RESUMO
In Morocco, cutaneous leishmaniasis (CL) represents a concern with three causative parasite species. Despite this, rapid diagnostic test (RDT) for CL is not part of the national control strategy. This study evaluates the acceptability and micro-costing of the CL Detect Rapid Test by Inbios International. The study was conducted from June 2019 to January 2020 and included 46 healthcare professionals from 40 primary healthcare centers and district labs. Data was collected by self-administered questionnaires and interviews and analysed using NVivo, Jamovi, and Python to generate a predictive model and sensitivity analysis by calculating the average Cost-Benefit Ratio for compared CL diagnostic scenarios. The exchange rate is 1 USD = 9.6 MAD (Moroccan Dirham) in November 2019. The CL-RDT received notable acceptance for its user-friendliness and time efficiency compared to traditional microscopy. Micro-costing data revealed that the average unit cost for microscopy is 15 MAD [7-31], whereas 75 MAD [52-131] for CL-RDT. Altogether, the diagnostic cost for microscopy is 115 MAD±4, marginally higher than the 102 MAD±2 for CL-RDT (p = 0,05). Sensitivity analysis identified the most cost-benefit scenarios based on a Cost-Benefit Ratio (CBR). The optimal approach involves using CL-RDT once at a primary healthcare centre (PHC) (CBR = 1.4), especially if the unitary cost is below 79 MAD. The second-best option is using CL-RDT once at a laboratory (CBR = 1.0), which is advantageous if priced under 54 MAD. However, using CL-RDT twice for the same lesion had a less favourable CBR of 0.6 and was only beneficial if priced below 09 MAD. The reference scenario was a single CL-RDT at the PHC followed by microscopy at a laboratory. In conclusion, the forthcoming CL-RDT, expected to feature enhanced sensitivity, is advocated for deployment in resource-limited endemic areas.
RESUMO
Three Leishmania species are responsible of cutaneous leishmaniasis (CL) in Morocco. Zoonotic CL due to Leishmania major and Leishmania infantum, the first is known as established in the eastern arid regions, whereas the latter evolves sporadically, especially in the North. While Leishmania tropica, classically considered anthroponotic, is endemic in the semi-arid regions and is largely distributed throughout the country. The aim of this study was to identify the Leishmania species causing CL in two Provinces in arid pre-Saharan region known as zoonotic CL foci, and to contribute an update to the national data concerning the distribution of Leishmania species in both regions. The recruitment of patients was done in six localities in Ouarzazate and Zagoura provinces in 2015 and 2016. Out of 81 samples collected, 66 were positive (81%) by ITS1-PCR amplification of Leishmania DNA extracted from stained smears. The highest rate of Leishmania infection was registered in children aged 9 years or less (71,2%). The ITS1-PCR- RFLP analysis revealed the predominance of L. major infecting 52 patients (79%), followed by L. tropica in 12 patients (18%) and L. infantum in 2 patients who had no history of travel outside the studied area (3%). The sequencing of the ITS1 of both L. infantum, showed 100% similarities with L. infantum strains isolated from dogs and visceral leishmaniasis patients from the south and north of Morocco. The coexistence of the 3 Leishmania species in the same focus, and the difficult distinction of infections associated to the different Leishmania species based only on clinical lesions' aspects complicate the diagnosis and then the national control strategy, as well as the therapeutic management. The epidemiological pattern of CL in the studied areas appears to have changed during the last decades, from a predominant zoonotic CL caused by L. major to a polymorphic disease that can be due to any of the 3 Leishmania species. The expansion of L. infantum and L. tropica in southern parts of Morocco, calls for in depth epidemiological investigations for a better understanding of the CL situations in Southern parts of the country and for an assessment of the climate impact and environment changes on the leishmaniasis transmission system.