ECDC NORMAL

SURVEILLANCE REPORT

Salmonellosis
Annual Epidemiological Report for 2021

Key facts
• Salmonellosis is the second most commonly reported gastrointestinal infection in the EU/EEA, and an
important cause of food-borne outbreaks.
• In 2021, 60 494 laboratory-confirmed cases of salmonellosis were reported, out of which 73 were fatal.
• The EU/EEA notification rate for salmonellosis was 16.6 cases per 100 000 population.
• Salmonellosis notification rates in the five years preceding the COVID-19 pandemic have been stable.
After a significant decline in cases in 2020, primarily as a consequence of the pandemic, the case
numbers increased by 14% in 2021.
• The reported case rate was highest in young children (0−4 years) with 93.1 cases per 100 000
population, eleven times higher than in adults (25–64 years).
• Eggs and egg products continue to be the highest risk foods in Salmonella outbreaks, though in 2021,
several of the largest outbreaks were linked to contaminated vegetables, fruits, seeds or products thereof.

Introduction
Enteric infections due to Salmonella are generally referred to by the term ‘salmonellosis’ when they are caused by
Salmonella species other than Salmonella Typhi and Salmonella Paratyphi. Various animals (especially poultry, pigs,
cattle and reptiles) can be reservoirs for Salmonella. Humans generally become infected by eating poorly cooked,
contaminated food. The incubation period and the symptoms depend primarily on the amount of bacteria present
in the food, and the immune status of the infected individual.

Methods
This report is based on data for 2021, retrieved from The European Surveillance System (TESSy) on 9 October
2022. TESSy is a system for the collection, analysis and dissemination of data on communicable diseases.
For a detailed description of the methods used to produce this report, please refer to the ‘Methods’ chapter in the
‘Introduction to the Annual Epidemiological Report’ [1]. An overview of the national surveillance systems is
available online [2].
A subset of the data used for this report is available through ECDC’s online Surveillance Atlas of Infectious Diseases [3].

Suggested citation: European Centre for Disease Prevention and Control. Salmonellosis. In: ECDC. Annual Epidemiological Report
for 2021. Stockholm: ECDC; 2022.

Stockholm, December 2022

© European Centre for Disease Prevention and Control, 2022. Reproduction is authorised, provided the source is acknowledged.
Annual Epidemiological Report for 2021 SURVEILLANCE REPORT

In 2021, 30 EU/EEA countries reported data on salmonellosis. Twenty-six countries reported data using either the
2008, 2012 or 2018 EU case definitions for salmonellosis. Compared with the 2008 and 2012 EU case definitions,
the 2018 EU case definition allows nucleic acid determination for laboratory confirmation, and includes a
requirement for antimicrobial susceptibility testing and reporting of results. Four countries used another case
definition, which was not specified.
Notification of non-typhoidal salmonellosis is mandatory in most of the EU Member States as well as Iceland,
Liechtenstein and Norway. In three Member States (Belgium, France, and the Netherlands), reporting is voluntary.
The surveillance systems for salmonellosis have national coverage in all Member States except in three (France,
the Netherlands and Spain). The population coverage in 2021 is estimated to be 48% in France and 64% in the
Netherlands. The variation in coverage was taken into consideration when calculating the national notification
rates. No information on estimated coverage was provided by Spain, and thus no notification rates were calculated.
During the peak pandemic years 2020 and 2021, Spain did not receive data from all the regions that normally
report cases, and the case numbers are therefore lower than expected. All countries reported case-based data
except Bulgaria, which reported aggregated data. Both reporting formats were included to calculate number of
cases, notification rates, disease trends, and age and gender distributions.
For 2020–2021, no data were reported by the United Kingdom (UK) due to its withdrawal from the EU on 31
January 2020.
Twenty-six EU/EEA countries reported antimicrobial resistance data for Salmonella for 2021. Twenty-five countries
reported phenotypic resistance data – 21 as disk zones or minimum inhibitory concentration (MIC) values, and four
as interpretation with clinical breakpoints. One country reported resistance predicted from whole genome
sequencing (WGS).
In 2021, 15 countries provided WGS data for centralised analysis to support ongoing multi-country outbreak
investigations.

Epidemiology
In 2021, 30 EU/EEA countries reported 61 236 salmonellosis cases, of which 60 494 were classified as laboratory-
confirmed (Table 1). This was an increase of 14% in cases, compared to 2020. The number of cases per 100 000
population was 16.6, which was higher than in 2020 but still lower compared to pre-COVID-19 pandemic levels.
Age-standardised notification rates did not differ substantially from crude rates.
The highest notification rates were reported by Czechia (93.7 cases per 100 000 population) and Slovakia
(81.3), followed by Malta (48.2), Hungary (33.9) and France (28.7) − Table 1, Figure 1. The lowest rates
were reported by Greece and Romania (2.7 cases per 100 000 population) and Bulgaria, Ireland and Portugal
(3.5 cases per 100 000 population).
The hospitalisation status was reported for 31 357 salmonellosis cases in 2021 and of those, 38% had been
hospitalised. The countries reporting the highest proportion of hospitalised cases were Cyprus, Greece and
Lithuania (92%, 84% and 73%, respectively).
Specimen type can also be used as an indicator of severity of the infection. Among 45 105 cases with specimen
type reported, 94% of Salmonella isolates were sampled from faeces, 2% from blood, 2% from urine and the
remaining reported as ‘other’. Out of 38 981 cases with known outcome, 73 were reported to have died,
accounting for a case fatality of 0.19%.
Table 1. Distribution of confirmed salmonellosis cases and rates per 100 000 population, by country
and year, EU/EEA, 2017–2021

2017 2018 2019 2020 2021

Country
Number Rate Number Rate Number Rate Number Rate Number Rate ASR

Austria 1 667 19.0 1 538 17.4 1 866 21.1 817 9.2 993 11.1 11.5

Belgium 2 298 20.2 2 958 26.0 2 527 22.1 1 595 13.8 2 084 18.0 17.7

Bulgaria 796 11.2 586 8.3 594 8.5 187 2.7 241 3.5 3.8

Croatia 1 242 29.9 1 323 32.2 1 308 32.1 786 19.4 593 14.7 15.6

Cyprus 59 6.9 44 5.1 62 7.1 70 7.9 41 4.6 4.4

Czechia 11 473 108.5 10 901 102.7 13 009 122.2 10 516 98.3 10 032 93.7 95.3

Denmark 1 067 18.6 1 168 20.2 1 119 19.3 614 10.5 692 11.8 11.5

2
SURVEILLANCE REPORT Annual Epidemiological Report for 2021

2017 2018 2019 2020 2021

Country
Number Rate Number Rate Number Rate Number Rate Number Rate ASR

Estonia 265 20.1 314 23.8 150 11.3 91 6.8 112 8.4 8.4

Finland 1 535 27.9 1 431 26.0 1 175 21.3 516 9.3 474 8.6 8.8

France 7 993 24.9 8 936 27.8 8 935 27.7 7 071 21.9 9 315 28.7 27.9

Germany 14 051 17.0 13 293 16.1 13 495 16.3 8 664 10.4 8 144 9.8 10.2

Greece 672 6.2 640 6.0 643 6.0 381 3.6 284 2.7 2.8

Hungary 3 922 40.0 4 161 42.6 4 452 45.6 2 964 30.3 3 298 33.9 34.7

Iceland 64 18.9 63 18.1 50 14.0 32 8.8 54 14.6 15.5

Ireland 379 7.9 352 7.3 347 7.1 214 4.3 173 3.5 3.5

Italy 3 347 5.5 3 635 6.0 3 256 5.4 2 713 4.5 3 768 6.4 6.9

Latvia 225 11.5 409 21.1 438 22.8 296 15.5 218 11.5 11.4

Liechtenstein ND ND ND ND ND ND ND ND 7 17.9 19.1

Lithuania 1 005 35.3 779 27.7 736 26.3 419 15.0 281 10.1 10.2

Luxembourg 118 20.0 135 22.4 131 21.3 93 14.9 133 21.0 21.3

Malta 107 23.2 116 24.4 131 26.5 176 34.2 249 48.2 47.7

Netherlands 954 8.7 1 061 9.6 1 197 10.8 695 6.2 862 7.7 7.6

Norway 992 18.9 961 18.1 1 092 20.5 441 8.2 389 7.2 7.1

Poland 8 921 23.5 9 064 23.9 8 373 22.0 5 192 13.7 7 708 20.4 21.0

Portugal 462 4.5 302 2.9 432 4.2 262 2.5 361 3.5 3.9

Romania 1 154 5.9 1 410 7.2 1 383 7.1 408 2.1 518 2.7 2.7

Slovakia 5 789 106.5 6 791 124.8 4 992 91.6 3 385 62.0 4 439 81.3 82.3

Slovenia 275 13.3 274 13.3 362 17.4 214 10.2 185 8.8 8.9

Spain 9 426 NR 8 730 NR 5 087 NR 3 526 NR 3 913 NR NR

Sweden 2 280 22.8 2 041 20.2 1 990 19.5 825 8.0 933 9.0 8.7

United
10 105 15.3 9 466 14.3 9 718 14.6 ND ND ND ND ND
Kingdom

EU/EEA 92 643 19.6 92 882 20.0 89 050 20.0 53 163 14.2 60 494 16.6 16.7

Source: country reports

ASR: age-standardised rate
ND: no data reported
NR: no rate calculated

3
Annual Epidemiological Report for 2021 SURVEILLANCE REPORT

Figure 1. Distribution of confirmed salmonellosis cases per 100 000 population by country, EU/EEA, 2021

The number of reported cases of salmonellosis in the EU/EEA was stable in the period from 2017−2019 but in
2020, a marked decrease in the number of reported cases was seen on a monthly basis from March onward
(Figures 2 and 3) compared to the previous years. All but two countries (Cyprus and Malta) reported a decrease in
the number of cases in 2020. Case numbers increased again in 2021, but not to the same level as in 2017–2019
i.e. pre-pandemic levels.
There is a clear seasonal distribution of salmonellosis cases by month of reporting, with a peak in July to
September (Figures 2, 3). The smaller peak normally observed in January was not visible in 2021.
Figure 2. Distribution of confirmed salmonellosis cases by month, EU/EEA, 2017–2021

Source: Country reports from Austria, Belgium, Cyprus, Czechia, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland,
Ireland, Italy, Latvia, Luxembourg, Malta, the Netherlands, Norway, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden.

4
SURVEILLANCE REPORT Annual Epidemiological Report for 2021

Figure 3. Distribution of confirmed salmonellosis cases by month, EU/EEA, 2017–2020 and 2021

Source: Country reports from Austria, Belgium, Cyprus, Czechia, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland,
Ireland, Italy, Latvia, Luxembourg, Malta, the Netherlands, Norway, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden.
There was no difference in salmonellosis notification rates by gender in the EU/EEA (male-female ratio 1:1). By age,
the highest notification rate was observed among young children (0–4 years), with 93.1 cases per 100 000 population
(Figure 4). The rate in young children was three times higher than in older children, and 11 times higher than in
adults (25–64 years). The countries with the largest difference in the rates between young children in the 0–4-year
age group and adults in the 25–44-year age group (the rates were 25–50 times higher in children) were: Slovenia,
Italy, Lithuania, Cyprus, Romania, Greece, Bulgaria, Poland and Portugal (by increasing order of magnitude).
Figure 4. Distribution of confirmed salmonellosis cases per 100 000 population, by age and gender,
EU/EEA, 2021

Source: Country reports from Austria, Belgium, Bulgaria, Croatia, Cyprus, Denmark, Estonia, Finland, France, Germany, Greece, Hungary,
Iceland, Ireland, Italy, Latvia, Liechtenstein, Lithuania, Luxembourg, Malta, the Netherlands, Norway, Poland, Portugal, Romania,
Slovakia, Slovenia, Spain, Sweden.

5
Annual Epidemiological Report for 2021 SURVEILLANCE REPORT

Out of 45 177 cases with known travel history, 1 591 (3.5%) were reported as travel-associated, the lowest rate
ever reported to TESSy. The EU average in 2017–2019 was 15.6% and in 2020, 4.4%. In the Nordic countries,
travel-related infections usually account for about 60–80% of salmonellosis cases, but in 2021, this proportion was
only 12–21%. The highest proportion of travel-related cases was observed in France, Iceland, Sweden and
Slovenia (19–21%).
Among the 1 495 travel-associated cases with information on the probable country of infection, Türkiye,
Spain and Italy were the most frequently reported travel destinations (accounting for 12%, 7% and 5% of
travel-related cases, respectively).

Microbiological surveillance
Serovars
Information on Salmonella serovars and serogroups was available for 87% of the confirmed cases from the EU/EEA
countries (Bulgaria and Poland did not report case-based serovar data). As in previous years, the three most
commonly reported Salmonella serovars in 2021 were S. Enteritidis (54%), S. Typhimurium (11%) and monophasic
S. Typhimurium 1,4,[5],12:i:- (9%). The proportions of these three serovars were at a similar level as 2019 but
with lower case numbers. The number of cases of the 4th–15th most common serovars in 2021 are presented in
Figure 5. During the last five years (2017–2021), 102 different serovars were identified in over 100 cases each.
Nine of these serovars had their highest case numbers reported in 2021 (Coeln, Chester, Braenderup, Montevideo,
Oranienburg, Anatum, Kedougo, Hessarek and Blockley). For four of these (Coeln, Braenderup, Chester and
Montevideo), multi-country or national outbreaks were reported in the European surveillance portal for infectious
diseases – EpiPulse (see the section, ‘Outbreaks and other threats’). In comparison, for the serovars with more
than 100 cases in 2017–2021, 33 serovars were reported at their lowest level in 2021.
Figure 5. Number of confirmed salmonellosis cases for the 4th–15th most common serovars in 2021,
and comparison with 2017–2020, EU/EEA

1600

1400
Number of confirmed cases

1200

1000

800

600

400

200

2021 Avg 2017-2020

Antimicrobial resistance
[Note that the analysis in this section has been done using epidemiological cut-off values (ECOFFs) and thus describes
microbiological/acquired resistance which does not take dosing into account. The clinical resistance is usually lower.]
Antimicrobial resistance (AMR) was commonly observed in Salmonella isolates from humans in 2021 with multidrug
resistance in 23% of the isolates (resistance to at least three of the nine monitored antimicrobial classes). Among the
investigated serovars, multidrug resistance was most common in monophasic S. Typhimurium (78%), S. Kentucky
(55%) and S. Infantis (38%).

6
SURVEILLANCE REPORT Annual Epidemiological Report for 2021

However, only a smaller fraction (0.8%) of the bacteria was resistant to both the critically important antimicrobial
classes for treatment – fluoroquinolones and third-generation cephalosporins. An increasing proportion of isolates was
observed to be resistant to fluoroquinolones in 12 countries in the period 2017–2021, particularly visible in S. Enteritidis.
Decreasing trends in resistance to ampicillin and tetracycline were observed in nine and 10 EU/EEA countries,
respectively. For ampicillin, the decrease was most evident in S. Typhimurium and S. Enteritidis, and for
tetracycline, in S. Typhimurium. The proportion of extended-spectrum β-lactamase (ESBL)-producing Salmonella
isolates was at a low but stable level in 2017–2021 (identified in 0.8% of tested isolates, except in 2020 when it
was identified in 0.6% of tested isolates).
The clones of multidrug resistant and ESBL-producing Salmonella that have been under special observation at the EU-level
in the last years – S. Infantis with blaCTX-M-1 , S. Kentucky with blaCTX-M-14b and S. Infantis with blaCTX-M-65 – did not seem to
expand their spread in 2021, being reported by only one, two and one country each, respectively. However, incomplete
genotyping results from some countries prevents a full assessment. No carbapenem-resistant isolates were
detected in 2021, and levels of azithromycin resistance were low (<1%).

Molecular typing data collection for outbreak support

In four of the multinational outbreak investigations coordinated by ECDC, Member States submitted sequences to
ECDC which were analysed to assess the relatedness between isolates from cases and suspected food items. Three
of these were communicated by Rapid Outbreak Assessments (ROAs) as a probable source could be identified (see
the next section, ‘Outbreaks and other threats’).

Outbreaks and other threats

In the summer of 2021, there was a transition from the Epidemic Intelligence Information System for Food and
Waterborne Diseases (FWD-EPIS) to the new EpiPulse system for the reporting of outbreaks/unusual events of
food- or waterborne diseases. In the entire year, 44 events with Salmonella infections were reported in FWD-
EPIS/EpiPulse. These were launched by nine EU/EEA countries (35 events) and two non-EU countries (the United
States and New Zealand) (9 events). Of these, 18 were multi-country events, and three resulted in a joint ECDC-
EFSA Rapid Outbreak Assessment.
The largest multi-country outbreak detected in the EU/EEA in 2021 involved 348 confirmed cases with S. Braenderup
sequence type 22 (ST22) which were reported by 12 EU/EEA countries and the United Kingdom (UK) between mid-
March and early July 2021. The cases were spread throughout the countries and only two reported travels. A total of
68 cases were hospitalised. The case interviews and an analytical epidemiological study suggested small melons (in
particular, Galia melons) as the possible vehicle of infection. S. Braenderup ST22 matching the outbreak strain was
isolated in the UK in two imported Galia melons from Honduras (that belonged to the same batch), and in Austria
from a pooled sample of melons (unknown origin) including Galia melons. The outbreak investigation led to the
implementation of control measures for imported melons in circulation in the EU market [4, 5].
A prolonged outbreak with 121 confirmed cases was reported from January 2019 to October 2021. It involved six
different serovars of Salmonella enterica (S. Havana, S. Mbandaka, S. Orion, S. Kintambo, S. Senftenberg and
S. Amsterdam), and was found linked to sesame-based products from Syria. Cases were reported in five EU/EEA
countries (plus Canada and the United States), and case interviews revealed the consumption of different types of
sesame-based products (halva or tahini) prior to illness. Almost half of the cases were children ≤10 years, who also
represented over half of the hospitalised cases. Despite the control measures implemented in August 2020 after
the findings of Salmonella-positive sesame-based products, cases continued to occur in 2021. This could partly be
explained by the long shelf-lives of the products [6].
In September 2021, France reported an increase in Salmonella Enteritidis ST11 infections to EpiPulse. By January
2022, 272 confirmed cases had been reported in five EU/EEA countries and the UK, with the majority of cases
(216) in France. Twenty-five cases were hospitalised and two deaths were recorded. Outbreak investigations
identified a link to the consumption of eggs/egg products, and via trace back of eggs from a restaurant visited by
some of the cases, one packing centre in Spain and a specific farm testing positive for the outbreak strain could be
identified. Not all cases could however be linked to the specific farm or the packing centre [7].
Two other multi-country outbreaks involving four EU/EEA countries each were identified via EpiPulse. They were
related to S. Chester (cases falling in from mid-July throughout August) and S. Montevideo (a prolonged outbreak with
sporadic cases occurring from January 2021 to January 2022), respectively, but no single source could be identified.
Among the national salmonellosis outbreaks reported to EpiPulse, the largest was detected in Finland in June,
where a total of 620 children and 108 employees at day-care centres across three cities fell ill with Salmonella
Typhimurium. All facilities were served by the same central kitchen and the outbreak strain was identified in the
vegetables served at lunch [8].

7
Annual Epidemiological Report for 2021 SURVEILLANCE REPORT

Finland also reported another S. Typhimurium outbreak in February, related to vegetables where 49 cases fell ill after
consuming salad containing contaminated tomato cubes that were sold frozen and had not been heated before use [9].
Sweden identified an outbreak of S. Coeln with 52 cases from 14 regions reported from end of August to October
2021. A national case-case study identified a link to the consumption of sprouts, further supported by an
investigation in one of the regions. No microbiological confirmation could be done in the suspected food item, as it
was a fresh produce thought to have been delivered to food stores, wholesalers and commercial kitchens at the
same point of time in August [10].

Discussion
Salmonellosis remains the second most common food-borne infection in the EU/EEA. After the significant decrease
in salmonellosis cases observed from 2007 to 2014, following targeted control measures in poultry production, a
stable incidence was observed at the EU/EEA level from 2015 to 2019. In 2020, a significant drop in cases was
observed, primarily as a consequence of the COVID-19 pandemic. All except two countries reported a decrease in
the number of cases. Factors mentioned by countries resulting in lower case numbers were: people avoiding
seeking medical care for mild symptoms due to risk of exposure to COVID-19 in healthcare facilities, limited
laboratory capacity due to reallocation of resources to SARS-CoV-2, fewer restaurant visits, increased hand
washing, less travel due to travel restrictions, etc.
Notification rates for salmonellosis in humans vary between Member States, reflecting variations in, for example,
quality, coverage and disease-severity focus of the surveillance systems, practices in sampling and testing,
prevalence in the food-producing animal population, food and animal trade between Member States, and the
proportion of travel-associated cases. In 2021, the proportion of travel-associated cases was the lowest ever
reported to TESSy. This was most likely an effect of the travel restrictions during the pandemic, particularly evident
in the countries that normally report a very high proportion of travel-associated cases.
The fact that the salmonellosis rate in young children is eleven times higher compared with adults may be
explained by a higher proportion of symptomatic infections among young children, an increased likelihood of
parents taking children to see a doctor on getting sick, and for doctors to take samples. Certain countries with very
large differences between the rates of young children and adults also reported high proportions of hospitalised
cases. This indicates that surveillance systems in those countries may mainly capture the most severe infections.
Among the food-borne outbreaks reported to the European Food Safety Agency (EFSA) in 2021, Salmonella
accounted for the largest proportion, 19%, as in previous years [11]. The majority (80%) of the reported
salmonellosis food-borne outbreaks were caused by S. Enteritidis. The most frequently implicated food vehicles in
strong-evidence salmonellosis food-borne outbreaks were, ‘eggs and egg products’, followed by ‘mixed foods’,
‘bakery products’, ‘pig meat and products thereof’, ‘vegetables and juices and other products thereof’, ‘broiler meat
and products thereof’ and ‘cheese’.
Among the Salmonella outbreaks reported to EpiPulse in 2021, the largest ones were mostly caused by
contaminated vegetables, fruits or seeds or products thereof (melons, sesame products, salads, tomatoes,
sprouts), as described in the section, ‘Outbreaks and other threats’. A similar conclusion was made by EFSA as they
found that among the strong-evidence salmonella outbreaks, ‘vegetables and juices and other products thereof’
caused the most number of cases in 2021, and the proportion of this category among causative agents increased
considerably compared with both 2020 and the pre-pandemic years [11].
The year 2021 was the last year for reporting multi-locus variable-number tandem repeat analysis (MLVA) typing data
via isolate-based reporting. The typing method has continuously been replaced by WGS in individual Member States.
This is also reflected in the outbreak reports and the events reported in EpiPulse. The benefits of using WGS in
facilitating the identification of linked cases in different countries and suspected food sources is promoted by ECDC,
PulseNet International and World Health Organization (WHO) [12, 13]. National examples of WGS systems allowing
comparison of sequences between sectors in a ‘One Health’ approach exists, for e.g., in the US and Germany [14, 15].
Mild infections with Salmonella should be treated with fluid and electrolyte replacement, and not with antimicrobials.
Some infections might however become more severe. In 2% of cases reported to the EU/EEA in 2021, the infection
had resulted in bacteraemia. Fluoroquinolones and macrolides (azithromycin) are the primary treatment for severe
infections in adults (for children, cephalosporins would be used instead of fluoroquinolones). In case of invasive
infections, intravenous cephalosporins are recommended [16]. Fluoroquinolone resistance in non-typhoidal Salmonella
subspecies. from humans have increased in the last few years in the EU/EEA, particularly observed in S. Enteritidis
which is a serovar mainly associated with eggs and poultry. In 2020, high to very high resistance to fluoroquinolones
was observed in isolates recovered from broilers, fattening turkeys and poultry carcasses/meat [17]. Resistance to
third-generation cephalosporins and macrolides however remain low in isolates from both humans and poultry.

8
SURVEILLANCE REPORT Annual Epidemiological Report for 2021

Since 2019, it is possible to report antimicrobial resistance predicted from WGS-derived resistance determinants for
Salmonella via isolate-based data collection. Testing of the quality of predicted resistance has also become a part
of the EQA (external quality assessment) panels for Salmonella, which are offered to laboratories with national
reference functions within the EU/EEA with support from ECDC.
In 2021, one country (Sweden) reported predicted resistance data to TESSy for Salmonella. With the increasing
use of WGS in many Member States as the method of choice for serotype determination and cluster analysis, the
resistance determinants could also be derived from the WGS data, specifically for countries with limited data from
phenotypic testing. The methodology also has the benefit of allowing harmonised data analysis and interpretation
between both countries and sectors (for example, the food sector). It could be an efficient tool for antimicrobial
resistance (AMR) surveillance within the EU/EEA, not the least for the monitoring of emerging antimicrobial
resistances of relevance to public health.

Public health implications

The rates of non-typhoidal salmonellosis vary between EU/EEA countries, reflecting differences in prevalence in
food and animals used for food production, animal trade between countries, the proportion of travel-associated
cases, and the quality and coverage of surveillance systems.
Eggs and egg products continue to be the highest risk foods in Salmonella outbreaks [11], although several
larger outbreaks from non-animal food sources were identified in 2021. Proper Salmonella-control measures
at the primary production level and sufficient laboratory capacity are prerequisites to reduce Salmonella
prevalence in food-producing animals.

9
Annual Epidemiological Report for 2021 SURVEILLANCE REPORT

References
1. European Centre for Disease Prevention and Control (ECDC). Introduction to the Annual Epidemiological Report.
Stockholm: ECDC; 2020. Available at: https://ecdc.europa.eu/en/annual-epidemiological-reports/methods

2. European Centre for Disease Prevention and Control (ECDC). Surveillance systems overview for 2021. Stockholm:
ECDC; 2022. Available at: https://www.ecdc.europa.eu/en/publications-data/surveillance-systems-overview-2021

3. European Centre for Disease Prevention and Control (ECDC). Surveillance Atlas of Infectious Diseases. Stockholm:
ECDC; 2021. Available at: http://atlas.ecdc.europa.eu

4. European Centre for Disease Prevention and Control (ECDC) and European Food Safety Authority (EFSA).
Rapid Outbreak Assessment: Multi-country outbreak of Salmonella Braenderup ST22, presumed to be linked
to imported melons. Stockholm/Parma: ECDC/EFSA; 20 July 2021.
Available at: https://www.ecdc.europa.eu/en/publications-data/rapid-outbreak-assessment-multi-country-
outbreak-salmonella-braenderup-st22

5. Chan Y-W, Hoban A, Moore H, Greig DR, Painset A, Jorgensen F, et al., on behalf of the Incident
Management Teams. Two outbreaks of foodborne gastrointestinal infection linked to consumption of
imported melons, United Kingdom, March to August 2021. Journal of Food Protection. 13 December 2022.
Available at: https://doi.org/10.1016/j.jfp.2022.100027.

6. European Centre for Disease Prevention and Control (ECDC) and European Food Safety Authority (EFSA).
Rapid Outbreak Assessment: Multi-country outbreak of multiple Salmonella enterica serotypes linked to
imported sesame-based products. Stockholm/Parma: ECDC/EFSA; 14 October 2021.
Available at: https://www.ecdc.europa.eu/en/publications-data/rapid-outbreak-assessment-multi-country-
outbreak-multiple-salmonella-enterica

7. European Centre for Disease Prevention and Control (ECDC) and European Food Safety Authority (EFSA).
Rapid Outbreak Assessment: Multi-country outbreak of Salmonella Enteritidis sequence type (ST)11
infections linked to eggs and egg products. Stockholm/Parma: ECDC/EFSA; 8 February 2022.
Available at: https://www.ecdc.europa.eu/en/publications-data/multi-country-outbreak-salmonella-
enteritidis-sequence-type-st11-infections

8. Terveyden ja hyvinvoinnin laitos (THL, The Finnish Institute for Health and Welfare). Elintarvike- ja
vesivälitteisten epidemioiden esiintyvyys (Prevalence of food-borne and waterborne epidemics), (in Finnish).
Helsinki: THL; 2021. Available at: Prevalence of foodborne and waterborne epidemics - THL

9. Kääriäinen S, Obach D, Paspaliari D , Tofferi M, Nieminen A, Pihlajasaari A, Kuronen H, Vainio A, Rimhanen-

Finne R. Salmonella Typhimurium outbreak associated with frozen tomato cubes at a restaurant in western
Finland, January to February 2021. Euro Surveill. 2022;27(41):pii=2200316.
Available at: https://doi.org/10.2807/1560-7917.ES.2022.27.41.2200316

10. Folkhälsomyndigheten. Salmonella (Sverige, augusti-okbotber 2021) (in Swedish). 18 November 2021.
Available at: https://www.folkhalsomyndigheten.se/smittskydd-beredskap/utbrott/utbrottsarkiv/salmonella-
sverige-augusti-oktober-2021/

11. European Food Safety Authority (EFSA) and European Centre for Disease Prevention and Control (ECDC).
The European Union One Health 2021 Zoonoses Report. EFSA Journal 2022;20(12):7666, 273 pp.
Available at: https://doi.org/10.2903/j.efsa.2022.7666

12. Nadon C, Van Walle I, Gerner-Smidt P, Campos J, Chinen I, Concepcion-Acevedo J, et al. PulseNet
International: Vision for the implementation of whole genome sequencing (WGS) for global food-borne
disease surveillance. Euro Surveill. June 2017, 22(23): 30544.
Available at: http://www.eurosurveillance.org/content/10.2807/1560-7917.ES.2017.22.23.30544

13. World Health Organization (WHO). Whole genome sequencing for foodborne disease surveillance:
landscape paper. Geneva: WHO; 2018.
Available at: https://www.who.int/publications/i/item/789241513869

14. Stevens EL, Carleton HA, Bael J, Tillman GE, Lindsey RL, Lauer AC et al. Use of Whole Genome Sequencing by
the Federal Interagency Collaboration for Genomics for Food and Feed Safety in the United States. J Food Prot.
March 2022; 85(5): 755–772. Available at: https://meridian.allenpress.com/jfp/article/85/5/755/478841/Use-of-
Whole-Genome-Sequencing-by-the-Federal

10
SURVEILLANCE REPORT Annual Epidemiological Report for 2021

15. Uelze L, Becker N, Borowiak M, Busch U, Dangel A, Deneke C, et al. Toward an Integrated Genome-Based
Surveillance of Salmonella enterica in Germany. Front Microbiol. 2021; 12:626941. Available at:
https://www.frontiersin.org/articles/10.3389/fmicb.2021.626941/full

16. Gilbert DN, Chambers HF, Saag MS, Pavia AT, and Boucher HW (ed.) The Sanford Guide to Antimicrobial
Therapy 2022. 52nd edition. Sperryville, VA, USA: Antimicrobial Therapy, Inc.; 2022.

17. European Food Safety Authority (EFSA) and European Centre for Disease Prevention and Control (ECDC).
The European Union Summary Report on Antimicrobial Resistance in zoonotic and indicator bacteria from
humans, animals and food in 2019–2020. EFSA Journal. March 2022, 20(3):7209.
Available at: https://doi.org/10.2903/j.efsa.2022.7209

11