Prevention and Detoxification of Mycotoxins in Human Food and Animal Feed using Bio-resources from South Mediterranean Countries: a Critical Review.

Mycotoxins, which are natural toxic compounds produced by filamentous fungi, are considered major contaminants in the food and feed chain due to their stability during processing. Their impacts in food and feedstuff pollution were accentuated due the climate change in the region. They are characterized by their toxicological effects on human and animal health but also by their harmful economic impact. Mediterranean countries: Algeria, Egypt, Libya, Morocco and Tunisia are characterized by high temperatures and high relative humidity, particularly in littoral regions that provide favorable conditions for fungal growth and toxinogenesis. Many scientific papers have been published recently in these countries showing mycotoxin occurrence in different commodities and an attempt at bio-detoxification using many bio-products. In order to minimize the bioavailability and/or to detoxify mycotoxins into less toxic metabolites (bio-transforming agents), safe and biological methods have been developed including the use of lactic acid bacteria, yeasts, plant extracts and clays minerals from Mediterranean regions. The aim of this review is to present the pollution of mycotoxins in food and feedstuff of humans and animals and to discuss the development of effective biological control for mycotoxin removal/detoxification and prevention using bio-products. This review will also elucidate the new used natural products to be considered as a new candidates for mycotoxins detoxification/prevention on animal feedstuffs.

[[A MULTICENTER SPANISH STUDY OF ATROPINE 0.01% IN CHILDHOOD MYOPIA PROGRESSION]].

Myopia, short-sightedness, is the most frequent cause of vision difficulty and its prevalence is expected to rise. Nowadays, the usage of atropine drops is effective for myopia progression control. Studies on the Asian population showed that atropine 0.01% is more efficient and safer than solutions that have a higher concentration. In this study, we report findings from a multicenter Spanish study that showed that atropine 0.01% decreases the progression of myopia in a pediatric population, with relatively few adverse effects. The results of this study may be relevant to doctors who treat children who have myopia, as well as to the children treated and their parents.

Adherence to the Mediterranean diet among adults in Mediterranean countries: a systematic literature review.

BACKGROUND AND AIM: While the Mediterranean diet (MD) is promoted in non-Mediterranean countries, inhabitants of Mediterranean countries seem to be shifting away from this healthy diet. The aim of this study is to provide an overview of MD adherence in the general adult population of Mediterranean countries. METHODS: A systematic review was conducted following the PRISMA 2020 (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidelines and registered in the Prospero database (CRD42020189337). Literature was searched in PubMed, Web of Science and PsycINFO databases for studies published from 2010 up to and including 2021. The following inclusion criteria were used: age 18 years and older, sample size > 1000 participants, and using a validated MD adherence score. Studies that only included participants with nutrition-related or other severe chronic disorders, as well as studies that only included specific subpopulations (e.g., pregnant women), were excluded in order to focus on the general adult population. A quality analysis of the included studies was done using the NCCMT scale. RESULTS: A total of 50 studies were included. The number of participants in the included studies ranged between 1013 and 94,113. Most of the included studies pertained to the European Mediterranean countries, with fewer studies from the Middle Eastern and North African Mediterranean countries. The vast majority of the included studies reported low or moderate MD adherence, both based on the mean adherence as well as the low or moderate adherence category often being the most prevalent. There were no clear differences noted between sex and age groups. The quality assessment generally showed weak or moderate scores. CONCLUSIONS: Mediterranean populations have been showing moderate adherence to MD in the past 10 years, indicating room for improving adherence to the MD in countries of its origin.

The Analysis of Trends of Preschool Child Stunting, Wasting and Overweight in the Eastern Mediterranean Region: Still More Effort Needed to Reach Global Targets 2025.

BACKGROUND: This study was undertaken to analyze and compare Eastern Mediterranean (EM) countries in achievement of WHO nutrition global targets for children growth indicators by 2025. METHODS: A total of 108 national surveys from 20 countries in EM region were analyzed to estimate the prevalence of stunting and wasting and 93 surveys to estimate the prevalence of overweight/obesity in children. These data were obtained from national surveys included in the WHO Global Database on Child Growth and Malnutrition. RESULTS: In EM region, the prevalence of childhood stunting was estimated to have a 38% decline from 2000 (34.7%) to 2025 (21.2%). Only three countries in EM region (Iran and Jordan, Saudi Arabia) were anticipated to achieve the expected WHO target by 2025. From 2000 to 2020, the prevalence of wasting decreased from 6.9 to 5.3. Six countries were presumed to achieve the expected WHO target by 2025. Nine countries will presumably have overweight rates >5% (Djibouti, Egypt, Iraq, Kuwait, Lebanon, Libya, Morocco, Syrian Arab Republic and Tunisia) in 2025 whereas five countries will have overweight rates above 10% (Egypt, Libya, Morocco, Syrian Arab Republic and Tunisia). CONCLUSION: Despite descending trends of child stunting and wasting and a secular trend of child obesity in EM region, it is expected that WHO targets will not be achieved by 2025. A diverse socio-economic condition in EM countries necessitates different action plans. International determination, political commitment and, above all, involvement of the families are needed to achieve 2025 targets for child stunting, wasting and overweight/obesity.

A systematic review on hospital inefficiency in the Eastern Mediterranean Region: sources and solutions.

BACKGROUND: Evaluating hospital efficiency is a process to optimize resource utilization and allocation. This is vital due to hospitals being the largest financial cost in a health system. To limit avoidable uses of hospital resources, it is important to identify the sources of hospital inefficiencies and to put in place measures towards their reduction and elimination. Thus, the purpose of this research is to examine the sources of hospital inefficiency in the Eastern Mediterranean Region, and existing strategies tackling this issue. METHODS: In this study, the electronic databases MEDLINE (via PubMed), Web of Science, Embase, Google, Google Scholar, and reference lists of selected articles, were explored. Studies on inefficiency, sources of inefficiency, and strategies for inefficiency reduction in the Eastern Mediterranean region hospitals, published between January 1999 and May 2018, were identified. A total of 1466 articles were selected using the initial criteria. After further reviews based on the inclusion and exclusion criteria, 56 studies were eligible for this study. The chosen studies were conducted in Iran (n = 35), Saudi Arabia (n = 5), Tunisia (n = 5), Jordan (n = 4), Pakistan (n = 2), the United Arab Emirates, Palestine, Iraq, Oman, and Afghanistan (n = 1 each). These studies were analyzed using content analysis in MAXQDA 10. RESULTS: The analysis showed that approximately 41% of studies used data envelopment analysis (DEA) to measure hospital efficiency. Sources of hospital inefficiency were divided into four categories for analysis: Hospital products and services, hospital workforce, hospital services delivery, and hospital system leakages. CONCLUSION: This study has revealed some sources of inefficiency in the Eastern Mediterranean Region hospitals. Inefficiencies are thought to originate from excess workforce, excess beds, inappropriate hospital sizes, inappropriate workforce composition, lack of workforce motivation, and inefficient use of health system inputs. It is suggested that health policymakers and managers use this evidence to develop appropriate strategies towards the reduction of hospital inefficiency.

Prevalence and emergence of carbapenemases-producing Gram-negative bacteria in Mediterranean basin.

The emergence and the global spread of carbapenemases concern to health services worldwide. Their celestial rise among Gram-negative bacilli has challenged both the scientific and pharmaceutical sectors. Indeed, infections caused by these bacteria have limited treatment options and have been associated with high mortality and morbidity rates. Carbapenemase producers are mainly identified among Klebsiella pneumoniae, Escherichia coli, Pseudomonas aeruginosa, and Acinetobacter baumannii and still mostly in hospital settings and rarely in the community. They are closely related to KPC, VIM, IMP, NDM, and OXA-48 types. The encoding genes are mostly plasmid located and associated with various mobile genetic elements. The Mediterranean area is of interest due to a great diversity and population mixing. The prevalence of carbapenemases is particularly high and variant among countries, partially depending on the population exchange relationship between the regions and the possible reservoirs of each carbapenemase. This review described the epidemiology of carbapenemases in this region of the world highlighting the worrisome situation and the need to screen and detect these enzymes to prevent and control their dissemination especially as it is clear that very few novel antibiotics will be introduced in the next few years, making the dissemination of carbapenem-resistant Gram-negative bacteria of crucial importance worldwide.

Profile of paediatric occupational therapy practice in Eastern Mediterranean countries.

BACKGROUND: Paediatric occupational therapy (OT) is considered the largest practice area in OT in several regions, including the Eastern Mediterranean (EM) countries. AIMS/OBJECTIVES: This study aimed to establish a profile of paediatric occupational therapists in EM countries to identify theoretical models, assessments and interventions employed. It also investigated the therapists' usage of evidence-based practice in their practice. MATERIAL AND METHODS: We conducted a cross-sectional survey using a questionnaire which was distributed electronically to occupational therapists working with children. RESULTS: The participants included 118 therapists. Majority of the participants were working at rehabilitation centres. The primary client groups were pre- and school-age children with autism spectrum disorder and cerebral palsy. The most frequently used assessments were sensory-related tools. Activities of daily living and play were the most often targeted interventional area. Participants highlighted some of the challenges faced in implementing evidence in their practice. CONCLUSION: Paediatric occupational therapists are usually exposed to specific age groups and conditions. However, a lack of knowledge practice in some areas and challenges in others exist. SIGNIFICANCE: Within the EM region, knowledge regarding therapists' practices is lacking. Actions should be taken to improve current practice and meet the current needs of clients, and utilise evidence-based practices.

Iodine Status in Cyprus and Neighboring Countries: A Review Article.

Despite the implementation of global iodine supplementation initiatives in the past decade, the problem of iodine deficiency persists as a significant public health concern in numerous countries. Although cretinism is now rare in developed countries, iodine deficiency can still lead to less severe cognitive deficits, which can negatively impact academic achievement, intellectual capacity, and work productivity. There is a scarcity of studies regarding the status of Cyprus, and the global database does not have any information pertaining to the prevalence of iodine deficiency in Cyprus. The geographical setting of the research is of importance as it pertains to the separation of Cyprus into two distinct areas. One region is predominantly inhabited by Greek Cypriots, where the practice of salt iodization is not mandatory. Conversely, the other region is primarily inhabited by Turkish Cypriots, who may potentially experience higher amounts of iodine contact due to their reliance on food imports from Turkey, where salt-iodisation is compulsory. The main objective of this study is to provide an overview of recent research conducted on the prevalence of iodine deficiency in Cyprus and neighboring Mediterranean nations. In this study, we assess the current method and subsequently offer public health recommendations for future research endeavors.

Antimicrobial Resistance: Stewardship and One Health in the Eastern Mediterranean Region.

Antimicrobial resistance (AMR) is a major threat in the Eastern Mediterranean region (EMR) due to factors such as the high prevalence of infectious diseases, weak health systems, and the misuse of antimicrobials. This paper aims to discuss how interdisciplinary action and collaboration, specifically through antimicrobial stewardship (AMS) and the One Health approach, can effectively address AMR in the EMR. The review focuses on successful AMS initiatives and the adoption of the One Health approach in countries within the EMR, including the Gulf Cooperation Countries (GCC), Egypt, Iran, Jordan, and Pakistan. The goal is to highlight the potential for progress in combating AMR and identify challenges and opportunities for strengthening interdisciplinary collaboration. The results showcase successful AMS programs and One Health initiatives in various EMR countries, demonstrating their potential to address AMR challenges. The paper also discusses the challenges faced by these nations, such as limited resources, fragmented health systems, and knowledge gaps. Additionally, opportunities for enhancing interdisciplinary action through regional cooperation, international partnerships, and research and innovation are outlined. In conclusion, this paper emphasizes the importance of a comprehensive and collaborative response to combat AMR in the EMR. It advocates for the One Health approach as a crucial framework to guide these efforts, promoting coordinated action, improved surveillance, responsible antimicrobial use, and enhanced interdisciplinary collaboration to effectively mitigate the threat of AMR.

Hospital efficiency in the eastern mediterranean region: A systematic review and meta-analysis.

Background: Recent rising costs and shortages of healthcare resources make it necessary to address the issue of hospital efficiency. Increasing the efficiency of hospitals can result in the better and more sustainable achievement of their organizational goals. Objective: The purpose of this research is to examine hospital efficiency in the Eastern Mediterranean Region (EMR) using data envelopment analysis (DEA). Methods: This study is a systematic review and meta-analysis of all articles published on hospital efficiency in Eastern Mediterranean countries between January 1999 and September 2020, identified by searching PubMed through MEDLINE, Web of Science, Scopus, Science Direct, and Google Scholar. The reference lists of these articles were checked for additional relevant studies. Finally, 37 articles were selected, and data were analyzed through Comprehensive Meta-Analysis Software (v.2.2.064). Results: Using the random-effects model, the mean hospital efficiency in Eastern Mediterranean hospitals was 0.882 ± 0.01 at 95% CI. Technical efficiency (TE) was higher in some countries such as Iraq (0.976 ± 0.035), Oman (0.926 ± 0.032), and Iran (0.921 ±0.012). A significant statistical correlation was observed between the hospital efficiency and the year of publication and sample size (p < 0.05). Conclusion: Efficiency plays a significant role in hospital growth and development. Therefore, it is important for healthcare managers and policymakers in the EMR to identify the causes of inefficiency, improve TE, and develop cost-effective strategies.

Dynamic effect of exchange rate depreciation on carbon emission in the Mediterranean basin: fresh insights from linear and non-linear ARDL approaches.

The key objective of this study is to explore the relationship between economic growth, renewable and non-renewable energy consumption, exchange rate variation, and environmental pollution by carbon dioxide (CO2) emissions in 19 coastline Mediterranean countries over the period 1995-2020. We suggest the application of two different approaches, namely, the symmetric autoregressive-distributed lag (ARDL) and the non-linear ARDL (NARDL) model. These methods distinguished from traditional ones by the fact that they assess both the long and short run dynamics among variables. More importantly, the NARDL method is the only technique enabling us to test the asymmetric effects of a shock in independent variables on dependent ones. Our results indicate that the long-term pollution is positively correlated with exchange rate for developed countries and negatively correlated for developing ones. Since environmental degradation in developing countries is more vulnerable to any fluctuation in exchange rate, we suggest that policymakers in Mediterranean developing countries must pay more attention to exchange rate variation as well as boosting renewable energy consumption in order to decrease CO2 emissions.

Hepatitis A and E in the Mediterranean: A systematic review.

Hepatitis A (HAV) and Hepatitis E (HEV) considered to be major public health threats worldwide. Although, both infections are more common in developing countries, an increased number of HAV and HEV cases have been reported in developed countries. This systematic review analyzes epidemiological profiles of HAV and HEV in the Mediterranean countries. By using PRISMA guideline, we searched for articles from 2010 to 2020 referring HAV and HEV outbreaks from online databases: Scopus, PubMed and Springerlink. From 33265 unique publications initially captured, data was extracted from 101 articles investigating country and year of outbreak, transmission mode, vehicle of infection, mean age and sex of patients, symptoms reported, vaccination applied and diagnostic method. Our results indicate that occurrence of HAV and HEV in Mediterranean countries had increased with main transmission vehicle reported as food or water and transmission point as refugee camps. More results (countries, differences, other characteristics). Thus, public health authorities should give a priority to face up challenges regarding the prevalence of both viruses and control strategies to prevent upcoming outbreaks.

Taxonomical Identification and Safety Characterization of Lactobacillaceae from Mediterranean Natural Fermented Sausages.

Fermented meat products represent an important industrial sector in Europe, particularly in the Mediterranean Countries (MC), where the presence of numerous local productions, still obtained through spontaneous fermentation, is recognized as a formidable treasure chest of unexplored microbial biodiversity. Lactobacillaceae naturally occurring in fifteen spontaneously fermented sausages from MC (Italy, Spain, Croatia, and Slovenia) were isolated and taxonomically characterized using molecular techniques. Additionally, a safety assessment for the presence of antibiotic resistances and biogenic amine (BA) production was performed to determine their suitability as autochthonous starter cultures. Molecular typing, performed using REP-PCR, discriminated 151 strains belonging to Latilactobacillus sakei (59.6%), Latilactobacillus curvatus (26.5%) and Companilactobacillus alimentarius (13.9%). The minimum inhibitory concentrations (MICs) of eight different antibiotics revealed a high resistance to streptomycin (27%), tetracycline (16%), followed by gentamycin (14%) and kanamycin (13%). Interestingly, the results showed a geographical distribution of resistant biotypes. tetM/tetS or ermB genes were identified in only six strains. The amino-biogenic potential of the strains was assessed, confirming the absence of this trait among L. sakei, while a high number of producer strains was found among L. curvatus. On the 151 analyzed strains, 45 demonstrated safety traits for their future use as starter food cultures. These results open the way to further studies on the technological properties of these promising autochthonous strains, strongly linked to the Mediterranean environment.

Early health system responses to the COVID-19 pandemic in Mediterranean countries: A tale of successes and challenges.

This paper conducts a comparative review of the (curative) health systems' response taken by Cyprus, Greece, Israel, Italy, Malta, Portugal, and Spain during the first six months of the COVID-19 pandemic. Prior to the COVID-19 pandemic, these Mediterranean countries shared similarities in terms of health system resources, which were low compared to the EU/OECD average. We distill key policy insights regarding the governance tools adopted to manage the pandemic, the means to secure sufficient physical infrastructure and workforce capacity and some financing and coverage aspects. We performed a qualitative analysis of the evidence reported to the 'Health System Response Monitor' platform of the European Observatory by country experts. We found that governance in the early stages of the pandemic was undertaken centrally in all the Mediterranean countries, even in Italy and Spain where regional authorities usually have autonomy over health matters. Stretched public resources prompted countries to deploy "flexible" intensive care unit capacity and health workforce resources as agile solutions. The private sector was also utilized to expand resources and health workforce capacity, through special public-private partnerships. Countries ensured universal coverage for COVID-19-related services, even for groups not usually entitled to free publicly financed health care, such as undocumented migrants. We conclude that flexibility, speed and adaptive management in health policy responses were key to responding to immediate needs during the COVID-19 pandemic. Financial barriers to accessing care as well as potentially higher mortality rates were avoided in most of the countries during the first wave. Yet it is still early to assess to what extent countries were able to maintain essential services without undermining equitable access to high quality care.

The nexus between human development and fishing footprint among mediterranean countries.

The last decades have shown that human activities damaged environmental quality and biodiversity. As accepted the need of sustainable development, there should be balance between economic, social and environmental issues in the long term. Ecological footprint is an important indicator that shows how human activities reduce environmental quality among a specific region or country. In addition, human capital is mostly used indicator to estimate economic and environmental development level. In this study, it is aimed to explore the effect of human capital on fishing footprint for 10 Mediterranean Countries during the period 1995-2018. According to empirical evidences, it is concluded that for relatively low human capital level, human capital has negative effect on sustainability and in the relatively high level, it has positive effect on sustainability.

Assessing the linkage between energy consumption, financial development, tourism and environment: evidence from method of moments quantile regression.

According to the United Nations World Tourism Organization (UNWTO), tourism sector ranks high in terms of her contribution to economic growth and employment opportunity generation in most economies. Several studies have been documented in the extant literature on the nexus between emission, tourism, and economic growth. However, the role of foreign direct investment that highlights either pollution haven or halo hypothesis and pivotal role of domestic credit to private sector in an environmental Kuznets curve (EKC) environment is lacking in the extant literature. To this end, this study used augmented mean group (AMG) and method of moment quantile regression (MM-QR) approaches to explore the nexus between per capital income and its square, tourism, foreign direct investment, domestic credit to private sector and CO2 emission. Empirical results show that tourism had a negative significant relationship with CO2 emission. Furthermore, income on the other hand had positive relationship with emissions while its square had negative relationship with emissions. This result also shows the presence of EKC indicating the inverted U-shaped curve. FDI has shown a positive significant relationship with pollution which indicates the pollutant haven hypothesis (PHH), and credit to private sector shows a positive relationship with CO2 emission. On the causality analysis from Dumitrescu and Hurlin panel causality test, there was a bi-directional causality between: tourism and CO2 emission, per capital income and CO2 emission as well as domestic credit and CO2 emission. From these outcomes, it shows that tourism development is not detrimental to environmental quality in the Mediterranean region investigated. However, there is need for caution on FDI influx and dirty economic activities that might compromise environmental quality in the study bloc.

Olive oil consumption is associated with a lower risk of cardiovascular disease and stroke.

BACKGROUND & AIMS: The specific association of olive oil consumption with coronary heart disease (CHD) or stroke has not been totally established. OBJECTIVE: to examine whether olive oil consumption is associated with subclinical atherosclerosis, the risk of total cardiovascular disease (CVD), CHD, and stroke. METHODS: Three cohorts were included: AWHS (2318 men), SUN Project (18,266 men and women), and EPIC-Spain (39,393 men and women). Olive oil consumption was measured at baseline using validated questionnaires. RESULTS: In the AWHS, 747 participants had a positive coronary artery calcium score (CACS>0), and the OR (95% CI) was 0.89 (0.72, 1.10) in those with virgin olive oil consumption ≥30 g/day (v. <10 g/day). In the SUN Project (follow-up 10.8 years) 261 total CVD cases occurred, and the HR was 0.57 (0.34, 0.96) for consumptions ≥30 g/day (v. <10 g/day). In the EPIC-Spain (follow-up 22.8 years) 1300 CHD cases and 938 stroke cases occurred; the HRs for stroke according, 0 to <10 (ref), 10 to <20, 20 to <30, and ≥30 g/day of olive oil consumption, were 0.84 (0.70, 1.02), 0.80 (0.66, 0.96), 0.89 (0.74, 1.07). A weaker association was observed for CHD. The association was stronger among those consuming virgin olive oil, instead of common (refined). CONCLUSIONS: Olive oil is associated with lower risk of CVD and stroke. The maximum benefit could be obtained with a consumption between 20 and 30 g/day. The association could be stronger for virgin olive oil and might operate from the early stages of the disease.

Between panic and motivation: did the first wave of COVID-19 affect scientific publishing in Mediterranean countries?

Due to the ongoing COVID-19 pandemic that began in the winter of 2020, all communities and activities globally have been positively or negatively affected. This scientometric study raises an interesting question concerning whether the volume and characteristics of scientific publishing in all disciplines in 23 Mediterranean countries have been impacted by the pandemic and whether variations in the cumulative totals of COVID-19 cases have resulted in significant changes in this context. The Scopus database and SciVal tool supplied the necessary data for the years targeted for comparison (2019 and 2020), and the annual growth rates and differences were computed. The study used the Mann-Whitney test to examine the significance of the differences between the two years and the Spearman and Kendall correlation tests to evaluate the effect of the number of infections on these differences for all aspects of scientific performance. The findings demonstrated that the COVID-19 pandemic served as a powerful incentive, and the Mediterranean region experienced considerable differences in the volume and features of publications during this crisis. The most substantial implications were the significant growth from 3.1 to 9.4% in productivity and the increases in the annual growth rates of international collaboration, by 12% for the collaboration among Mediterranean countries and 10% for collaboration with the top ten epidemic countries. It was also proven that some characteristics of the publications were positively correlated with the total number of infections. This investigation can help university leaders and decision-makers in higher education and research institutions in these countries make decisions and implement measures to bridge the gaps and motivate researchers in all fields to conduct more research during this ongoing pandemic. Supplementary Information: The online version contains supplementary material available at 10.1007/s11192-022-04391-w.

The Effectiveness of Environmental Taxes in Reducing CO2 Emissions in Passenger Vehicles: The Case of Mediterranean Countries.

The transport sector is the biggest source of CO2 emissions in Europe. It is responsible for over a quarter of all greenhouse gas emissions. Passenger vehicles, alone, account for nearly 41% of these emissions, resulting in human health impacts. To meet the Paris climate commitments, cars and vans should be decarbonized until 2050. Such a transformation requires general changes, such as how the vehicles are owned, taxed, and driven. The European Federation for Transport and Environment revealed that Mediterranean countries tend to emit less per vehicle compared to the northern and central Europeans. Intriguingly, this does not necessarily correspond to motorization rates. In this article, we assess whether the observed reductions in CO2 emissions in the Mediterranean countries can be attributed to vehicle taxation on CO2 emissions. We apply panel data econometric techniques using data on annual registrations from 2008 to 2018 and model the demand for new-vehicle purchases and their responsiveness to changes in both CO2-based taxation and circulation tax. Our results show the determinants of new-vehicle demand and the change in the emissions rate in each country under the taxation currently adopted. We found that fiscal policies can have an important role in reducing the emission in the Mediterranean countries.

Regime-dependent effect of tourism on carbon emissions in the Mediterranean countries.

This study aims to test the effects of the number of tourist arrivals and tourism receipts on carbon emissions for the Mediterranean countries. The study investigates 15 Mediterranean countries including Albania, Algeria, Bosnia and Herzegovina, Croatia, Cyprus, Egypt, France, Greece, Israel, Italy, Lebanon, Morocco, Spain, Tunisia, and Turkey. The sample countries are selected considering the availability of the data. The annual data covering the period between 2001 and 2017 is used for the empirical analysis. The study employs econometrics models to test the EKC (environmental Kuznets curve) hypothesis. The results show that tourist arrival and tourism receipts reduce carbon emissions. However, this effect differs for equations taking per capita income as regime variables into account. Thus, tourist arrivals increase carbon emission up to a certain threshold within the scope of EKC hypothesis; it decreases carbon emission above this level. On the other hand, the effects of tourism receipts on carbon emissions are statistically insignificant in the first regime and reduce carbon emissions in the second regime.