The Burden and Genetic Diversity of Mycobacterium bovis Infection in Humans in the Middle East and North Africa: A Systematic Review and Meta-Analysis.

Zoonotic tuberculosis (zTB) includes human tuberculosis caused by animal-associated Mycobacterium species, Mycobacterium bovis (M. bovis) being the major cause of zTB. This systematic review and meta-analysis was conducted to estimate the pooled burden of human M. bovis infection and describe the genetic diversity of M. bovis isolated from humans in the Middle East and North Africa (MENA) region. A literature search was conducted in PubMed/MEDLINE, Scopus, Web of Science, Embase, and Google Scholar, followed by manual screening of additional references. The literature used for this paper were published between 2000 and 2025. A random-effects meta-analysis was used to estimate the pooled prevalence of human M. bovis infection. Heterogeneity was assessed using the I2 statistic, while sensitivity analysis and Egger's regression test were used to assess the robustness of the findings and potential small-study effects, respectively. Totally, 27 studies from 10 MENA countries involving 6224 participants and 154 M. bovis-infected cases were included. The pooled prevalence of human M. bovis infection was 3% (95% CI: 2%-4%), with substantial heterogeneity (I2 = 73.9%). The pooled prevalence was 4% in North Africa and 3% in the Middle East (p = 0.408). The individual study did not have an effect on the pooled prevalence as the leave-one-out sensitivity analysis did not change the pooled prevalence. The funnel plot showed some visual asymmetry, while Egger's regression test did not provide statistical evidence of small-study effects (p = 0.852). The M. bovis isolated from humans in MENA region were classified under European 1 (Eu1) and European 2 (Eu2) clonal complexes. In conclusion, the review highlighted the significance of M. bovis infection in humans in the MENA region, although there is a shortage of epidemiological data from more than 50% of the countries of the region. The isolation of Eu1 and Eu2 M. bovis clonal complexes from human M. bovis isolates suggested the importation was infected from Europe, which further transmitted the strains to humans. Strengthening of a One Health approach-based surveillance and molecular epidemiological studies in all MENA countries would contribute to the control of M. bovis in animals and humans in the region.