2).</footnote>
## 4.4 | Overview of the places of exposure in strong-evidence outbreaks in 2023

The places of exposure for strong-evidence FBOs were reported for 547 FBOs (94.6% of all strong-evidence FBOs) by 21 MSs (all MSs reporting strong-evidence FBOs except Bulgaria and Czechia) and the United Kingdom (Northern Ireland). Information on the place of exposure is described below for 503 FBOs only, since for 44 FBOs the place of exposure was reported as 'others' with no further details. Key statistics are shown in Table 57.

Although the number of strong-evidence FBOs in 'domestic premises' in 2023 exceeded that of any other place of exposure in the EU, other sites were more frequently identified by the cases as the places of consumption of the implicated food (i.e. place of exposure). In detail, 'restaurant or cafe or pub or bar or hotel or catering service', 'multiple places of exposure in one country' and 'school or kindergarten' were places associated with a larger number of cases compared with FBOs occurring in 'domestic premises'. Overall, 5632 cases were exposed to contaminated food in one of the three above-mentioned places (50.5% of total cases involved in strong-evidence FBOs).

The overall impact of strong-evidence FBOs in 'domestic premises' was higher compared with 2022, with 51 more strong-evidence FBOs (35.2% increase), 168 more cases (24.1% increase) and 75 more hospitalisations (35.4% increase). The health impact of FBOs in 'domestic premises' is likely even higher since only 13 MSs (Austria, Finland, France, Greece, Italy, Lithuania, Malta, Poland, Portugal, Romania, Slovakia, Slovenia and Spain) and one non-MS (Serbia) provided information to EFSA on strong-evidence FBOs in domestic premises. As described above (see Section 4.1 on the countries reporting food-borne outbreak data in 2023), not all MSs report information on 'household' outbreaks (i.e. FBOs where all the human cases live in one single household), which are mostly associated with the place of exposure 'domestic premises'. *Salmonella*, and in particular S. Enteritidis, was by far the most frequent food-borne pathogen identified in these strong-evidence FBOs, causing more than half of FBOs in this setting (N = 115).

Strong-evidence FBOs in a 'restaurant or cafe or pub or bar or hotel or catering service' were reported by 17 MSs (Austria, Belgium, Croatia, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Italy, Lithuania, Poland, Romania, Slovakia, Spain and Sweden) and three non-MSs (Republic of North Macedonia, Serbia and Switzerland), i.e. a higher number of countries than in 2022 (14 MSs and one non-MS). Among MSs FBOs linked to this place of exposure also increased in 2023 compared with 2022 (47 more outbreaks, 35.1% increase) as did cases (844 more cases, 47.8% increase), hospitalisations (136 more hospitalisations, 101.5% increase) and deaths (no deaths had been communicated in 2022 for this place of exposure). The most frequently implicated causative agents in strong-evidence FBOs occurring in a 'restaurant or cafe or pub or bar or hotel or catering service' were *Salmonella* (73 outbreaks, 992 cases, 199 hospitalisations and 3 deaths), norovirus (and other calicivirus) (30 outbreaks, 720 cases, 2 hospitalisations), *Staphylococcus aureus* toxins (14 outbreaks, 211 cases, 47 hospitalisations) and *Clostridium perfringens* toxins (8 outbreaks, 173 cases, 1 hospitalisation).

Eleven MSs (Belgium, France, Germany, Hungary, Italy, Lithuania, Poland, Portugal, Romania, Slovakia and Spain) contributed to information on strong-evidence FBOs in a 'school or kindergarten'. Outbreaks occurring in these settings are frequently medium, large or very large in size. In 2023, there were 13 (44.8%) strong-evidence FBOs including 25 or more cases in these places of exposure and the four largest outbreaks totalled altogether 955 cases (63.5% of cases involving these places of exposure). The health impact of these FBOs was characterised by a limited number of hospitalisations and no deaths and was not substantially different from that observed in the four previous years.

A sharp increase in the number of cases was observed in the 10 strong-evidence FBOs occurring in a 'canteen or workplace catering' setting. In 2023 cases increased by 134.8% compared to 2022 (407 more cases) mainly due to a very large outbreak caused by norovirus reported from Germany, which included more than 500 cases (see also Section 4.4 on the places of exposure in strong-evidence outbreaks in 2023 and Table 54).

The same number of strong-evidence FBOs in 'health care and residential facilities' was reported as in 2022 (30 outbreaks), but with fewer cases (543 fewer cases) and hospitalisations (21 fewer hospitalisations). There was however a high death toll from the strong-evidence FBOs associated with these facilities (eight deaths), which is cause for concern because the people in these settings are more vulnerable compared with the general population, and frequently suffer from multiple conditions that contribute to make the impact of food-borne diseases more severe than in most other population subgroups. Causative agents associated with deaths in these strong-evidence FBOs included *Listeria monocytogenes* (two deaths), *Bacillus cereus* toxins and *Clostridium perfringens* toxins (one death each). For four deaths, the causative agent was not identified.

Strong-evidence FBOs with 'multiple places of exposure' in one or multiple countries were reported by 11 MSs (Austria, Belgium, Denmark, Finland, France, Germany, Italy, Netherlands, Portugal, Spain and Sweden) and the United Kingdom (Northern Ireland). The causative agents most frequently reported in these strong-evidence FBOs were bacteria (*Salmonella*, *Campylobacter*, *Shiga toxin-producing E. coli* (STEC), *Escherichia coli* other than STEC) and norovirus.

For a more interactive look at FBO data by places of exposure, visit the dedicated page in EFSA's dashboard on FBO (here).
<table><caption>TABLE 57 Frequency distribution of strong-evidence food-borne outbreaks by place of exposure (setting), in reporting EU MSs, 2023.</caption><thead><tr><th rowspan="3">Place of exposure</th><th colspan="4">Strong-evidence outbreaks</th><th colspan="2">Hospitalisations</th><th colspan="2">Deaths</th><th colspan="2">Outbreak reporting rate per 100,000</th></tr><tr><th colspan="2">Outbreaks</th><th colspan="2">Cases</th><th rowspan="2">N</th><th rowspan="2">% of total</th><th rowspan="2">N</th><th rowspan="2">% of total</th><th rowspan="2">2023</th><th rowspan="2">2019-2022</th></tr><tr><th>N</th><th>% of total</th><th>N</th><th>% of total</th></tr></thead><tbody><tr><td>Domestic premises</td><td>196</td><td>33.9</td><td>866</td><td>7.8</td><td>287</td><td>30.4</td><td>3</td><td>16.7</td><td>0.043</td><td>0.036</td></tr><tr><td>Restaurant, pub, street vendors, take away, etc.</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Restaurant or cafe or pub or bar or hotel or catering service</td><td>181</td><td>31.3</td><td>2608</td><td>23.4</td><td>270</td><td>28.6</td><td>3</td><td>16.7</td><td>0.040</td><td>0.025</td></tr><tr><td>Take-away or fast-food outlet</td><td>4</td><td>0.69</td><td>154</td><td>1.4</td><td>54</td><td>5.7</td><td>0</td><td>0</td><td>0.001</td><td>0.001</td></tr><tr><td>Mobile retailer or market/street vendor</td><td>3</td><td>0.52</td><td>15</td><td>0.13</td><td>8</td><td>0.85</td><td>0</td><td>0</td><td>0.001</td><td>0.001</td></tr><tr><td>Canteen or catering at workplace, school, etc.</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>School or kindergarten</td><td>29</td><td>5.0</td><td>1504</td><td>13.5</td><td>32</td><td>3.4</td><td>0</td><td>0</td><td>0.006</td><td>0.006</td></tr><tr><td>Canteen or workplace catering</td><td>10</td><td>1.7</td><td>709</td><td>6.4</td><td>3</td><td>0.32</td><td>0</td><td>0</td><td>0.002</td><td>0.002</td></tr><tr><td>Catering on aircraft or ship or train</td><td>2</td><td>0.35</td><td>53</td><td>0.47</td><td>2</td><td>0.21</td><td>0</td><td>0</td><td>&lt;0.001</td><td>&lt;0.001</td></tr><tr><td>Multiple places of exposure</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Multiple places of exposure in one country</td><td>33</td><td>5.7</td><td>1520</td><td>13.6</td><td>156</td><td>16.5</td><td>3</td><td>16.7</td><td>0.007</td><td>0.005</td></tr><tr><td>Multiple places of exposure in more than one country</td><td>3</td><td>0.52</td><td>23</td><td>0.21</td><td>9</td><td>0.95</td><td>0</td><td>0</td><td>0.001</td><td>0.001</td></tr><tr><td>Health care and residential facilities</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Residential institution (prison or boarding school)<sup>a</sup></td><td>12</td><td>2.1</td><td>263</td><td>2.4</td><td>2</td><td>0.21</td><td>1</td><td>5.6</td><td>0.003</td><td>—</td></tr><tr><td>Nursing home<sup>a</sup></td><td>12</td><td>2.1</td><td>237</td><td>2.1</td><td>5</td><td>0.53</td><td>2</td><td>11.1</td><td>0.003</td><td>—</td></tr><tr><td>Hospital and medical care facility</td><td>6</td><td>1.0</td><td>221</td><td>2.0</td><td>32</td><td>3.4</td><td>5</td><td>27.8</td><td>0.001</td><td>0.002</td></tr><tr><td>Other place of exposure</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Others</td><td>44</td><td>7.6</td><td>1650</td><td>14.8</td><td>40</td><td>4.2</td><td>1</td><td>5.6</td><td>0.010</td><td>0.005</td></tr><tr><td>Camp or picnic</td><td>7</td><td>1.2</td><td>172</td><td>1.5</td><td>15</td><td>1.6</td><td>0</td><td>0</td><td>0.002</td><td>0.002</td></tr><tr><td>Temporary mass catering (fairs or festivals)</td><td>3</td><td>0.52</td><td>10</td><td>0.09</td><td>3</td><td>0.32</td><td>0</td><td>0</td><td>0.001</td><td>&lt;0.001</td></tr><tr><td>Farm</td><td>1</td><td>0.17</td><td>2</td><td>0.02</td><td>1</td><td>0.11</td><td>0</td><td>0</td><td>&lt;0.001</td><td>&lt;0.001</td></tr><tr><td>Primary production</td><td>1</td><td>0.17</td><td>14</td><td>0.13</td><td>0</td><td>0</td><td>0</td><td>0</td><td>&lt;0.001</td><td>&lt;0.001</td></tr><tr><td>Unknown</td><td>31</td><td>5.4</td><td>1139</td><td>10.2</td><td>25</td><td>2.6</td><td>0</td><td>0</td><td>0.007</td><td>0.006</td></tr><tr><td>EU Total</td><td>578</td><td>100</td><td>11,160</td><td>100</td><td>944</td><td>100</td><td>18</td><td>100</td><td>0.128</td><td>0.098</td></tr></tbody></table>

<footnote><sup>a</sup>Since 2024, food-borne outbreaks occurring in nursing homes could be reported specifically within the 'nursing homesetting'. Previously, this setting was grouped under 'residential institution (nursing home, prison or boarding school)'. As no information on FBOs occurring specifically in nursing homes in 2019-2022 was available, the outbreak reporting rate could not be estimated in this period.</footnote>
## 4.5 | Contributing factors in strong-evidence food-borne outbreaks in 2023

Information on factors contributing to strong-evidence FBOs was available for 196 FBOs (33.9% of all strong-evidence FBOs).

‘Inadequate heat treatment’ and ‘inadequate chilling’ were reported to have contributed to 49 and 24 strong-evidence FBOs, respectively. In particular, ‘inadequate heat treatment’ was the contributory factor reported most often in strong-evidence FBOs caused by *Salmonella* (29 out of 74 outbreaks corresponding to 39.2% of strong-evidence *Salmonella* FBOs with information on contributory factors available) and by *Campylobacter* (eight outbreaks, 40.0%). ‘Unprocessed contaminated ingredient’, which was reported for 41 strong-evidence FBOs overall, also made a major contribution to *Campylobacter* FBOs (eight outbreaks, 40.0%) and FBOs caused by norovirus and other calicivirus (10 outbreaks, 37.0%). ‘Cross-contamination’ was reported in 41 strong-evidence FBOs. This factor was the most frequently reported in FBOs caused by *Listeria monocytogenes* (three outbreaks, 75.0%). ‘Time storage/temperature abuse’ was reported in 36 strong-evidence FBOs and was the top contributory factor in FBOs caused by *Clostridium perfringens* (11 outbreaks, 73.3%), *Bacillus cereus* (three outbreaks, 75.0%), histamine and scombrotoxin (two outbreaks, 50.0%), and *Escherichia coli* other than STEC (two outbreaks, 50.0%). ‘Infected food handler’ was identified in 31 strong-evidence FBOs and ranked first among factors contributing to FBOs caused by norovirus (and other calicivirus) (11 outbreaks, 40.7%) and *Staphylococcus aureus* toxins (eight outbreaks, 61.5%). ‘Water treatment failure’ and ‘untreated drinking water’ were reported in two and three strong-evidence water-borne outbreaks, respectively.

The distribution of contributory factors by either type of implicated food or place of exposure indicates that the use of an ‘unprocessed contaminated ingredient’ was the most important factor in strong-evidence FBOs implicating ‘foods of non-animal origin’ (six outbreaks, 46.2%), ‘fish and fishery products’ (eight outbreaks, 38.1%) and ‘milk and milk products’ (four outbreaks, 26.7%), as well as in strong-evidence FBOs involving cases exposed to contaminated food in ‘multiple places of exposure’ (15 outbreaks, 71.4%). Outbreaks occurring in ‘domestic premises’ were mostly associated with ‘inadequate heat treatment’ (24 outbreaks, 61.5%). This factor was of primary importance also in strong-evidence FBOs caused by ‘eggs and egg products’ (14 outbreaks, 46.7%), while in strong-evidence FBOs associated with the consumption of ‘composite foods, multi-ingredient foods and other foods’, this role was played by ‘infected food handler’ (23 outbreaks, 41.1%). ‘Infected food handler’ also ranked first among all contributory factors in strong-evidence FBOs associated with a ‘restaurant, pub, street vendors, take away, etc.’ (24 outbreaks, 28.6%), followed by ‘cross-contamination’ (20 outbreaks, 23.8%) and ‘storage time/temperature abuse’ (16 outbreaks, 19.0%). For strong-evidence FBOs caused by ‘meat and meat products’, ‘cross-contamination’ and ‘storage time/temperature abuse’ were the top contributory factors, while the use of ‘untreated drinking water’ was conceivably the most important contributor to strong-evidence FBOs implicating ‘water (and other beverages)’ (three outbreaks, 75.0%). ‘Storage time/temperature abuse’ contributed the most to strong-evidence FBOs connected to a ‘canteen or catering at workplace, school, etc.’ (eight outbreaks, 50.0%), while ‘cross-contamination’ was the most frequent factor reported in ‘health care and residential facilities’ (four outbreaks, 36.4%).

See the EFSA story map on FBOs (here), section on ‘How, why and where food contamination may occur’.

## 4.6 | Temporal trends by causative agents, 2014–2023

### 4.6.1 | Temporal trends at EU level

The number of FBOs reported by MSs over 2014–2023, by causative agent, is illustrated in Figure 21. Since the collection of FBO data is not fully harmonised across the EU, and changes in FBO surveillance might have occurred over the years in MSs, the annual fluctuations in the distribution of causative agents reported in Figure 21 might not accurately represent the true epidemiological pattern at the EU level.

For a more interactive look at time trends in FBO data, visit the dedicated page in EFSA's dashboard on FBO (here).
<figure><img src="image_118.png" /><figcaption>**FIGURE 21** Number of food-borne outbreaks by causative agent, reported to the EU by MSs, 2014–2023. 'Marine biotoxins' includes ciguatoxin, muscle-paralysing toxin and unspecified marine biotoxins. 'Norovirus (and other calicivirus)' includes norovirus (Norwalk-like virus), sapovirus (Sapporo-like virus) and unspecified calicivirus. 'Other bacteria (incl. unspecified)' includes *Aeromonas*, *Arcobacter*, *Cronobacter sakazakii*, *E. coli* other than STEC, *Enterococcus*, *Francisella*, *Leptospira*, *Mycobacterium spp.*, *Shigella*, *Streptococcus*, *Vibrio cholerae* (non-toxigenic), *Vibrio cholerae* (toxigenic), *Vibrio parahaemolyticus* and other unspecified bacteria. 'Other parasites (incl. unspecified)' includes *Anisakis*, *Cysticerci*, *Enterocytozoon bieneusi*, *Giardia* and other unspecified parasites. 'Other viruses (incl. unspecified)' includes adenovirus, enterovirus, flavivirus (incl. tick-borne encephalitis virus), hepatitis E virus, unspecified hepatitis virus, rotavirus and other unspecified virus. 'Other agents (incl. unspecified)' includes atropine, chemical agents, lectins, monosodium glutamate, mushroom toxins, mycotoxins, unspecified toxins, wax esters (from fish) and other unspecified agents.</figcaption></figure>

### 4.6.2 | Temporal country-specific trends by causative agent

Only statistically significant trends in the number of FBOs, by causative agent and country, are described in this section. More information on the methodology used for trend analyses is provided in the section on data analyses of this chapter (Section 3 on Data Analysis). Figures on statistically significant country-specific temporal trends by causative agent, over the 2014–2023 period, are available in the 'Addendum on food-borne outbreaks, complementing the European Union One Health Zoonoses Report 2023', Section 5, published on the EFSA Knowledge Junction at Zenodo (here).

Various statistically significant increasing or decreasing trends, by causative agent and reporting EU MS, were observed over the period 2014–2023.

The trend analysis for **Salmonella** highlighted a significant decreasing trend for four MS (Germany, Latvia, Lithuania and Romania), two fewer countries with statistically significant decreasing trends than 2022. For Germany, Latvia and Lithuania this decrease was primarily due to a significant decrease in the number of outbreaks due to **S. Enteritidis**. In Austria, a significant decrease in the number of FBOs was observed for **S. Enteritidis** and **S. Typhimurium**.

The second bacterial agent with statistically significant trends was **Campylobacter**. A significant decreasing trend over 2014–2023 was observed in two MS (Austria and Germany), while the trend increased significantly in France. A significant decrease was also detected for FBOs caused by *Shigella* in Germany.

Considering **norovirus**, a statistically significant decreasing trend was observed in the Netherlands. Other agents with a statistically significant reduction in the number of FBOs over the 2014–2023 period were **Trichinella** in Romania and **marine biotoxins** in France.
Lastly, in the EU, a statistically significant decrease in the number of FBOs with an unknown agent was observed in Finland and Sweden, while Czechia, Italy and the Netherlands experienced a significant increase. In non-MSs, a decreasing trend was observed in Norway and an increase in Switzerland. The differences in trends across these countries may be attributed to variations in outbreak surveillance sensitivity, as well as changes in laboratory testing and subtyping methods.

### 4.6.3 | Temporal trends by implicated food vehicle

Only strong-evidence FBOs were considered for the trend analysis by implicated food vehicle at country level. Few statistically significant trends were detected for food vehicles over the 2014–2023 period.

Decreasing trends were identified for strong-evidence FBOs associated with the consumption of 'pig meat' and 'buffet meals' in Romania, 'cheese' in France and 'sweets and chocolate' in Poland. The decreasing trends observed for France and Poland were both driven by a significant decrease in FBOs caused by *Salmonella* in 'cheese' and 'sweets and chocolate', respectively (p < 0.05). Only for Italy an increasing trend was observed in the number of FBOs associated with 'pig meat'.

Figures describing statistically significant temporal trends in the number of outbreaks, both by causative agent and MS and by food vehicle and MS, are available as downloadable files from the EFSA knowledge junction at Zenodo here.

## 4.7 | Water-borne outbreaks

In 2023, 42 water-borne outbreaks were reported by 11 MSs (Belgium, Croatia, Czechia, Finland, France, Greece, Ireland, Italy, Slovakia, Spain and Sweden) and three by two non-MSs (Norway and Switzerland). In the EU, water-borne outbreaks involved a total of 1954 human cases with nine hospitalisations, corresponding to four fewer cases and 41 fewer hospitalisations than in 2022. No deaths were reported in water-borne outbreaks.

Among the FBOs observed in the EU, 10 outbreaks were considered strong-evidence and included outbreaks caused by 'tap water, including well water' (N=8) and 'potable water' (N=2).

The causative agents involved were norovirus and other calicivirus (N=10), *Cryptosporidium* (N=7), Shiga toxin-producing *E. coli* (STEC) (N=4), *Campylobacter* (N=2), *Shigella* (N=1), *Clostridium perfringens* toxins (N=1) and *Giardia* (N=1). In 16 outbreaks the aetiology remained unknown.

Water-borne outbreaks often include a large or very large number of cases. In 2023 the mean size of water-borne outbreaks in the EU was 46.5 cases per outbreak (range 2–580 cases). Two very large outbreaks (≥ 100 cases each) were reported to EFSA, both from Spain. The largest one involved 580 cases and was caused by norovirus, resulting from a failure in the water treatment system, while the other outbreak involved 119 cases and was caused by *Cryptosporidium*. Two other outbreaks were reported jointly to EFSA from Spain and were caused by *Cryptosporidium* involving altogether 450 cases.

Norway also reported a very large water-borne outbreak (140 cases) with unknown aetiology. In addition, Norway and Switzerland reported two other outbreaks linked to 'water' and 'potable water', which were caused by *E. coli* other than STEC and an unknown agent, respectively.

## 4.8 | ECDC and EFSA rapid outbreak assessment (ROA)

ECDC and EFSA jointly assessed the public risk of various FBOs occurring in 2023, publishing Rapid Outbreak Assessments (ROA).

The first ROA referred to a cross-border outbreak caused by *Salmonella* Virchow ST16, which involved 210 cases in five EU countries (Denmark, France, Germany, Ireland and Netherlands), the United Kingdom (UK) and the United States of America over the period 2017–2023. The proportion of hospitalisations varied across countries. No deaths were reported. Information from case interviews, food traceability investigations and whole genome sequencing (WGS) cluster analysis identified chicken meat products including chicken kebab as the likely vehicle of infection. However, the source(s) of contamination had not been established at the date of publication of this ROA (ECDC and EFSA, 2023b).

A second outbreak was caused by S. Senftenberg ST14 and occurred in the years 2022 and 2023. This outbreak caused 92 cases in 11 EU/EEA countries (Austria, Belgium, Czechia, Estonia, Finland, France, Germany, Ireland, Netherlands, Norway and Sweden), the UK and the US, involving predominantly women. Twelve cases were hospitalised while one patient died. Case interviews pointed to cherry tomatoes as the likely source of infection. The outbreak strain was detected in a mixed salad dish containing cherry tomatoes. However, following traceability investigations, no common epidemiological (trade) link between the traced back food business operators and the countries reporting cases was revealed. Since June 2023, the number of cases has declined as well as the risk of new infections (ECDC and EFSA, 2023a).

In 2023, S. Enteritidis ST11 was the causative agent responsible for an outbreak causing 335 cases, nine hospitalisations and one death in 14 EU/EEA countries, the UK and the US. Three different molecular clusters were identified based on WGS analysis. Food exposure information and microbiological investigations identified chicken meat and chicken meat products, including kebab, as the likely vehicle of human infections. Traceability information revealed that some kebab products shared common food business operators in Poland. However, at the time of publication of the ROA, further traceability and microbiological investigations were still needed to identify the source of contamination and infections (ECDC and EFSA, 2023e).
An update of the multi-country outbreak caused by S. Mbandaka ST413, described in 2022 (ECDC and EFSA, 2022), was published in March 2024 (ECDC and EFSA, 2024a). This outbreak involved 300 cases, with an increase of 53.1% (104 new cases in 2023) compared with 2022, in six EU countries (Estonia, Finland, France, Germany, Ireland and Netherlands) and the UK. Twenty-three cases were hospitalised and one patient died. Case interviews, microbiological analyses and traceability investigations indicated frozen steam-cooked chicken breast, produced by a Ukrainian factory, as the source of infection. Various control measures were adopted, and the contaminated batches were assumed to no longer be on the market. However, other undetected routes of exposures might still be present posing a risk of new infections (ECDC and EFSA, 2024a).

Two other assessments were published and concerned clusters of *Listeria monocytogenes* of two different sequence types (ST). The first ROA described a cluster of *L. monocytogenes* ST155, serogroup IIa. Three sub-clusters were identified through genomic similarity analysis; however, the assessment focused on sub-cluster 1, which occurred between 2016 and 2023. A total of 64 cases and 10 deaths were reported by five EU countries (Austria, Belgium, Italy, Germany and Netherlands). Case interviews identified ready-to-eat fish products as the likely vehicle of infection, and traceability and genomic investigations pointed to three Lithuanian processing plants (ECDC and EFSA, 2023c).

The second ROA focused on a cluster caused by *L. monocytogenes* ST1607, identified in three EU countries (Denmark, Germany and Italy) between 2019 and 2024. Twenty cases and five deaths were notified. Case interviews, and microbiological and food traceability investigations identified smoked salmon products as the probable source of infections. The outbreak strain was identified from products and from the environment of a Danish processing plant. Various control measures were soon adopted by the Danish factory, including withdrawal and recall of the contaminated batches (ECDC and EFSA, 2024b).

# 5 | CONCLUSIONS

## 5.1 | Health impact, causative agents and trends

In 2023, the reporting of FBOs in the EU did not substantially change compared with 2022 in terms of total outbreaks, cases, hospitalisations and deaths. Despite a slight reduction in the overall number of outbreaks, there was an increase in the number of cases, likely attributable to the identification of a higher proportion of larger FBOs compared with the previous year. Most of the reported FBOs were general outbreaks, involving cases belonging to more than one household. A total of 65 deaths were reported in 2023 in the EU, the highest value reported to EFSA in the last 10 years.

The outbreak and case reporting rate observed in 2023 showed an increase compared with the average annual rate for the 2019-2022 period, which was lower primarily because it included the years of the COVID-19 pandemic (2020-2021). The resurgence in the rates observed in 2023 indicated a return to pre-pandemic levels. At the national level, significant variability was observed in the epidemiological indicators used to describe FBOs, including reporting rates, mean outbreak size, type of outbreak and severity. This variability reflects both epidemiological differences and disparities in the approach and sensitivity of FBO surveillance across countries.

In the EU, various multi-country outbreaks were reported in 2023, with *Salmonella* being the most frequently reported causative agent. The widespread use of WGS across countries has revolutionised outbreak detection and investigation and has considerably improved the early detection of cases of food-borne infections, even among countries (Brown et al., 2019; Gilchrist et al., 2015). WGS has significant potential in the surveillance and monitoring of emerging health threats, also in the context of food-borne outbreaks, by enabling accurate characterisation of pathogens, and supporting cross-border food-borne outbreak investigation and management (EFSA, 2022).

The key results from the 2023 data indicate that the health impact of FBOs caused by *Salmonella*, and in particular by S. Enteritidis, continues to be very high in Europe. The high number of deaths is a major finding emerging from the 2023 data analysis, since non-typhoidal *Salmonella* infections typically cause mild, self-limiting enterocolitis in industrialised countries, usually characterised by abdominal pain, diarrhoea, nausea and vomiting, and resolving spontaneously (Coburn et al., 2007). The rise in deaths from *Salmonella* infections highlights the potential for severe and fatal infection from outbreaks of *Salmonella*, particularly in vulnerable population subgroups (i.e. young children, elderly, immunocompromised individuals), which may develop severe and invasive diseases (Acheson & Hohmann, 2001). These population subgroups are also at risk from the development of severe listeriosis (i.e. septicaemia, meningitis and meningoencephalitis). *Listeria monocytogenes* continues to be the causative agent associated with the highest case fatality rate. Many deaths caused by severe listeriosis were reported among epidemic cases in healthcare settings in 2023. These findings need to be carefully considered, with particular attention paid to the wide variety of food vehicles, even some that are not traditionally considered as likely sources of infections (e.g. table olives), which may support the growth of *L. monocytogenes* and cause FBOs (e.g. meat and meat products, fish and fish products, mixed and multi-ingredient foods, dairy products and vegetables) (Desai et al., 2019; Koopmans et al., 2023).

Interestingly, in the EU, more FBOs in 2023 than in 2022 involved travel-related cases, with *Salmonella* being the most frequent causative agent. This finding highlights the need to continue raising awareness among the public regarding food safety and the risk of developing food-borne illness while travelling, particularly in regions with less stringent food safety standards compared with the EU.
## 5.2 | Food vehicles and places of exposure

Directive 2003/99/EC focuses on the importance of collecting information on FBOs in Europe. This is the only data source that allows the simultaneous collection of information on food vehicles and human disease cases. The assessment of the level of uncertainty with respect to the evidence associating epidemic cases with the food vehicles and, in general, with the context in which the outbreak occurred is an important element contributing to the quality of EFSA's epidemic data collection. It enables an assessment of the accuracy of findings evaluated in the epidemic context.

The data collection carried out by EFSA in 2023 on food vehicles linked to epidemic outbreaks and the places where these foods were consumed reveals information that consolidates the results of previous years and related trends. Findings emerging from the analysis of 2023 data on food vehicles concur with those for the entire 2019–2022 period. ‘Composite foods, multi-ingredient foods and other foods’ followed by ‘meat and meat products’, ‘eggs and egg products’ and ‘fish and fishery products’ were the food groups most frequently identified in strong-evidence outbreaks and having the highest impact in terms of cases and hospitalisations.

The number of outbreaks associated with ‘composite foods, multi-ingredient foods and other foods’ and in particular ‘mixed foods’ has increased steadily since 2020. This finding is not surprising since this group includes a wide miscellanea of food of different natures obtained by mixing ingredients of either animal or non-animal origin. The contamination of mixed foods may arise from a single contaminated ingredient which remains unidentified during the outbreak investigation. Problems leading to contamination of single ingredients or contributing to boost the level of contamination in the final mixed food preparation may originate and propagate through different mechanisms and at various stages of the food production chain and meal preparation at the consumer level. Food handling increases the risk of contamination and even of microbial growth when food is prepared by an infected food handler or through mechanisms of cross-contamination, in particular when food is prepared under poor hygiene procedures or at temperatures allowing microbial growth. Findings from the 2023 EFSA data analysis on FBOs indicate that all these factors have made a major contribution to outbreaks linked to public catering, making it even more important to strengthen HACCP implementation.

Training, attitudes, knowledge awareness and practices of operators in the catering service sector and in particular in restaurants, pubs, cafés and hotel catering, etc. are crucial to keep the risk of exposure to contaminated food under control, since public catering (either for leisure or connected to daily activities such as school and the workplace) is very frequently implicated in food-borne outbreaks in the EU. The importance of restaurants, pubs, cafés and hotel catering, etc. increased sharply in 2023, with more MSs reporting outbreaks connected to these places (either more outbreaks, cases, hospitalisations or deaths) compared with 2022. These variations, however, do not necessarily indicate an increased risk of exposure to contaminated food for consumers as they may be the result of more meals and food consumed in these settings. Recent data from the EFSA/Eurobarometer study (EFSA, 2022) indicate that the total household expenditure on catering services is on the rise in most MSs, which suggests an increased tendency to eat out.

People's eating behaviours vary considerably among MSs and among population subgroups, with important socio-demographic and food environment factors influencing the patterns and the places of food consumption. As an example, young adults and people living in urban areas are more frequently exposed to food prepared in public catering than older adults and people living in rural area or suburbs who more frequently consume meals at home. Education at home on how to prepare and consume food safely, including the importance of following the instructions on food labels, is crucial to improve food safety in domestic kitchens. EFSA recommends once again the importance of promoting food-safety education programmes such as the WHO Five Keys campaign<fnref n="47" /> in domestic kitchens and is directly committed to supporting MSs in the annual communication campaigns for consumers.

The 2023 annual FBO data collection revealed that that ‘inadequate heat treatment’ was the most frequent factor contributing to food-borne outbreaks in domestic premises. Not paying attention to information about food safety has a direct impact on the risk of exposure to contaminated food in this place of exposure. The recent Special Eurobarometer 97.2 study on Food safety in the EU (EFSA, 2022) shed light on the reasons underpinning the lack of consumer engagement with food safety. Conviction that food sold is safe, a perception by consumers that they know enough to avoid or mitigate food risks and difficulties in understanding food safety information due to highly technical and complex language were the main identified reasons. Such factors may hamper the adoption of correct food handling and consumption behaviours at home, in particular by the most vulnerable groups of the population. Consumers' self-awareness of their personal role and responsibility in keeping food safe at home is therefore critical. Unfortunately, older adults have been found in a recent study to perceive themselves as having lower levels of risk than other individuals, suggesting perceptions of optimistic bias and personal invulnerability (Evans & Redmond, 2019).

In conclusion, food-borne outbreaks remain a significant public health threat in the EU, with increasing cases and deaths in 2023, particularly affecting vulnerable groups. Advances in genome sequencing have probably improved outbreak detection in the EU, in particular detection of large general outbreaks disseminated in the community. On the other hand improper food handling and errors in food preparation, especially in public and domestic premises, continue to represent major risk factors in food contamination and consumer exposure to contaminated food. Globalisation, shifting consumption habits and population movements further heighten the risk of food-borne outbreaks, posing ongoing challenges to public health.

<footnote n="47">⁴⁷The core messages of the WHO Five Keys campaign are: keep clean; separate raw and cooked; cook thoroughly; keep food at safe temperatures; and use safe water and raw materials.</footnote>
# ZOONOSES AND ZOONOTIC AGENTS MONITORED ACCORDING TO THE EPIDEMIOLOGICAL SITUATION (DIRECTIVE 2003/99/EC LIST B)

## 1 | YERSINIA

### Human cases [EU, 2023]

<figure><img src="image_119.png" /></figure>

8738 Cases of illness

<figure><img src="image_120.png" /></figure>

4929 Infections acquired in the EU

<figure><img src="image_121.png" /></figure>

152 Infections acquired outside the EU

<figure><img src="image_122.png" /></figure>

3657 Unknown travel status or unknown country of infection

Notification rate
(per 100,000 population)

2.4

Trend
(2019-2023)

<figure><img src="image_123.png" /></figure>

Increasing
Decreasing
Stable

651 Hospitalisations (25.5%)*

1 Death (0.02%)*

<figure><img src="image_124.png" /></figure>

ECDC data

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

<figure><img src="image_125.png" /></figure>

17 Foodborne outbreaks

2

Strong-evidence outbreaks

<figure><img src="image_126.png" /></figure>

15

Weak-evidence outbreaks

<figure><img src="image_127.png" /></figure>

73 Cases of illness

9 Hospitalisations (12.3%)*

N of outbreaks

<table><tr><td>Austria</td><td>1</td></tr><tr><td>Belgium</td><td>0</td></tr><tr><td>Bulgaria</td><td>0</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>4</td></tr><tr><td>Germany</td><td>1</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>3</td></tr><tr><td>Portugal</td><td>0</td></tr><tr><td>Romania</td><td>0</td></tr><tr><td>Slovakia</td><td>2</td></tr><tr><td>Slovenia</td><td>0</td></tr><tr><td>Spain</td><td>5</td></tr><tr><td>Sweden</td><td>1</td></tr><tr><td>UK (N. Ireland)</td><td>0</td></tr></table>

N of outbreaks per 100,000 population **

<table><tr><td>AT</td><td>0.011</td></tr><tr><td>BE</td><td>0</td></tr><tr><td>BG</td><td>0</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>0.006</td></tr><tr><td>DE</td><td>0.001</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>0.008</td></tr><tr><td>PT</td><td>0</td></tr><tr><td>RO</td><td>0</td></tr><tr><td>SK</td><td>0.037</td></tr><tr><td>SI</td><td>0</td></tr><tr><td>ES</td><td>0.010</td></tr><tr><td>SE</td><td>0.010</td></tr><tr><td>XI</td><td>0</td></tr></table>

N of outbreak cases per 100,000 population

<table><tr><td>AT</td><td>0.022</td></tr><tr><td>BE</td><td>0</td></tr><tr><td>BG</td><td>0</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>0.016</td></tr><tr><td>DE</td><td>0.002</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>0.057</td></tr><tr><td>PT</td><td>0</td></tr><tr><td>RO</td><td>0</td></tr><tr><td>SK</td><td>0.074</td></tr><tr><td>SI</td><td>0</td></tr><tr><td>ES</td><td>0.027</td></tr><tr><td>SE</td><td>0.190</td></tr><tr><td>XI</td><td>0</td></tr></table>

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

Top food vehicles

<figure><img src="image_128.png" /></figure>

Vegetables and juices and other products thereof

1 Outbreak

<figure><img src="image_129.png" /></figure>

Meat and meat products, unspecified

1 Outbreak

<figure><img src="image_130.png" /></figure>

EFSA data

<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>
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 Yersinia, the following interactive tool is available:

Yersinia

<figure><img src="image_131.png" /></figure>

STORY MAP

<figure><img src="image_132.png" /></figure>

## 1.1 | Key facts

* In 2023, there were 8738 confirmed cases of human yersiniosis, corresponding to a European Union notification rate of 2.4 cases per 100,000 population. This was an increase of 13.5% compared with 2022 (2.2 per 100,000 population).

* The overall trend for Yersinia infection showed a statistically significant increase (p < 0.01) in the 2019–2023 period.

* In 2023, Yersinia enterocolitica was the species reported in the majority (97.7%) of human cases, while Yersinia pseudotuberculosis was notified in 2.3% of human cases for which the information on Yersinia species was available.

* In 2023, none of 314 'ready-to-eat' (RTE) food sampling units reported by four Member States were positive for Yersinia. Of 1210 'non-RTE' sampling units reported by six Member States, 10.2% were positive. The only positive category was 'meat and meat products' with a rate of 10.2%. Of 953 'fresh meat' sampling units, only 'fresh meat from pigs' showed Yersinia-positive sampling units, with a rate of 12.6%.

* In 2023, Yersinia was detected by six Member States in more than eight different animal categories, which overall include more than 30 animal species. The majority of the units tested in the European Union (N=6901) were from cattle, and the proportion of positives was 0.97% for Yersinia enterocolitica and 1.0% for Yersinia pseudotuberculosis. The proportions of positive sampling units from 'small ruminants', pigs and 'pet animals' were 0.60%, 1.5% and 1.4% for Y. enterocolitica, and 0.25%, 0% and 2.9% for Y. pseudotuberculosis, respectively.

## 1.2 | Surveillance and monitoring of Yersinia in the EU

### 1.2.1 | Humans

In 2023, 26 MSs reported information on yersiniosis in humans. Surveillance of yersiniosis is mandatory in 22 MSs. In four MSs (Belgium, France, Greece and Italy), notification is based on a voluntary system. No yersiniosis surveillance system is in place in the Netherlands. The EU case definition was used by 21 MSs, and five MSs used a different case definition for reporting (Denmark, France, Germany, Greece and Italy). All MSs, except two (Greece and Italy) had a comprehensive surveillance system. The yersiniosis surveillance system covers the whole population in all MSs, except France, Italy and Spain. No population coverage estimates were provided for France and Italy, so no notification rates were calculated for these two MSs in any year. The estimated coverage of the surveillance system was 92% in Spain. This estimated proportion of population coverage was used in the calculation of notification rates for this MS. For the period 2021–2022, the estimated coverage of surveillance systems was 91%, while for the years 2019–2020, the rate could not be calculated as no information on coverage was provided. All countries reported case-based data, except Bulgaria and Greece, which reported aggregated data.

### 1.2.2 | Food and animals

Although it is not mandatory to report the presence of Yersinia in food and animals, MSs can report monitoring data on Yersinia to EFSA, in accordance with Directive 2003/99/EC. The directive specifies that, in addition to the zoonoses and zoonotic agents for which monitoring is mandatory, zoonoses such as yersiniosis and agents thereof must also be monitored according to the epidemiological situation.

At present, no harmonised Yersinia monitoring plan is in place for food or animals in the EU. Therefore, data on Yersinia in food and animals submitted to EFSA by the MSs are not harmonised. Nevertheless, an EFSA Scientific Opinion recommends the most optimal monitoring methods for Yersinia enterocolitica and Yersinia pseudotuberculosis in foodstuffs and animal populations from a public health perspective (EFSA, 2007), whereas harmonised monitoring and reporting criteria for Y. enterocolitica in slaughter pigs were recommended in an EFSA scientific report (EFSA, 2009b).

At the EU level, monitoring data submitted by MSs for Yersinia in food and animals allow for descriptive summary statistics only, and do not support trend analyses and trend watching (Table 1). Consequently, the reported occurrence of
Yersinia in major food categories for the year 2023 and for the 4-year period 2019–2023 was summarised descriptively, making a distinction between ‘ready-to-eat’ (RTE) and ‘non-RTE’ foods. Only results obtained from samples collected and tested for Yersinia under an ‘objective sampling’ strategy were considered, in order to limit selection bias. Objective sampling means that MSs collected and tested the samples according to a planned strategy based on a random sampling design representative of the population under study.

## 1.3 | Results

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

Table 58 summarises EU-level statistics on human yersiniosis, and on the occurrence of Yersinia in food and animals, for the period 2019–2023. Although yersiniosis was the fourth most frequently reported food-borne gastrointestinal infection in humans in the EU in 2023, data on Yersinia in food and animals continue to be reported by few MSs, like in previous years. More detailed descriptions of these statistics are provided in the below subsections and in the chapter on food-borne outbreaks.

<table><caption>TABLE 58 Summary of Yersinia statistics relating to humans, major food categories and main animal species, 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 colspan="7"><strong>Humans</strong></td></tr><tr><td>Total number of confirmed cases</td><td>8738</td><td>7929</td><td>7009</td><td>5737</td><td>6967</td><td>ECDC</td></tr><tr><td>Total number of confirmed cases/100,000 population (notification rates)</td><td>2.4</td><td>2.2</td><td>1.9</td><td>1.7</td><td>1.7</td><td>ECDC</td></tr><tr><td>Number of reporting MSs</td><td>26</td><td>25</td><td>26</td><td>26</td><td>27</td><td>ECDC</td></tr><tr><td>Infection acquired in the EU</td><td>4929</td><td>3954</td><td>3548</td><td>2745</td><td>3468</td><td>ECDC</td></tr><tr><td>Infection acquired outside the EU</td><td>152</td><td>81</td><td>18</td><td>61</td><td>96</td><td>ECDC</td></tr><tr><td>Unknown travel status or unknown country of infection</td><td>3657</td><td>3894</td><td>3443</td><td>2931</td><td>3403</td><td>ECDC</td></tr><tr><td>Number of food-borne outbreak-related cases</td><td>73</td><td>96</td><td>125</td><td>236</td><td>160</td><td>EFSA</td></tr><tr><td>Total number of food-borne outbreaks</td><td>17</td><td>14</td><td>21</td><td>16</td><td>23</td><td>EFSA</td></tr><tr><td colspan="7"><strong>Food<sup>a</sup></strong></td></tr><tr><td colspan="7"><strong>Meat and meat products</strong></td></tr><tr><td>Number of sampling units</td><td>2245</td><td>1640</td><td>1789</td><td>1597</td><td>2304</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>8</td><td>4</td><td>6</td><td>6</td><td>6</td><td>EFSA</td></tr><tr><td colspan="7"><strong>Fruits and vegetable products</strong></td></tr><tr><td>Number of sampling units</td><td>212</td><td>83</td><td>142</td><td>256</td><td>17</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>5</td><td>3</td><td>3</td><td>4</td><td>2</td><td>EFSA</td></tr><tr><td colspan="7"><strong>Animals<sup>a</sup></strong></td></tr><tr><td colspan="7"><strong>Cattle (bovine animals)</strong></td></tr><tr><td>Number of sampling units</td><td>6901</td><td>15,764</td><td>19,218</td><td>14,796</td><td>16,885</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>4</td><td>4</td><td>5</td><td>5</td><td>4</td><td>EFSA</td></tr><tr><td colspan="7"><strong>Pigs</strong></td></tr><tr><td>Number of sampling units</td><td>2718</td><td>2010</td><td>2164</td><td>2368</td><td>2591</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>5</td><td>3</td><td>5</td><td>4</td><td>5</td><td>EFSA</td></tr></tbody></table>

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

### 1.3.2 | Human yersiniosis

In 2023, 8738 confirmed cases of yersiniosis were reported by 26 MSs. The notification rate of confirmed yersiniosis cases in the EU was 2.4 cases per 100,000 population. This was an increase of 13.5% compared with 2022 (2.2 per 100,000 population). As in recent years, Germany accounted for the highest number of cases, followed by France and Spain (Table 59). Cases reported by these three countries together accounted for 53.0% of all confirmed yersiniosis cases in the EU. As in the previous year, the highest notification rates in 2023 were reported by Denmark (20.2 cases per 100,000 population), followed by Czechia (5.7 cases per 100,000 population). The lowest rates in 2023 were observed in Bulgaria, Croatia, Greece, Hungary, Ireland, Poland, Portugal and Romania (≤ 0.83 per 100,000) (Table 59).

<footnote><sup>a</sup>The total number of sampling units was calculated by summing all reported sub-level entries for sampling units, stages, strategies and samplers, as listed in the EFSA Catalogue (EFSA and Ioannidou, 2019).</footnote>
For most (96.9%) of the reported yersiniosis cases of known origin, the infection was acquired in the EU (Table 58), as compared with 98.0% in 2022 and an average of 98.2% in the period 2019–2021. Thirteen countries reported data on imported cases. The proportion of domestic cases with known data was above 90.0% in all reporting countries, except for five MSs that reported the highest proportion of travel-associated cases: Finland (25.3%), Luxembourg (23.1%), Sweden (15.1%), Austria (14.6%) and Denmark (12.5%). The proportion of observed travel-associated cases among those with such information available in 2023 was 7.0%. The number of infections acquired outside the EU in 2023 was 152, which is almost double the number of cases compared with 2022 (i.e. a relative increase of 87.7%). Of the 334 travel-associated cases with a known country of origin, 182 cases (54.5%) were linked to travel within the EU, with most infections probably acquired in Spain, Greece, Italy and Croatia (21.4%, 12.1%, 9.9% and 8.2%, respectively).

<table><caption>TABLE 59 Reported confirmed human cases of yersiniosis 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>100</td><td>1.1</td><td>131</td><td>1.5</td><td>138</td><td>1.5</td><td>128</td><td>1.4</td><td>112</td><td>1.3</td></tr><tr><td>Belgium</td><td>Y</td><td>C</td><td>393</td><td>3.3</td><td>357</td><td>3.1</td><td>329</td><td>2.8</td><td>336</td><td>2.9</td><td>406</td><td>3.5</td></tr><tr><td>Bulgaria</td><td>Y</td><td>A</td><td>15</td><td>0.23</td><td>8</td><td>0.12</td><td>5</td><td>0.07</td><td>4</td><td>0.06</td><td>11</td><td>0.16</td></tr><tr><td>Croatia</td><td>Y</td><td>A</td><td>28</td><td>0.73</td><td>-</td><td>-</td><td>12</td><td>0.30</td><td>11</td><td>0.27</td><td>12</td><td>0.29</td></tr><tr><td>Cyprus</td><td>Y</td><td>C</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><td>0</td><td>0</td></tr><tr><td>Czechia</td><td>Y</td><td>C</td><td>614</td><td>5.7</td><td>525</td><td>5.0</td><td>456</td><td>4.3</td><td>437</td><td>4.1</td><td>618</td><td>5.8</td></tr><tr><td>Denmark</td><td>Y</td><td>C</td><td>1199</td><td>20.2</td><td>746</td><td>12.7</td><td>453</td><td>7.8</td><td>413</td><td>7.1</td><td>221</td><td>3.8</td></tr><tr><td>Estonia</td><td>Y</td><td>C</td><td>57</td><td>4.2</td><td>53</td><td>4.0</td><td>45</td><td>3.4</td><td>44</td><td>3.3</td><td>42</td><td>3.2</td></tr><tr><td>Finland</td><td>Y</td><td>C</td><td>279</td><td>5.0</td><td>408</td><td>7.4</td><td>331</td><td>6.0</td><td>386</td><td>7.0</td><td>406</td><td>7.4</td></tr><tr><td>France<sup>b</sup></td><td>N</td><td>C</td><td>1384</td><td>-</td><td>1568</td><td>-</td><td>1451</td><td>-</td><td>988</td><td>-</td><td>1135</td><td>-</td></tr><tr><td>Germany</td><td>Y</td><td>C</td><td>1931</td><td>2.3</td><td>1814</td><td>2.2</td><td>1912</td><td>2.3</td><td>1860</td><td>2.2</td><td>2164</td><td>2.6</td></tr><tr><td>Greece</td><td>Y</td><td>A</td><td>12</td><td>0.12</td><td>9</td><td>0.09</td><td>7</td><td>0.07</td><td>3</td><td>0.03</td><td>13</td><td>0.12</td></tr><tr><td>Hungary</td><td>Y</td><td>C</td><td>54</td><td>0.56</td><td>60</td><td>0.62</td><td>50</td><td>0.51</td><td>25</td><td>0.26</td><td>38</td><td>0.39</td></tr><tr><td>Ireland</td><td>Y</td><td>C</td><td>29</td><td>0.55</td><td>17</td><td>0.34</td><td>19</td><td>0.38</td><td>13</td><td>0.26</td><td>9</td><td>0.18</td></tr><tr><td>Italy<sup>b</sup></td><td>N</td><td>C</td><td>34</td><td>-</td><td>36</td><td>-</td><td>35</td><td>-</td><td>21</td><td>-</td><td>12</td><td>-</td></tr><tr><td>Latvia</td><td>Y</td><td>C</td><td>87</td><td>4.6</td><td>76</td><td>4.1</td><td>83</td><td>4.4</td><td>88</td><td>4.6</td><td>60</td><td>3.1</td></tr><tr><td>Lithuania</td><td>Y</td><td>C</td><td>146</td><td>5.1</td><td>114</td><td>4.1</td><td>153</td><td>5.5</td><td>123</td><td>4.4</td><td>181</td><td>6.5</td></tr><tr><td>Luxembourg</td><td>Y</td><td>C</td><td>34</td><td>5.1</td><td>35</td><td>5.4</td><td>12</td><td>1.9</td><td>26</td><td>4.2</td><td>18</td><td>2.9</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</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Netherlands<sup>c</sup></td><td>Y</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>Poland</td><td>Y</td><td>C</td><td>305</td><td>0.83</td><td>180</td><td>0.48</td><td>142</td><td>0.38</td><td>90</td><td>0.24</td><td>196</td><td>0.52</td></tr><tr><td>Portugal</td><td>Y</td><td>C</td><td>25</td><td>0.24</td><td>36</td><td>0.35</td><td>34</td><td>0.33</td><td>25</td><td>0.24</td><td>29</td><td>0.28</td></tr><tr><td>Romania</td><td>Y</td><td>C</td><td>23</td><td>0.12</td><td>14</td><td>0.07</td><td>15</td><td>0.08</td><td>6</td><td>0.03</td><td>36</td><td>0.19</td></tr><tr><td>Slovakia</td><td>Y</td><td>C</td><td>288</td><td>5.3</td><td>287</td><td>5.3</td><td>213</td><td>3.9</td><td>168</td><td>3.1</td><td>255</td><td>4.7</td></tr><tr><td>Slovenia</td><td>Y</td><td>C</td><td>56</td><td>2.6</td><td>54</td><td>2.6</td><td>50</td><td>2.4</td><td>26</td><td>1.2</td><td>28</td><td>1.3</td></tr><tr><td>Spain<sup>d</sup></td><td>N</td><td>C</td><td>1317</td><td>3.0</td><td>1162</td><td>2.7</td><td>754</td><td>1.7</td><td>296</td><td>-</td><td>409</td><td>-</td></tr><tr><td>Sweden</td><td>Y</td><td>C</td><td>328</td><td>3.1</td><td>238</td><td>2.3</td><td>310</td><td>3.0</td><td>220</td><td>2.1</td><td>393</td><td>3.8</td></tr><tr><td>EU Total 27</td><td>-</td><td>-</td><td>8738</td><td>2.4</td><td>7929</td><td>2.2</td><td>7009</td><td>1.9</td><td>5737</td><td>1.7</td><td>6804</td><td>2.1</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>163</td><td>0.24</td></tr><tr><td>EU Total</td><td>-</td><td>-</td><td>8738</td><td>2.4</td><td>7929</td><td>2.2</td><td>7009</td><td>1.9</td><td>5737</td><td>1.7</td><td>6967</td><td>1.7</td></tr><tr><td>Iceland</td><td>Y</td><td>C</td><td>8</td><td>2.1</td><td>1</td><td>0.27</td><td>4</td><td>1.1</td><td>3</td><td>0.82</td><td>2</td><td>0.56</td></tr><tr><td>Norway</td><td>Y</td><td>C</td><td>86</td><td>1.6</td><td>117</td><td>2.2</td><td>85</td><td>1.6</td><td>83</td><td>1.5</td><td>85</td><td>1.6</td></tr><tr><td>Liechtenstein<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>Switzerland<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></tbody></table>

Abbreviations: MSs, Member States; –, Data not reported.

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

<sup>b</sup>Sentinel surveillance; no information on estimated coverage. Notification rate cannot be estimated.

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

<sup>d</sup>Sentinel surveillance; notification rates calculated with an estimated population coverage of 92% in 2023 and 91% in 2021–2022. No information on estimated coverage in 2019–2020, so notification rate cannot be estimated.
The trend for human yersiniosis cases in the EU for 2019–2023 showed a statistically significant increase (p < 0.01) (Figure 22). Poland, Slovakia and Sweden reported significantly decreasing trends (p < 0.05) during the period 2019–2023. Denmark, France, Hungary, Ireland, Italy, Portugal, Slovenia and Spain reported significantly increasing trends (p < 0.05) over the same period.

<figure><img src="image_133.png" /><figcaption>**FIGURE 22** Trend in reported confirmed human cases of yersiniosis in the EU, by month, 2019–2023. Source: Austria, Cyprus, Czechia, Denmark, Estonia, Finland, Germany, Hungary, Ireland, Italy, Latvia, Luxembourg, Poland, Romania, Slovakia, Slovenia, Spain, Sweden.</figcaption></figure>

Yersinia species information was provided by 21 MSs for 94.5% of confirmed cases reported in the EU, in 2023. Of these cases, 97.7% (N=8021) were Y. enterocolitica and 2.3% (N=188) were Y. pseudotuberculosis. Information on Y. enterocolitica bioserotypes was provided for 1975 confirmed cases (22.7%). The most common bioserotypes were 4/O3 (86.9%) and 2/O9 (10.7%).

### 1.3.3 | Yersinia in food

A summary table showing the occurrence of Yersinia in the main food categories in 2023 and over the 4-year period of 2019–2022 in the EU is provided on the EFSA Knowledge Junction at Zenodo [here]. A distinction is made between RTE and non-RTE foods, and fresh meat. No Yersinia-positive sampling units were detected in any RTE foods. The proportions of Yersinia-positive sampling units in non-RTE categories were 10.2%. In fresh meat, 12.1% of sampling units were positive.

In 2023, most of the 314 RTE food sampling units reported by four MSs originated from 'fruit and vegetables' (65.3%), followed by 'meat and meat products' (34.4%) and only one sampling unit (0.32%) for 'milk and milk products'. In contrast with no Yersinia-positive sampling units in 2023, between 2019 and 2022, of 2356 RTE sampling units analysed, 5.1% tested positive for Yersinia. Specifically, 5.7% of 'meat and meat products' were Yersinia-positive, with 'mixed meat and meat products from bovine animals and pigs' showing a 7.1% positivity rate and 'mixed meat' showing a rate of 4.4%.

Unlike during 2019–2022, when a few sampling units were tested for the categories 'RTE salads' (N=4), 'other processed food products and prepared dishes' (N=23) and 'other foods' (N=4), no sampling units were tested for these categories in 2023.

Despite evidence supporting the need to sample in particular RTE foods, few MSs reported monitoring this type of food for Yersinia to EFSA, even though these foods represent a direct risk to consumers.

Most of the results reported in 2023 by six MSs for the 1210 'non-RTE' sampling units originated from the 'meat and meat products' (99.4%) food category, where a total of 123 (10.2%) sampling units tested positive for Yersinia. In 2023, no sampling was carried out for the 'milk and milk products' category, although in 2019–2022, 'milk and milk products' was the most commonly contaminated food category (11.0%), followed by 'meat and meat products' (6.2%).

Six MSs reported results for 'fresh meat' categories. The highest percentage of Yersinia-positive units was for 'fresh meat from pigs' (12.6%), which was 96.0% (N=915) of 'all fresh meat' sampling units. In 2023, the number of sampling units for the 'non-RTE' and 'fresh meat' categories increased compared with 2022, with 'non-RTE' sampling units rising from 404 to
1210, and 'fresh meat' sampling units increasing from 166 to 953. To detect the presence of *Yersinia* in food, microbiological methods were used for the analysis of 1296 sampling units and molecular methods for 282 sampling units, with *Yersinia*-positive rates of 8.7% and 3.5%, respectively.

### 1.3.4 | *Yersinia* in animals

A summary table showing the number of animal samples positive for *Y. enterocolitica* or *Y. pseudotuberculosis* in 2023 is provided on the EFSA Knowledge Junction at Zenodo [here]. These data, reported by six MSs and one non-MS, span over eight different animal categories, including more than 30 animal species. The total number of animal units tested in 2023 (N=14,215) was lower than in 2022 (N=23,705), primarily due to a decrease in cattle units tested, which dropped from 15,764 in 2022 to 6901 in 2023. Analysis of the submitted results for 14,215 animals showed the presence of *Y. enterocolitica* and *Y. pseudotuberculosis* in a similar percentage of positive samples: 0.96% and 0.74%, respectively. In the EU, the reported data were primarily related to cattle (48.5%, N=6901), followed by 'small ruminants' (22.3%, N=3172) and pigs (19.1%, N=2718). In these three animal categories, the proportion of positive samples for *Y. enterocolitica* was highest in pigs (1.5%), followed by cattle (0.97%) and 'small ruminants' (0.60%), while for *Y. pseudotuberculosis*, the highest proportion was in cattle (1.0%), followed by 'small ruminants' (0.25%) and no positive samples were detected for pigs. 'Wild animals' represented 7.8% of all animals sampled, with percentages of *Y. enterocolitica* and *Y. pseudotuberculosis*-positive samples of 0.45% and 1.4%, respectively. Although 'pet animals' comprised a very small proportion of the samples tested in 2023, the positive rates for *Y. enterocolitica* and *Y. pseudotuberculosis* were 1.4% and 2.9%, respectively. The highest positivity rate for *Y. pseudotuberculosis* in 'pet animals' was found particularly in mice and canaries. In order to assess the occurrence of *Y. enterocolitica* and *Y. pseudotuberculosis* in animal categories for which this information was available (cattle, deer, leporidae, pigs and 'small ruminants'), microbiological methods were used for the analysis of 12,793 sampling units and molecular methods for 31 samples, with *Yersinia*-positive rates of 2.1% and 25.8%, respectively.

## 1.4 | Discussion

In 2023, 26 MSs provided information on yersiniosis, which is the fourth most commonly reported food-borne gastrointestinal infection in humans in the EU. Since 2021, an increase in the notification rates and number of confirmed cases of yersiniosis has been reported. In 2023, there was a 13.5% increase in the annual notification rate compared with the year 2022. This was the highest number of cases, and the highest notification rate reported at the EU level in the last 10 years. The overall trend for human yersiniosis cases in the EU for 2019–2023 showed a statistically significant increase (p < 0.01).

In particular, Denmark reported a steady increase in yersiniosis cases, from 221 cases (3.8 cases per 100,000 population) in 2019 to 1199 cases (20.2 cases per 100,000 population) in 2023. In Denmark, the increase of yersiniosis cases is considered a diagnostic and reporting issue and not a real increase of cases. The increase is mostly related to the increased use of culture-independent diagnostic tests in the clinical laboratories (SSI personal info).

In 2023, the MSs with the highest proportion of domestic cases, above 98.0% with available data, were Czechia, Estonia, Hungary, Ireland, Italy, Lithuania, Poland, Portugal, Slovakia and Spain. These countries remained largely the same as in 2022, except for Estonia, Ireland and Italy, where the proportion of domestic cases the year before was 96.2%, 77.8% and 80.0%, respectively.

As in previous years, in 2023, *Y. enterocolitica* was the species reported in the majority (97.7%) of human cases, while *Y. pseudotuberculosis* was notified in only 2.3% of human cases for which information on *Yersinia* species was available. Compared with the previous year, the number of *Y. pseudotuberculosis* cases increased from 98 in 2022 to 188 in 2023. Five MSs (Belgium, Finland, France, Germany and Sweden), reported the majority of *Y. pseudotuberculosis* cases in both years.

In 2023, the most common bioserotypes of *Y. enterocolitica* in humans were 4/O3 (86.9%) and 2/O9 (10.7%), like in previous years. However, little information is available on the biotypes and serotypes of *Y. enterocolitica* isolated from animals and foodstuffs. The availability of information on biotypes would allow for a better understanding of the epidemiology of human *Y. enterocolitica* infection and better investigation of relevant animal and food sources.

In 2023, few MSs reported data on *Yersinia* sampling activities in food and animals. This is probably due to the lack of mandatory monitoring plans for non-human sources, resulting in considerable differences between MSs in their approach to monitoring *Yersinia* in food and animals. The lack of homogeneity makes statistical analysis and monitoring of trends impossible.

Only four MSs provided data on *Yersinia* in RTE foods, with 314 sampling units reported in 2023, similar to the 328 units in 2022. The proportion of positive samples remained unchanged at 0% compared to 2022. This result differs from the cumulative data reported for the period 2019–2022, where the percentage of positive samples was 5.1%. Only one MS reported a single sampling unit for 'milk and milk products', while no sampling units for 'RTE salads' were reported. Nevertheless, it is important to sample RTE foods, such as 'RTE vegetables', to monitor potential *Yersinia* contamination, as these products are normally not subjected to physical interventions that will eliminate the occurrence of pathogens (EFSA BIOHAZ Panel, 2014). In this regard, two EFSA scientific opinions (EFSA BIOHAZ Panel, 2013c, 2014) have highlighted the risk of *Yersinia* contamination in non-animal origin food due to factors such as water or food handlers. Only six MSs provided data on 'non-RTE' foods for *Yersinia*, and the number of sampling units was higher (N=1210) compared with 2022 (N=404), with a proportion of positive samples of 10.2%, compared with 3.5% positive samples in 2022.
Only 6 MSs reported information on *Yersinia* in animals with 14,215 samples reported in 2023, fewer than the units reported in 2022 (N = 23,705). Cattle were the most represented animal category, making up 48.5% (N = 6901) of all tested units. The proportion of positive samples for cattle was similar for *Y. enterocolitica* and *Y. pseudotuberculosis*, at 0.97% and 1.0%, respectively. As expected, the highest positivity rate for *Y. enterocolitica* among the main 'farmed animals' categories (cattle, 'small ruminants' and pigs) was observed in pigs, at 1.5%. Moreover, of 953 'fresh meat' sampling units, only 'fresh meat from pigs' showed *Yersinia*-positive sampling units, with a proportion of 12.6%. Pigs are in fact the principal reservoir of *Y. enterocolitica* (Bottone, 1999), particularly for the low pathogenic bioserotype 4/O3, which is the most prevalent bio serotype in human yersiniosis in the EU. No animals positive for *Y. pseudotuberculosis* were detected in pigs. Furthermore, although 'pet animals' represented only a small proportion of the sampling units, the highest positivity rate for *Y. pseudo tuberculosis* (2.9%) was found in this category, particularly in mice and canaries. This finding is consistent with the literature (see EFSA story map on *Yersinia* (here), section on 'where *Yersinia* is found').

To investigate the presence of *Yersinia* in food and animals, conventional microbiological (ISO 10273:2017) and mo lecular methods (ISO/TS 18867) were used (ISO, 2015b, 2017). Although few data are available on the use of molecular methods, these seem to detect *Yersinia* better in animals. Molecular methods are valid systems for screening and detec tion (ISO, 2015b) of *Y. pseudotuberculosis* and *Y. enterocolitica* in animals, food and environmental samples. In this context, various studies have described the application of molecular methods to detect *Y. enterocolitica* and *Y. pseudotuberculosis* in humans, food, animals and environmental samples (Rivas et al., 2021; Tast et al., 2023).

## 2 | TOXOPLASMA GONDII

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 available [here].

For additional information about *Toxoplasma gondii* and for the consultation of data collected, the following interactive tool is available:

Toxoplasma gondii

<figure><img src="image_134.png" /></figure>

STORY MAP

<figure><img src="image_135.png" /></figure>

### 2.1 | Key facts

* This chapter shows the human congenital toxoplasmosis data for 2022 due to 2-year delayed reporting of data from France. As in previous years, France accounted the majority (74.6%) of reported cases of congenital toxoplasmosis in the European Union due to its active screening approach for pregnant women.

* In 2022, there were 173 confirmed cases of human congenital toxoplasmosis, corresponding to a European Union notifi cation rate of 5.8 cases per 100,000 live births. This was an increase of 4.2% compared with the rate in 2021 (5.6 cases per 100,000 live births).

* Overall, in the period 2018–2022, the number of human cases of congenital toxoplasmosis in the European Union (with- out the United Kingdom) showed a decrease, particularly during the COVID-19 pandemic (2020–2021), mainly mirroring the number of cases reported by a single Member State (France).

* In total, 13 Member States and three non-Member States reported 2023 monitoring data on *Toxoplasma gondii* infections in animals and food. Most animals tested were small ruminants, which also showed the highest overall percentage of posi tive samples of *T. gondii* infections in animals (21.7%), as reported by 10 Member States and the United Kingdom (Northern Ireland). Most samples with information provided on the sampling context were obtained from clinical investigations. It is impossible to accurately estimate the percentage of positive samples of *T. gondii* infections in animals due to different diag nostic methods, sampling schemes in Member States and lack of information on the animals' ages and rearing conditions.

### 2.2 | Surveillance and monitoring of *Toxoplasma* in the EU

#### 2.2.1 | Humans

Twenty MSs reported 2022 congenital toxoplasmosis data to TESSy in 2022. Surveillance of toxoplasmosis was compulsory in 19 MSs; in one (France) it was voluntary. Data from France are reported to TESSy with a 2-year delay. Seven MSs (Austria, Belgium, Denmark, Greece, Italy, the Netherlands and Sweden) do not have a surveillance system for toxoplasmosis. In
2022, 19 MSs used the EU case definition, but 1 MS (France) reported the use of another case definition. All reporting MSs had a comprehensive surveillance system with full national coverage. Spain did not have national surveillance nor provided an estimate for population coverage prior to 2022, so no notification rate was calculated before 2022. All MSs reported case-based data, except Bulgaria, which reported aggregated data.

Regarding congenital toxoplasmosis surveillance only, six countries (Austria, Belgium, France, Greece, Slovakia and Slovenia) have active surveillance of congenital cases with compulsory screening of pregnant women. However, Austria, Belgium and Greece do not report their data to ECDC. Four countries (Bulgaria, Czechia, Germany and Hungary) have voluntary screening of pregnant women. Six MSs have no screening policies and/or surveillance of congenital toxoplasmosis in pregnant women, but two of these countries (Estonia and Ireland) report to ECDC.

## 2.2.2 | Animals and food

There are no specific EU regulations concerning the surveillance and monitoring of *T. gondii* in animals and food. Therefore, the available and reported information relies on national legislation and whether the countries have a mandatory reporting system following the detection of *T. gondii*. As a result, data allow only for descriptive summaries at the EU level (Table 1). The main animal species tested are those intended for human consumption (small ruminants (goats and sheep), cattle and pigs) as well as pet animals (cats and dogs), using samples from aborted animals (ruminants) or clinically suspect animals. Mainly blood samples, but also samples from tissues and organs or faecal samples, are analysed either by direct methods, such as PCR, histology, immunohistochemistry and flotation, or by indirect antibody detection methods, including enzyme-linked immunosorbent assay, latex agglutination test, direct agglutination and immunofluorescence assay. For food testing, meat is the primary matrix to be analysed by PCR or direct agglutination.

## 2.3 | Results

### 2.3.1 | Human congenital toxoplasmosis

Twenty MSs reported congenital toxoplasmosis data in 2022 (Table 60), with 173 confirmed cases. Eleven MSs reported zero cases (Table 60). As a result of a slightly higher number of cases reported mainly by France and Poland for 2022, the notification rate in the EU (5.8 per 100,000 live births) increased by 4.2% compared with 2021 (5.6 per 100,000 live births) (Table 60). The highest notification rate was in France (18.5 per 100,000 live births), followed by Poland (9.2), Slovenia (5.3), Czechia and Slovakia (1.8 each) and Hungary (1.1) (Table 60). Three MSs (Germany, Romania and Spain) have notification rates below 1 per 100,000 live births.

France reported the highest number of congenital toxoplasmosis cases in the EU in 2022 and accounted for 74.6% of all reported cases, followed by Poland (17.3%).

Between 2018 and 2022, a constant decrease in reported cases was observed in Germany (a decrease of 72.2% in 2022 compared with 2018). In the same period (2018–2022), a marked drop in the number of reported cases was observed in France and Poland, related to the COVID-19 pandemic period (particularly 2020). However, the number of cases reported by MSs in 2022 was in line with data reported in 2019, before the COVID-19 pandemic.

<table><caption>TABLE 60 Reported confirmed human cases of congenital toxoplasmosis and notification rates per 100,000 live births in EU MSs and non-MS countries, by country and year, 2018–2022.</caption><thead><tr><th rowspan="3">Country</th><th colspan="2">2022</th><th colspan="2">2021</th><th colspan="2">2020</th><th colspan="2">2019</th><th colspan="2">2018</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<sup>b</sup></td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td></tr><tr><td>Belgium<sup>b</sup></td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td></tr><tr><td>Bulgaria</td><td>Y</td><td>A</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>Y</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>2.7</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</td><td>0</td><td>0</td></tr><tr><td>Czechia</td><td>Y</td><td>C</td><td>2</td><td>1.8</td><td>4</td><td>3.7</td><td>0</td><td>0</td><td>1</td><td>0.88</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></tr><tr><td>Estonia</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>1</td><td>7.2</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</td><td>0</td><td>0</td></tr><tr><td>France</td><td>Y</td><td>C</td><td>129</td><td>18.5</td><td>117</td><td>16.9</td><td>110</td><td>15.5</td><td>134</td><td>18.8</td></tr><tr><td>Germany</td><td>Y</td><td>C</td><td>5</td><td>0.63</td><td>11</td><td>1.4</td><td>14</td><td>1.8</td><td>17</td><td>2.2</td></tr><tr><td>Greece<sup>c</sup></td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>0</td><td>0</td><td>0</td></tr></tbody></table>
<table><caption>TABLE 60 (Continued)</caption><thead><tr><th rowspan="3">Country</th><th colspan="2">2022</th><th colspan="2">2021</th><th colspan="2">2020</th><th colspan="2">2019</th><th colspan="2">2018</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>Hungary</td><td>Y</td><td>C</td><td>1</td><td>1.1</td><td>1</td><td>1.1</td><td>0</td><td>0</td><td>1</td><td>1.1</td><td>0</td><td>0</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</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Italy<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>Latvia</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>1</td><td>5.2</td><td>0</td><td>0</td></tr><tr><td>Lithuania</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>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>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<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>Poland</td><td>Y</td><td>C</td><td>30</td><td>9.2</td><td>13</td><td>3.7</td><td>9</td><td>2.5</td><td>14</td><td>3.7</td><td>25</td><td>6.3</td></tr><tr><td>Portugal</td><td>Y</td><td>C</td><td>0</td><td>0</td><td>2</td><td>2.4</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td></tr><tr><td>Romania</td><td>Y</td><td>C</td><td>1</td><td>0.58</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>1</td><td>0.48</td></tr><tr><td>Slovakia</td><td>Y</td><td>C</td><td>1</td><td>1.8</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>Y</td><td>C</td><td>1</td><td>5.3</td><td>0</td><td>0</td><td>0</td><td>0</td><td>1</td><td>5.1</td><td>2</td><td>9.9</td></tr><tr><td>Spain<sup>d</sup></td><td>Y</td><td>C</td><td>3</td><td>0.89</td><td>2</td><td>—</td><td>0</td><td>—</td><td>0</td><td>—</td><td>2</td><td>—</td></tr><tr><td>Sweden<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><strong>EU Total 27</strong></td><td></td><td></td><td><strong>173</strong></td><td><strong>5.8</strong></td><td><strong>150</strong></td><td><strong>5.6</strong></td><td><strong>133</strong></td><td><strong>5.1</strong></td><td><strong>169</strong></td><td><strong>6.2</strong></td><td><strong>201</strong></td><td><strong>7.1</strong></td></tr><tr><td>United Kingdom</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>7</td><td>0.91</td><td>7</td><td>0.91</td><td>—</td></tr><tr><td><strong>EU Total</strong></td><td></td><td></td><td><strong>173</strong></td><td><strong>5.8</strong></td><td><strong>150</strong></td><td><strong>5.6</strong></td><td><strong>133</strong></td><td><strong>5.1</strong></td><td><strong>176</strong></td><td><strong>5.1</strong></td><td><strong>208</strong></td><td><strong>5.8</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>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>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>

Abbreviations: –, Data not reported.

ªY: yes; N: no; A: aggregated data; C: case-based data.

ᵇNot notifiable, no surveillance system in place.

ᶜNot under surveillance.

ᵈNo information on estimated coverage prior to 2022. Notification rate cannot be estimated.

## 2.3.2 | *Toxoplasma gondii* in food and animals

### *Toxoplasma gondii* in food

One MS (Poland) submitted monitoring results for *T. gondii* in non-ready-to-eat (non-RTE) foods in 2023. A total of 534 meat samples from minced pig meat preparation were reported. Nineteen samples (3.5%) were positive.

### *Toxoplasma gondii* in animals

Monitoring data on *T. gondii* for 2023 in livestock, pet or zoo animals and wildlife were provided by 12 MSs and by 3 non-MSs (Norway, Republic of North Macedonia and Switzerland). Most samples with information provided on the sampling context (programme type) were obtained from clinical investigations.

In small ruminants (sheep and goats), 10 MSs (Austria, Finland, Germany, Greece, Hungary, Ireland, Italy, Latvia, the Netherlands and Slovakia) and the United Kingdom (Northern Ireland) reported animal data (Table 61). In total, 4489 animals were tested, and 973 were found to be positive (21.7%). Moreover, two MSs (Italy and Spain) reported herd/flock data: 357 herds/flocks were tested and 67 (18.7%) were positive. Two non-MSs (Norway and Switzerland) reported data: 16 animals were tested and five were positive (31.2%).

In cattle, five MSs (Austria, Germany, Italy, Latvia and Slovakia) and the United Kingdom (Northern Ireland) reported data on *Toxoplasma*. In total, 643 animals were tested and 84 were found to be positive (13.1%). Moreover, one MS (Italy) reported herd/flock data: 43 herds/flocks were tested and three (7.0%) were positive. One non-MS (Switzerland) reported information on one tested animal, which was negative.
In pigs, two MSs (Austria and Germany) and the United Kingdom (Northern Ireland) reported monitoring data (Table 61). In total, 413 animals were tested and no positive results were identified. In addition, one MS (Italy) reported 73 herd/flock investigations, with 12 positive results (16.4%).

For other livestock (solipeds, alpacas, leporidae and water buffaloes), four MSs (Austria, Germany, Italy and Slovakia) and one non-MS (Switzerland) reported monitoring data. In total, 22 animals were tested and one animal (soliped) (4.5%) was positive.

In pet animals (cats, dogs and rabbits), eight MSs (Austria, Finland, Germany, Hungary, Italy, Latvia, the Netherlands and Slovakia) tested a total of 3140 animals (1901 cats, 1236 dogs and 3 rabbits). There were 334 (10.6%) positive samples with 84 (4.4%) positive samples from cats, 249 (20.1%) positive samples from dogs and 1 positive sample from rabbits. One non-MS (Switzerland) tested a total of 310 cats, with 46 (14.8%) positive samples and 59 dogs with 5 (8.4%) positive samples.

Regarding zoo animals, four MSs (Austria, Italy, Latvia and Slovakia) tested in total 66 animals and 4 (6.0%) were positive. Two non-MSs (Republic of North Macedonia and Switzerland) tested in total 14 animals and 7 (50.0%) were positive.

Three MSs (Austria, Finland and Italy) reported on testing for *T. gondii* in wildlife. In total, 41 samples (5.7%) mainly from Italy, were positive out of a total of 721 animals tested. One non-MS (Switzerland) reported on testing for *T. gondii* in wildlife.

<table><caption>TABLE 61 Summary of *Toxoplasma gondii* statistics in the main animal species at the individual level, EU, 2019–2023.</caption><thead><tr><th>Animals<sup>a</sup></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>Small ruminants</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Number of tested animals</td><td>4489</td><td>4068</td><td>4525</td><td>6113</td><td>12,120</td><td>EFSA</td></tr><tr><td>Number of positive animals</td><td>21.7</td><td>29.0</td><td>16.8</td><td>21.3</td><td>13.5</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>11</td><td>11</td><td>12</td><td>10</td><td>11</td><td>EFSA</td></tr><tr><td><strong>Cattle (bovine animals)</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Number of tested animals</td><td>643</td><td>703</td><td>726</td><td>254</td><td>664</td><td>EFSA</td></tr><tr><td>Number of positive animals</td><td>13.1</td><td>4.3</td><td>2.5</td><td>9.8</td><td>9.2</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>6</td><td>7</td><td>7</td><td>4</td><td>6</td><td>EFSA</td></tr><tr><td><strong>Pigs</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Number of tested animals</td><td>413</td><td>519</td><td>599</td><td>948</td><td>1108</td><td>EFSA</td></tr><tr><td>Number of positive animals</td><td>0</td><td>11.0</td><td>5.0</td><td>9.7</td><td>11.7</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>3</td><td>6</td><td>5</td><td>3</td><td>4</td><td>EFSA</td></tr><tr><td><strong>Cats</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Number of tested animals</td><td>1901</td><td>2361</td><td>3275</td><td>1880</td><td>1525</td><td>EFSA</td></tr><tr><td>Number of positive animals</td><td>4.4</td><td>3.8</td><td>9.8</td><td>6.5</td><td>5.2</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>7</td><td>7</td><td>8</td><td>6</td><td>8</td><td>EFSA</td></tr></tbody></table>

Abbreviation: MSs, Member States.

## 2.4 | Discussion

Cases of congenital toxoplasmosis in the EU are strongly biased by the high number of cases reported by France, which has accounted for most reported cases since 2009 (ECDC Surveillance Atlas of Infectious Diseases), representing 74.6%–82.7% of overall EU cases in 2018–2022 (excluding data from the United Kingdom). The systematic screening for toxoplasmosis in pregnant women in France, established in 1978 and then mandatory since 1992, can explain the high reporting rate for this MS. Seronegative women are followed up during pregnancy to detect seroconversion early, and congenital toxoplasmosis cases are laboratory-confirmed (ECDC, 2024).

The fluctuation of cases reported in the EU in the 2018–2022 period mainly mirrors the trend in cases reported by France. A decrease was observed between 2018 and 2020 (a reduction of 33.8% in the EU and 27.1% in France), whereas an increase was found between 2020 and 2022 (30.1% in the EU and 17.3% in France), likely because of the impact of the COVID-19 pandemic on data collection in 2020–2021.

Although the number of notified cases of congenital toxoplasmosis recorded for the year 2022 was slightly higher compared with the years during the COVID-19 pandemic (2020–2021), the overall number of cases reported in France (and in the EU) is constantly decreasing (151 in 2018 vs. 129 in 2022 in France). The lower reporting of congenital toxoplasmosis in France is likely the result of a gradual seroprevalence decrease in pregnant women (54.0% in 1995, 31.0% in 2016) and a decrease in the number of seroconversions during pregnancy (from 5.4 per 1000 at-risk pregnancies in 1995, to 2.1 in 2010 and expected to be 1.6 by 2020) (Robinson et al., 2021). An education campaign for pregnant women and reduced exposure to contaminated raw/undercooked meat (e.g. changes in food habits and improved hygiene practices in meat production) or other raw foods at risk of contamination (e.g. fresh produce, molluscs and raw milk) likely contributed to the lower incidence of *T. gondii*.

<footnote><sup>a</sup>Summary statistics were obtained by totalling all samples from single animals (no flocks or herds included), from all sampling stages at primary production (conservation facilities, farm, hunting, natural habitat, retail, slaughterhouse, unspecified, veterinary activities, veterinary clinics and zoo), sampling strategies (convenience sampling, objective sampling, suspect sampling and unspecified) and samplers (HACCP and own-check, industry sampling, not applicable, official sampling and private sampling). Indirect and direct diagnostic methods were taken together for the summary statistics to calculate the proportion of positive units.</footnote>
infection during pregnancy in France, reflecting the lower number of congenital toxoplasmosis cases (Opsteegh et al., 2015; Robinson et al., 2021). Interestingly, despite literature data on hospital discharge records of infants in Poland indicating that the number of cases of congenital toxoplasmosis fluctuated in the 2007–2021 period (Rząd et al., 2023), the increase in cases reported to TESSy by Poland in 2018–2022 might reflect the introduction in 2018 of standards of perinatal care by the Polish Ministry of Health (Rząd et al., 2023). Surveillance for congenital toxoplasmosis in other MSs is highly variable, with countries reporting zero cases or simply not reporting to ECDC or lacking surveillance (Rząd et al., 2023). The lack of surveillance can result in abortion, stillbirth, perinatal death or congenital diseases with immediate or late manifestations (up to adolescence), including ocular diseases, seizures and learning disabilities. All possible strategies for preventing congenital toxoplasmosis, including appropriate information for pregnant women and active screening, should be reinforced.

The 2023 monitoring data from animals reported by MSs and non-MSs showed that *T. gondii* is present in most livestock species across the EU, as well as in pet/zoo animals and wildlife. Concerning the MSs, the highest proportion of positive samples was observed in small ruminants (21.7%), followed by cattle (13.1%) and pets (10.6%). Similarly, in a recent systematic review and modelling of *T. gondii* prevalence in Europe, Dámek et al. (2023) showed that the highest estimated seroprevalence was observed for outdoor sheep (63.3%), while it was as low as 5.2% for indoor pigs. When comparing the data for 2022 to 2023, a noticeable fluctuation in *T. gondii* percentage of positive samples is observed for pigs and cattle, with a remarkable decrease for pigs (from 11.0% in 2022 to 0% in 2023) and an increase for cattle (from 4.3% in 2022 to 13.1% in 2023). The situation is stable for cats, with a proportion of positive samples of 3.8% in 2022 and 4.4% in 2023. However, when comparing the data over the last 5 years (2019–2023), no clear pattern of positivity is observed in animals.

The current European surveillance system of *T. gondii* in animals is strongly affected by several important limitations: (i) the small number of tested animals, (ii) the use of different indirect and direct detection methods, which were in most cases not validated by an independent body, (iii) unknown age of the tested animals and (iv) no information on the type of husbandry system (housing). Furthermore, according to the literature, there is no relationship between the presence of anti-*T. gondii* antibodies and infecting parasites in cattle and horses (Aroussi et al., 2015; Blaga et al., 2019; Opsteegh et al., 2019). For pigs, poultry and small ruminants, serological methods could be useful for the detection of high-risk animals or herds, but serology is not an indicator of infection in individual animals, as the agreement between direct and indirect methods was estimated to be low to moderate (Opsteegh et al., 2019). The limitations associated with toxoplasmosis detection, diagnosis and surveillance mentioned above preclude direct comparison of the reported data across MSs. Therefore, findings should be interpreted with caution.

## 3 | RABIES

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 rabies and for the consultation of data collected, the following interactive tools are available:

<figure><img src="image_136.png" /></figure>

### 3.1 | Key facts

* In 2023, European Union Member States reported no human lyssavirus infections acquired within the European Union. During the last 5 years (2018–2022), only one European Union-acquired non rabies lyssavirus infection was reported in 2019 and was caused by European bat lyssavirus 1 (EBLV-1).

* In animals excluding bats, a total of 71 cases of rabies of autochthonous origin were reported by three Member States: 7 cases in Poland (6 foxes and 1 dog), 49 cases in Romania (28 cattle, 16 foxes, 4 dogs and 1 badger) and 15 cases in Hungary (9 foxes, 3 dogs, 2 cattle and 1 cat). The total number of reported indigenous rabies cases in non-flying animals in the European Union is stable in 2023 compared with 2022 (71 cases) but was lower than in 2021 (118 cases) and higher than in 2020 (12 cases) and 2019 (5 cases).

* Surveillance data on lyssavirus in bats were reported by 18 European Union Member States. Seven Member States (Austria, France, Germany, Hungary, the Netherlands, Poland and Spain) reported 23 positive results for lyssavirus, 22 European bat 1 lyssavirus (EBLV-1) and one Bokeloh bat lyssavirus (BBLV). One non-Member State (Switzerland) reported a positive result in a bat for European bat lyssavirus 2 (EBLV-2).
## 3.2 | Surveillance and monitoring of rabies in the EU

### 3.2.1 | Humans

For 2023, 26 MSs reported data on human lyssavirus infections. Denmark did not report data. Reporting was mandatory in all reporting countries. EU case definitions were used by 23 MSs. France, Germany and Italy declared that they did not use the EU case definition. Twenty-four MSs had passive surveillance, whereas two countries (Czechia and Slovakia) applied active surveillance.

### 3.2.2 | Animals

The objective of **passive rabies surveillance** is to detect the presence and assess the geographic distribution of the virus over time, to allow timely dissemination of information for immediate integrated control actions among different sectors, such as the public health and veterinary sectors. For rabies-free countries, surveillance aims to confirm the absence of the disease. In accordance with Regulation (EU) No 652/2014⁴⁸ and CDR (EU) No 2020/689, multiannual control programmes and surveillance programmes for rabies, as well as oral rabies vaccination (ORV) campaigns were conducted in 11 MSs (Bulgaria, Croatia, Estonia, Finland, Greece, Hungary, Latvia, Lithuania, Poland, Romania and Slovakia), as well as in some EU-bordering countries. Surveillance of rabies is carried out by sampling and testing 'indicator animals'; these are wild or domestic animals (foxes, raccoon dogs, jackals, badgers, dogs, cattle, cats, sheep, equines, goats, etc.) that are found dead (including road-killed) and/or suspect animals, i.e. animals showing neurological clinical signs or abnormal behaviour compatible with rabies, like biting, licking a wound or scratching a human in the absence of clear neurological signs.

To monitor the efficacy of ORV campaigns, apparently healthy animals of the wild species targeted by oral vaccination, which are foxes, raccoon dogs and golden jackals, are hunted and the animal carcases are used to determine rabies immunity and oral vaccine bait uptake. This specific **active rabies surveillance** is traditionally designated as 'ORV monitoring' or 'monitoring' and 'active rabies surveillance' when rabies diagnosis is performed on such sampling. These hunted animals can also be tested for rabies and very few of them (below 5%) are usually found to be positive for the disease.

Imported or travel-related companion animals (mainly dogs and cats) from territories and non-EU countries not included in Annex II of Commission Implementing Regulation (EU) No 577/2013⁴⁹ are currently tested for rabies virus neutralising antibodies.

In accordance with CIR (EU) 2020/2002, EU MSs must notify outbreaks of infection with rabies virus in non-flying animals to the EU Animal Disease Information System, ADIS<fnref n="50" />; these are the animal species and groups of species: *Carnivora*, *Bovidae*, *Suidae*, *Equidae*, *Cervidae* and *Camelidae*, but not *Chiroptera* (bats).

The data reported here include all animals tested for rabies, and those collected for disease surveillance or for ORV monitoring (active surveillance) purposes.

## 3.3 | Results

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

A summary of EU-level rabies statistics in humans and in wild and domestic animals is shown in Table 62. For animals, the total number of samples analysed for passive surveillance from foxes, raccoon dogs, golden jackals, dogs, cats and bats, as well as the number of MSs from which these samples originated, are shown. A decrease was observed in the number of tested samples of foxes, which are the main reservoir of the virus in Europe, compared with 2022. The number of tested raccoon dogs remained stable compared with 2022, while the tested samples of jackals increased in 2023 compared with 2022. In 2023, the number of tested bats remained stable as compared with 2022. For cats and dogs, the numbers of samples reported increased slightly compared with those for the 2019–2022 period. The number of samples tested from domestic farmed mammals increased sharply in 2023 compared with numbers for the 2019–2022 period. Compared with previous years, the number of positive cases in 2023 increased markedly in cattle, while it decreased in red foxes and remained stable in cats and dogs.

Table 62 also displays the active surveillance (ORV monitoring) statistics for ORV target species (foxes, raccoon dogs and golden jackals). In the context of ORV monitoring, the number of tested foxes increased considerably in 2023 compared with 2022; however, the number remained stable compared with numbers for the 2019–2021 period. The number of tested raccoon dogs increased, while the number of tested jackals in two MSs decreased considerably compared with numbers

<footnote n="48">⁴⁸Regulation (EU) No 652/2014 of the European Parliament and of the Council of 15 May 2014 laying down provisions for the management of expenditure relating to the food chain, animal health and animal welfare, and relating to plant health and plant reproductive material, amending Council Directives 98/56/EC, 2000/29/EC and 2008/90/EC, Regulations (EC) No 178/2002, (EC) No 882/2004 and (EC) No 396/2005 of the European Parliament and of the Council, Directive 2009/128/EC of the European Parliament and of the Council and Regulation (EC) No 1107/2009 of the European Parliament and of the Council and repealing Council Decisions 66/399/EEC, 76/894/EEC and 2009/470/EC. OJ L 189, 27.6.2014, pp. 1–32.</footnote>

<footnote n="49">⁴⁹Commission Implementing Regulation (EU) No 577/2013 of 28 June 2013 on the model identification documents for the non-commercial movement of dogs, cats and ferrets, the establishment of lists of territories and third countries and the format, layout and language requirements of the declarations attesting compliance with certain conditions provided for in Regulation (EU) No. 576/2013 of the European Parliament and of the Council. OJ L 178, 28.6.2013, pp. 109–148.</footnote>

<footnote n="50">⁵⁰EU 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>