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EMIS 2017 Journal Articles 2017 Published Articles

Modelling the health and cost implications of expanded access to HIV, HCV and sexually transmitted infection testing in Switzerland

Swiss Medical Weekly, 155(12):4581, 2025 (doi:10.57187/s.4581).

Authors: Harsh Vivek Harkare, Marina Antillón, Axel J. Schmidt, Fabrizio Tediosi

Background: This study was conducted as part of the Swiss National Programme to Stop HIV, Hepatitis B Virus, Hepatitis C Virus and Sexually Transmitted Infections (NAPS), which aims to reduce the spread of sexually transmitted infections in Switzerland. The goal was to identify the most effective and cost-efficient screening strategies to lower the incidence of human immunodeficiency virus (HIV), hepatitis C virus (HCV), syphilis, Neisseria gonorrhoeae and Chlamydia trachomatis by improving access to screening.

Methods: A Markov model was developed to assess the impact of various screening strategies among key populations over two years, including men who have sex with men (MSM), female sex workers (FSW) and people who inject drugs (PWID). The model further stratifies individuals based on partner number (MSM) and injection-equipment sharing (PWID). Comprehensive cost estimates for screening and treatment were derived from insurance data, literature and expert opinions. The effectiveness of screening interventions was evaluated by measuring reductions in disease incidence and cost savings, comparing the costs of screening to those of acute and chronic care for prevented infections.

Results: Increased screening frequency among key populations led to a reduction in incidence for all five infections studied. The largest effect was seen in people who inject drugs who share injecting equipment, where HCV incidence fell by up to 76% with four annual screens. However, only screening for HIV, HCV and syphilis proved to be cost-saving. Screening for Chlamydia trachomatis and Neisseria gonorrhoeae consistently incurred net costs due to the high screening costs and relatively low treatment costs.

Conclusion: Targeted expansion of screening among key populations can reduce the incidence of HIV, HCV and syphilis in Switzerland, with regular screening offering potential cost savings to insurers under specific coverage and treatment scenarios.

Available online

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EMIS 2017 Journal Articles 2017 Published Articles

Self-reported hepatitis A and B vaccination coverage among men who have sex with men (MSM), associated factors and vaccination recommendations in 43 countries of the WHO European Region: results from the European MSM Internet Survey, EMIS-2017

EuroSurveillance, 2024; 29(45):pii=2400100 (doi: 10.2807/1560- 7917.ES.2024.29.45.2400100).

Authors: Michael Brandl, Axel J Schmidt, Ulrich Marcus, Erika Duffell, Ettore Severi, Antons Mozalevskis, Anda Kivite-Urtane, Matthias an der Heiden, Sandra Dudareva.

Abstract

Background. Hepatitis A and B vaccinations are recommended for men who have sex with men (MSM), given their increased risk of infection. However, data on vaccination programmes are scarce.

Aim. To use information on vaccination recommendations and vaccine uptake among MSM in the WHO European Region to guide prevention.

Methods. From a large pan-European MSM Internet Survey (EMIS-2017), we analysed data on self-reported hepatitis A and B vaccination status by age, education, financial coping, settlement size, outness (disclosure of sexual behaviour), migration history and diagnosis with hepatitis C or HIV, using multivariable logistic regression. Additionally, we collected information on national hepatitis A and B vaccination recommendations.

Results. We present data of 113,884 MSM, median age 36 years (IQR: 27–47). Vaccination for hepatitis A and B was recommended and free for MSM in 7 and 18 of 43 countries, respectively. Of all respondents, 48% (n = 50,966) reported ever being vaccinated against hepatitis A, and 53% (n = 56,889) against hepatitis B. Odds for being vaccinated against hepatitis A increased with outness (‘out to (almost) all’ aOR: 1.78, 95% CI: 1.72–1.85 vs ‘out to none’) and were higher in countries where vaccination was recommended and free for MSM (aOR:2.22, 95% CI: 1.29–3.82 vs ‘no recommendation’). Results for hepatitis B were similar (outness: aOR:1.81, 95%CI:1.75–1.88 and MSM-specific vaccination recommendation: aOR: 2.44, 95% CI: 1.54–3.85).

Conclusion. Large proportions of MSM in Europe remain vulnerable to hepatitis A and B, despite available vaccination. Implementation of MSM-specific vaccination recommendations and greater efforts to improve the societal climate for MSM are needed to address gaps in vaccine coverage.

Available online

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EMIS 2017 Journal Articles 2017 Published Articles

Viral hepatitis knowledge and vaccination awareness among men who have sex with men (MSM) in 43 countries of the WHO European Region: results from the European MSM Internet Survey, EMIS-2017

EuroSurveillance, 2024; 29(45):pii=2400099 (doi: 10.2807/1560-7917.ES.2024.29.45.2400099).

Authors: Sofia Burdi, Michael Brandl, Ulrich Marcus, Erika Duffell, Ettore Severi, Antons Mozalevskis, Kristi Rüütel, Achim Dörre, Axel J Schmidt*, Sandra Dudareva*.

Abstract

Background. Recent hepatitis A virus outbreaks in Europe affecting men who have sex with men (MSM) and ongoing hepatitis B virus transmission among MSM underscore the ongoing need for viral hepatitis prevention in this population.

Aim. To describe viral hepatitis knowledge and associated factors among MSM in the WHO European Region to inform targeted prevention.

Methods. In the European MSM Internet Survey (EMIS-2017), basic knowledge was defined as correctly identifying at least 4 of 5 statements about viral hepatitis and vaccination. We described basic knowledge by country. In a multilevel logistic regression model, we estimated adjusted odds ratios (aOR) with 95% confidence intervals (CI) for having basic knowledge and explanatory variables: sociodemographic characteristics, history of hepatitis C and/or HIV diagnosis, sexual orientation disclosure at last sexually transmitted infections (STI) test and outness..

Results. Of 113,884 participants across 43 WHO European Region countries, 68% demonstrated basic knowledge, ranging from 50% in Israel to 80% in the Netherlands. Basic knowledge was significantly associated with older age (≥ 40 years vs < 25 years, aOR: 2.9, 95% CI: 2.7–3.0), a history of hepatitis C and/or HIV diagnosis (aOR:1.8, 95% CI: 1.7–1.9) and sexual orientation disclosure at last STI test (aOR: 1.3, 95% CI: 1.2– 1.3), among other factors.

Conclusion. We found a knowledge disparity regard- ing viral hepatitis and hepatitis vaccination aware- ness among MSM across Europe, highlighting a need to address these gaps. A non-judgemental, accept- ing climate that allows individuals attending medical services to safely disclose their sexual orientation is fundamental to enable healthcare professionals to target information and preventative measures more effectively.

Available online

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EMIS 2017 Journal Articles 2010 Journal Articles 2017 Published Articles

HIV Testing and Treatment among HIV-Positive Men who have Sex with Men (MSM) Living in Russia: Data from Two Waves of the European MSM Internet Survey

AIDS and Behavior, 2024; 28:4040–4045 (doi: 10.1007/s10461-024-04476-y).

Authors: Rigmor C. Berg, Vegard Skogen, Axel J. Schmidt, Roman Nesterov & Andrey Beloglazov.

Abstract

We examined changes in HIV testing and medical care among men who have sex with men (MSM) in Russia. Data come from the 2010 and 2017 waves of the European MSM Internet Survey. From 2010 to 2017 there was an increase in the proportion who had ever received an HIV test (+ 11.2%), had tested for HIV in the last year (+ 2.1%), had ever taken antiretroviral therapy (ART) (+ 31.9), were currently taking ART (+ 31.5%), and had an undetectable viral load (+ 19.4%). These results are encouraging, yet they also reveal that substantial proportions of MSM experience considerable unmet prevention and treatment needs.

Available online

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EMIS 2017 Journal Articles 2017

Determinants of HIV Testing Among Migrant Men Who Have Sex With Men from Sub‐Saharan Africa and Other Regions Residing in 10 European Countries

AIDS and Behavior, 2024; 28:488–506 (doi: 10.1007/s10461-023-04239-1).

Authors: Oladipupo Shobowale, Axel J. Schmidt, Paula Meireles, Daniela Rojas Castro, Sandrine Detandt, Sarah E. Stutterheim, Peter Weatherburn, Kai J. Jonas.

Abstract

Migrant men who have sex with men (mMSM) from sub-Saharan Africa (SSA) and other regions outside Europe are highly vulnerable to HIV. However, research on the determinants of HIV testing among mMSM from SSA, and how these differ across the categories of mMSM living in Europe, is limited.

Using data from the European MSM Internet Survey (EMIS- 2017), we assessed HIV testing prevalence and recency in mMSM from SSA and other mMSM residing in ten European countries, as well as the determinants of HIV testing across different mMSM categories with logistic regression analyses.

Ever-testing for HIV was slightly higher in mMSM from SSA (83%) compared to other mMSM categories (75–80%), except for mMSM from Latin America and Caribbean region (84%). Overall, 20% of mMSM had never tested. In multivariable analysis, higher age (adjusted odds ratio [AOR] 1.05, 95% confidence interval [CI] 1.01–1.10), higher HIV knowledge (AOR 1.45, 95%-CI 1.11–1.90), and residence in smaller settlements (AOR 0.45, 95%-CI 0.21–0.96) were significantly associated with ever testing for HIV in mMSM from SSA. Comparing mMSM from SSA to mMSM from other regions, we found varying significant similarities (higher age, residence in smaller settlements and HIV knowledge) and differences (lower educational attainment, not identifying as gay, being a student, and limited disclosure of homosexual attraction) in the determinants of ever-testing for HIV.

Community-specific interventions addressing identified sociodemographic and behavioral determinants to increase HIV testing uptake in the different mMSM categories and better data for further research are warranted.

Available online

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EMIS 2017 Journal Articles 2017

Comparison of the burden of self-reported bacterial sexually transmitted infections among men having sex with men across 68 countries on four continents

BMC Public Health 2023; 23:1008 (doi: 10.1186/s12889-023-15946-8)

Authors: Ulrich Marcus, Maria Veras, Jordi Casabona, Carlos F. Caceres, Nathan Lachowsky, Susanne B. Schink, Axel J. Schmidt

Abstract

Background 

Men who have sex with men (MSM) are in general more vulnerable to sexually transmitted infections (STIs) than the heterosexual men population. However, surveillance data on STI diagnoses lack comparability across countries due to differential identification of MSM, diagnostic standards and methods, and screening guidelines for asymptomatic infections.

Methods 

We compared self-reported overall diagnostic rates for syphilis, gonorrhea, and chlamydia infections, and diagnostic rates for infections that were classified to be symptomatic in the previous 12 months from two online surveys. They had a shared methodology, were conducted in 68 countries across four continents between October 2017 and May 2018 and had 202,013 participants.

Results 

Using multivariable multilevel regression analysis, we identified age, settlement size, number of sexual partners, condom use for anal intercourse, testing frequency, sampling rectal mucosa for extragenital testing, HIV diagnosis, and pre-exposure prophylaxis use as individual-level explanatory variables. The national proportions of respondents screened and diagnosed who notified some or all of their sexual partners were used as country-level explanatory variables. Combined, these factors helped to explain differences in self-reported diagnosis rates between countries. The following differences were not explained by the above factors: self-reported syphilis diagnoses were higher in Latin America compared with Europe, Canada, Israel, Lebanon, and the Philippines (aOR 2.30–3.71 for symptomatic syphilis compared to Central-West Europe); self-reported gonorrhea diagnoses were lower in Eastern Europe and in Latin America compared with all other regions (aOR 0.17–0.55 and 0.34–0.62 for symptomatic gonorrhea compared to Central-West Europe); and self-reported chlamydia diagnoses were lower in Central East and Southeast Europe, South and Central America, and the Philippines (aOR 0.25–0.39 for symptomatic chlamydia for Latin American subregions compared to Central West Europe).

Conclusions 

Possible reasons for differences in self-reported STI diagnosis prevalence likely include different background prevalence for syphilis and syndromic management without proper diagnosis, and different diagnostic approaches for gonorrhea and chlamydia.

Available online

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EMIS 2017 Journal Articles 2017

Spatio-temporal changes in pre-exposure prophylaxis uptake among MSM in mainland France between 2016 and 2021: a Bayesian small area approach with MSM population estimation

J. Int. AIDS Soc. 2023, 26:e26089 (doi: 10.1002/jia2.26089)

Authors: Haoyi Wang, Jean-Michel Molina, Rosemary Dray-Spira, Axel J. Schmidt, Ford Hickson, David van de Vijver, Kai J. Jonas

Abstract:

Introduction

In France, oral pre-exposure prophylaxis (PrEP) for HIV prevention has been publicly available since 2016, mainly targeting at men who have sex with men (MSM). Reliable and robust estimations of the actual PrEP uptake among MSM on a localized level can provide additional insights to identify and better reach marginalized MSM within current HIV prevention service provision. This study used national pharmaco-epidemiology surveillance data and regional MSM population estimations to model the spatio-temporal distribution of PrEP uptake among MSM in France 2016–2021 to identify marginalized MSM at risk for HIV and increase their PrEP uptake.


Methods

We first applied Bayesian spatial analyses with survey-surveillance-based HIV incidence data as a spatial proxy to estimate the size of (1) regional HIV-negative MSM populations and (2) MSM who could be eligible for PrEP use according to French PrEP guidelines. We then applied Bayesian spatio-temporal ecological regression modelling to estimate the regional prevalence and relative probability of the overall- and new-PrEP uptake from 2016 to 2021 across France.


Results

HIV-negative and PrEP-eligible MSM populations vary regionally across France. Île-de-France was estimated to have the highest MSM density compared to other French regions. According to the final spatio-temporal model, the relative proba- bility of overall PrEP uptake was heterogeneous across France but remained stable over time. Urban areas have higher-than- average probabilities of PrEP uptake. The prevalence of PrEP use increased steadily (ranging from 8.8% [95% credible interval 8.5%;9.0%] in Nouvelle-Aquitaine to 38.2% [36.5%;39.9%] in Centre-Val-de-Loire in 2021).


Conclusions

Our results show that using Bayesian spatial analysis as a novel methodology to estimate the localized HIV- negative MSM population is feasible and applicable. Spatio-temporal models showed that despite the increasing prevalence of PrEP use in all regions, geographical disparities and inequalities of PrEP uptake continued to exist over time. We identified regions that would benefit from greater tailoring and delivery efforts. Based on our findings, public health policies and HIV prevention strategies could be adjusted to better combat HIV infections and to accelerate ending the HIV epidemic.

Available online

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EMIS 2017 National reports 2017

EMIS-2017 National Reports

Since data collection has closed in February 2018, we have distributed 39 country of residence datasets to our EMIS-2017 partners who are working on a wide range of national reports, in a variety of formats. As these reports are published they will be added here. No datasets were requested from Luxemburg, Bosnia iH, Iceland, or Turkey. As of July 2023, 22 countries have provided at least one national report. Many countries were interrupted in their report writing by the COVID-19 pandemic. We might still receive a report from the Netherlands, Poland, Portugal, and Slovakia. No reports are expected from Bulgaria, Croatia, Finland, Hungary, Lebanon, Lithuania, Latvia, North Macedonia, Romania, Serbia, Slovenia, the Philippines, or the United Kingdom.

EMIS-2017: Austria EMIS-2017 National Reports

EMIS-2017: Belarus EMIS-2017 National Reports

EMIS-2017: Belgium (België) EMIS-2017 National Reports

EMIS-2017: Belgium (Belgique) EMIS-2017 National Reports

EMIS-2017: Canada (main report) EMIS-2017 National Reports

EMIS-2017: Canada (Infographic summary) EMIS-2017 National Reports

EMIS-2017: Czechia EMIS-2017 National Reports

EMIS-2017: Cyprus EMIS-2017 National Reports

EMIS-2017: Denmark EMIS-2017 National Reports

EMIS-2017: Estonia EMIS-2017 National Reports

EMIS-2017: France EMIS-2017 National Reports

EMIS-2017: Germany EMIS-2017 National Reports

EMIS-2017: Greece (1) EMIS-2017 National Reports

EMIS-2017: Greece (2) EMIS-2017 National Reports

EMIS-2017: Ireland (Main Report) EMIS-2017 National Reports

EMIS-2017: Ireland (Community Report 1) EMIS-2017 National Reports

EMIS-2017: Ireland (Community Report 2) EMIS-2017 National Reports

EMIS-2017: Ireland (Community Report 3) EMIS-2017 National Reports

EMIS-2017: Ireland (Community Report 4) EMIS-2017 National Reports

EMIS-2017: Ireland (Infographic Demographics) EMIS-2017 National Reports

EMIS-2017: Ireland (Infographic Health) EMIS-2017 National Reports

EMIS-2017: Ireland (Infographic Behaviours) EMIS-2017 National Reports

EMIS-2017: Ireland (Infographic Needs) EMIS-2017 National Reports

EMIS-2017: Ireland (Infographic Interventions) EMIS-2017 National Reports

EMIS-2017: Ireland (Health technology assessment for PrEP) EMIS-2017 National Reports

EMIS-2017: Israel EMIS-2017 National Reports

EMIS-2017: Italy EMIS-2017 National Reports

EMIS-2017: Malta EMIS-2017 National Reports

EMIS-2017: Moldova EMIS-2017 National Reports

EMIS-2017: Norway EMIS-2017 National Reports

EMIS-2017: Russia EMIS-2017 National Reports

EMIS-2017: Spain EMIS-2017 National Reports

EMIS-2017: Sweden EMIS-2017 National Reports

EMIS-2017: Switzerland (Suisse) EMIS-2017 National Reports

EMIS-2017: Switzerland (Schweiz) EMIS-2017 National Reports

EMIS-2017: Ukraine EMIS-2017 National Reports

Categories
EMIS 2017 International reports 2017

EMIS-2017 and LAMIS: UNAIDS

For World AIDS Days 2018–2021 we partnered with UNAIDS to present some key findings from the European and Latin American MSM Internet Surveys on the UNAIDS website for key populations. Findings are shown as interactive maps that include various sexual health indicatiors for gay men, bisexual men and other MSM. EMIS and LAMIS indicators were used until 2024.

Recruitment and Outness
  • Crude Recruitment Rate: Number of men reached by EMIS-2017/LAMIS, per 10,000 men aged 15–65
  • Not open about sexual orientation (non-outness): “Out” to few or none of friends, family, work (%)
HIV
  • HIV diagnosis: ever diagnosed with HIV (%)
  • Recent HIV diagnosis: HIV diagnosis in the past 12 months (%), excluding men diagnosed with HIV more than 12 months ago
  • HIV testing: Tested for HIV in the last 12 months (%), excluding those diagnosed longer ago
  • Community-based HIV testing: Using community HIV- testing at last HIV test (%, denominator includes untested  men)
Sexually Transmitted Infections: Testing, Diagnosis, and Partner Notifiaction
  • Comprehensive STI screen: HIV test, STI blood test, rectal swab, urethral (trans men if applicable: vaginal) swab or urine in the last 12 months (%), excluding men diagnosed with HIV more than 12 months ago
  • STI testing: any test for a sexually transmitted infection, in the previous 12 months (%)
  • Disclosure in health care: Disclosure of same-sex contacts towards health care provider during STI-testing in the last 12 months (%)
  • Syphilis: diagnosed in the previous 12 months (%)
  • Symptomatic syphilis: in the previous 12 months (%)
  • Gonorrhoea: diagnosed in the previous 12 months (%)
  • Symptomatic gonorrhoea: in the previous 12 months (%)
  • Chlamydia: diagnosed in the previous 12 months (%)
  • Symptomatic chlamydia: in the previous 12 months (%)
  • Partner notification among men with syphilis (%)
  • Partner notification among men with gonorrhoea (%)
Interventions
  • Targeted information:  Saw or heard information about HIV/STIs for MSM, last 12 months (%)
  • Received free condoms: Received free condom from NGOs, clinics, bars, or saunas, last 12 months (%)
Risk and precaution behaviour
  • Condomless anal sex: Condomless anal sex with non-steady male partners of unknown HIV status, last 12 months (%)
  • PrEP use:  Currently taking HIV pre-exposure prophylaxis daily or on demand (%), excluding HIV-diagnosed men
Knowledge
  • Lack of PrEP knowledge: Not knowing that PrEP is a pill taken before as well as after sex to prevent HIV infection (%) 
  • Lack of PEP knowledge: Not knowing that PEP stops HIV infection after exposure (%)
  • Lack of U=U knowledge: Not knowing U=U (that a person with undetectable viral load cannot pass on HIV, %) 
Vaccinations
  • HAV vaccination: history of at least one dose of hepatitis A vaccine (%), exluding those with a history of hepatitis A
  • HBV vaccination: history of at least one dose of hepatitis B vaccine (%), exluding those with a history of hepatitis B

Suggested citation for EMIS/LAMIS indicators on the UNAIDS website for key populations until 2024:

UNAIDS Key Population Atlas: EMIS & LAMIS Indicators for men-who-have-sex-with-men. Geneva, 2018–21. Available at: https://kpatlas.unaids.org/dashboard

Disclaimer: Indicators published on the UNAIDS website for key populations based on data collected by the Latin America MSM Internet Survey (LAMIS) are not official/governmental data of the participating countries.

Available in 33 languages, the European MSM Internet Survey (EMIS-2017) recruited 137,358 qualifying participants from 46 countries across Europe and Lebanon, Israel, Canada and the Philippines. The Latin American MSM Internet Survey (LAMIS) recruited 64,655 participants from 18 countries.

EMIS-2017 was undertaken by researchers from Sigma Research at the London School for Hygiene and Tropical Medicine and the Robert Koch Institute. Data was collected between 18 October 2017 and 31 January 2018.

LAMIS, using the same questionnaire and finishing data collection on 12 May 2018, was the first multi-country survey for gay, bisexual, and other men who have sex with men (MSM) in Latin America. It was implemented by researchers from Right PLUS*, a coalition of researchers from Latin America, Portugal, Spain and the Netherlands, with support from the EMIS team.

EMIS and LAMIS required a great deal of international cooperation and relied on the support of national stakeholders to aid local recruitment. Through this cooperation comparable data are now available for the first time for more than 60 countries across 4 continents.

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EMIS 2017 Questionnaires 2017

EMIS-2017 Questionnaires & Variable Manual

The following questionnaires have been used in EMIS-2017. Individuals and organisations are welcome to use individual questions, or whole questionnaires, on the understanding that they credit Sigma Research / LSHTM in any written outputs from the project.

Manual

EMIS-2017 Variable Manual

Questionnaires

EMIS-2017 English language version (PDF of online only questionnaire)

EMIS-2017 Albanian language version (PDF of online only questionnaire)

EMIS-2017 Arabic language version (PDF of online only questionnaire)

EMIS-2017 Bulgarian language version (PDF of online only questionnaire)

EMIS-2017 Croatian / Serbian language version (PDF of online only questionnaire)

EMIS-2017 Czech language version (PDF of online only questionnaire)

EMIS-2017 Danish language version (PDF of online only questionnaire)

EMIS-2017 Dutch language version (PDF of online only questionnaire)

EMIS-2017 Estonian language version (PDF of online only questionnaire)

EMIS-2017 Filipino Cebuano language version (PDF of online only questionnaire)

EMIS-2017 Filipino Tagalog language version (PDF of online only questionnaire)

EMIS-2017 Finnish language version (PDF of online only questionnaire)

EMIS-2017 French language version (PDF of online only questionnaire)

EMIS-2017 German language version (PDF of online only questionnaire)

EMIS-2017 Greek language version (PDF of online only questionnaire)

EMIS-2017 Hebrew language version (PDF of online only questionnaire)

EMIS-2017 Hungarian language version (PDF of online only questionnaire)

EMIS-2017 Italian language version (PDF of online only questionnaire)

EMIS-2017 Latvian language version (PDF of online only questionnaire)

EMIS-2017 Lithuanian language version (PDF of online only questionnaire)

EMIS-2017 Macedonian language version (PDF of online only questionnaire)

EMIS-2017 Maltese language version (PDF of online only questionnaire)

EMIS-2017 Norwegian language version (PDF of online only questionnaire)

EMIS-2017 Polish language version (PDF of online only questionnaire)

EMIS-2017 Portuguese language version (PDF of online only questionnaire)

EMIS-2017 Romanian language version (PDF of online only questionnaire)

EMIS-2017 Russian language version (PDF of online only questionnaire)

EMIS-2017 Slovak language version (PDF of online only questionnaire)

EMIS-2017 Slovenian language version (PDF of online only questionnaire)

EMIS-2017 Spanish language version (PDF of online only questionnaire)

EMIS-2017 Swedish language version (PDF of online only questionnaire)

EMIS-2017 Turkish language version (PDF of online only questionnaire)

EMIS-2017 Ukrainian language version (PDF of online only questionnaire)