Resurgence of an international hepatitis A outbreak linked to imported frozen strawberries, Germany, 2018 to 2020

Antiviral Activity of Natural Compounds for Food Safety

Gastroenteritis and hepatitis are the most common illnesses resulting from the consumption of food contaminated with human enteric viruses. Several natural compounds have demonstrated antiviral activity against human enteric viruses, such as human norovirus and hepatitis A virus, while little information is available for hepatitis E virus. Many in-vitro studies have evaluated the efficacy of different natural compounds against human enteric viruses or their surrogates. However, only few studies have investigated their antiviral activity in food applications. Among them, green tea extract, grape seed extract and carrageenans have been extensively investigated as antiviral natural compounds to improve food safety. Indeed, these extracts have been studied as sanitizers on food-contact surfaces, in produce washing solutions, as active fractions in antiviral food-packaging materials, and in edible coatings. The most innovative applications of these antiviral natural extracts include the development of coatings to extend the shelf life of berries or their combination with established food technologies for improved processes. This review summarizes existing knowledge in the underexplored field of natural compounds for enhancing the safety of viral-contaminated foods and underscores the research needs to be covered in the near future.

A Reliable Multifaceted Solution against Foodborne Viral Infections: The Case of RiLK1 Decapeptide

Food-borne transmission is a recognized route for many viruses associated with gastrointestinal, hepatic, or neurological diseases. Therefore, it is essential to identify new bioactive compounds with broad-spectrum antiviral activity to exploit innovative solutions against these hazards. Recently, antimicrobial peptides (AMPs) have been recognized as promising antiviral agents. Indeed, while the antibacterial and antifungal effects of these molecules have been widely reported, their use as potential antiviral agents has not yet been fully investigated. Herein, the antiviral activity of previously identified or newly designed AMPs was evaluated against the non-enveloped RNA viruses, hepatitis A virus (HAV) and murine norovirus (MNV), a surrogate for human norovirus. Moreover, specific assays were performed to recognize at which stage of the viral infection cycle the peptides could function. The results showed that almost all peptides displayed virucidal effects, with about 90% of infectivity reduction in HAV or MNV. However, the decapeptide RiLK1 demonstrated, together with its antibacterial and antifungal properties, a notable reduction in viral infection for both HAV and MNV, possibly through direct interaction with viral particles causing their damage or hindering the recognition of cellular receptors. Hence, RiLK1 could represent a versatile antimicrobial agent effective against various foodborne pathogens including viruses, bacteria, and fungi.

Global outbreaks of foodborne hepatitis A: Systematic review and meta-analysis

Hepatitis A Virus (HAV) is a significant threat in terms of food safety. A systematic literature search with the research question "What are the clinical outcomes of foodborne Hepatitis A virus infections?" was conducted. The pooled estimate of the outcomes-mortality, hospitalization, and severity rates, along with a 95% confidence interval (CI), was estimated. After screening, 33 studies were included for the data extraction and meta-analysis. The pooled prevalence of hospitalization among the HAV-positive patients was estimated to be 32% (95% CI 21-44), with high heterogeneity (I2 = 98%, p < 0.01). Australia had the highest hospitalization rate, with 82%, followed by Europe (42%). The hospitalization rate showed a significantly increasing trend (beta = 0.015, p=0.002) over the period. The pooled prevalence of mortality among the HAV-positive patients was estimated to be <1%, with low heterogeneity (I2 = 5%, p = 0.39). A wide range of food products were linked with the HAV outbreaks.

Loxapine inhibits replication of hepatitis A virus in vitro and in vivo by targeting viral protein 2C

No antiviral drugs currently are available for treatment of infection by hepatitis A virus (HAV), a causative agent of acute hepatitis, a potentially life-threatening disease. Chemical screening of a small-compound library using nanoluciferase-expressing HAV identified loxapine succinate, a selective dopamine receptor D2 antagonist, as a potent inhibitor of HAV propagation in vitro. Loxapine succinate did not inhibit viral entry nor internal ribosome entry site (IRES)-dependent translation, but exhibited strong inhibition of viral RNA replication. Blind passage of HAV in the presence of loxapine succinate resulted in the accumulation of viruses containing mutations in the 2C-encoding region, which contributed to resistance to loxapine succinate. Analysis of molecular dynamics simulations of the interaction between 2C and loxapine suggested that loxapine binds to the N-terminal region of 2C, and that resistant mutations impede these interactions. We further demonstrated that administration of loxapine succinate to HAV-infected Ifnar1-/- mice (which lack the type I interferon receptor) results in decreases in the levels of fecal HAV RNA and of intrahepatic HAV RNA at an early stage of infection. These findings suggest that HAV protein 2C is a potential target for antivirals, and provide novel insights into the development of drugs for the treatment of hepatitis A.

One Health Perspectives on Food Safety in Minimally Processed Vegetables and Fruits: From Farm to Fork

While food markets and food production chains are experiencing exponential growth, global attention to food safety is steadily increasing. This is particularly crucial for ready-to-eat products such as fresh-cut salads and fruits, as these items are consumed raw without prior heat treatment, making the presence of pathogenic microorganisms quite frequent. Moreover, many studies on foodborne illnesses associated with these foods often overlook the transmission links from the initial contamination source. The prevention and control of the dissemination of foodborne pathogens should be approached holistically, involving agricultural production, processing, transport, food production, and extending to final consumption, all while adopting a One Health perspective. In this context, our objective is to compile available information on the challenges related to microbiological contamination in minimally handled fruits and vegetables. This includes major reported outbreaks, specific bacterial strains, and associated statistics throughout the production chain. We address the sources of contamination at each stage, along with issues related to food manipulation and disinfection. Additionally, we provide potential solutions to promote a healthier approach to fresh-cut fruits and vegetables. This information will be valuable for both researchers and food producers, particularly those focused on ensuring food safety and quality.

Hepatitis A outbreak in a refugee shelter in Kiel, northern Germany

In the spring of 2023, three Ukrainian war refugees from a municipal community shelter and a volunteer caregiver at an affiliated daycare center in Kiel, Germany, were diagnosed with infectious jaundice attributable to a single hepatitis A virus (HAV) subgenotype IA strain. Similar HAV sequences have been observed in Germany and other European countries for several years. One refugee and the volunteer required hospitalization. Four children were asymptomatically infected but excreted high levels of HAV ribonucleic acid in the stool. The infections were probably acquired in Germany, but a source could not be determined. The outbreak was contained through vaccination, increased hygiene, and education. The existing HAV vaccination recommendation for refugee shelter staff and volunteers should be consistently implemented.

Quantitative Risk Assessment of Five Foodborne Viruses in Shellfish Based on Multiplex qPCR

Foodborne diseases are currently the most critical food safety issue in the world. There are not many hazard identification and exposure assessments for foodborne viruses (Norovirus GI, GII, Hepatitis A Virus, Rotavirus, Adenovirus) in shellfish. Multiplex qPCR for the simultaneous detection of five foodborne viruses was established and used to assess infection risk based on a 1-year pathogenesis study. The sensitivity, specificity and reproducibility of the multiplex qPCR method are consistent with that of conventional qPCR, which saves more time and effort. Overall, 37.86% of shellfish samples had one or more foodborne viruses. Risk assessment formulae and matrices were used to develop risk assessments for different age groups, different seasons and different shellfish. The annual probability of contracting a foodborne virus infection from shellfish is greater than 1.6 × 10-1 for all populations, and even for infants aged 0-4 years, it is greater than 1.5 × 10-2, which is much higher than the risk thresholds recommended by WHO (10-6) and the US EPA (10-4). High risk (level IV) is associated with springtime, and medium risk (level III) is associated with Mussel consumption. This study provides a basis for the risk of foodborne viral infections in people of different ages, in different seasons, and by consuming different shellfish.

Hepatitis A Virus and Hepatitis E Virus as Food- and Waterborne Pathogens-Transmission Routes and Methods for Detection in Food

Foodborne viruses are an important threat to food safety and public health. Globally, there are approximately 5 million cases of acute viral hepatitis due to hepatitis A virus (HAV) and hepatitis E virus (HEV) every year. HAV is responsible for numerous food-related viral outbreaks worldwide, while HEV is an emerging pathogen with a global health burden. The reported HEV cases in Europe have increased tenfold in the last 20 years due to its zoonotic transmission through the consumption of infected meat or meat products. HEV is considered the most common cause of acute viral hepatitis worldwide currently. This review focuses on the latest findings on the foodborne transmission routes of HAV and HEV and the methods for their detection in different food matrices.

Hepatitis A seroprevalence, vaccination status and demographic determinants in children and adolescents in Germany, 2014-2017, a population-based study

Children play an important role in hepatitis A virus (HAV) transmission but, due to frequent asymptomatic or mild courses, these infections are underrecognized in routine surveillance. Here, we analyzed hepatitis A (HA) seroprevalence, vaccination status and demographic determinants and estimated previous HAV infections in a cross-sectional population-based study of children and adolescents with residence in Germany 2014-2017, performing weighted univariable and multivariable logistic regression. Of 3567 participants aged 3-17 years, serological results were available for 3013 (84.5%), vaccination records for 3214 (90.1%) and both for 2721 (76.3%). Of 2721 with complete results, 467 (17.2%) were seropositive, thereof 412 (15.1%) with and 55 (2.0%) without previous HA vaccination, indicating previous HAV infection. Seropositivity was associated with age, residence in Eastern states, high socioeconomic status and migration background with personal migration experience. Participants with migration background and personal migration experience also had the highest odds ratios for previous HAV infection. Germany remains a country with very low HA endemicity. The current vaccination recommendations focusing on individuals with a high risk for HAV exposure (e.g. travelers to endemic countries) or severe disease appear appropriate. Migration and travel patterns as well as the endemicity in other countries influence the domestic situation, warranting further monitoring.

Hepatitis A notifications in the EU/EEA, 2010-2019: what can we learn from case reporting to the European Surveillance System?

BackgroundEuropean Union/European Economic Area (EU/EEA) countries annually report hepatitis A (HepA) notifications to The European Surveillance System (TESSy).AimTo describe EU/EEA HepA notifications from 2010 to 2019 and identify infection drivers and surveillance improvements.MethodsWe analysed demographic, clinical and transmission information of HepA confirmed cases from TESSy. We stratified countries by population susceptibility profile and performed time-series analysis to describe trends in notification rates, sex distribution and travel history.ResultsTwenty-nine EU/EEA countries reported 139,793 HepA cases. Six eastern EU countries reported > 60% of these cases. EU/EEA notification rate during the study period was 3.2 cases per 100,000 population (range 2.7-5.6). Notifications peaked in 2014 and 2017, with marked differences in case demographic characteristics. Notification trends varied across different country susceptibility groups. In 2017, the proportion of males (74%) and case median age (31 years) increased steeply, while no changes occurred in 2014. Travel history showed seasonal case peaks following the summer. More than 47,000 hospitalisations were reported. Annual case fatality was < 0.2% for all years. Information on travel history, hospitalisation, death and mode of transmission was suboptimal.DiscussionApart from some countries in its east, the EU/EEA is characterised by low HepA incidence baseline and susceptible to recurrent large cross-border outbreaks. Analysis of European surveillance data highlighted the need for stronger prevention policies for eastern EU countries, men who have sex with men and travellers. Improving surveillance data-quality will enhance knowledge on food-borne, and travel-related exposures to inform more effective and tailored regional prevention policies.

Hepatitis A occurrence and outbreaks in Europe over the past two decades: A systematic review

Hepatitis A (HA) is a vaccine-preventable liver disease with >170 million new cases occurring yearly. In recent outbreaks in the USA, hospitalization and case-fatality ratios were >60% and ~1%, respectively. In Europe, endemicity persists and outbreaks continue to occur. We performed a systematic literature review to understand the changes in HA occurrence in Europe over the past two decades. PubMed and Embase were systematically searched for peer-reviewed articles published between 1 January 2001 and 14 April 2021 using terms covering HA, 11 selected European countries, outbreaks, outcomes and HA virus circulation. Here, we focus on HA occurrence and outbreaks in the five countries with the largest population and the most comprehensive vaccination recommendations: France, Germany, Italy, Spain and the UK; 118 reports included data for these five European countries. Notification rates (≤9.7/100,000 population) and percentages of men among cases (≤83.0%) peaked in 2017. The number of person-to-person-transmitted cases and outbreaks decreased in children but increased in other risk groups, such as men who have sex with men (MSM). Sexually transmitted outbreaks in MSM clustered around 2017. Travel-related outbreaks were few; the proportion of travel-related cases decreased during the past two decades, while the number of domestic cases increased. Despite the existing risk-based vaccination recommendations, HA transmission shifted in proportions from travelers and children to other risk groups, such as MSM and older age groups. Because a substantial proportion of the European population is susceptible to HA, adherence to existing recommendations should be monitored more closely, and enhanced vaccination strategies should be considered.

Macrophage Depletion Reactivates Fecal Virus Shedding following Resolution of Acute Hepatitis A in Ifnar1-/- Mice

Although hepatitis A virus (HAV) is associated only with acute hepatitis in humans, HAV RNA persists within the liver for months following resolution of liver inflammation and cessation of fecal virus shedding in chimpanzees and murine models of hepatitis A. Here, we confirm striking differences in the kinetics of HAV RNA clearance from liver versus serum and feces in infected Ifnar1-/- mice and investigate the nature of viral RNA persisting in the liver following normalization of serum alanine aminotransferase (ALT) levels. Fecal shedding of virus produced in hepatocytes declined >3,000-fold between its peak at day 14 and day 126, whereas intrahepatic HAV RNA declined only 32-fold by day 154. Viral RNA was identified within hepatocytes 3 to 4 months after inoculation and was associated with membranes, banding between 1.07 and 1.14 g/cm3 in isopycnic iodixanol gradients. Gradient fractions containing HAV RNA demonstrated no infectivity when inoculated into naive mice but contained neutralizing anti-HAV antibody. Depleting CD4+ or CD8+ T cells at this late point in infection had no effect on viral RNA abundance in the liver, whereas clodronate-liposome depletion of macrophages between days 110 and 120 postinoculation resulted in a striking recrudescence of fecal virus shedding and the reappearance of viral RNA in serum coupled with reductions in intra-hepatic Ifnγ, Tnfα, Ccl5, and other chemokine transcripts. Our data suggest that replication-competent HAV RNA persists for months within the liver in the presence of neutralizing antibody following resolution of acute hepatitis in Ifnar1-/- mice and that macrophages play a key role in viral control late in infection. IMPORTANCE HAV RNA persists in the liver of infected chimpanzees and interferon receptor-deficient Ifnar1-/- mice for many months after neutralizing antibodies appear, virus has been cleared from the blood, and fecal virus shedding has terminated. Here, we show this viral RNA is located within hepatocytes and that the depletion of macrophages months after the resolution of hepatic inflammation restores fecal virus shedding and circulating viral RNA. Our study identifies an important role for macrophages in virus control following resolution of acute hepatitis A in Ifnar1-/- mice and may have relevance to relapsing hepatitis A in humans.

A community-wide epidemic of hepatitis A virus genotype IA associated with consumption of shellfish in Yantai, eastern China, January to March 2020

During the first quarter of 2020, a considerable increase in reports of symptomatic hepatitis A cases was noted in Yantai, a coastal city in eastern China. This study aimed to characterize the epidemic and identify the probable source. Serum samples from cases with onsets from 1 January to 31 March 2020 and suspected bivalve mollusk samples from the local seafood market were screened for hepatitis A virus (HAV) RNA by PCR amplification and sequencing of the VP1/2A region. We also analyzed the characteristics and risk exposures of these cases. In total, 110 confirmed cases were notified during the epidemic. Among the 103 cases investigated, the median age was 41 years (range: 25-70 years), and 74 (71.8%) were male. Eighty-eight cases (85.4%) reported having eaten shellfish and 72 (69.9%) specifically oysters. HAV RNA was detected and sequenced successfully in 80.2% (69/86) of the cases, as well as in one oyster out of 20 shellfish samples. Phylogenetic analysis revealed that all isolates belonged to a single genotype IA but presented the co-circulation of five distinct genomic sub-lineages. The oyster-derived HAV strain shared over 98.2% nucleotide identity with all clinical strains obtained during the epidemic, particularly 100% homology with the strains of seven cases. These data indicated that contaminated oyster consumption was probably a common source of this epidemic, although multiple HAV strains were involved. We recommend strengthening shellfish surveillance, changing dietary habits in seafood consumption, and encouraging vaccination for target adults in coastal areas with a high prevalence of hepatitis A.

A 2019 Outbreak Investigation of Hepatitis A Virus Infections in the United States Linked to Imported Fresh Blackberries

Globally, hepatitis A virus (HAV) is one of the most common agents of acute viral hepatitis and causes approximately 1.4 million cases and 90,000 deaths annually despite the existence of an effective vaccine. In 2019, federal, state, and local partners investigated a multi-state outbreak of HAV infections linked to fresh blackberries sourced from multiple suppliers in Michoacán, Mexico. A total of 20 individuals with outbreak-related HAV infection were reported in seven states, including 11 hospitalizations, and no deaths. The Food and Drug Administration (FDA), the Centers for Disease Control and Prevention (CDC), and Nebraska State and Douglas County Health Departments conducted a traceback investigation for fresh blackberries reportedly purchased by 16 ill persons. These individuals reported purchasing fresh blackberries from 11 points of service from September 16 through 29, 2019 and their clinical isolates assessed through next-generation sequencing and phylogenetic analysis were genetically similar. The traceback investigation did not reveal convergence on a common grower or packing house within Mexico, but all of the blackberries were harvested from growers in Michoacán, Mexico. FDA did not detect the pathogen after analyzing fresh blackberry samples from four distributors, one consumer, and from nine importers at the port of entry as a result of increased screening. Challenges included gaps in traceability practices and the inability to recover the pathogen from sample testing, which prohibited investigators from determining the source of the implicated blackberries. This multi-state outbreak illustrated the importance of food safety practices for fresh produce that may contribute to foodborne illness outbreaks.

Molecular epidemiology and genotype-specific disease severity of hepatitis E virus infections in Germany, 2010-2019

Zoonotic hepatitis E virus (HEV) is endemic in Europe. Genotype 3 (HEV-3) is predominant but information on subtype distribution, trends and clinical implications in Germany is scarce. We analysed 936 HEV RNA positive samples of human origin and corresponding national surveillance data from 2010 to 2019. Samples were referred to the National Consultant Laboratory and sequenced in at least one of four genomic regions. Sequences were analysed using bioinformatics methods and compared to the latest HEV reference set. 1,656 sequences were obtained from 300 female, 611 male and 25 of unknown sex aged 3–92 years (median 55 years). HEV-3c was predominant (67.3%) followed by HEV-3f, HEV-3e and HEV-3i(-like) with 14.3%, 9.7% and 4.0% (other subtypes ≤1.1%). The proportion of HEV-3 group 2 (3abchijklm) strains increased over time. Jaundice, upper abdominal pain, fever, hospitalization, and death due to HEV were significantly more often reported for patients infected with HEV-3 group 1 (3efg) compared to group 2. Larger spatio-temporal clusters of identical sequences were not observed. HEV-3 group 1 infections are more severe as compared to the predominant group 2. Detection of group 2 strains increased over the last years, possibly due to more frequent diagnosis of asymptomatic and mild courses. The diversity of strains and the space–time distribution is compatible with a foodborne zoonosis with supra-regional distribution of the infection vehicle (pork products).

Detection of Norovirus and Hepatitis A Virus in Strawberry and Green Leafy Vegetables by Using RT-qPCR in Egypt

There is an upward trend of consumption of organic fresh vegetables due to consumer demand for healthy foods without chemical additives. On the other hand, the number of food borne outbreaks associated with contaminated fresh produce has raised, being human norovirus genogroup I (GI), GII and hepatitis A virus (HAV) the most commonly reported causative agents. This study aimed to detect the presence of these viruses in green leafy vegetables (watercress, leek, coriander, and parsley) and strawberry using quantitative reverse transcription polymerase chain reaction (RT-qPCR). Samples were collected from the Egyptian regions of Kalubia, Giza, and Mansoura. Overall HAV average occurrence in fresh strawberry was 48% with a mean concentration of 6.1 × 10³ GC/g; Also NoV GI overall average occurrence was 25% with a mean concentration of 9.7 × 10² genome copies (GC)/g, while NoV GII was 40% with a mean concentration of 2.4 × 10³ GC/g. For strawberry collected directly from Kalubia farms, neither HAV nor HNoV GI & GII were detected. In green leafy vegetable samples, the occurrence of HAV was 31.2% with a mean concentration of 9.2 × 10⁴ GC/g, while occurrence of NoV GI and NoV GII were 20% and 30% with a mean concentrations of 1.1 × 10⁴ and 2.03 × 10³ GC/g, respectively. In conclusion, the importance of a virus surveillance program for soft fruits and fresh vegetables is highlighted by the outcomes of this study. Our findings should help with the management and control of microbial concerns in fresh foods, reducing the danger of consuming contaminated foods.

Severity of the clinical presentation of hepatitis A in five European countries from 1995 to 2014

OBJECTIVES

We analysed hepatitis A (HepA) notifications and hospitalisations in Italy, the Netherlands, Norway, Spain, and Sweden for available periods between 1995 and 2014. We aimed to investigate whether decreasing HepA incidence is associated with increasing age at infection and worsening HepA presentation and to identify groups at risk of severe disease.

METHODS

We performed a retrospective cohort study including 36 734 notified and 36 849 hospitalised patients. We used negative binomial regressions to identify over time: i) trends in hospitalisation and notification rates; ii) proportion of hospitalised and notified patients aged ≥40 years; iii) proportion of "severe hospitalisations"; and iv) risk factors for severe hospitalisation.

RESULTS

During the study period both HepA notifications and hospitalisations decreased, with notification rates decreasing faster, patients aged ≥40 years increased, however, the proportion of severe HepA hospitalisations remained stable. Older patients and patients with comorbidities, particularly liver diseases, were more likely to experience severe disease.

CONCLUSIONS

We used digitalised health information to confirm decreasing trends in HepA hospitalisations and notifications, and the increasing age of patients with HepA in Europe. We did not identify an increase in the severity of the clinical presentation of patients with HepA. Older patients with liver diseases are at increased risk of severe disease and should be prioritised for vaccination.

[Epidemiology of viral hepatitis A to E in Germany]

Viral hepatitis A to E describes various infectious inflammations of the liver parenchyma that are caused by the hepatitis viruses A to E (HAV, HBV, HCV, HDV, and HEV). Although the clinical pictures are similar, the pathogens belong to different virus families and differ in terms of pathogenesis, transmission routes, clinical course, prevention, and therapy options. In Germany, there is mandatory reporting according to the Infection Protection Act (IfSG) for direct or indirect laboratory evidence and for suspicion, illness, and death of viral hepatitis. The data are transmitted to the Robert Koch Institute.In this article, on the basis of published studies and notification data, we describe the epidemiology of hepatitis A to E as well as current challenges and prevention approaches. In particular, the latter contains the improvement of existing vaccination recommendations (hepatitis A and B); improvement of access to prevention, testing, and care including therapy with antiviral drugs (hepatitis B, C, and D) and the detection and prevention of foodborne infections and outbreaks; and improvements in the field of food safety (hepatitis A and E).

The European Union One Health 2020 Zoonoses Report

This report of the EFSA and the European Centre for Disease Prevention and Control presents the results of zoonoses monitoring activities carried out in 2020 in 27 EU Member States (MS) and nine non-MS. Key statistics on zoonoses and zoonotic agents in humans, food, animals and feed are provided and interpreted historically. Two events impacted 2020 MS data collection and related statistics: the Coronavirus Disease 2019 (COVID-19) pandemic and the withdrawal of the United Kingdom from the EU. In 2020, the first and second most reported zoonoses in humans were campylobacteriosis and salmonellosis, respectively. The EU trend for confirmed human cases of these two diseases was stable (flat) from 2016 to 2020. Fourteen of the 26 MS reporting data on Salmonella control programmes in poultry met the reduction targets for all poultry categories. Salmonella results for carcases of various species performed by competent authorities were more frequently positive than own-checks conducted by food business operators. This was also the case for Campylobacter quantification results from broiler carcases for the MS group that submitted data from both samplers, whereas overall at EU level, those percentages were comparable. Yersiniosis was the third most reported zoonosis in humans, with 10-fold less cases reported than salmonellosis, followed by Shiga toxin-producing Escherichia coli (STEC) and Listeria monocytogenes infections. Illnesses caused by L. monocytogenes and West Nile virus infections were the most severe zoonotic diseases with the highest case fatality. In 2020, 27 MS reported 3,086 foodborne outbreaks (a 47.0% decrease from 2019) and 20,017 human cases (a 61.3% decrease). Salmonella remained the most frequently reported causative agent for foodborne outbreaks. Salmonella in 'eggs and egg products', norovirus in 'crustaceans, shellfish, molluscs and products containing them' and L. monocytogenes in 'fish and fish products' were the agent/food pairs of most concern. This report also provides updates on tuberculosis due to Mycobacterium bovis or Mycobacterium caprae, Brucella, Trichinella, Echinococcus, Toxoplasma, rabies, Coxiella burnetii (Q fever) and tularaemia.