for the 2019–2022 period. Several countries did not report data from ORV monitoring, as rabies diagnosis in apparently healthy hunted wild animals is no longer included in EU co-funded eradication programmes.<fnref n="51" />

<table><caption>TABLE 62 Summary of rabies lyssavirus statistics relating to humans and the main animal reservoirs, 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>1<sup>a</sup></td><td>0</td><td>0</td><td>0</td><td>4</td><td>ECDC</td></tr><tr><td>Total number of confirmed cases/100,000 population (notification rates)</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>ECDC</td></tr><tr><td>Number of reporting countries</td><td>26</td><td>26</td><td>26</td><td>26</td><td>28</td><td>ECDC</td></tr><tr><td>Infection acquired in the EU</td><td>0</td><td>0</td><td>0</td><td>0</td><td>1</td><td>ECDC</td></tr><tr><td>Infection acquired outside the EU</td><td>1<sup>a</sup></td><td>0</td><td>0</td><td>0</td><td>3</td><td>ECDC</td></tr><tr><td>Unknown travel status or unknown country of infection</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>ECDC</td></tr><tr><td colspan="7"><strong>Animals under passive surveillance</strong></td></tr><tr><td colspan="7"><strong>Dogs (Canis lupus familiaris)</strong></td></tr><tr><td>Number of tested animals</td><td>2167</td><td>2137</td><td>1823</td><td>1730</td><td>1901</td><td>EFSA</td></tr><tr><td>Number of positive animals</td><td>8</td><td>11</td><td>3</td><td>4</td><td>–</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>21</td><td>23</td><td>21</td><td>22</td><td>22</td><td>EFSA</td></tr><tr><td colspan="7"><strong>Cats (Felis catus)</strong></td></tr><tr><td>Number of tested animals</td><td>2723</td><td>2957</td><td>2335</td><td>2440</td><td>2389</td><td>EFSA</td></tr><tr><td>Number of positive animals</td><td>1</td><td>1</td><td>8</td><td>2</td><td>–</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>25</td><td>22</td><td>20</td><td>21</td><td>22</td><td>EFSA</td></tr><tr><td colspan="7"><strong>Farmed mammals<sup>b</sup></strong></td></tr><tr><td>Number of tested animals</td><td>540<sup>c</sup></td><td>374</td><td>406</td><td>392</td><td>394</td><td>EFSA</td></tr><tr><td>Number of positive animals</td><td>30</td><td>15</td><td>4</td><td>3</td><td>1</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>16</td><td>16</td><td>17</td><td>17</td><td>15</td><td>EFSA</td></tr><tr><td colspan="7"><strong>Wild animals – Red foxes (Vulpes vulpes)</strong></td></tr><tr><td>Number of tested animals</td><td>11,445</td><td>18,486</td><td>12,907</td><td>9805</td><td>5336</td><td>EFSA</td></tr><tr><td>Number of positive animals</td><td>31</td><td>43</td><td>97</td><td>6</td><td>2</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>20</td><td>18</td><td>17</td><td>18</td><td>16</td><td>EFSA</td></tr><tr><td colspan="7"><strong>Wild animals – Raccoon dogs (Nyctereutes procyonoides)</strong></td></tr><tr><td>Number of tested animals</td><td>1176</td><td>1096</td><td>1339</td><td>1214</td><td>1241</td><td>EFSA</td></tr><tr><td>Number of positive animals</td><td>–</td><td>–</td><td>2</td><td>–</td><td>–</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>7</td><td>7</td><td>6</td><td>6</td><td>7</td><td>EFSA</td></tr><tr><td colspan="7"><strong>Wild animals – Jackals (Canis aureus)</strong></td></tr><tr><td>Number of tested animals</td><td>913</td><td>241</td><td>230</td><td>102</td><td>42</td><td>EFSA</td></tr><tr><td>Number of positive animals</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>7</td><td>7</td><td>5</td><td>6</td><td>5</td><td>EFSA</td></tr><tr><td colspan="7"><strong>Wild animals – Bats (order Chiroptera)</strong></td></tr><tr><td>Number of tested animals</td><td>1658</td><td>1622</td><td>1316</td><td>1308</td><td>2069</td><td>EFSA</td></tr><tr><td>Number of positive animals</td><td>23</td><td>26</td><td>29</td><td>31</td><td>39</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>18</td><td>16</td><td>16</td><td>15</td><td>18</td><td>EFSA</td></tr><tr><td colspan="7"><strong>Animals under active surveillance (ORV monitoring)<sup>d</sup></strong></td></tr><tr><td colspan="7"><strong>Red foxes (Vulpes vulpes)</strong></td></tr><tr><td>Number of tested animals</td><td>13,399</td><td>1801</td><td>10,581</td><td>14,416</td><td>17,805</td><td>EFSA</td></tr><tr><td>Number of positive animals</td><td>4</td><td>–</td><td>–</td><td>–</td><td>1</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>8</td><td>6</td><td>9</td><td>10</td><td>9</td><td>EFSA</td></tr></tbody></table>

(Continues)

<footnote n="51">51 Guidelines for the Union co-funded programmes of eradication, control and surveillance of animal diseases and zoonoses for the years 2021–2022, available online at https://food.ec.europa.eu/system/files/2021-06/cff_animal_vet-progs_guidance_progs_erad_wd-2021-10502.pdf.</footnote>
<table><caption>**TABLE 62** (Continued)</caption><thead><tr><th></th><th>2023</th><th>2022</th><th>2021</th><th>2020</th><th>2019</th><th>Data source</th></tr></thead><tbody><tr><td colspan="7"><strong>Raccoon dogs (Nyctereutes procyonoides)</strong></td></tr><tr><td>Number of tested animals</td><td>331</td><td>221</td><td>369</td><td>324</td><td>301</td><td>EFSA</td></tr><tr><td>Number of positive animals</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>3</td><td>3</td><td>4</td><td>4</td><td>3</td><td>EFSA</td></tr><tr><td colspan="7"><strong>Jackals (Canis aureus)</strong></td></tr><tr><td>Number of tested animals</td><td>115</td><td>1100</td><td>1499</td><td>1319</td><td>1045</td><td>EFSA</td></tr><tr><td>Number of positive animals</td><td>-</td><td>-</td><td>-</td><td>-</td><td>-</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>2</td><td>1</td><td>3</td><td>3</td><td>2</td><td>EFSA</td></tr></tbody></table>

Notes: Sampling context items for historical data: Passive surveillance: clinical investigations, monitoring–passive, surveillance, control and eradication programmes; Active surveillance: monitoring–active and unspecified. Sampling context items for 2023 data: Passive surveillance: clinical investigations and monitoring–passive; Active surveillance: monitoring–active.

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

ªIn 2023, one case was reported by France, probably infected in Morocco.

ᵇIncluded cattle (bovine animals), horses, sheep, goats, pigs and any other mammals where 'farmed' has been specified (e.g. farmed foxes, farmed minks).

ᶜIncluded 124 farmed foxes reported from Germany, all negative.

ᵈSamples collected in the framework of oral rabies vaccination (ORV) monitoring.

### 3.2.2 | Humans

No human cases acquired within the EU were reported between 2020 and 2023. In 2023, one case was reported by France, which was probably infected in Morocco. France reported an EU-acquired infection in 2019, due to European bat lyssavirus 1 (EBLV-1).

### 3.3.3 | Animals

#### Rabies cases in wildlife

In 2023, 11,445 foxes (Vulpes vulpes) were tested using passive surveillance by 20 MSs. In total, 31 cases of rabies were detected in foxes in the EU: 16 cases in Romania, 9 in Hungary and 6 in Poland. The geographical distribution and number of cases in foxes per NUTS 3 (Nomenclature of territorial units for statistics),<fnref n="52" /> as well as a choropleth map of the total number of foxes sampled per MS for passive surveillance, are shown in Figure 23. Three non-EU countries (Republic of North Macedonia, Serbia and Switzerland) reported a total of 14 foxes tested under passive surveillance schemes and found none to be positive.

<footnote n="52">⁵²The NUTS are a hierarchical system divided into three levels. NUTS 1: major socio-economic regions, NUTS 2: basic regions for the application of regional policies, NUTS 3: small regions for specific diagnoses. (https://ec.europa.eu/eurostat/web/gisco/geodata/reference-data/administrative-units-statistical-units/nuts).</footnote>
<figure><img src="image_137.png" /><figcaption>**FIGURE 23** Number of tested and positive foxes in the framework of passive surveillance and the geographical distribution of the rabies cases reported in foxes in EU MSs and non-EU countries, 2023. For Hungary, the geographical distribution of reported cases was not provided. EU MSs and the United Kingdom (Northern Ireland) were represented with a blue label, the EFTA/EEA countries were represented with a grey label, and all the candidate countries were represented with an orange label. The designation of Kosovo is without prejudice to positions on status, and is in line with UNSCR 1244/1999 and the ICJ Opinion on the Kosovo declaration of independence.</figcaption></figure>

In 2023, 1176 raccoon dogs (Nyctereutes procyonoides) were tested for rabies by seven MSs (Estonia, Finland, Italy, Latvia, Lithuania, Poland and Slovakia) and none were found to be positive. Most (93%) of these samples came from raccoon dogs originating from two MSs (Estonia and Latvia).

Eighteen MSs reported data from passive surveillance for 3912 non-flying wild animals other than foxes, raccoon dogs or golden jackals. The other most widely tested wild animal species were raccoons (N=1188), badgers (N=889), martens (N=793), deer and reindeer, roe and fallow deer (N=346) and wolves (N=268). One badger tested positive for rabies in Romania. Other species tested included mice, lynx, otters, squirrels, hedgehogs, rats, wild boars, bears, ferrets, dormice, wild cats, wolverines, minks, beavers, polecats, alpine chamois, alpacas, guinea pigs, voles, hamsters, marine mammals, land game mammals, seals, coypus, hares, rodents, kangaroos, bison and moose. All the animals tested negative for rabies. Three non-MSs (Norway, Republic of North Macedonia and Switzerland) analysed eight wolves, one badger, one lynx, one reindeer, one beaver and one marten, and all samples tested negative.

In 2023, 18 MSs and one non-MSs reported surveillance data on bats. In total, 1658 bats were investigated in the EU (Figure 24). Of these, 23 samples tested positive in seven MSs: Germany (12 EBLV-1 and 1 Bokeloh bat lyssavirus), Poland (1 EBLV-1 and 3 unspecified lyssavirus), France (2 EBLV-1), Austria (1 EBLV-1), Hungary (1 unspecified lyssavirus), Spain (1 EBLV-1) and the Netherlands (1 EBLV-1). One non-MS, Switzerland, analysed 23 bats and one bat tested positive (EBLV-2).
<figure><img src="image_138.png" /><figcaption>**FIGURE 24** Number of tested and positive bats, and the geographical distribution of the rabies cases reported in bats in EU MSs and non-EU countries, 2023. For Austria, Germany, Hungary, Spain, the Netherlands and Switzerland, the geographical distribution of reported cases was not provided. EU MSs and the United Kingdom (Northern Ireland) were represented with a blue label, the EFTA/EEA countries were represented with a grey label, and all the candidate countries were represented with an orange label. The designation of Kosovo is without prejudice to positions on status, and is in line with UNSCR 1244/1999 and the ICJ Opinion on the Kosovo declaration of independence.</figcaption></figure>

Rabies cases in domestic animals

In 2023, 39 autochthonous domestic animals tested positive for rabies. Twenty-five MSs tested in total 4890 samples for dogs and cats: 2167 dogs (from 21 MSs) and 2723 cats (from 25 MSs). A total of eight pet dogs tested positive: in Romania four cases (RABV), in Hungary three cases (unspecified lyssavirus) and in Poland one case (RABV). One case in a pet cat (unspecified lyssavirus) was reported by Hungary. Three non-EU countries (Republic of North Macedonia, Serbia and Switzerland) reported in total results for 37 dogs and 31 cats, with no rabies positives. The geographical distribution and number of tested and reported cases in pets (dogs and cats) are shown in Figure 25.
<figure><img src="image_139.png" /><figcaption>**FIGURE 25** Number of tested and positive pets, and the geographical distribution of the rabies cases reported in pets in EU MSs and non-EU countries, 2023. For Hungary, the geographical distribution of reported cases was not provided. EU MSs and the United Kingdom (Northern Ireland) were represented with a blue label, the EFTA/EEA countries were represented with a grey label, and all the candidate countries were represented with an orange label. The designation of Kosovo is without prejudice to positions on status, and is in line with UNSCR 1244/1999 and the ICJ Opinion on the Kosovo declaration of independence.</figcaption></figure>

A total of 540 samples from farmed mammals (Figure 26) were tested by 16 MSs (reports included mainly cattle, small ruminants and domestic solipeds). Of these, 30 samples from cattle tested positive: 28 cases (RABV) in Romania and two cases in Hungary (unspecified lyssavirus). Two non-EU countries reported three samples tested from farmed ruminants (Serbia (one bovine) and Switzerland (two bovines)); all of them tested negative.
<figure><img src="image_140.png" /><figcaption>**FIGURE 26** Number of tested and positive farmed animals, and the geographical distribution of the rabies cases reported in farmed animals in EU MSs and non-EU countries, 2023. For Hungary, the geographical distribution of reported cases was not provided. EU MSs and the United Kingdom (Northern Ireland) were represented with a blue label, the EFTA/EEA countries were represented with a grey label, and all the candidate countries were represented with an orange label. The designation of Kosovo is without prejudice to positions on status, and is in line with UNSCR 1244/1999 and the ICJ Opinion on the Kosovo declaration of independence.</figcaption></figure>

**3.4 | Discussion**

In Europe, human rabies is a rare disease, with the last autochthonous EU case of RABV human infection dating back to 2012 (Romania). Although non-RABV lyssavirus infections are rare, the identification of an EU-acquired human case due to EBLV-1 (France, 2019) from an infected bat underlines the need to continue monitoring the occurrence of this fatal encephalitis in EU Member States. Five human deaths have been reported so far in Europe, more specifically in Ukraine (1977: species not characterised), Russia (1985: EBLV-1), Finland (1985: EBLV-2), the United Kingdom (2002: EBLV-2) and the recent case acquired in France (2019: EBLV-1) (Fooks et al., 2003; Regnault et al., 2021).

All these infections were linked to direct exposure to infected bats; however, human exposure to bat lyssaviruses by contact with infected domestic animals such as free-roaming cats (they have been occasionally found infected by bat lyssavirus) leading to secondary transmission must not be overlooked as, even if never documented, could theoretically be possible. In this context, the absence of prevention and control tools for divergent lyssaviruses circulating in European bats must be highlighted (Echevarría et al., 2019). Nowadays, RABV infections are mainly acquired abroad in countries where dog rabies is endemic and development of the disease is due to the absence of pre-exposure prophylaxis or late/inappropriate/incomplete administration of post-exposure prophylaxis.

The EU programmes for rabies eradication include disease surveillance, oral vaccination campaigns, monitoring of ORV and awareness activities. Results in 2023 (71 rabies cases reported from passive surveillance) show maintenance of the infection in Romania (in total 49 cases, including wildlife and domestic species, more particularly cattle with 28 reported cases) and in Poland (in total 7 cases, including foxes and a dog). The disease is also maintained in Hungary (15 cases in 2023 compared with 4 cases in 2022), which lost its rabies-free status in 2022. This MS had reported the last cases in 2017. The epidemiological data localised these cases close to the borders with Ukraine and Romania. In Romania, the data for 2023 show a markedly increased number of cases (49 compared with 26 cases in 2022) and an extension of the infected areas. Most cases were detected in bordering areas with Moldova, Ukraine and Hungary. The situation seems to have improved in Poland (36 cases detected in 2022 and 7 cases in 2023), but the overall situation in the EU shows how fragile
the epidemiological context of a country is, and how it is linked to that of neighbouring countries. The cases still being reported over several years in the few remaining MSs with infections, or re-emergence of rabies, highlight the importance of a sustainable surveillance programme and awareness campaigns for the general public and professionals, to ensure the early detection of any potential cases. They also stress the importance of implementing ORV programmes in all infected areas on a biannual basis (in spring and autumn) and establishing cross-border collaborations to achieve disease-free status. Data relating to passive rabies surveillance in wildlife, mainly in foxes and raccoon dogs, show relative stability in the number of samples tested over the 2019–2023 period, due to the surveillance efforts maintained by most rabies-free and infected MSs for early detection of the virus and for controlling the last foci.

Data relating to active surveillance (ORV monitoring) are reported for foxes, raccoon dogs and jackals. This surveillance is conducted by hunting apparently healthy animals and using the animal carcases to assess the efficacy of vaccination campaigns in infected and rabies-free countries involved in eradication programmes. A sample size linked to the area covered by vaccination is recommended. The data reveal a substantial decrease in the number of analysed foxes between 2019 and 2022, reflecting the decrease in the size of vaccinated areas in the EU, hence the success of ORV programmes. However, in 2023, the data show a marked increase in the number of analysed foxes in the infected countries compared to 2022. In 2023, three MSs reported four positive foxes sampled during ORV monitoring.

Regarding rabies surveillance in bats, the number of tests was stable in 2023 compared with 2022, despite a higher number of MSs reporting. Positive results obtained in the framework of bat surveillance (23 cases) are in line with the findings of the previous years and confirm that European bats act as reservoirs for lyssaviruses other than rabies virus, reaffirming the public recommendation to handle bats with utmost caution, if at all. The public health hazard of bat lyssaviruses in Europe should not be underestimated.

As rabies is still endemic in countries bordering the EU, in areas not far from the borders, several MSs are involved in collaborations with these countries for the implementation of vaccination and testing schemes in buffer zones. The Global Framework for the Progressive Control of Transboundary Animal Diseases (GF-TADs) created a Standing Group of Experts on Rabies (SGE RAB) in 2019, and the fifth meeting was organised in 2023 with the goal of coordinating rabies control and improving surveillance activities, primarily in the Balkan sub-region, where a case was detected in a dog in 2020.

Maintaining appropriate surveillance is of paramount importance for all MSs, due to regular resurgence of the disease in rabies-free areas and the persistence of active foci in Hungary, Poland and Romania. Apparent disappearance of the virus has been achieved in most EU territories and maintaining appropriate surveillance efforts and relevant ORV implementation remain the most challenging issues to attaining rabies elimination in the EU.

## 4 | Q FEVER

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 Q fever and for the consultation of data collected, the following interactive tool is available:

Q fever

<figure><img src="image_141.png" /></figure>

STORY MAP

<figure><img src="image_142.png" /></figure>

### 4.1 | Key facts

* In 2023, there were 805 confirmed cases of human Q fever, corresponding to a European Union notification rate of 0.19 cases per 100,000 population. This was an increase of 11.5% compared with 2022 (0.17 cases per 100,000 population).

* The overall trend for human *Coxiella burnetii* infections did not show any significant increase or decrease in the 2019–2023 period.

* In 2023, 17 Member States and five non-Member States reported data for *C. burnetii* in animals. Cattle and small ruminants were predominantly sampled during clinical investigations and passive monitoring of animals with suspected infection. At the European Union level, among the animals tested using direct detection methods (N=3738), the proportion of positive cases was 4.7% in sheep, 11.2% in goats and 6.0% in cattle. For herds tested using direct detection methods (N=5256), the positive proportion was 23.8% for sheep, 20.0% for goats and 8.5% for cattle. Serological testing revealed that 27.0% of sheep, 25.9% of goats and 6.0% of cattle were seropositive among the 8722 animals tested. At the herd level, 0.75% of sheep flocks, 4.8% of goat herds and 6.4% of cattle herds tested seropositive out of 5429 herds.

* Among other farmed, domestic and wild animals tested (N=528 animals, N=21 herds from nine reporting countries), positivity was reported mainly in Italy, in donkeys, horses, mouflons, water buffalos, dogs and deer. Additionally, Belgium reported one positive deer holding.
## 4.2 | Surveillance and monitoring of *Coxiella burnetii* in the EU

### 4.2.1 | Humans

For 2023, 25 MSs provided data on Q fever in humans. No surveillance system is in place in Austria. Denmark did not report data for 2020–2023. Surveillance is mandatory in 24 MSs and voluntary in France. Moreover, in 2023, France adopted the EU case definition. The EU case definition was used by 23 countries; two MSs (Germany and Italy) reported use of another case definition. Disease surveillance is comprehensive and generally passive except in Czechia and Slovakia. The Q fever surveillance systems cover the whole population in all reporting MSs. All countries reported case-based data except Belgium, Bulgaria and Croatia, which provided aggregated data.

### 4.2.2 | Animals

Q fever is a 'Category E' disease, for which there is a need for surveillance and annual reporting of confirmed cases by MSs in *Bison* ssp., *Bos* ssp., *Bubalus* ssp., *Ovis* ssp. and *Capra* ssp. (CIR (EU) 2018/1882, CIR (EU) 2020/2002).

However, since neither surveillance nor reporting of animal Q fever has been harmonised in the EU, data may not be representative of the disease situation in each European country and should not be used for tracking or assessing EU-level temporal and spatial trends (Table 63).

The primary animal categories tested for *C. burnetii* were sheep, goats and cattle. Most samples were blood, placental tissue, vaginal swabs and samples from foetuses and stillborn animals suspected of infection, along with bulk milk samples used for screening. Testing methods included serological assays to detect antibodies indicating past or recent exposure to *C. burnetii*, and direct detection methods like PCR, which identify bacterial material indicating carriage. In most MSs, testing was conducted during clinical investigations and passive monitoring. However, a few countries – Belgium, Bulgaria, the Netherlands, Poland, Slovenia – implemented planned surveillance in cattle and small ruminants. Poland (N=4871 herds) and Slovenia (N=84 herds) used ELISA serological tests on serum, along with Sweden and Norway to check for sporadic cases. Belgium and the Netherlands regularly carried out PCR tests on bulk tank milk from dairy sheep and goats, while Iceland used serological tests on this type of sample. Some countries reported very low numbers of tests, typically linked to local surveys or selective investigations. In addition, samples were collected from other farmed and domestic animals, particularly water buffalos in Italy, as well as wild animal species in zoos or natural habitats.

## 4.3 | Results

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

Table 63 summarises EU-level statistics on human Q fever, and on the occurrence of *C. burnetii* in animals, for the period 2019–2023. More detailed descriptions of these statistics are provided in the subsections below.

<table><caption>TABLE 63 Summary of *Coxiella burnetii* statistics relating to humans and the 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><strong>Humans</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Total number of confirmed cases</td><td>805</td><td>719</td><td>470</td><td>547</td><td>1021</td><td>ECDC</td></tr><tr><td>Total number of confirmed cases/100,000 population (notification rates)</td><td>0.19</td><td>0.17</td><td>0.11</td><td>0.13</td><td>0.20</td><td>ECDC</td></tr><tr><td>Number of reporting EU MSs</td><td>25</td><td>25</td><td>25</td><td>25</td><td>27</td><td>ECDC</td></tr><tr><td>Infection acquired in the EU</td><td>622</td><td>597</td><td>366</td><td>364</td><td>804</td><td>ECDC</td></tr><tr><td>Infection acquired outside the EU</td><td>19</td><td>5</td><td>3</td><td>6</td><td>15</td><td>ECDC</td></tr><tr><td>Unknown travel status or unknown country of infection</td><td>164</td><td>117</td><td>101</td><td>177</td><td>202</td><td>ECDC</td></tr><tr><td><strong>Animals<sup>a</sup></strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td><strong>Sheep<sup>b</sup></strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td><strong>Animals</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Serology<sup>c</sup></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Number of tested animals</td><td>1891</td><td>526</td><td>750</td><td>911</td><td>666</td><td>EFSA</td></tr><tr><td>% positive animals</td><td>27.0</td><td>11.4</td><td>10.3</td><td>11.4</td><td>9.9</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>7</td><td>8</td><td>8</td><td>8</td><td>9</td><td>EFSA</td></tr></tbody></table>
<table><caption>TABLE 63 (Continued)</caption><thead><tr><th></th><th>2023</th><th>2022</th><th>2021</th><th>2020</th><th>2019</th><th>Data source</th></tr></thead><tbody><tr><td><strong>Direct detection<sup>d</sup></strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Number of tested animals</td><td>1040</td><td>752</td><td>85</td><td>358</td><td>224</td><td>EFSA</td></tr><tr><td>% positive animals</td><td>4.7</td><td>3.6</td><td>5.9</td><td>8.7</td><td>18.3</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>7</td><td>7</td><td>5</td><td>4</td><td>4</td><td>EFSA</td></tr><tr><td><strong>Other methods/unknown</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Number of tested animals</td><td>0</td><td>0</td><td>521</td><td>1555</td><td>2244</td><td>EFSA</td></tr><tr><td>% positive animals</td><td>-</td><td>-</td><td>0</td><td>21.7</td><td>13.3</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>-</td><td>-</td><td>1</td><td>2</td><td>2</td><td>EFSA</td></tr><tr><td><strong>Herds</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td><strong>Serology<sup>c</sup></strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Number of tested herds</td><td>2270</td><td>128</td><td>2238</td><td>17</td><td>25</td><td>EFSA</td></tr><tr><td>% positive herds</td><td>0.75</td><td>97.7</td><td>18.9</td><td>5.9</td><td>28.0</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>3</td><td>1</td><td>1</td><td>2</td><td>1</td><td>EFSA</td></tr><tr><td><strong>Direct detection<sup>d</sup></strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Number of tested herds</td><td>1947</td><td>2812</td><td>3130</td><td>2890</td><td>2902</td><td>EFSA</td></tr><tr><td>% positive herds</td><td>23.8</td><td>4.9</td><td>4.1</td><td>1.4</td><td>1.2</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>4</td><td>6</td><td>5</td><td>4</td><td>4</td><td>EFSA</td></tr><tr><td><strong>Other methods/unknown</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Number of tested herds</td><td>0</td><td>0</td><td>0</td><td>39</td><td>53</td><td>EFSA</td></tr><tr><td>% positive herds</td><td>-</td><td>-</td><td>-</td><td>15.4</td><td>30.2</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>-</td><td>-</td><td>-</td><td>1</td><td>1</td><td>EFSA</td></tr><tr><td><strong>Goats</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td><strong>Animals</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td><strong>Serology<sup>c</sup></strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Number of tested animals</td><td>135</td><td>140</td><td>540</td><td>651</td><td>656</td><td>EFSA</td></tr><tr><td>% positive animals</td><td>25.9</td><td>17.9</td><td>24.6</td><td>25.0</td><td>18.0</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>7</td><td>8</td><td>6</td><td>7</td><td>8</td><td>EFSA</td></tr><tr><td><strong>Direct detection<sup>d</sup></strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Number of tested animals</td><td>661</td><td>961</td><td>200</td><td>248</td><td>189</td><td>EFSA</td></tr><tr><td>% positive animals</td><td>11.2</td><td>2.1</td><td>16.5</td><td>11.3</td><td>9.5</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>7</td><td>7</td><td>4</td><td>4</td><td>4</td><td>EFSA</td></tr><tr><td><strong>Other methods/unknown</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Number of tested animals</td><td>0</td><td>0</td><td>777</td><td>831</td><td>845</td><td>EFSA</td></tr><tr><td>% positive animals</td><td>-</td><td>-</td><td>0.13</td><td>0</td><td>0</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>-</td><td>-</td><td>1</td><td>2</td><td>2</td><td>EFSA</td></tr><tr><td><strong>Herds</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td><strong>Serology<sup>c</sup></strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Number of tested herds</td><td>976</td><td>-</td><td>4</td><td>141</td><td>30</td><td>EFSA</td></tr><tr><td>% positive herds</td><td>4.8</td><td>-</td><td>50.0</td><td>78.7</td><td>73.3</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>3</td><td>-</td><td>1</td><td>1</td><td>1</td><td>EFSA</td></tr><tr><td><strong>Direct detection<sup>d</sup></strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Number of tested herds</td><td>1200</td><td>1189</td><td>1283</td><td>1175</td><td>1167</td><td>EFSA</td></tr><tr><td>% positive herds</td><td>20.0</td><td>3.5</td><td>2.0</td><td>1.2</td><td>2.8</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>4</td><td>5</td><td>5</td><td>4</td><td>4</td><td>EFSA</td></tr><tr><td><strong>Other methods/unknown</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Number of tested herds</td><td>0</td><td>82</td><td>0</td><td>12</td><td>207</td><td>EFSA</td></tr><tr><td>% positive herds</td><td>-</td><td>62.2</td><td>-</td><td>0</td><td>84.1</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>-</td><td>1</td><td>-</td><td>1</td><td>1</td><td>EFSA</td></tr></tbody></table>

(Continues)
<table><caption>TABLE 63 (Continued)</caption><thead><tr><th></th><th>2023</th><th>2022</th><th>2021</th><th>2020</th><th>2019</th><th>Data source</th></tr></thead><tbody><tr><td colspan="7"><strong>Cattle (bovine animals)</strong></td></tr><tr><td colspan="7"><strong>Animals</strong></td></tr><tr><td colspan="7"><strong>Serology<sup>c</sup></strong></td></tr><tr><td>Number of tested animals</td><td>6696</td><td>7031</td><td>3405</td><td>4664</td><td>8722</td><td>EFSA</td></tr><tr><td>% positive animals</td><td>6.0</td><td>2.8</td><td>12.2</td><td>9.6</td><td>10.5</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>8</td><td>9</td><td>11</td><td>9</td><td>11</td><td>EFSA</td></tr><tr><td colspan="7"><strong>Direct detection<sup>d</sup></strong></td></tr><tr><td>Number of tested animals</td><td>2037</td><td>1260</td><td>458</td><td>842</td><td>739</td><td>EFSA</td></tr><tr><td>% positive animals</td><td>6.0</td><td>2.7</td><td>5.2</td><td>3.8</td><td>3.0</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>8</td><td>5</td><td>4</td><td>5</td><td>4</td><td>EFSA</td></tr><tr><td colspan="7"><strong>Other methods/unknown</strong></td></tr><tr><td>Number of tested animals</td><td>0</td><td>0</td><td>343</td><td>3860</td><td>4240</td><td>EFSA</td></tr><tr><td>% positive animals</td><td>-</td><td>-</td><td>0.29</td><td>0.08</td><td>0.66</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>-</td><td>-</td><td>1</td><td>2</td><td>2</td><td>EFSA</td></tr><tr><td colspan="7"><strong>Herds</strong></td></tr><tr><td colspan="7"><strong>Serology<sup>c</sup></strong></td></tr><tr><td>Number of tested herds</td><td>2101</td><td>113</td><td>1201</td><td>312</td><td>551</td><td>EFSA</td></tr><tr><td>% positive herds</td><td>6.7</td><td>30.1</td><td>15.1</td><td>14.4</td><td>30.7</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>4</td><td>3</td><td>1</td><td>2</td><td>2</td><td>EFSA</td></tr><tr><td colspan="7"><strong>Direct detection<sup>d</sup></strong></td></tr><tr><td>Number of tested herds</td><td>2109</td><td>3934</td><td>4311</td><td>3571</td><td>3673</td><td>EFSA</td></tr><tr><td>% positive herds</td><td>8.5</td><td>7.7</td><td>4.8</td><td>6.7</td><td>6.3</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>8</td><td>6</td><td>8</td><td>5</td><td>5</td><td>EFSA</td></tr><tr><td colspan="7"><strong>Other methods/unknown</strong></td></tr><tr><td>Number of tested herds</td><td>0</td><td>6</td><td>0</td><td>0</td><td>43</td><td>EFSA</td></tr><tr><td>% positive herds</td><td>-</td><td>100</td><td>-</td><td>-</td><td>95.3</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>-</td><td>1</td><td>-</td><td>-</td><td>1</td><td>EFSA</td></tr></tbody></table>

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

### 4.3.2 | *Coxiella burnetii* in humans

For 2023, 25 EU MSs reported a total of 805 confirmed cases of Q fever, with a notification rate of 0.19 cases per 100,000 population. This is an increase of 11.5% compared with the rate in 2022 (0.17 per 100,000 population). More than 50% of cases were reported by Romania and Spain, while Estonia, Finland, Latvia, Lithuania and Malta reported zero cases. The highest notification rate was recorded in Bulgaria (0.73 per 100,000 population) and Hungary (0.72 per 100,000 population), followed by Spain and Romania, with 0.69 and 0.64 cases per 100,000 population, respectively (Table 64).

Of those with available travel status information (N=641), most Q fever cases (97.0%, N=622), were reported to have been acquired in the EU, representing a slight decrease compared with 2022 (99.2%). Nineteen cases (2.4%) were acquired outside the EU, and 20.4% (N=164) were reported as unknown travel status or unknown country of infection (Table 64).

A total of 32 imported cases were registered in nine MSs (Czechia, France, Germany, Hungary, the Netherlands, Slovakia, Slovenia, Spain and Sweden) and for 12 cases the most probable country of infection was documented.

In 2023, cases occurred year-round. Most Q fever cases occurred from March to August, in line with the spring/summer seasonal pattern (Figure 27).

The number of Q fever cases increased compared with 2022. However, the overall Q fever trend in 2019–2023 did not show a significant increase or decrease in the EU. At the country level, a significant increasing trend was observed in Hungary (*p* < 0.05).

<footnote><sup>a</sup>Number of tested animals and herds were obtained by totalling respectively the animal sampling unit, and the herd or holding sampling units, of all sampling stages (backyard, border control posts, farm, hunting, natural habitat, unspecified, veterinary activities and zoo), sampling strategies (census, convenience sampling, objective sampling selective sampling and suspect sampling) samplers (HACCP and own-check, industry sampling, official sampling, not applicable and private sampling) and sampling contexts (clinical investigations, monitoring, outbreak investigation, surveillance, survey and unspecified).</footnote>

<footnote><sup>b</sup>Sheep' also includes the 'sheep and goats' category (NB, some countries reported both livestock types together).</footnote>

<footnote><sup>c</sup>Serology includes the complement fixation test (CFT), ELISA, competitive ELISA (C-ELISA), indirect ELISA (I-ELISA), IgG ELISA and the immunofluorescence antibody test (IFAT).</footnote>

<footnote><sup>d</sup>Direct detection methods include fluorescent in situ hybridisation (FISH), immunohistochemistry (IHC), microbiological tests, multiplex PCR, PCR, real-time PCR, real-time PCR (CEN TC 275/WG 6).</footnote>
<table><caption>TABLE 64 Reported human cases of Q fever 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 rowspan="3">National coverage<sup>a</sup></th><th rowspan="3">Data format<sup>a</sup></th><th colspan="2">2023</th><th colspan="2">2022</th><th colspan="2">2021</th><th colspan="2">2020</th><th colspan="2">2019</th></tr><tr><th colspan="2">Confirmed cases and 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><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><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><td>—</td><td>—</td></tr><tr><td>Belgium</td><td>Y</td><td>A</td><td>4</td><td>0.03</td><td>6</td><td>0.05</td><td>6</td><td>0.05</td><td>4</td><td>0.03</td><td>10</td><td>0.09</td></tr><tr><td>Bulgaria</td><td>Y</td><td>A</td><td>47</td><td>0.73</td><td>13</td><td>0.19</td><td>31</td><td>0.45</td><td>103</td><td>1.5</td><td>36</td><td>0.51</td></tr><tr><td>Croatia</td><td>Y</td><td>A</td><td>2</td><td>0.05</td><td>22</td><td>0.57</td><td>0</td><td>0</td><td>2</td><td>0.05</td><td>8</td><td>0.20</td></tr><tr><td>Cyprus</td><td>Y</td><td>C</td><td>2</td><td>0.22</td><td>2</td><td>0.22</td><td>2</td><td>0.22</td><td>1</td><td>0.11</td><td>1</td><td>0.11</td></tr><tr><td>Czechia</td><td>Y</td><td>C</td><td>2</td><td>0.02</td><td>2</td><td>0.02</td><td>1</td><td>0.01</td><td>1</td><td>0.01</td><td>1</td><td>0.01</td></tr><tr><td>Denmark<sup>c</sup></td><td>Y</td><td>C</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>0</td><td>0</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>0</td><td>0</td><td>0</td><td>0</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><td>2</td><td>0.04</td></tr><tr><td>France</td><td>Y</td><td>C</td><td>75</td><td>0.11</td><td>127</td><td>0.19</td><td>92</td><td>0.14</td><td>96</td><td>0.14</td><td>156</td><td>0.23</td></tr><tr><td>Germany</td><td>Y</td><td>C</td><td>74</td><td>0.09</td><td>65</td><td>0.08</td><td>99</td><td>0.12</td><td>55</td><td>0.07</td><td>148</td><td>0.18</td></tr><tr><td>Greece</td><td>Y</td><td>C</td><td>10</td><td>0.10</td><td>10</td><td>0.10</td><td>4</td><td>0.04</td><td>4</td><td>0.04</td><td>14</td><td>0.13</td></tr><tr><td>Hungary</td><td>Y</td><td>C</td><td>69</td><td>0.72</td><td>67</td><td>0.69</td><td>41</td><td>0.42</td><td>34</td><td>0.35</td><td>47</td><td>0.48</td></tr><tr><td>Ireland</td><td>Y</td><td>C</td><td>4</td><td>0.08</td><td>0</td><td>0</td><td>0</td><td>0</td><td>2</td><td>0.04</td><td>2</td><td>0.04</td></tr><tr><td>Italy</td><td>Y</td><td>C</td><td>7</td><td>0.01</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>6</td><td>0.01</td></tr><tr><td>Latvia</td><td>Y</td><td>C</td><td>0</td><td>0</td><td>2</td><td>0.11</td><td>0</td><td>0</td><td>1</td><td>0.05</td><td>0</td><td>0</td></tr><tr><td>Lithuania</td><td>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>1</td><td>0.15</td><td>3</td><td>0.46</td><td>0</td><td>0</td><td>2</td><td>0.32</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>2</td><td>0.38</td><td>1</td><td>0.19</td><td>0</td><td>0</td><td>1</td><td>0.20</td></tr><tr><td>Netherlands</td><td>Y</td><td>C</td><td>4</td><td>0.02</td><td>12</td><td>0.07</td><td>6</td><td>0.03</td><td>7</td><td>0.04</td><td>16</td><td>0.09</td></tr><tr><td>Poland</td><td>Y</td><td>C</td><td>6</td><td>0.02</td><td>2</td><td>0.01</td><td>0</td><td>0</td><td>0</td><td>0</td><td>4</td><td>0.01</td></tr><tr><td>Portugal</td><td>Y</td><td>C</td><td>33</td><td>0.32</td><td>25</td><td>0.24</td><td>18</td><td>0.17</td><td>22</td><td>0.21</td><td>32</td><td>0.31</td></tr><tr><td>Romania</td><td>Y</td><td>C</td><td>122</td><td>0.64</td><td>49</td><td>0.26</td><td>5</td><td>0.03</td><td>12</td><td>0.06</td><td>109</td><td>0.56</td></tr><tr><td>Slovakia</td><td>Y</td><td>C</td><td>4</td><td>0.07</td><td>0</td><td>0</td><td>2</td><td>0.04</td><td>5</td><td>0.09</td><td>1</td><td>0.02</td></tr><tr><td>Slovenia</td><td>Y</td><td>C</td><td>3</td><td>0.14</td><td>1</td><td>0.05</td><td>0</td><td>0</td><td>1</td><td>0.05</td><td>6</td><td>0.29</td></tr><tr><td>Spain</td><td>Y</td><td>C</td><td>334</td><td>0.69</td><td>303</td><td>0.64</td><td>159</td><td>0.34</td><td>194</td><td>0.41</td><td>402</td><td>0.86</td></tr><tr><td>Sweden</td><td>Y</td><td>C</td><td>2</td><td>0.02</td><td>6</td><td>0.06</td><td>3</td><td>0.03</td><td>1</td><td>0.01</td><td>10</td><td>0.10</td></tr><tr><td><strong>EU Total 27</strong></td><td></td><td></td><td><strong>805</strong></td><td><strong>0.19</strong></td><td><strong>719</strong></td><td><strong>0.17</strong></td><td><strong>470</strong></td><td><strong>0.11</strong></td><td><strong>547</strong></td><td><strong>0.13</strong></td><td><strong>1012</strong></td><td><strong>0.23</strong></td></tr><tr><td>United Kingdom</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>9</td><td>0.01</td></tr><tr><td><strong>EU Total</strong></td><td></td><td></td><td><strong>805</strong></td><td><strong>0.19</strong></td><td><strong>719</strong></td><td><strong>0.17</strong></td><td><strong>470</strong></td><td><strong>0.11</strong></td><td><strong>547</strong></td><td><strong>0.13</strong></td><td><strong>1021</strong></td><td><strong>0.20</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</td><td>Y</td><td>C</td><td>3</td><td>0.05</td><td>4</td><td>0.07</td><td>4</td><td>0.07</td><td>5</td><td>0.09</td><td>8</td><td>0.15</td></tr><tr><td>Liechtenstein</td><td>Y</td><td>C</td><td>1</td><td>2.5</td><td>0</td><td>0</td><td>0</td><td>0</td><td>53</td><td>0.61</td><td>102</td><td>1.2</td></tr><tr><td>Switzerland<sup>d</sup></td><td>Y</td><td>C</td><td>101</td><td>1.1</td><td>89</td><td>1.0</td><td>111</td><td>1.3</td><td></td><td></td><td></td><td></td></tr></tbody></table>

Abbreviation: –, Data not reported.

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

<footnote><sup>b</sup>Not notifiable, no surveillance system exists.</footnote>

<footnote><sup>c</sup>Denmark did not report data in 2020–2023.</footnote>

<footnote><sup>d</sup>Switzerland provided data directly to EFSA. The human data for Switzerland include data from Liechtenstein for the years from 2019 to 2020.</footnote>
<figure><img src="image_143.png" /><figcaption>**FIGURE 27** Trend in reported confirmed human cases of Q fever in the EU by month, 2019–2023. Source: Cyprus, Czechia, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Malta, the Netherlands, Poland, Portugal, Romania, Slovakia, Slovenia, Spain and Sweden.</figcaption></figure>

### 4.3.3 | Coxiella burnetii in animals

#### Overview of key statistics, main animal species, EU, 2019–2023

Animal data of interest were grouped into three main species categories (sheep, goats and cattle) and aggregated by year for the period 2019–2023, to provide an annual summary of the submitted data (Table 63). The total number and the proportions of positive cases – at both the individual animal level and the herd, holding or flock level – were further categorised based on the analytical testing method used (serology or direct detection).

In 2023, compared to 2022, the number of individual animal samples submitted by EU MSs increased for cattle (+5.3%, N=8733) and sheep (+129.3%, N=2931), but decreased for goats (–27.7%, N=796). Concomitantly, the number of sampled herds increased by 3.9% for cattle (N=4210 in 2023), 43.4% for sheep (N=4217 in 2023) and 71.2% for goats (N=2176 in 2023). Compared to 2022, the overall number of samples submitted at both the animal and herd levels increased by 4.9% for cattle (N=12,943 in 2023), 25.3% for goats (N=2972 in 2023) and 69.5% for sheep (N=7148 in 2023), reaching the highest submission level in the past 5 years.

The proportions of positive serological tests varied greatly across years and sampling contexts. From 2019 to 2023, the overall proportion of positive animal samples ranged from 9.9% to 27.0% for sheep (27.0% in 2023), 17.9% to 25.9% for goats (25.9% in 2023) and 2.8% to 12.2% for cattle (6.0% in 2023). At the herd level, positive serological tests ranged from 0.75% to 97.7% for sheep (0.75% in 2023, primarily based on 2251 herds reported by Poland, whereas data had been reported from direct tests in 2022), from 4.8% to 78.7% for goats (4.8% in 2023, based largely on 887 herds from Poland, whereas data had been reported from direct tests in 2022) and from 6.7% to 30.7% for cattle (6.7% in 2023, based on 1733 herds reported by Poland, whereas data had been reported from direct tests in 2022).

The range and the proportions of positive direct detection tests were generally lower than those of serological tests but were slightly higher in 2023 compared to the previous 4 years, particularly for sheep and goat herds. This increase was mostly driven by data from Spain which reported 1374 tests for sheep (28.9% positivity) and 504 tests for goats (39.7% positivity). For cattle, the increased proportion of positive direct detection tests was driven by Ireland (1071 tests, 4.9% positivity) and Austria (389 tests, 9.3% positivity). Overall, during 2019–2023, the proportion of positive animal samples ranged from 3.6% to 18.3% for sheep (4.7% in 2023), from 2.1% to 16.5% for goats (11.2% in 2023) and from 2.7% to 6.0% for cattle (6.0% in 2023). At the herd level, positive direct detection results ranged from 1.2% to 23.8% for sheep (23.8% in 2023), from 1.2% to 20.0% for goats (20.0% in 2023) and from 4.8% to 8.5% for cattle (8.5% in 2023).
# Overview of key statistics, main animal species, EU, 2023

## Sheep

Eleven MSs and three non-MS (Republic of North Macedonia, Serbia and Switzerland) reported data for a total of 3157 animals and 4217 flocks. At the animal level, serological tests – primarily ELISA (N=1891, 27.0% positive) – were used more frequently than direct detection methods (N=1266, 5.8% positive). The Netherlands conducted one-third of the direct detection tests (N=442, 0% positive), while Italy performed the largest number of ELISA tests (N=1294), with 29.0% positivity. At the herd level, most serological tests were from Poland (N=2251, 0.18% positive), while Spain accounted for most direct detection tests (N=1374, 28.9% positive).

## Goats

Ten MSs and one non-MS (Switzerland) reported data for 949 animals and 2176 herds. At the animal level, direct detection tests (N=814, 12.3% positive) were used more frequently than serological tests (N=135, 25.9% positive). The Netherlands (N=419, 0% positive), Italy (N=203; 32.0% positive) and Switzerland (N=153, 17.0% positive) conducted most direct detection tests. Serological tests were primarily carried out by Italy (N=61, 24.6% positive), Austria (N=26, 19.2% positive), Bulgaria (N=25, 60.0% positive) and Slovakia (N=23, 0% positive). At the herd level, Spain led direct detection testing (N=504, 39.7% positive), followed by the Netherlands (N=404, 0% positive) and Belgium (N=228, 10.1% positive). Poland reported the most serological tests (N=887, 0.34% positive) while Italy reported 83 serological tests with 48.2% positivity.

## Cattle

Seventeen MSs and five non-MS (Iceland, Norway, Republic of North Macedonia, Serbia and Switzerland) provided data, covering a total of 12,585 animals and 4292 herds. At the animal level, direct detection tests (N=5581, 9.3% positive) were less often used than serological tests (N=7004, 5.8% positive). Italy (N=3314, 4.0% positive), Austria (N=1825, 6.5% positive), Slovakia (N=948, 1.2% positive) and Bulgaria (N=360, 34.2% positive) accounted for nearly 89% of serological testing. Switzerland and Ireland conducted the highest number of direct detection tests (N=3542 and N=1071, respectively), with positivity rates of 11.2% and 4.9%. At the herd level, most direct detection tests were reported by Belgium (N=1830, 2.7% positive), while Poland contributed most serological tests (N=1733, 3.6% positive).

## Other animal species

Data on species other than sheep, goats and cattle were reported by seven MS (Austria, Belgium, Ireland, Italy, Slovakia, Slovenia and Sweden) and two non-MS (Norway and Switzerland) covering 19 species. In total, 528 animals and 21 herds were tested, primarily by Italy, from a variety of domestic and wild species including other ruminants (buffalos, alpacas, mouflons, deer), solipeds, pigs, pets (dogs) and other species. Italy reported positivity in several species: buffalos (N=261, 1.5% positive), deer (N=47, 2.1% positive), dogs (N=89, 2.2% positive), mouflons (N=24, 8.3%), horses (N=13, 15.4% positive) and donkeys (N=2, 50.0% positive). At the herd level, Italy also reported positivity in horses (N=7, 28.6%) and in buffaloes (N=13, 15.4%), while Belgium documented one positive deer herd (N=1 herd, 100% positive).

## 4.4 | Discussion

Q fever, caused by *C. burnetii*, affects humans and animals. Due to its microbial characteristics that include high virulence, environmental resistance and aerosol dissemination, it is classified as a potential biological weapon. Humans mainly acquire the infection through environmental contamination arising from bacterial shedding in infected animals, but also possibly through tick-borne transmission and a food-borne route (Basanisi et al., 2022). In Europe, most clinical cases are sporadic. However, several outbreaks among humans have been reported. Up to 2016, France and Germany reported most of the confirmed cases and in 2017, two outbreaks were reported from Bulgaria (Genova-Kalou et al., 2019). Year 2021 saw the lowest number of human Q fever cases recorded in the EU. Since 2017, Spain has reported the highest number of cases annually, mostly explained by a change in their reporting system from voluntary to mandatory (Christodoulou et al., 2023). In 2022, the number of human Q fever cases increased compared with the 2020–2021 pandemic years and an outbreak of Q fever was recorded in Croatia (Tomljenovic et al., 2023).

In 2023, the number of human Q fever cases increased compared to 2022, with 90% of cases occurring in Bulgaria, France, Germany, Hungary, Romania and Spain. Overall, the Q fever trend for the 2019–2023 period did not show any significant increase or decrease in the EU. Spain accounted for the largest proportion (41.5%) of cases, and, historically, the Basque Country reports most of the cases and outbreaks (Hurtado et al., 2023). Moreover, seroprevalence studies have confirmed Q fever endemicity in the Basque and the Canarian populations. In the Basque provinces of Biscay and Alava, a significant association was found between *C. burnetii*-positive farm dust samples and human cases (Cifo et al., 2024). Additionally, recent research highlights the importance of indirect transmission, especially in urban communities without evidence of conventional risk factors, leading to an underestimation of Q fever diseases (Tan et al., 2024). Outside of
occupational exposure, human infection may be influenced by environmental and meteorological conditions. Wind speed direction and geographical dispersion are important risk factors to consider as a source of infection and environmental microbial maintenance (Clark & Soares, 2018).

The results obtained from animals – primarily from small ruminants and cattle – remain insufficient for analysing trends for Q fever at the EU level. The start of annual EU reporting in 2021, after Q fever was classified as a ‘Category E’ disease in the new EU Animal Health Law, has yet to result in consistent harmonisation across MSs countries. The results submitted by different MSs and non-MSs are not directly comparable, mainly due to differences in sampling strategy (sample types, testing methods, coverage of the monitoring), data completeness and sensitivity of the surveillance method. France and Germany, for example, still do not report data on Q fever in animals, further complicating the ability to analyse trends.

While progress has been made in familiarising countries with testing methods, challenges persist. The lack of standardised case definitions for animals and herds, along with confusion between reporting at the animal and herd levels, complicates the ability to conduct coherent and comparative analyses in domestic ruminants. This not only impedes accurate intra- and inter-herd evaluations, but also hinders the identification of key positive and negative factors influencing Q fever seroprevalence. Monitoring these factors is crucial, especially in the context of climate change, which may influence disease transmission dynamics.

Moreover, bulk tank milk sampling is increasingly used as a method for monitoring *C. burnetii* in dairy herds. However, questions remain about its sensitivity, particularly in relation to herd size and the number of lactating females raising concerns about its overall efficacy as a surveillance tool.

In addition to farmed ruminants, other animals – including pets and wild species – may act as potential reservoirs for *C. burnetii* and should be included in epidemiological investigations, if needed (Alessiani et al., 2024; Georgiev et al., 2013). In the coming years, it will be crucial to investigate sources of *C. burnetii* infection and understand how environmental contamination persists (Carrié et al., 2019; Hurtado et al., 2023). A key challenge will be reducing human exposure to this zoonosis through a preventive ‘One Health’ approach. In Spain, where Q fever cases have been notably high, a surveillance programme for ruminant herds was updated in 2023. As a result, new control measures have been introduced to mitigate human outbreaks, with plans to harmonise these actions at the national level in the near future (Cifo et al., 2024).

## 5 | WEST NILE VIRUS

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 West Nile virus and for the consultation of data collected, the following interactive tool is available:

West Nile Virus

<figure><img src="image_144.png" /></figure>

DASHBOARD

<figure><img src="image_145.png" /></figure>

### 5.1 | Key facts

* In 2023, there were 751 confirmed and probable cases of human West Nile virus infections, corresponding to a European Union notification rate of 0.17 cases per 100,000 population. This represented a decrease of 37.2% in the European Union rate of locally acquired cases (0.16 case per 100,000), compared with 2022 (0.25 cases per 100,000 population).

* In 2023, 320 birds and 182 equines tested positive for West Nile virus, as reported to EFSA. This represents a decrease of 25.8% and an increase of 9.6%, respectively, compared with 2022.

* In 2023, 425 outbreaks in animals were reported to the European Union Animal Disease Information System by nine Member States, with the number of avian outbreaks (N = 266) reported for 2023 being as high as the number reported by Member States in 2022. Austria, Bulgaria, France, Germany, Greece, Hungary, Italy and Spain reported outbreaks in birds, with Italy accounting for 79.7% of the total number of avian outbreaks reported in 2023.

* Seven Member States reported 159 outbreaks in equids to European Union Animal Disease Information System, with the highest proportions in France and Spain accounting for 30.8% and 23.9% of the total number of outbreaks, respectively.
# 5.2 | Surveillance and monitoring of West Nile virus in the EU

## 5.2.1 | Humans

In 2023, 27 MSs reported data on West Nile virus infection in humans. Surveillance is mandatory in 24 EU Member States, voluntary in France and Belgium and in Germany, this information was not specified. The EU case definition was used by 25 MSs, France reported a different case definition and Germany did not specify the case definition used. All countries had a comprehensive surveillance system, except for Germany, which did not provide details. In all EU Member States, the West Nile virus surveillance systems have national coverage. Croatia reports aggregated data, while the remaining EU Member States conducting West Nile virus surveillance report case-based data.

For the human disease due to West Nile virus (WNV), ECDC uses the term WNV infection in line with WHO ICD-11. This includes the febrile form, West Nile fever (WNF) and the neurological form, West Nile neuro-invasive disease (WNND), as well as asymptomatic infections.

## 5.2.2 | Animals

From a veterinary standpoint, WNV is the causative agent of West Nile Fever (WNF), a disease that develops into asymptomatic forms, benign forms (flu-like syndrome) and neuro-invasive forms (WOAH, 2023) in line with the World Organisation for Animal Health (WOAH) terminology. WNV surveillance in animals is mostly passive, including surveillance based on the diagnosis of neuro-invasive cases in equids, although some countries implement active surveillance of equids and/or captive birds and/or wild birds. Active surveillance involves actively looking for cases (symptomatic and asymptomatic) from targeted groups of animals to provide better insight into WNV ecology and circulation. Furthermore, EU MSs and Switzerland submit reports to EFSA on animal surveillance and monitoring activities. Two sources of information are used to complete this reporting. Firstly, data are submitted to EFSA by EU MSs and Switzerland from annual surveillance and monitoring activities in accordance with Directive 2003/99/EC. WNV is listed in Annex I, Part B (viruses transmitted by arthropods) as a virus to be monitored, according to the epidemiological situation in a MS, in compliance with Article 4.1 of the same Directive. Secondly, it is mandatory for MSs to notify outbreaks of equine and avian WNV to ADIS,<fnref n="53" /> in accordance with CIR (EU) 2020/2002.

# 5.3 | Results

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

In 2023, WNV cases were reported in humans, equids and birds. Over the past 5 years, the number of countries reporting surveillance data in animals and humans has been relatively stable (Table 65).

The number of probable and confirmed human cases of WNV infection reported in 2023 was 751, corresponding to an EU notification rate of 0.17 per 100,000 population.

While the number of tested equids decreased drastically in 2023, there has been an overall increase in the number of tested birds since 2020, which intensified in 2023 thanks to the contribution of surveillance data from the Netherlands, reflecting a strengthening of the surveillance system in place.

More detailed descriptions of these statistics are provided in the subsections below.

<table><caption>TABLE 65 Summary of West Nile virus (WNV) infection statistics relating to humans, birds and equids, EU, 2019–2023.</caption><thead><tr><th></th><th>2023</th><th>2022</th><th>2021</th><th>2020</th><th>2019</th><th>Data source</th></tr></thead><tbody><tr><td><strong>Humans</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Total number of confirmed and probable cases</td><td>751</td><td>1140</td><td>158</td><td>333</td><td>443</td><td>ECDC</td></tr><tr><td>Total number of confirmed and probable cases/100,000 population (notification rates)</td><td>0.17</td><td>0.26</td><td>0.04</td><td>0.08</td><td>0.09</td><td>ECDC</td></tr><tr><td>Number of reporting MSs<sup>a</sup></td><td>27</td><td>27</td><td>26</td><td>26</td><td>27</td><td>ECDC</td></tr><tr><td>Infection acquired in the EU</td><td>725</td><td>1129</td><td>153<sup>b</sup></td><td>331</td><td>435</td><td>ECDC</td></tr><tr><td>Infection acquired outside the EU</td><td>13</td><td>8</td><td>5</td><td>2</td><td>5</td><td>ECDC</td></tr><tr><td>Unknown travel status or unknown country of infection</td><td>13</td><td>3</td><td>0</td><td>0</td><td>3</td><td>ECDC</td></tr></tbody></table>

(Continues)

<footnote n="53">⁵³EU Animal Disease Information System (ADIS). More information is available at: https://food.ec.europa.eu/animals/animal-diseases/animal-disease-information-system-adis_en.</footnote>
<table><caption>TABLE 65 (Continued)</caption><thead><tr><th></th><th>2023</th><th>2022</th><th>2021</th><th>2020</th><th>2019</th><th>Data source</th></tr></thead><tbody><tr><td><strong>Animals</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td><strong>Birds</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Number of animals tested<sup>c</sup></td><td>32,086</td><td>18,882</td><td>19,640</td><td>11,141</td><td>14,932</td><td>EFSA</td></tr><tr><td>Number of positive animals by PCR-based methods</td><td>320</td><td>431</td><td>146</td><td>165</td><td>104</td><td>EFSA</td></tr><tr><td>Number of MSs reporting surveillance/monitoring data to EFSA</td><td>15</td><td>14</td><td>13</td><td>11</td><td>13</td><td>EFSA</td></tr><tr><td>Number of outbreaks notified to ADIS</td><td>266</td><td>266</td><td>8</td><td>2</td><td>53</td><td>ADIS</td></tr><tr><td>Number of MSs notifying outbreaks to ADIS</td><td>8</td><td>5</td><td>2</td><td>1</td><td>2</td><td>ADIS</td></tr><tr><td><strong>Equids</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Number of animals tested</td><td>1829</td><td>4336</td><td>6114</td><td>6749</td><td>5563</td><td>EFSA</td></tr><tr><td>Number of positive animals by PCR<sup>d</sup>-based methods</td><td>0</td><td>0</td><td>1</td><td>1</td><td>4</td><td>EFSA</td></tr><tr><td>Number of animals positive for IgM by ELISA</td><td>182</td><td>166</td><td>47</td><td>209</td><td>74</td><td>EFSA</td></tr><tr><td>Number of MSs reporting surveillance/monitoring data to EFSA</td><td>12</td><td>13</td><td>14</td><td>14</td><td>14</td><td>EFSA</td></tr><tr><td>Number of outbreaks notified to ADIS</td><td>159</td><td>101</td><td>44</td><td>190</td><td>99</td><td>ADIS</td></tr><tr><td>Number of MSs notifying outbreaks to ADIS</td><td>7</td><td>9</td><td>7</td><td>8</td><td>8</td><td>ADIS</td></tr></tbody></table>

Abbreviations: ADIS, Animal Disease Information System; ECDC, European Centre for Disease Prevention and Control; EFSA, European Food Safety Authority; ELISA, enzyme-linked immunosorbent assay; MSs, Member States; PCR, polymerase chain reaction.

<sup>a</sup>Data from the United Kingdom were taken into account for 2017–2019, because the United Kingdom was an EU MS, but it became a third country on 1 February 2020.

<sup>b</sup>One case reported from the EU was later found to have originated in Mayotte.

<sup>c</sup>Samples tested using an unspecified analytical method are not included. The number of animals tested corresponds to the number of samples tested, irrespective of the analyses carried out by each Member State as part of its surveillance activities. The number of positive cases corresponds solely to positive cases reported specifically for a given method (PCR-based methods, IgM ELISA).

<sup>d</sup>PCR: Polymerase Chain Reaction.

### 5.3.2 | West Nile virus infections in humans

Among all reported confirmed and probable WNV infections, 725 (96.5%) were acquired in the EU (Table 65), 13 cases (1.7%) were acquired outside the EU and in 13 cases (1.7%), the travel status or country of infection was unknown (Table 65).

Among the 725 cases acquired within the EU, 713 were locally acquired, i.e. within the reporting MS (Table 66) and 12 were imported from another EU country, namely from France, Germany, Hungary, Italy and Slovenia. The EU notification rate for locally acquired cases decreased by 37.2% compared with 2022 (Table 3).

Eight EU MSs (Cyprus, France, Germany, Greece, Hungary, Italy, Romania and Spain) reported at least one locally acquired confirmed or probable human case of WNV infection in 2023. Most of the locally acquired infections were reported by Italy and Greece, accounting respectively for 47.8% and 22.7% of the total number of probable/confirmed cases acquired locally in the EU.

<table><caption>TABLE 66 Locally acquired human West Nile virus (WNV) infection cases (confirmed and probable) 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="3">2023</th><th colspan="6">2022</th><th colspan="6">2021</th><th colspan="6">2020</th><th colspan="6">2019</th></tr><tr><th rowspan="2">National coverage<sup>a</sup></th><th rowspan="2">Data format<sup>a</sup></th><th rowspan="2">Confirmed cases</th><th colspan="2">Total cases and rate</th><th colspan="2">Total cases and rate</th><th colspan="2">Total cases and rate</th><th colspan="2">Total cases and rate</th><th colspan="2">Total cases and rate</th><th colspan="2">Total cases and rate</th><th colspan="2">Total cases and rate</th><th colspan="2">Total cases and rate</th><th colspan="2">Total 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><th>Cases</th><th>Rate</th><th>Cases</th><th>Rate</th><th>Cases</th><th>Rate</th><th>Cases</th><th>Rate</th><th>Cases</th><th>Rate</th></tr></thead><tbody><tr><td>Austria</td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>6</td><td>0.07</td><td>3</td><td>0.03</td><td>0</td><td>0</td><td>0</td><td>0</td><td>4</td><td>0.05</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Belgium</td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>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>Bulgaria</td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>1</td><td>0.01</td><td>0</td><td>0</td><td>0</td><td>1</td><td>0.01</td><td>5</td><td>0.07</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Croatia</td><td>Y</td><td>A</td><td>0</td><td>0</td><td>0</td><td>5</td><td>0.13</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Cyprus</td><td>Y</td><td>C</td><td>5</td><td>5</td><td>0.54</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>23</td><td>2.6</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td></tr></tbody></table>
<table><caption>TABLE 66 (Continued)</caption><thead><tr><th rowspan="3">Country</th><th colspan="3">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 rowspan="2">Confirmed cases</th><th colspan="2">Total cases and rate</th><th colspan="2">Total cases and rate</th><th colspan="2">Total cases and rate</th><th colspan="2">Total cases and rate</th><th colspan="2">Total 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><th>Cases</th><th>Rate</th></tr></thead><tbody><tr><td>Czechia</td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>1</td><td>0.01</td><td></td></tr><tr><td>Denmark</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></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>0</td><td>0</td><td>0</td><td></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><td>0</td><td></td></tr><tr><td>France</td><td>Y</td><td>C</td><td>33</td><td>43</td><td>0.06</td><td>6</td><td>0.01</td><td>1</td><td>&lt;0.01</td><td>0</td><td>0</td><td>2</td></tr><tr><td>Germany</td><td>Y</td><td>C</td><td>7</td><td>7</td><td>0.01</td><td>17</td><td>0.02</td><td>4</td><td>&lt;0.01</td><td>22</td><td>0.03</td><td>5</td></tr><tr><td>Greece</td><td>Y</td><td>C</td><td>99</td><td>162</td><td>1.6</td><td>286</td><td>2.7</td><td>59</td><td>0.55</td><td>144</td><td>1.3</td><td>227</td></tr><tr><td>Hungary</td><td>Y</td><td>C</td><td>22</td><td>30</td><td>0.31</td><td>14</td><td>0.14</td><td>7</td><td>0.07</td><td>3</td><td>0.03</td><td>36</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</td><td>Y</td><td>C</td><td>341</td><td>341</td><td>0.58</td><td>723</td><td>1.2</td><td>65</td><td>0.11</td><td>69</td><td>0.12</td><td>54</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>0</td><td>0</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</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>8</td><td>0.05</td><td>0</td></tr><tr><td>Poland</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>Portugal</td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Romania</td><td>Y</td><td>C</td><td>83</td><td>104</td><td>0.55</td><td>53</td><td>0.28</td><td>7</td><td>0.04</td><td>6</td><td>0.03</td><td>67</td></tr><tr><td>Slovakia</td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>1</td><td>0.02</td><td>0</td><td>0</td><td>0</td><td>0</td><td>1</td></tr><tr><td>Slovenia</td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Spain</td><td>Y</td><td>C</td><td>15</td><td>21</td><td>0.04</td><td>4</td><td>0.01</td><td>6</td><td>0.01</td><td>77</td><td>0.16</td><td>0</td></tr><tr><td>Sweden</td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>EU Total 27</td><td>–</td><td>–</td><td>605</td><td>713</td><td>0.16</td><td>1116</td><td>0.25</td><td>152</td><td>0.03</td><td>330</td><td>0.07</td><td>425</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>0</td><td>0</td></tr><tr><td>EU Total</td><td>–</td><td>–</td><td>605</td><td>713</td><td>0.16</td><td>1116</td><td>0.25</td><td>152</td><td>0.03</td><td>330</td><td>0.07</td><td>425</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</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>Liechtenstein</td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>1</td><td>0.01</td><td>1</td></tr><tr><td>Switzerland<sup>b,c</sup></td><td>Y</td><td>C</td><td>1</td><td>1</td><td>0.01</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td></tr></tbody></table>

Abbreviation: –, Data not reported.

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

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

<footnote><sup>c</sup>Switzerland communicated that the cases reported in 2019, 2020 and 2023 were not locally acquired.</footnote>
<figure><img src="image_146.png" /><figcaption>**FIGURE 28** Geographical distribution of locally acquired West Nile virus infections among humans (NUTS 3 level<fnref n="54" />) and outbreaks notified to ADIS among equids and birds (X, Y coordinates) across the EU, 2023 transmission season. EU MSs and the United Kingdom (Northern Ireland) were represented with a blue label, the EFTA/EEA countries were represented with a grey label, and all the candidate countries were represented with an orange label. The designation of Kosovo is without prejudice to positions on status, and is in line with UNSCR 1244/1999 and the ICJ Opinion on the Kosovo declaration of independence.</figcaption></figure>

### 5.3.3 | West Nile virus infections in animals

In 2023, 18 EU MSs and Switzerland submitted WNV monitoring and surveillance data from birds and/or equids to EFSA. Belgium and Poland did not submit WNV data to either ADIS or EFSA in 2022.

**Figure 28** displays the geographical distribution of outbreaks in animals (ADIS data) together with the geographical distribution of locally acquired West Nile virus infections among humans.

In birds, 15 MSs reported a total of 32,086 analysed samples as part of their surveillance and monitoring activities (Table 65). Italy and the Netherlands submitted 50.7% and 31.5% of these data, respectively, while a total of 320 infected birds were reported to EFSA by Austria, Bulgaria, France, Germany, Greece, Hungary, Italy and Spain. WNV infections occurred in crows, doves, goshawks, jays, magpies, owls, passerines, pheasants, pigeons and starlings. The same MSs that reported infected birds also notified avian outbreaks to ADIS. Italy notified the highest numbers of outbreaks in birds, accounting for 79.7% of the total number of avian outbreaks reported in 2023. Switzerland, a non-EU country, reported 15 analyses with no PCR-positive animals to EFSA.

In equids, 12 MSs reported a total of 1829 analysed samples to EFSA as part of their surveillance and monitoring activities (Table 65). Seven MSs reported a total of 182 equid cases that were confirmed by IgM ELISA. France reported 49 IgM ELISA positive animals, accounting for 26.9% of the total number of WNV-positive animals reported to EFSA. One non-EU country, Switzerland, reported 13 analyses with no PCR-confirmed positives. Seven MSs (Austria, France, Germany, Hungary, Italy, Portugal and Spain) reported a total of 159 equid outbreaks to ADIS. The highest numbers of outbreaks were reported by France and Spain, accounting for 30.8% and 23.9% of the total number of outbreaks, respectively. Moreover, Austria and Denmark reported a total of 11 tested domestic ruminant and wild ungulate samples and 144 bat samples to EFSA, as part of their surveillance and monitoring activities. Austria reported a PCR-positive alpaca to EFSA. No bats were found to be infected by West Nile virus.

See dashboard referenced at the start of the chapter.

<footnote n="54">⁵⁴The NUTS (Nomenclature of territorial units for statistics) is a hierarchical system divided into three levels. NUTS 1: major socio-economic regions, NUTS 2: basic regions for the application of regional policies, NUTS 3: small regions for specific diagnoses. (https://ec.europa.eu/eurostat/web/gisco/geodata/reference-data/administrative-units-statistical-units/nuts).</footnote>
### 5.3.4 | Joint analysis of seasonality

WNV is endemic in several EU Member States and both animal and human cases of WNV infections are reported every year (Figure 29). Infections in Europe occur seasonally, with most cases being reported between July and September. During the period 2019–2023, one unusually intense transmission season was documented in 2022. In 2023, the EU notification rate of reported cases of locally acquired WNV human infections (N total = 713; Table 66; Figure 29) decreased by 37.2% compared with 2022.

In 2023, the WNV transmission season among animals started earlier than in years with lower notification rates. WNV outbreaks in animals (N total = 392; Figure 30) were higher than the number reported in 2022. The WNV outbreak detection trend in birds and equids was similar to that observed in 2022. The first multiple animal outbreaks were reported within Europe in June, with outbreaks peaking, as in previous years, in September (156 outbreaks, Figure 30). Consistently with previous years, the number of reported human infections in 2023 peaked in August, preceding the peak in the notification of animal outbreaks (Figure 30).

<figure><img src="image_147.png" /><figcaption>**FIGURE 29** Reported locally acquired human cases of West Nile virus infection in EU MSs, by month, 2014–2023. Source: Austria, Belgium, Bulgaria, Cyprus, Czechia, Estonia, Finland, France, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, the Netherlands, Poland, Romania, Slovakia, Slovenia, Spain, Sweden.</figcaption></figure>

<figure><img src="image_148.png" /><figcaption>**FIGURE 30** Reported locally acquired human cases of West Nile virus infection and outbreaks in birds and equids, in the EU, by month, 2019–2023.</figcaption></figure>
## 5.4 | Discussion

WNV circulation is influenced by environmental conditions, such as low precipitation in winter and high spring temperatures (Farooq et al., 2022; Marini et al., 2021), and by factors related to land use (Lu et al., 2024). Climate change has been shown to be one of the drivers of the increased risk of WNV circulation in Europe (Erazo et al., 2024). These conditions can contribute to the density of *Culex* mosquitoes and the movement of reservoir hosts (Fornasiero et al., 2020; Lu et al., 2024; Reisen et al., 2006). Over the past years, the number of EU MSs reporting local WNV transmission has increased (Young et al., 2021).

There is evidence that frequent introductions of West Nile virus lineages 1a and 2 have occurred in the past few decades in Europe (Koch et al., 2024), followed by local spread and evolution. Lineage 2 emerged in different European countries between 2004 and 2012 (Hernández-Triana et al., 2014) and has become the dominant lineage. It has been associated with significant human epidemics (Beck et al., 2020; Hernández-Triana et al., 2014; Pacenti et al., 2020; Papa et al., 2011). Both WNV lineages are currently co-circulating in Europe (Koch et al., 2024).

During the period 2019–2023, an intense level of transmission was documented in 2022 (Pervanidou et al., 2023; Riccardo et al., 2022).

In 2023, the number of reported animal outbreaks was similar to 2022. The majority of EU MSs reported cases in birds and equids to either EFSA or ADIS. Nevertheless, some countries did not submit monitoring and surveillance data this year. There is substantial under-detection/under-reporting of clinically asymptomatic and/or mildly symptomatic WNV infections, for humans as well as animals, which should be considered when reading the data presented. Similarly, most EU countries limit screening of WNV in animals to suspected symptomatic cases. It would be expected that the seasonal peak in animals should precede the one in humans. Indeed, WNV is maintained in nature through a transmission cycle primarily involving mosquitoes and birds. WNV activity in birds and mosquitoes often peaks earlier in the season compared to human cases. Human infections tend to occur later in the season. Moreover, animal surveillance is not uniform across all MSs, which may mask the presence of the virus in certain areas and lead to under-reporting of cases. These limitations highlight the importance of interpreting surveillance data between humans and animals with caution as implemented surveillance systems are not harmonised between MSs.

The observed findings on the occurrence of WNV infection in birds reported by MSs performing an active surveillance as Italy underscore the importance of monitoring birds' infection as an early detection system of the pathogen. The Netherlands carried out, in 2023, an extensive active screening for WNV in birds, with no positive results, indicating that the virus is not circulating in the country. These two examples highlight the importance of continued surveillance and monitoring of bird population to detect WNV circulation.

Although the number of tested equines reported to EFSA in 2023 was the lowest since 2019, the number of positive animals was one of the highest. This suggests an ongoing circulation of the virus and the potential for significant yearly variations in case numbers highlighting the complex epidemiology of WNV across different host species (Beck et al., 2020; Mingione et al., 2023; Valleriani et al., 2024).

The ECDC Technical report 'Surveillance, prevention and control of West Nile virus and Usutu virus infections in the EU/EEA', published in September 2023 (ECDC and EFSA, 2023d), gave an overview of the WNV epidemiological situation in the EU/EEA. It described the laboratory diagnostic, surveillance systems and preventive measures applied to ensure the safety of substances of human origin, as well as pinpointing the gaps that need to be addressed for a better understanding of the changing epidemiology of WNV in Europe.

## 6 | TULAREMIA

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 tularaemia, the following interactive tool is available:

Tularaemia

<figure><img src="image_149.png" /></figure>

STORY MAP

<figure><img src="image_150.png" /></figure>

## 6.1 | Key facts

In 2023, there were 1185 confirmed cases of human tularaemia, corresponding to a European Union notification rate of 0.27 cases per 100,000 population. This was an increase of 89.3% compared with the rate in 2022 (0.14 per 100,000 population).
In 2023, *Francisella tularensis* was detected in three animal categories across three Member States, encompassing a total of five species. The majority of samples tested in the European Union were from hares (N = 145), with 20.7% testing positive. Other species sampled, such as monkeys and squirrels, showed no positive results. However, 32.3% of leporids (N = 31) and 50% of dogs tested (N = 8) were positive.

## 6.2 | Surveillance and monitoring of tularaemia in the EU

### 6.2.1 | Humans

For 2023, 25 EU MSs provided data on tularaemia in humans. There is no surveillance system in place for tularaemia in Denmark and Luxembourg did not report for 2023. Surveillance is mandatory in all reporting MSs and is mostly passive, except in Czechia and Slovakia, where it is active. Surveillance systems are comprehensive with full national coverage in all reporting countries. The EU case definition was used by 23 MSs, while Germany and Italy reported using other case definitions. All countries reported case-based data except Belgium, Bulgaria and Croatia, which reported aggregated data.

### 6.2.2 | Animals

Monitoring data for *F. tularensis* in animals is voluntarily submitted to EFSA by EU MSs and non-MS countries. For 2023, data were provided by three EU MSs – Austria, Finland and Sweden – along with one non-MS country, Switzerland. Surveillance was mostly passive.

## 6.3 | Results

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

Table 67 summarises EU-level statistics on tularaemia in humans and in major animal species, respectively, for 2019–2023. More detailed descriptions of these statistics are provided in the subsections below.

<table><caption>TABLE 67 Summary of *Francisella tularensis* statistics relating to humans and the 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>1185</td><td>624</td><td>881</td><td>693</td><td>1321</td><td>ECDC</td></tr><tr><td>Total number of confirmed cases/100,000 population (notification rate)</td><td>0.27</td><td>0.14</td><td>0.20</td><td>0.16</td><td>0.26</td><td>ECDC</td></tr><tr><td>Number of reporting MSs</td><td>25</td><td>26</td><td>26</td><td>26</td><td>27</td><td>ECDC</td></tr><tr><td>Infection acquired in the EU</td><td>1022</td><td>480</td><td>722</td><td>514</td><td>1204</td><td>ECDC</td></tr><tr><td>Infection acquired outside the EU</td><td>7</td><td>1</td><td>2</td><td>2</td><td>3</td><td>ECDC</td></tr><tr><td>Unknown travel status or unknown country of infection</td><td>156</td><td>143</td><td>157</td><td>177</td><td>114</td><td>ECDC</td></tr><tr><td>Number of food-borne outbreak-related cases</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>EFSA</td></tr><tr><td>Total number of food-borne outbreaks</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>EFSA</td></tr><tr><td colspan="7"><strong>Animals<sup>a</sup></strong></td></tr><tr><td colspan="7"><strong>Hares</strong></td></tr><tr><td>Number of sampled animals</td><td>145</td><td>363</td><td>317</td><td>222</td><td>211</td><td>EFSA</td></tr><tr><td>Number of positive animals</td><td>30</td><td>36</td><td>70</td><td>81</td><td>67</td><td>EFSA</td></tr><tr><td>% of positive animals</td><td>20.7</td><td>9.9</td><td>22.1</td><td>36.5</td><td>31.8</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>2</td><td>3</td><td>3</td><td>3</td><td>2</td><td>EFSA</td></tr><tr><td colspan="7"><strong>Animals other than hares</strong></td></tr><tr><td>Number of sampled animals</td><td>43</td><td>107</td><td>18</td><td>5</td><td>152</td><td>EFSA</td></tr><tr><td>Number of positive animals</td><td>14</td><td>8</td><td>5</td><td>1</td><td>8</td><td>EFSA</td></tr><tr><td>% of positive animals</td><td>32.6</td><td>7.5</td><td>27.8</td><td>20.0</td><td>5.3</td><td>EFSA</td></tr><tr><td>Number of reporting MSs</td><td>2</td><td>3</td><td>3</td><td>1</td><td>1</td><td>EFSA</td></tr></tbody></table>

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

<footnote>ªThe number of sampled animals was obtained by totalling all animal-level results, sampling stages (natural habitat, unspecified, veterinary activities, veterinary clinics and zoo), sampling strategies (convenience sampling, selective sampling and suspect sampling) and samplers (industry sampling, not applicable and official sampling).</footnote>
### 6.3.2 | Tularaemia in humans

For 2023, 25 EU MSs reported a total of 1185 confirmed cases of tularaemia, with a notification rate of 0.27 cases per 100,000 population. This was an increase of 89.3% compared with the rate in 2022 (0.14 per 100,000 population). Similarly to 2022, about 78.9% of cases were reported by Finland, France, Germany, and Sweden, while six MSs (Bulgaria, Cyprus, Greece, Latvia, Malta and Romania) reported zero cases. In 2023, Sweden had the highest notification rate with 6.2 per 100,000 population, followed by Finland, Austria and Hungary, with 1.9, 0.58 and 0.56 per 100,000 population, respectively (Table 68). A total of 1022 tularaemia cases (86.2%) were reported as having been acquired in the EU, which was an increase compared with the 2020–2022 period (range from 74.2% to 82.0%) and a decrease compared to 2019 (91.1%). Seven cases (0.59%) were acquired outside the EU, and 13.2% (156/1185) were reported as having an unknown travel status or unknown country of infection (Table 67).

A total of 28 imported cases with a known place of infection were registered in nine MSs (Austria, Germany, Hungary, Ireland, Lithuania, the Netherlands, Poland, Portugal and Sweden) and for 20 of those cases, the probable country of infection was within the EU.

Tularaemia cases mainly occurred from July to November, but cases were observed all throughout the year. In 2023, infections peaked in the summer months, in line with the seasonal pattern (Figure 31).

<table><caption>TABLE 68 Reported confirmed human cases of tularaemia and notification rates per 100,000 population in EU MSs and non-MS countries, by country and by 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>53</td><td>0.58</td><td>35</td><td>0.39</td><td>58</td><td>0.65</td><td>33</td><td>0.37</td><td>20</td><td>0.23</td></tr><tr><td>Belgium</td><td>Y</td><td>A</td><td>13</td><td>0.11</td><td>6</td><td>0.05</td><td>9</td><td>0.08</td><td>1</td><td>0.01</td><td>4</td><td>0.03</td></tr><tr><td>Bulgaria</td><td>Y</td><td>A</td><td>0</td><td>0</td><td>1</td><td>0.01</td><td>0</td><td>0</td><td>2</td><td>0.03</td><td>1</td><td>0.01</td></tr><tr><td>Croatia</td><td>Y</td><td>A</td><td>9</td><td>0.23</td><td>1</td><td>0.03</td><td>0</td><td>0</td><td>0</td><td>0</td><td>1</td><td>0.02</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><td>0</td><td>0</td></tr><tr><td>Czechia</td><td>Y</td><td>C</td><td>50</td><td>0.46</td><td>46</td><td>0.44</td><td>50</td><td>0.48</td><td>67</td><td>0.63</td><td>102</td><td>0.96</td></tr><tr><td>Denmark<sup>b</sup></td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td></tr><tr><td>Estonia</td><td>Y</td><td>C</td><td>4</td><td>0.29</td><td>3</td><td>0.23</td><td>1</td><td>0.08</td><td>1</td><td>0.08</td><td>2</td><td>0.15</td></tr><tr><td>Finland</td><td>Y</td><td>C</td><td>103</td><td>1.9</td><td>93</td><td>1.7</td><td>86</td><td>1.6</td><td>143</td><td>2.6</td><td>48</td><td>0.87</td></tr><tr><td>France</td><td>Y</td><td>C</td><td>78</td><td>0.11</td><td>67</td><td>0.10</td><td>146</td><td>0.22</td><td>82</td><td>0.12</td><td>85</td><td>0.13</td></tr><tr><td>Germany</td><td>Y</td><td>C</td><td>103</td><td>0.12</td><td>68</td><td>0.08</td><td>113</td><td>0.14</td><td>59</td><td>0.07</td><td>70</td><td>0.08</td></tr><tr><td>Greece</td><td>Y</td><td>C</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Hungary</td><td>Y</td><td>C</td><td>54</td><td>0.56</td><td>9</td><td>0.09</td><td>7</td><td>0.07</td><td>20</td><td>0.20</td><td>22</td><td>0.23</td></tr><tr><td>Ireland</td><td>Y</td><td>C</td><td>1</td><td>0.02</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Italy</td><td>Y</td><td>C</td><td>1</td><td>&lt;0.01</td><td>4</td><td>0.01</td><td>3</td><td>0.01</td><td>0</td><td>0</td><td>1</td><td>&lt;0.01</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>0</td><td>0</td><td>2</td><td>0.10</td></tr><tr><td>Lithuania</td><td>Y</td><td>C</td><td>13</td><td>0.45</td><td>15</td><td>0.53</td><td>7</td><td>0.25</td><td>2</td><td>0.07</td><td>4</td><td>0.14</td></tr><tr><td>Luxembourg</td><td>Y</td><td>C</td><td>—</td><td>—</td><td>0</td><td>0</td><td>3</td><td>0.47</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</td><td>Y</td><td>C</td><td>5</td><td>0.03</td><td>1</td><td>0.01</td><td>5</td><td>0.03</td><td>1</td><td>0.01</td><td>3</td><td>0.02</td></tr><tr><td>Poland</td><td>Y</td><td>C</td><td>30</td><td>0.08</td><td>33</td><td>0.09</td><td>43</td><td>0.11</td><td>5</td><td>0.01</td><td>21</td><td>0.06</td></tr><tr><td>Portugal</td><td>Y</td><td>C</td><td>1</td><td>0.01</td><td>0</td><td>0</td><td>0</td><td>0</td><td>1</td><td>0.01</td><td>1</td><td>0.01</td></tr><tr><td>Romania</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>Slovakia</td><td>Y</td><td>C</td><td>5</td><td>0.09</td><td>4</td><td>0.07</td><td>0</td><td>0</td><td>12</td><td>0.22</td><td>20</td><td>0.37</td></tr><tr><td>Slovenia</td><td>Y</td><td>C</td><td>8</td><td>0.38</td><td>12</td><td>0.57</td><td>54</td><td>2.6</td><td>1</td><td>0.05</td><td>7</td><td>0.34</td></tr><tr><td>Spain</td><td>Y</td><td>C</td><td>3</td><td>0.01</td><td>6</td><td>0.01</td><td>4</td><td>0.01</td><td>16</td><td>0.03</td><td>90</td><td>0.19</td></tr><tr><td>Sweden</td><td>Y</td><td>C</td><td>651</td><td>6.2</td><td>220</td><td>2.1</td><td>292</td><td>2.8</td><td>247</td><td>2.4</td><td>817</td><td>8.0</td></tr><tr><td><strong>EU Total 27</strong></td><td></td><td></td><td><strong>1185</strong></td><td><strong>0.27</strong></td><td><strong>624</strong></td><td><strong>0.14</strong></td><td><strong>881</strong></td><td><strong>0.20</strong></td><td><strong>693</strong></td><td><strong>0.16</strong></td><td><strong>1321</strong></td><td><strong>0.30</strong></td></tr><tr><td>United Kingdom</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>—</td><td>0</td><td>0</td><td>0</td></tr><tr><td><strong>EU Total</strong></td><td></td><td></td><td><strong>1185</strong></td><td><strong>0.27</strong></td><td><strong>624</strong></td><td><strong>0.14</strong></td><td><strong>881</strong></td><td><strong>0.20</strong></td><td><strong>693</strong></td><td><strong>0.16</strong></td><td><strong>1321</strong></td><td><strong>0.26</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></tbody></table>
<table><caption>**TABLE 68** (Continued)</caption><thead><tr><th rowspan="3">Country</th><th colspan="2">2023</th><th colspan="2">2022</th><th colspan="2">2021</th><th colspan="2">2020</th><th colspan="2">2019</th></tr><tr><th rowspan="2">National coverage<sup>a</sup></th><th rowspan="2">Data format<sup>a</sup></th><th colspan="2">Confirmed cases and rate</th><th colspan="2">Confirmed cases and rate</th><th colspan="2">Confirmed cases and rate</th><th colspan="2">Confirmed cases and rate</th></tr><tr><th>Cases</th><th>Rate</th><th>Cases</th><th>Rate</th><th>Cases</th><th>Rate</th><th>Cases</th><th>Rate</th></tr></thead><tbody><tr><td>Norway</td><td>Y</td><td>C</td><td>149</td><td>2.7</td><td>58</td><td>1.1</td><td>95</td><td>1.8</td><td>99</td><td>1.8</td><td>183</td><td>3.4</td></tr><tr><td>Liechtenstein</td><td>Y</td><td>C</td><td>1</td><td>2.5</td><td>1</td><td>2.5</td><td>2<sup>c</sup></td><td>5.1</td><td>131</td><td>1.5</td><td>153</td><td>1.8</td></tr><tr><td>Switzerland<sup>d</sup></td><td>Y</td><td>C</td><td>109</td><td>1.2</td><td>119</td><td>1.4</td><td>227</td><td>2.6</td><td></td><td></td><td></td><td></td></tr></tbody></table>

Abbreviations: –, Data not reported.

<figure><img src="image_151.png" /><figcaption>**FIGURE 31** Number of confirmed human cases of tularaemia in the EU, by month and year, 2014–2023. Source: Austria, Cyprus, Czechia, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Latvia, Malta, Poland, Romania, Slovakia, Slovakia, Spain, Sweden.</figcaption></figure>

### 6.3.3 | Tularaemia in animals

For 2023, overall, three EU MSs (Austria, Finland and Sweden) reported 30 hares, 10 leporids and 4 dogs positive for tularaemia, while Switzerland (non-EU MS) reported three positive hares. The number of samples and number of animal species tested were lower than in 2022, data are provided on the EFSA Knowledge Junction at Zenodo here.

### 6.4 | Discussion

Tularaemia is widely distributed throughout most of Europe and is endemic in Scandinavian countries (Hennebique et al., 2019; Hestvik et al., 2015; Yeni et al., 2021). In the EU, for the years 2019–2022, Sweden and Finland reported notification rates ranging from 0.87 to 8.0 cases per 100,000 population. In the course of the same period, several human cases occurred in Austria, Czechia, France and Germany, while very few cases (up to 0.1 cases per 100,000 inhabitants) were recorded in Belgium, Bulgaria, Croatia, Italy, Latvia, the Netherlands and Portugal. From 2019 to 2022, no cases were reported from Cyprus, Greece, Ireland, Malta or Romania.

In 2023, the number of human tularaemia cases increased compared with 2022; Finland, France, Germany and Sweden accounted for the majority of cases. About 55.0% of cases were reported by Sweden.

Early disease detection and surveillance systems are crucial for preventive measures and to promptly intercept a resurgence of the disease related to risk factors such as environmental alterations, intensification of exposure and contaminated sources of infection.

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

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

<footnote><sup>c</sup>Liechtenstein communicated that one case was notified in 2021.</footnote>

<footnote><sup>d</sup>Switzerland provided data directly to EFSA. The human data for Switzerland include data from Liechtenstein for the years 2019–2020.</footnote>
Wildlife continues to play a role in maintaining *F. tularensis* in the ecological cycle, and also in the occurrence of human cases. *Francisella* spp. are present in wild animals (such as hares) and in vectors (e.g. ticks and mosquitoes), which can be sources of infections for humans (Maurin & Gyuranecz, 2016; WHO, 2007).

The circulation of *F. tularensis* among wild animals has been reported in numerous countries across north-central Europe, where the pathogen is considered endemic (Faber et al., 2018; Hestvik et al., 2015; Seiwald et al., 2020), as well as in Spain (Mínguez-González et al., 2021). Over the past 5 years, data from reporting Member States showed an increasing trend in hare testing (from 211 to 363 samples) until 2022. However, in 2023, testing decreased despite an increase in human cases, with 20.7% positive hares. Positive cases were also reported in leporids (32.3%) and dogs (50.0%). This finding is notable, as dogs, due to their close contact with humans, may share similar exposure risks to *F. tularensis* (Kwit et al., 2020).

It is important to recognise that passive tularaemia surveillance does not provide a comprehensive overview of the disease in entire animal populations. For instance, the positivity rate reported in dogs in 2022 and 2023 may not accurately reflect the prevalence of the disease in this population.

Notably, risks of exposure and/or new outbreaks in humans are often preceded by the appearance of the disease in animals, particularly wildlife such as hares, which serve as reliable indicators of *F. tularensis* activity. Thus, monitoring wildlife is essential. Due to the complex nature of tularaemia, effective control requires strong cooperation between veterinary and human health sectors. Coordinated epidemiological, laboratory and clinical investigations are crucial for early detection of tularaemia cases and to prevent further human exposure. Timely communication between these sectors is key, as disease outbreaks in one often serve as a warning of pathogen circulation in the other. Human cases, for instance, can signal the presence of *F. tularensis* in wild animals or the environment.

# 7 | OTHER ZOONOSES AND ZOONOTIC AGENTS

The summary data which make up this chapter are published as supporting information for this report on the EFSA Knowledge Junction at Zenodo here.

In 2023, data on *Bacillus*, *Chlamydia*, *Clostridium*, *Klebsiella*, *Erysipelothrix*, non-pathogenic *Escherichia coli*, *Proteus*, *Staphylococcus*, *Streptococcus*, *Vibrio*, caliciviruses, flaviviruses other than West Nile virus, hepatitis virus, *Cysticercus*, *Leishmania*, *Leptospira* and *Sarcocystis* were reported to EFSA.

## 7.1 | *Bacillus* spp.

Italy and Luxembourg submitted data on *Bacillus cereus* in various foods collected at retail establishments, canteens or workplace catering establishments, mobile food retailers, collective catering establishments (restaurant or cafe or pub or bar or hotel or catering service), schools or kindergartens, and from manufacturing plants. Of the 4852 sampling units, only 60 (1.2%) were positive. The contaminated food categories were primarily 'other processed food products and prepared dishes', 'ready-to-eat salads' and 'soups'.

Greece reported data on *B. anthracis* in 15 animals, including bovine animals, goats, sheep and pigs. One bovine animal and one goat tested positive.

## 7.2 | Caliciviruses (including norovirus)

Six MSs (Bulgaria, Croatia, France, Portugal, Romania and Slovenia) reported data on caliciviruses, testing a total of 24 batches and 304 individual sampling units, from fish, fruits, spices and herbs, and vegetables. No positive samples were detected.

## 7.3 | *Chlamydia* spp.

Two MSs (Austria and Denmark) and one non-MS (Republic of North Macedonia) reported data on *Chlamydia* spp. in various animal species. Austria reported 211 (12.4%) positives out of 1695 samples, Denmark reported 44 (59.5%) positives out of 74 samples, and the Republic of North Macedonia reported 13 (22.8%) positives out of 57 samples.

## 7.4 | *Clostridium* spp.

Three MSs (Italy, Lithuania and Romania) and one non-MS (Republic of North Macedonia) provided data on *Clostridium* spp. in foods, testing a total of 295 sampling units. No positive sampling units were detected.

Greece and the Republic of North Macedonia reported data on *Clostridium* spp. from various ruminant species, with a total of 51 samples collected during clinical investigations. Greece detected 29 (65.9%) positives out of 44 animal samples, while the Republic of North Macedonia detected one (14.3%) positive out of seven samples.
Additionally, Romania reported *Clostridium botulinum* neurotoxins in two of three (66.7%) 'meat from pig' sampling units collected during a botulism outbreak investigation at the household level.

## 7.5 | Hepatitis virus

Four MSs (Bulgaria, France, Slovenia and Romania) provided data on hepatitis A virus in fruit (both pre-cut and non-pre-cut), spices and herbs, and leafy vegetables collected from the primary production, manufacturing and distribution (wholesale and retail) levels. None of the 257 sampling units tested were positive.

## 7.6 | Proteus spp.

Greece tested 168 sampling units of milk collected from dairy cows, goats and sheep for *Proteus* spp. during clinical investigations, and found nine positives (5.4%).

## 7.7 | Staphylococcus spp.

Five MSs (Croatia, Germany, Greece, Italy and Spain) reported data on *Staphylococcus* spp. (including reports on *Staphylococcus*, unspecified *Staphylococcus* spp. and on *S. aureus*) in various food matrices (N=6700) and animals (N=8913). Overall, 5.4% of the food sampling units and 10.8% of the animal samples tested positive. The food categories with the highest number of positive results included 'raw milk', 'other processed food products and prepared dishes', 'meat products - ready-to-eat' and 'cheeses fresh, hard, soft and semi-soft' and 'butter'.

## 7.8 | Cysticercus spp.

Eight MSs (Belgium, Finland, Luxembourg, Malta, Slovakia, Slovenia, Spain and Sweden) provided data on *Cysticercus* spp. in various animal species.

* Belgium collected 774,684 bovine carcases from slaughterhouses and found 769 positive samples (0.10%).

* Finland reported no positive samples out of 1,989,652 carcases from bovine animals, pigs or farmed wild boars.

* Luxembourg detected 59 positive bovine carcases (0.23%) out of 26,135 samples.

* Malta reported no positives out of 59,645 bovine animal, pig, sheep and goat samples.

* Slovakia found no positive bovine carcases out of 30,620 samples, no positive pig carcases out of 517,310 samples and 169 positive sheep carcases (0.39%) out of 43,039 samples.

* Slovenia tested 112,994 bovine and 212,577 pig carcases, detecting only two positive bovine samples (< 0.01%).

* Spain reported data on *Cysticercus* spp. in various animal species, with the following results: 805 positive samples (0.03%) out of 2,349,746 bovine animals; 145,270 positive samples (2.5%) out of 5,923,776 sheep; 12,996 positive samples (1.6%) out of 830,300 goats; 3825 positive samples (0.01%) out of 38,431,328 pigs; two positive samples (0.05%) out of 4247 domestic solipeds; 89 positive samples (0.05%) out of 190,118 wild boars; and four positive samples (< 0.01%) out of 230,790 deer. No positives were found in 9004 mouflons and 1 mountain goat.

* Sweden reported no positive samples out of 421,420 bovine and 2,571,350 pig carcases.

## 7.9 | Leishmania

Greece reported data on *Leishmania* from 3669 blood samples of dogs, detecting 605 positive cases (16.5%). The Republic of North Macedonia, a non-MS, collected blood samples from 3901 stray dogs and 71 pet animals, finding 185 positive cases (4.7%) among the strays and eight positive cases (11.3%) among the pets.

## 7.10 | Sarcocystis spp.

Belgium reported data from 774,684 bovine animals collected at the slaughterhouse, with 100 samples (0.01%) testing positive for *Sarcocystis* spp.
## 7.11 | Other

Greece provided data on *Erysipelothrix* spp. in pigs, with none of the five samples collected during a clinical investigation testing positive.

Three MSs (Greece, Malta and Latvia) and one non-MS (Republic of North Macedonia) reported data on *Escherichia coli* and non-pathogenic *E. coli* in various food matrices and animals. Out of 506 food sampling units, six (1.2%) tested positive. Among 555 animal samples, 473 (85.2%) tested positive.

Two MSs (Cyprus and Italy) and one non-MS (Switzerland) provided data to verify the presence of flaviviruses other than West Nile virus in various animal species. Cyprus detected 25 positive cases (19.5%) out of 128 domestic solipeds and 17 positive cases (3.5%) out of 484 birds. Italy tested 348 wild birds and 30 domestic solipeds with no positives detected, while Switzerland reported no positives from 28 domestic solipeds and birds.

Greece reported data on *Klebsiella* spp. in milk from various ruminants (dairy cows, goats, sheep), detecting two positives (1.2%) out of 168 sampling units.

Greece also provided data on *Streptococcus* spp. in milk from bovine animals and small ruminants, detecting 19 positives (11.1%) out of 171 sampling units.

Three MSs (Greece, Netherlands and Portugal) tested for *Vibrio* spp. in 16 single sampling units and 592 batches of 'raw fish' 'live molluscs', 'crustaceans - shrimp' and 'other foods' collected at border control posts and processing plants. *Vibrio cholerae* was detected in 53 batches, and *V. parahaemolyticus* was found in 8 single sampling units and 35 batches. Overall, 74 positive results (12.2%) were detected out of 608 tested sampling units.

Two MSs (Bulgaria and Slovenia) provided data on *Leptospira* in various animal species. Bulgaria reported no positives out of 6981 samples, while Slovenia detected four positives (2.5%) out of 162 samples.

# MICROBIOLOGICAL CONTAMINANTS SUBJECT TO FOOD SAFETY CRITERIA (COMMISSION REGULATION (EC) NO 2073/2005)

This chapter summarises the 2023 data and information provided by reporting countries on microbiological contaminants in food for which food safety criteria (FSC) have been set down in EU legislation (Commission Regulation (EC) No 2073/2005): histamine, staphylococcal enterotoxins and *Cronobacter sakazakii*.

In accordance with the Regulation (EU) 2017/625, competent authorities (CAs) are required to use methods that comply with relevant internationally recognised standards or protocols, including those accepted by the European Committee for Standardization (CEN). This is achieved through the use of EN ISO methods, which are ISO methods recognised by CEN. Therefore, unlike in previous legislation, CAs are no longer permitted to use alternative methods listed in Commission Regulation (EC) No 2073/2005 when conducting official controls to verify the correct implementation of the provisions of this Regulation by food business operators (FBOs).

For the first time in 2022, EFSA applied requirements of Regulation (EU) 2017/625 in the collection of zoonosis data.

## 1 | HISTAMINE

### 1.1 | Histamine data in the context of Commission Regulation (EC) No 2073/2005

Histamine is a thermostable biogenic amine occurring naturally in the human body that plays a role in key physiological functions. However, when ingested in high concentrations through food, histamine can cause health disorders such as scombroid poisoning. Scombroid, which resembles an allergy, remains a relevant concern in seafood safety.

The amino acid histidine is decarboxylated to histamine by bacterial or tissue enzymes.

In histidine rich foods, such as some fish species, high amounts of histamine can be found due to microbial contamination, inadequate conditions during food processing or storage, so its concentration can be used as a parameter of process hygiene and food spoilage/quality.

EU legislation has therefore set maximum limits for histamine in fish and fish products.

Commission Regulation (EC) No 2073/2005 on microbiological criteria for foodstuffs sets FSC for histamine in three categories at the retail level:

* 'Fishery products from fish species associated with a high amount of histidine' (food category 1.26),

* 'Fishery products which have undergone enzyme maturation treatment in brine, manufactured from fish species associated with a high amount of histidine' (food category 1.27) and

* 'Fish sauce produced by fermentation of fishery products' (food category 1.27a).

At the manufacturing level, information is collected to ensure the proper application of good manufacturing practices (GMP) and the maintenance of the cold chain, which are crucial for preventing the development or increase of histamine in fish and fish products.
Histamine data were reported by 14 MSs (Bulgaria, Czechia, Denmark, Estonia, France, Germany, Italy, Latvia, Lithuania, Luxembourg, Romania, Slovakia, Slovenia and Spain) and one non-MS (Albania).

## Fishery products from fish species associated with a high amount of histidine (food category 1.26)

Among 5438 official control samples for histamine in food category 1.26 at the distribution level, 0.99% exceeded 200 mg/kg of histamine, 0.80% had histamine levels between 100 and 200 mg/kg, and 10.8% had detectable levels above the limit of detection, up to 100 mg/kg. Of the total samples, 33.1% originated from EU countries (including Denmark, Italy, Latvia, Lithuania, Norway, Romania, Spain), 18.3% were from non-EU countries (including Colombia, Ecuador, Ghana, Greenland, Japan, Madagascar, Maldives, Mauritius, Morocco, Philippines, Seychelles, Thailand, the United Kingdom, Vietnam), while origin information was unavailable for 48.4%. In total, 43.2%, 33.0%, 12.9% and 0.85% of samples were taken from retail, wholesale, border control posts and Restaurant or Cafe or Pub or Bar or Hotel or Catering service respectively. For 10.1% of the samples, no specific source information was provided.

In terms of product type, 9.4% of samples were from canned fish, 9.2% from raw fish, while 81.3% lacked detailed product information.

At the manufacturing level, 424 official control sampling units were collected from processing plants. Of these, 0.70% had histamine levels above the limit of detection, but less than or equal to 100 mg/kg. Of the total samples, 87.0% were from the EU (Italy), while for 13.0%, origin information was unavailable. Regarding product types, 26.4% of the samples came from canned fish, 5.7% from raw fish and for 67.9%, no product details were reported.

## Fishery products which have undergone enzyme maturation treatment in brine, manufactured from fish species associated with a high amount of histidine (food category 1.27)

For food category 1.27, a total of 1583 official control samples were collected at the distribution level and 129 at the manufacturing level. At the distribution level, 8.2% of samples had a histamine concentration of up to 200 mg/kg, while 0.25% had histamine levels between 200 and 400 mg/kg. Of the total samples, 11.4% originated from EU countries (Denmark, Romania), 10.2% from non-EU countries and for 78.4% of samples, origin information was not provided. In terms of sample collection locations, 48.3%, 28.5% and 16.3% of samples were taken from border control posts, retail and wholesale, respectively. For 6.9% of samples, no specific collection information was available.

At the manufacturing level, all 129 samples tested negative. Of these, 98.4% were of EU origin (Italy), with origin details missing for the remaining 1.6%.

## Fish sauce produced by fermentation of fishery products (food category 1.27a)

For food category 1.27a at the distribution level, 12 official control samples were reported. Of these, 50.0% had a histamine content between the limit of detection and 400 mg/kg, while none exceeded 400 mg/kg. Regarding the origin of the samples, 16.6% were from non-EU countries (Thailand), with no origin information provided for the remaining 83.4%.

The histamine results from the 2023 official food control samples, collected under Commission Regulation (EC) No 2073/2005, are comparable to those of the previous year and do not appear to have been impacted by the implementation of Regulation (EU) 2017/625.

## 1.2 | Other surveillance, monitoring or outbreak investigation data for histamine

MSs also collected and analysed fishery products for surveillance, monitoring or outbreak investigation purposes, outside the scope of Commission Regulation (EC) 2073/2005 on microbiological criteria for foodstuffs.

### Surveillance

A total of 2267 single sampling units and 3176 batches were collected as part of surveillance activities, reported by 10 MSs (Austria, Belgium, Estonia, Greece, Italy, Poland, Portugal, Romania, Slovakia and Spain) and one non-MS (Serbia). This included 936 single sampling units and 227 batches at the distribution level, and 1331 sampling units and 90 batches at the manufacturing level.

At the distribution level, 76.2%, 23.3% and 1.1% of the 936 sampling units were categorised as 1.26, 1.27 and 1.27a, respectively. In category 1.26, 1.5% of the sampling units had histamine levels exceeding 200 mg/kg, while 10.0% of category 1.27a sampling units contained histamine levels over 400 mg/kg. In total, 40.0%, 14.4%, 2.1% and 4.5% of sampling units were taken from retail, border control posts, wholesale and Restaurant or Cafe or Pub or Bar or Hotel or Catering service, respectively, while for 39.0% no specific information was reported. Regarding origin, 30.9% were from EU countries (Austria, Italy, Portugal), 14.7% from non-EU countries (Ecuador, Seychelles, Sri Lanka, South Africa, Morocco), while 54.4% had no origin information available.

All the batches (N=227) taken at border control posts were categorised as 1.26, with 4.0% showing histamine levels above 200 mg/kg. All batches were of non-EU origin (Ecuador, Morocco, Thailand, Türkiye).
*At the manufacturing level*, 1331 samples were taken at processing plants or packing centres. Of these, 84.4% were categorised as category 1.26 and 15.6% as category 1.27. Only 0.89% of category 1.26 samples had histamine levels exceeding 200 mg/kg, and all sampling units in category 1.27 were negative. In terms of origin, 91.1% were from EU countries (Estonia, Italy, Portugal, Poland, Romania) and 4.1% from non-EU countries (the United Kingdom and others), with 4.8% unreported.

All batches (N=90) taken at processing plants were categorised as 1.26, originating from the EU (Greece). Of these, 23.3% had histamine levels above the detection limit but below or equal to 100 mg/kg.

## Monitoring

Two single sampling units were collected as part of *monitoring activities*; reported by Czechia. Both sampling units were taken at retail: one was categorised as 1.26 of non-EU origin (Vietnam), while the other was categorised as 1.27a, with no origin information available.

## Outbreak investigation

Eight sampling units were collected as part of *outbreak investigations*, reported by Romania and Croatia. All sampling units were taken from Restaurant or Cafe or Pub or Bar or Hotel or Catering service and were of EU origin (Croatia, Romania and EU countries). Of the total, 12.5% and 87.5% were categorised in categories 1.26 and 1.27, respectively. All category 1.26 sampling units had a histamine level exceeding 200 mg/kg and all category 1.27 sampling units had a histamine concentration less than or equal to 200 mg/kg.

# 2 | STAPHYLOCOCCAL ENTEROTOXINS

## 2.1 | Staphylococcal enterotoxin data in the context of Commission Regulation (EC) No 2073/2005

Seven MSs (Bulgaria, Greece, Italy, Romania, Slovenia, Slovakia and Spain) reported data on staphylococcal enterotoxins. At the *distribution level*, 2557 official control samples were tested, with five positive results (0.2%) detected by Spain. The positive food category identified was 'hard cheeses made from sheep's milk' collected at both wholesale and retail level. At the *manufacturing level*, 1076 official control samples were tested, with eight positive results (0.7%) detected by Italy and Romania. The food categories with positive results included 'soft and semi-soft cheeses made from cows' milk' and 'unspecified cheeses made from mixed milk from cows, sheep and/or goats' collected at processing plants.

## 2.2 | Other surveillance data for staphylococcal enterotoxins

Twelve MSs reported data on staphylococcal enterotoxins collected outside the scope of Commission Regulation (EC) No 2073/2005. Of the 5316 sampling units tested, 20 (0.38%) were positive. Positive food categories included 'other processed food products and prepared dishes', 'hard, and soft and semi-soft cheeses made from cows' milk', and 'unspecified cheeses made from raw or low heat-treated milk from sheep'. These positive sampling units were predominantly collected at the distribution and manufacturing levels.

# 3 | CRONOBACTER SAKAZAKII

## 3.1 | Cronobacter sakazakii data in the context of Commission Regulation (EC) No 2073/2005

Seven Member States (Cyprus, Czechia, Hungary, Italy, Slovenia, Slovakia and Spain) reported data on *Cronobacter sakazakii* in 'Infant formulae' and 'Foodstuffs intended for special nutritional uses' collected at the *distribution level*. Out of 678 samples tested, none were positive. No samples were collected at the manufacturing level.

## 3.2 | Other surveillance data for Cronobacter sakazakii

Thirteen MSs reported data on *Cronobacter* spp. collected outside the scope of Commission Regulation (EC) No 2073/2005. Sampling units included 'Infant formulae', 'Foodstuffs intended for special nutritional uses' and 'Dairy products, excluding cheeses'. These sampling units were collected from retail, processing plants, wholesale levels or from hospital or medical care facilities for surveillance or monitoring purposes. In total, 1392 single sampling units and 126 batches were tested. Only one sample (0.06%) - a 'dairy product (excluding cheeses) - milk powder and whey powder' collected by Germany at a processing plant - tested positive.
# KEY DEFINITIONS

## Definitions adopted by TESSy (ECDC) for describing surveillance systems

### Legal character of surveillance:

* 'Compulsory' (Co): the surveillance system has a legal basis (at the national administrative level or other) under which reporting of cases of the disease(s) under surveillance is compulsory

* 'Voluntary' (V): the surveillance system is based on a voluntary agreement (at the national level or other) by which reporting of cases of the disease(s) under surveillance is voluntary

* 'Other' (O): any system that does not fall under one of the above descriptions

* 'Unknown': not specified/unknown

### Comprehensiveness of surveillance:

* 'Comprehensive' (Cp): reporting is based on cases occurring within the whole population of the geographical area where the surveillance system is set up (national, regional, etc.),

* 'Sentinel' (Se): reporting is based on a selected group of physicians/hospitals/laboratories, or other institutions' notifications, and/or cases occurring within a selected population defined by age group, gender, exposure or other selection criteria,

* 'Other' (O): reporting is based on a part of the population or group of physicians (or other institutions) which is not specified, for example reporting from laboratories with no selection criteria,

* 'Unknown': not specified/unknown

### National coverage

* Defined as covering the entire population of the country, or a part of it. May be unknown when not specified.

### Origin of human cases

* Domestic/Locally acquired cases are defined as cases declared in the dataset as 'not imported'

* Travel-related cases (or imported cases) are defined as cases declared in the dataset as 'imported'

* Place of infection is defined in the dataset as the probable country of infection

* Cases of infection acquired in the EU (domestic cases + travel in EU)

* Active/Passive (human surveillance):

* 'Active' (A): the surveillance system is based on the public health officials' initiative to contact the physicians, laboratory or hospital staff, or other relevant sources to report data

* 'Passive' (P): the surveillance system relies on the physicians, laboratory or hospital staff, or other relevant sources to take the initiative to report data to the health department

* 'Unknown': not specified/unknown

### Active/Passive (for monitoring of rabies in animals)

* Definitions for Active and passive will be given in accordance with the current regulations

* The following definitions are used to describe data provided to EFSA in the EUOHZ 2023:

* **Surveillance:** This programme type term infers to a careful observation of one or more food or feed businesses, food or feed business operators or their activities (in the context of Regulation (EU) 2017/625). In general, it means a close and continuous observation for the purpose of control. As opposed to monitoring, active control measures are frequently taken when positive cases are detected. This type of programme does not necessarily have a defined target for reducing the occurrence of diseases/contamination.

* **Surveillance, based on Regulation 2073:** This programme type term is used to report the samples collected and analysed in accordance with the Commission Regulation (EC) No 2073/2005 on microbiological criteria. These samples can be taken either to check the compliance with Process hygiene criteria (*Salmonella* in carcases (2.1.3, 2.1.4, 2.1.5)) or with Food Safety criteria (*Salmonella* in meat and meat products (1.4 to 1.20, 1.22; 1.23; 1.28), *Listeria monocytogenes* (1.1, 1.2, 1.3), *Staphylococcus enterotoxins* (1.21), *Cronobacter* (1.24), *Histamine* (1.26; 1.27;1.27a), *STEC* (1.29)).

* **Active rabies surveillance:** This specific rabies programme type term is used for reporting of data on active testing in the context of the monitoring of the efficacy of oral rabies vaccination (ORV) campaigns in wildlife (i.e. in foxes, raccoon dog and/or jackals).

* **Monitoring:** This programme type term infers to a system of collecting, analysing and disseminating data on the occurrence of zoonoses, zoonotic agents and antimicrobial resistance related thereto. As opposed to surveillance, no active control measures are taken when positive cases are detected (Directive 2003/99/EC).

* **Objective sampling:** Objective sampling – planned strategy based on the selection of a random sample, which is statistically representative of the population to be analysed. Each unit, within the framework population, has a specified
probability of being selected. This strategy provides data from which statistical inference can be implemented. That means that the results inferred are comparable. Objective sampling is often the case in monitoring and surveillance schemes as well as in surveys.

## Terms used to describe prevalence or proportion-positive values for EFSA data

In the EUOHZ report a set of standardised terms are used to characterise the proportion of positive sample units or the prevalence of zoonotic agents in animals and foodstuffs:

* Rare: < 0.1%

* Very low: 0.1%-1%

* Low: > 1%-10%

* Moderate: > 10%-20%

* High: > 20%-50%

* Very high: > 50%-70%

* Extremely high: > 70%

* Majority of MSs: 60% (in 2023 this was 17 MSs)

* Most MSs: 75% (in 2023 this was 21 MSs)

## ABBREVIATIONS

<table><tr><td>A</td><td>aggregated data</td></tr><tr><td>ADIS</td><td>Animal Disease Information System</td></tr><tr><td>AE</td><td>alveolar echinococcosis</td></tr><tr><td>AHAW</td><td>Animal Health and Welfare</td></tr><tr><td>AHL</td><td>Animal Health Law</td></tr><tr><td>AMR</td><td>antimicrobial resistance</td></tr><tr><td>ANSES</td><td>French Agency for Food, Environmental and Occupational Health & Safety</td></tr><tr><td>ATLAS</td><td>Surveillance Atlas of Infectious Diseases</td></tr><tr><td>BBLV</td><td>Bokeloh bat lyssavirus</td></tr><tr><td>BIOHAZ</td><td>EFSA Scientific Panel on Biological Hazards</td></tr><tr><td>C</td><td>case-based data</td></tr><tr><td>CA</td><td>competent authority</td></tr><tr><td>CDR</td><td>Commission Delegated Regulation</td></tr><tr><td>CE</td><td>cystic echinococcosis</td></tr><tr><td>CEN</td><td>European Committee for Standardization</td></tr><tr><td>CFU</td><td>colony forming units</td></tr><tr><td>cgMLST</td><td>core genome multi-locus sequence typing</td></tr><tr><td>CI</td><td>confidence interval</td></tr><tr><td>CIR</td><td>Commission Implementing Regulation</td></tr><tr><td>DCF</td><td>EFSA's Data Collection Framework</td></tr><tr><td>DFS</td><td>disease-free status</td></tr><tr><td>EBLV</td><td>European bat lyssavirus</td></tr><tr><td>ECDC</td><td>European Centre for Disease Prevention and Control</td></tr><tr><td>EEA</td><td>European Economic Area</td></tr><tr><td>EFTA</td><td>European Free Trade Association</td></tr><tr><td>ELISA</td><td>enzyme-linked immunosorbent assay</td></tr><tr><td>EU MS</td><td>EU Member State</td></tr><tr><td>EU-FORS</td><td>European Union Foodborne Outbreak Reporting System</td></tr><tr><td>EUOHZ</td><td>The European Union One Health Zoonoses Report</td></tr><tr><td>EURL</td><td>European Reference Laboratory</td></tr><tr><td>EVD</td><td>emerging and vector-borne Diseases</td></tr><tr><td>FAO</td><td>Food and Agricultural Organization</td></tr><tr><td>FBO</td><td>food-borne outbreak</td></tr><tr><td>FBOp</td><td>food business operator</td></tr><tr><td>FBOs</td><td>food-borne outbreaks</td></tr><tr><td>FNAO</td><td>foods of non-animal origin</td></tr><tr><td>FSC</td><td>food safety criteria</td></tr><tr><td>FWD</td><td>Food and Waterborne Diseases and Zoonoses</td></tr><tr><td>GAP</td><td>good agricultural practices</td></tr><tr><td>GF-TADs</td><td>The Global Framework for the Progressive Control of Transboundary Animal Diseases</td></tr><tr><td>GMP</td><td>Good Manufacturing Practices</td></tr><tr><td>HACCP</td><td>hazard analysis and critical control point</td></tr></table>
<table><tr><td>HUS</td><td>haemolytic-uraemic syndrome</td></tr><tr><td>IgG</td><td>immunoglobulin G</td></tr><tr><td>IgM</td><td>immunoglobulin M</td></tr><tr><td>ISO</td><td>International Organization for Standardization</td></tr><tr><td>MS</td><td>Member State</td></tr><tr><td>MSM</td><td>mechanically separated meat</td></tr><tr><td>MSs</td><td>Member States</td></tr><tr><td>MTBC</td><td>Mycobacterium tuberculosis complex</td></tr><tr><td>NCP</td><td>National control programme</td></tr><tr><td>non-RTE</td><td>non-ready-to-eat</td></tr><tr><td>NS</td><td>not significant</td></tr><tr><td>NUTS</td><td>Nomenclature of territorial units for statistics</td></tr><tr><td>ORV</td><td>oral rabies vaccination</td></tr><tr><td>PCR</td><td>polymerase Chain Reaction</td></tr><tr><td>PHC</td><td>process hygiene criteria</td></tr><tr><td>RABV</td><td>Rabies virus</td></tr><tr><td>ROA</td><td>rapid outbreak assessment</td></tr><tr><td>ROC</td><td>receiver operating characteristic</td></tr><tr><td>RTE</td><td>ready-to-eat</td></tr><tr><td>SGE RAB</td><td>Standing Group of Experts on Rabies</td></tr><tr><td>SSI</td><td>Staten Serum Institut</td></tr><tr><td>ST</td><td>sequence types</td></tr><tr><td>STEC</td><td>shiga toxin-producing Escherichia coli</td></tr><tr><td>TB</td><td>tuberculosis</td></tr><tr><td>TESSy</td><td>The European Surveillance System</td></tr><tr><td>UEP</td><td>under eradication programme</td></tr><tr><td>WGS</td><td>whole genome sequencing</td></tr><tr><td>WHO</td><td>World Health Organization</td></tr><tr><td>WNF</td><td>West Nile Fever</td></tr><tr><td>WNND</td><td>West Nile Neuro-Invasive Disease</td></tr><tr><td>WNV</td><td>West Nile Virus</td></tr><tr><td>WOAH</td><td>World Organisation for Animal Health</td></tr><tr><td>ZOE</td><td>Zoonoses under a One health perspective in the EU</td></tr></table>

## COUNTRY CODES

### EU Member States

<table><tr><td>Austria</td><td>AT</td></tr><tr><td>Belgium</td><td>BE</td></tr><tr><td>Bulgaria</td><td>BG</td></tr><tr><td>Croatia</td><td>HR</td></tr><tr><td>Cyprus</td><td>CY</td></tr><tr><td>Czechia</td><td>CZ</td></tr><tr><td>Denmark</td><td>DK</td></tr><tr><td>Estonia</td><td>EE</td></tr><tr><td>Finland</td><td>FI</td></tr><tr><td>France</td><td>FR</td></tr><tr><td>Germany</td><td>DE</td></tr><tr><td>Greece</td><td>GR</td></tr><tr><td>Hungary</td><td>HU</td></tr><tr><td>Ireland</td><td>IE</td></tr><tr><td>Italy</td><td>IT</td></tr><tr><td>Latvia</td><td>LV</td></tr><tr><td>Lithuania</td><td>LT</td></tr><tr><td>Luxembourg</td><td>LU</td></tr><tr><td>Malta</td><td>MT</td></tr><tr><td>Netherlands</td><td>NL</td></tr><tr><td>Poland</td><td>PL</td></tr><tr><td>Portugal</td><td>PT</td></tr><tr><td>Romania</td><td>RO</td></tr><tr><td>Slovakia</td><td>SK</td></tr><tr><td>Slovenia</td><td>SI</td></tr><tr><td>Spain</td><td>ES</td></tr></table>
<table><tr><td>Sweden</td><td>SE</td></tr><tr><td>United Kingdom (Northern Ireland)</td><td>XI</td></tr></table>

## EU non-MS countries

<table><tr><td>Albania</td><td>AL</td></tr><tr><td>Bosnia and Herzegovina</td><td>BA</td></tr><tr><td>Iceland</td><td>IS</td></tr><tr><td>Kosovo<sup>55</sup></td><td>XK</td></tr><tr><td>Liechtenstein</td><td>LI</td></tr><tr><td>Montenegro</td><td>ME</td></tr><tr><td>Norway</td><td>NO</td></tr><tr><td>Republic of North Macedonia</td><td>MK</td></tr><tr><td>Serbia</td><td>RS</td></tr><tr><td>Switzerland</td><td>CH</td></tr><tr><td>Turkey</td><td>TK</td></tr></table>

## ACKNOWLEDGEMENTS

EFSA and the ECDC wish to thank the members of the EFSA Scientific Network for Zoonoses Monitoring Data and of the ECDC Food and Waterborne Diseases and Zoonoses Network, the ECDC Emerging and Vector-borne Diseases Network and the ECDC Tuberculosis Network, who provided the data and reviewed the report; the members of the Scientific Network for Zoonoses Monitoring Data for their endorsement of this scientific report; the EFSA staff members (Frank Boelaert, Giusi Amore, Mirko Rossi, Valentina Rizzi, Anca Stoicescu, Luca Pasinato, Sandra Luisa De Almeida Florentino Correia, Michaela Hempen, Inmaculada J Aznar Asensio), the ECDC staff members (Taina Niskanen, Joana Haussig and Veronica Cristea) and the EFSA and ECDC contractor: Istituto Superiore di Sanita (Gaia Scavia, Ilaria Altieri, Fabrizio Anniballi, Pierfrancesco Barbariol, Antonino Bella, Simone Cacciò, Adriano Casulli, Alessandra Ciervo, Elisabetta Delibato, Maria Grazia Dente, Michele Luca D'Errico, Aurora Garcia Fernandez, Laura Ferroni, Federico Giannoni, Alessandra Ludovisi, Gianluca Marucci, Maria Angeles Gomez Morales, Francesca Iacoponi, Arnold Knijn, Marco Lalle, Claudia Lucarelli, Cinzia Marianelli, Stefano Morabito, Marco Francesco Ortoffì, Flavia Riccardo, Elisabetta Suffredini, Rosangela Tozzoli, Eleonora Ventola and Laura Villa); Istituto Zooprofilattico delle Venezie (Giorgia Angeloni, Lisa Barco, Grazia Manca, Aurora Boscolo, Laura Bortolami, Katia Capello, Giulia Cento, Paola De Benedictis, Laura Gagliazzo, Annie Ishebabi, Elena Lazzaro, Monica Lorenzetto, Marzia Mancin, Claudio Mantovani, Angelo Sardella, Martina Simonato and Marica Toson); Istituto Zooprofilattico Sperimentale dell'Abruzzo e del Molise 'G. Caporale' (Laura Amato, Americo Bonanni, Paolo Calistri, Giuseppe Cerratti, Annamaria Conte, Marta Cresci, Enrico De Albentiis, Fabrizio De Massis, Andrea De Ruvo, Alessio Di Lorenzo, Mauro Ferella, Giuliano Garofolo, Raffaella Lucchini, Diana Palma, Francesco Pomilio, Luigi Possenti, Susanna Tora and Valentina Zenobio); Istituto Zooprofilattico Sperimentale della Lombardia ed. Emilia Romagna B. Ubertini - IZSLER (Maria Beatrice Boniotti, Nadia Vicari, Silvia Bellini, Gabriele Casadei) the French Agency for Food, Environmental and Occupational Health & Safety (Adrien Asséré, Christophe Cordevant, Aurélie Couesnon, Radu Blaga, Florence Cliquet, Corinne Danan, Luca Freddi, Gaëlle Gonzalez, Camille Migné, Claire Ponsart, Dana Pottratz, Emmanuelle Robardet, Elodie Rousset and Isabelle Vallée), for the support provided to this scientific report.

## REQUESTOR

European Commission

## QUESTION NUMBER

EFSA-Q-2021-00764

## AMENDMENT

An editorial correction was carried out that does not materially affect the contents or outcome of this scientific output. In particular, one number was corrected on page 85 and page 90. To avoid confusion, the original version of the output has been removed from the EFSA Journal, but is available on request.

## COPYRIGHT FOR NON-EFSA CONTENT

EFSA may include images or other content for which it does not hold copyright. In such cases, EFSA indicates the copyright holder and users should seek permission to reproduce the content from the original source.

## MAP DISCLAIMER

The designations employed and the presentation of material on any maps included in this scientific output do not imply the expression of any opinion whatsoever on the part of the European Food Safety Authority concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The designation of Kosovo is without prejudice to positions on status, and is in line with UNSCR 1244/1999 and the ICJ Opinion on the Kosovo declaration of independence.

<footnote>55This designation is without prejudice to positions on status, and is in line with UNSCR 1244/1999 and the ICJ Opinion on the Kosovo declaration of independence.</footnote>
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