A review of cutaneous leishmaniasis in Morocco: A vertical analysisto determine appropriate interventions for control and prevention.

Leishmaniasis is considered one of the most neglected diseases worldwide. In Morocco, cutaneous leishmaniasis is an important public health problem. Leishmania major and Leishmania tropica are the two major species in this country. Despite all efforts, monitoring and control of the cutaneous leishmaniasis is still challenging. We used for the first time a vertical analysis of the control of cutaneous leishmaniasis in Morocco from the document review and publications. This analysis allowed us to develop an epidemiological model that emphasized key possible interventions. No evaluation studies of these interventions in Morocco were done. Global Evidence underline the effectiveness of preventive interventions produced in integrate inter-sectorial strategy framework (e.g use of insecticide-treated bednets, indoor residual spraying and rodents' control) rather than treatments such as based thermotherapy, cryotherapy, photodynamic therapy, CO2 laser and paromomycin. Therefore, integrated vector management control (IVMC) with communityc participation is recommended as effective strategy. Strengthening of the IVMC with community involvement are necessary conditions to improve the program of cutaneous leishmaniasis and prevent epidemic foci appearance.

Human cystic echinococcosis in Morocco: Ultrasound screening in the Mid Atlas through an Italian-Moroccan partnership.

BACKGROUND: Cystic echinococcosis (CE) is a neglected parasitic zoonosis with considerable socioeconomic impact on affected pastoral communities. CE is endemic throughout the Mediterranean, including Morocco, where the Mid Atlas is the most prevalent area for both human and animal infection. The highest hospital annual incidence of human CE is recorded in the provinces of Ifrane and El Hajeb. However, hospital-based statistics likely underestimate the real prevalence of infection, as a proportion of cases never reach medical attention or official records. METHODOLOGY/PRINCIPAL FINDINGS: In 2012, a project on clinical management of CE in Morocco was launched with the aims of estimating the prevalence of human abdominal CE in selected rural communes of the above mentioned provinces using ultrasound (US) screening and training local physicians to implement US-based focused assessment and rational clinical management of CE according to the WHO-IWGE Expert Consensus. A total of 5367 people received abdominal US during four campaigns in April-May 2014. During the campaigns, 24 local general practitioners received >24 hours of hands-on training and 143 health education sessions were organized for local communities. We found an overall CE prevalence of 1.9%, with significantly higher values in the rural communes of Ifrane than El Hajeb (2.6% vs 1.3%; p<0.001). CE cysts were predominantly in inactive stage, especially in older age groups. However, active cysts were present also in adults, indicating acquisition of infection at all ages. Province of residence was the only risk factor consistently associated with CE infection. CONCLUSIONS/SIGNIFICANCE: Our results show a high prevalence and on-going, likely environmental transmission of CE in the investigated provinces of Morocco, supporting the implementation of control activities in the area by national health authorities and encouraging the acceptance and divulgation of diagnosis and treatment algorithms based on imaging for CE at both national and local level.

Urbanization of human visceral leishmaniasis in Morocco.

Human visceral leishmaniasis one of the seven most neglected tropical diseases in the world. In Morocco, HVL is widespread in all regions; but it is more common in the northern part with sporadic cases observed in the South. During the period between 2004 and 2013, the most affected Moroccan provinces were Taounate province, with 220 cases (16.09% of all cases), followed by Chefchaouen with 13.17% and Taza with 10.46% of the total cases. Children < 5 years old are the most affected age group, most cases registered were male. Geographic distribution of HVL showed predominance in rural areas but we noted that it's opening to be urban.

Epidemiological characteristics of visceral leishmaniasis in Morocco (1990-2014): an update.

Leishmaniases are parasitic diseases frequent in the Mediterranean Basin. Visceral leishmaniasis (VL) is a notifiable parasitic disease that increased in incidence in Morocco over the past few years and has recently emerged in several new foci, causing a public health problem in Morocco. The aim of this study is to describe the spatio-temporal distribution of VL in Morocco between 1990 and 2014 period in order to highlight important features and trends of VL and its epidemiology and to assess whether the activity of the unit reflects the situation of the disease at the national level and whether it could constitute an indicator of public health relevance. Two thousand four hundred and twenty one cases were reported in Morocco between 1990 and 2014 with an average annual reported incidence rate of 0.4 cases per 100.000 inhabitants. Before 1996 the average annual incidence of VL was 50 cases on average. After this date the number of cases increased and then remained stable with around 100-150 cases per year. Children whose age varies between 1 and 4 years old are the most affected with 1327 (74%) of total cases; nevertheless the adult starts to be affected by the disease. In 2000, 65% of positive cases of VL are concentrated at both northern regions: Taza-Al Hoceima- Taounate with 45% of cases, Tanger- Tetouan mainly represented by Chefchaoun with 20% of cases. The Fez-Boulemane region located in the center recorded 12% of cases. Throughout the years the map VL distribution has been progressively changed and spatial spread of the disease to the center is noted in 2007. 2014 has been marked by an even greater extension of the disease to the center and south of Morocco. Nationally in 2014, 34 of 75 provinces and prefectures are affected compared to 2000, when 22 out of 82 provinces and prefectures were affected. Leishmania infantum was identified the causative agent based on species- specific PCR-Lei70 assay. VL remains a sporadically endemic parasitic disease in Morocco with a progressive extension of its range of distribution. Such a situation would relate to the geographical succession of Phlebotomine sand fly vectors, the difficulty of actions against the canine population reservoirs of L. infantum and unfavorable socio-economic factors.

Phlebotomus sergenti in a cutaneous leishmaniasis focus in Azilal province (High Atlas, Morocco): molecular detection and genotyping of Leishmania tropica, and feeding behavior.

BACKGROUND: Phlebotomus (Paraphlebotomus) sergenti is at least one of the confirmed vectors for the transmission of cutaneous leishmaniasis caused by Leishmania tropica and distributed widely in Morocco. This form of leishmaniasis is considered largely as anthroponotic, although dogs were found infected with Leishmania tropica, suggestive of zoonosis in some rural areas. METHODOLOGY AND FINDINGS: This survey aimed at (i) studying the presence of Leishmania in field caught Phlebotomus sergenti, (ii) investigating genetic diversity within Leishmania tropica and (iii) identifying the host-blood feeding preferences of Phlebotomus sergenti. A total of 4,407 sand flies were collected in three rural areas of Azilal province, using CDC miniature light traps. Samples collected were found to consist of 13 species: Phlebotomus spp. and 3 Sergentomyia spp. The most abundant species was Phlebotomus sergenti, accounting for 45.75 % of the total. 965 female Phlebotomus sergenti were screened for the presence of Leishmania by ITS1-PCR-RFLP, giving a positive rate of 5.7% (55/965), all being identified as Leishmania tropica. Nucleotide heterogeneity of PCR-amplified ITS1-5.8S rRNA gene-ITS2 was noted. Analyses of 31 sequences obtained segregated them into 16 haplotypes, of which 7 contain superimposed peaks at certain nucleotide positions, suggestive of heterozygosity. Phlebotomus sergenti collected were found to feed on a large variety of vertebrate hosts, as determined by Cytochrome b sequencing of the DNA from the blood meals of 64 engorged females. CONCLUSION: Our findings supported the notion that Phlebotomus sergenti is the primary vector of Leishmania tropica in this focus, and that the latter is genetically very heterogeneous. Furthermore, our results might be suggestive of a certain level of heterozygosity in Leishmania tropica population. This finding, as well as the feeding of the vectors on different animals are of interest for further investigation.

Schistosoma haematobium detection in snails by DraI PCR and Sh110/Sm-Sl PCR: further evidence of the interruption of schistosomiasis transmission in Morocco.

BACKGROUND: This is the first study in Morocco to estimate snail infection rates at the last historic transmission sites of schistosomiasis, known to be free from new infection among humans since 2004. Screening of large numbers of snails for infection is one way to confirm that Schistosoma haematobium transmission has stopped and does not resurge. METHODS: A total of 2703 Bulinus truncatus snails were collected from 24 snail habitats in five provinces of Morocco: Errachidia, El Kelaa des Sraghna, Tata, Beni Mellal, and Chtouka Ait Baha. All visible snails were collected with a scoop net or by hand. We used waders and gloves as simple precautions. Snails were morphologically identified according to Moroccan Health Ministry guide of schistosomiasis (1982).All snails were analyzed in pools by molecular tool, using primers from the newly identified repeated DNA sequence, termed DraI, in the S. haematobium group. To distinguish S. bovis and S. haematobium, the snails were analyzed by Sh110/Sm-Sl PCR that was specific of S. haematobium. RESULTS: The results showed that snails from Errachidia, Chtouka Ait Baha, sector of Agoujgal in Tata and sector of Mbarkiya in El kelaa des Sraghna were negative for DraI PCR; but, snails from remaining snail habitats of El Kelaa des Sraghna, Tata and Beni Mellal were positive. This led to suggest the presence of circulating schistosome species (S. haematobium, S. bovis or others) within these positive snail habitats. Subsequently, confirmation with S. haematobium species specific molecular assay, Sh110/Sm-Sl PCR, showed that none of the collected snails were infected by S. haematobium in all historic endemic areas. CONCLUSION: The absence of S. haematobium infection in snails supports the argument of S. haematobium transmission interruption in Morocco.