Micro-costing from healthcare professional's perspective and acceptability of cutaneous leishmaniasis diagnostic tools in Morocco: A mixed-methods study.

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.

Geographical distribution and molecular survey of freshwater snail intermediate hosts of Schistosoma haematobium by DraI/Sh73 PCR in eliminated foci of Morocco.

Morocco had reached the level of schistosomiasis elimination 16 years ago. However the spread of freshwater snails in several breeding sites, and imported schistosome infection, still exist. Therefore, snail survey is a crucial component to sustain elimination progress. This study aimed to evaluate and to incorporate DraI/Sh73 PCR, for detecting early prepatent Schistosoma haematobium infection in snail host, into epidemiologic surveillance for schistosomiasis, particularly in reportedly eliminated foci where S.bovis overlaps with S. haematobium. The geographical distribution and the density of Bulinus truncatus and Planorbarius metidjensis were monitored for six years (2014-2019) and snail sampling were conducted in Fkih Ben Saleh province. All snails were analyzed in pools by DraI/Sh73 PCR. Results showed absence of Planorbarius metidjensi and none of the collected Bulinus truncatus snails were infected by S. haematobium. DraI/Sh73 PCR using pooled snail extracts is specific, feasible and suitable in routine malacological survey in the post elimination phase of schistosomiasis in Morocco.

Environmental, Climatic, and Parasite Molecular Factors Impacting the Incidence of Cutaneous Leishmaniasis Due to Leishmania tropica in Three Moroccan Foci.

Cutaneous leishmaniasis (CL) occurring due to Leishmania tropica is a public health problem in Morocco. The distribution and incidence of this form of leishmaniasis have increased in an unusual way in the last decade, and the control measures put in place are struggling to slow down the epidemic. This study was designed to assess the impact of climatic and environmental factors on CL in L. tropica foci. The data collected included CL incidence and climatic and environmental factors across three Moroccan foci (Foum Jemaa, Imintanout, and Ouazzane) from 2000 to 2019. Statistical analyses were performed using the linear regression model. An association was found between the occurrence of CL in Imintanout and temperature and humidity (r2 = 0.6076, df = (1.18), p-value = 3.09 × 10-5; r2 = 0.6306, df = (1.18), p-value = 1.77 × 10-5). As a second objective of our study, we investigated the population structure of L.tropica in these three foci, using the nuclear marker internal transcribed spacer 1 (ITS1). Our results showed a low-to-medium level of geographic differentiation among the L.tropica populations using pairwise differentiation. Molecular diversity indices showed a high genetic diversity in Foum Jemaa and Imintanout; indeed, 29 polymorphic sites were identified, leading to the definition of 13 haplotypes. Tajima's D and Fu's F test statistics in all populations were not statistically significant, and consistent with a population at drift-mutation equilibrium. Further analysis, including additional DNA markers and a larger sample size, could provide a more complete perspective of L. tropica's population structure in these three regions. In addition, further research is needed to better understand the impact of climatic conditions on the transmission cycle of Leishmania, allowing both for the development of effective control measures, and for the development of a predictive model for this parasitosis.

Epidemiological features of cutaneous leishmaniasis in diagnosed patients from an endemic area (central Morocco).

Cutaneous leishmaniasis represents the most neglected tropical disease across the world. In Morocco, this disease is endemic and constitutes a major public health problem, with a national control program been implemented. The current study aimed to determine the pattern and epidemiological features of cutaneous leishmaniasis in affected patients in an area covered by the CL control and prevention program (Central Morocco). A total of 161 patients suspected for cutaneous leishmaniasis were diagnosed according to WHO laboratory methods, and 82 cases were confirmed positive for CL. The reports were analysed by patients' socio-geographic status, gender and age. The number and distribution of CL lesions by location, gender and age were investigated. Overall the confirmed cases, 89 % were infected by Leishmania tropica versus 21 % for Leishmania major. Females were significantly more affected than males (p < 0.01). Children (0-15 years), especially those ≤ 7 years of age, were the most affected. For the distribution of lesions, single lesion cases were largely preponderant (70.7 %) compared to multiple lesions. Face location was significantly more frequent (62.2 %) compared to limbs (26.8 %). Face lesions were found more prevalent in children than in adults while limb lesions were highly observed in adults. The pattern of the disease is affected by many factors (e.g. environment, gender, age, etc.) and has specifics to be considered in prevention and control programs in endemic areas.

Retrospective study on imported schistosomiasis in Morocco between 2005 and 2017.

Since 2004, no indigenous cases of schistosomiasis have been found in Morocco; only imported cases have been detected. The aim of the present study was to describe and analyse the epidemiological profile of imported schistosomiasis between 2005 and 2017, and, by this, attract attention to the probability of a reintroduction of this disease. During this period, 27 cases were recorded in Morocco, with a male predominance (13:1). All cases reported were found among African immigrants from Mauritania (37%), Mali (18%) and Senegal (15%). Schistosoma heamatobium was the most dominant specie. Most cases were reported in Rabat and Agadir, where there are many snail habitats. To prevent a re-emergence of the disease, the main challenge would be to consolidate and maintain a sustainable surveillance and control system of the importation of bilharzia. The frequency of asymptomatic schistosomiasis justifies a systematic health check-up for all travellers, migrants and immigrants.

The pattern of cystic echinococcosis in children in an endemic area in Morocco.

Cystic echinococcosis is a parasitic infection of major public health concern. The infection is generally acquired during childhood and the disease incubation period can last many years. The occurrence and characteristics of the disease in children were not well studied. The present study aimed to explore the pattern and features of cystic echinococcosis in children in rural and urban environments in Morocco. A total of 338 children diagnosed and treated for cystic echinococcosis were investigated. The trend of the infection, risk and exposure factors and the distribution of the anatomic locations of cysts were studied. A non-uniform decrease in proportions of infected children was found. Children from rural environs had significantly higher infection rates than children from urban environs (p < 0.001). Males were significantly more infected than females. Children aged 7-11 years were the most affected. For cysts locations, single organ involvement was found in 94.4% of the children versus 5.6% with multi-organ localization. Despite control program, active transmission of echinococcosis still occurred in children and remains a major public health problem. The infection in younger population may have some features that need to be considered in the prevention and control programs in endemic areas.

Thirty years of cutaneous leishmaniasis in Tadla-Azilal focus, Morocco.

Cutaneous leishmaniasis (CL) due to Leishmania tropica is a major health problem in Tadla-Azilal focus, Morocco, where the first case was registered, here, in one locality named Tanant in 1987. So far, CL remains endemic and largely widespread. The objective of this study was to analyze the current eco-epidemiological situation after thirty years of active transmission. Data used are the official ones, obtained from the Moroccan Ministry of Health. Between 1998 and 2015, 5518 CL cases were registered in three provinces; Azilal, Béni Mellal and Fquih Ben Salah. CL has spread, from the historical focus in Azilal along two axes; one to the Northeastern Mountains and the other to the Northwestern plains. CL infected both genders and all ages, with large number of women (53%) and children (75% had <9 years old). More interestingly, age range at risk was larger within females than males, and this difference was more pronounced in Fquih Ben Salah where the disease had newly emerged. Similarly, age ranges at risk were larger and fluctuated significantly each year particularly in new emerging areas in Béni Mellal and Fquih Ben Salah. All these variations may testify, at least in part, to the process of acquiring immunity. Altitude structured CL spatiotemporal distribution. CL was more prevalent in two altitudes ranges; 400-500 m and 800-900 m. The situation and duration of period of diagnostic of CL varied largely according to the altitude. These different scenarios could be related to the seasonal dynamics of vector populations.

Accuracy of a Rapid Diagnostic Test Based on Antigen Detection for the Diagnosis of Cutaneous Leishmaniasis in Patients with Suggestive Skin Lesions in Morocco.

In rural areas in Morocco, diagnosing cutaneous leishmaniasis (CL) can be challenging. We evaluated the accuracy of a rapid diagnostic test (RDT) based on antigen detection, CL Detect Rapid Test™ (Inbios International Inc., Seattle, WA), in this setting. We consecutively recruited patients with new skin ulcers in nine primary health centers. We took a dental broach sample for the RDT and two other tissue samples by scraping the border and center of the lesion with a scalpel and smearing it on a slide. We duplicated each smear by pressing a clean slide against it and processed the slides by microscopy, polymerase chain reaction (PCR) internal transcribed spacer 1, and kDNA minicircle PCR. In a subgroup with positive PCR, the Leishmania species was identified using PCR-restriction fragment length polymorphism and PCR-sequencing of hsp70 genes. A participant with positive microscopy and/or PCR was considered a confirmed CL case. We computed sensitivity (Se) and specificity (Sp) of the RDT compared with this reference standard (ClinicalTrials.gov registration: NCT02979002). Between December 2016 and July 2017, we included 219 patients, 50% of them were under 18 years old. Rapid diagnostic test Se was 68% [95% confidence interval (CI): 61-74], Sp 94% [95% CI: 91-97], positive predictive value 95% [95% CI: 92-98], and negative predictive value 64% [95% CI: 58-70]. Despite its low Se, this novel RDT is a useful addition to clinical management of CL in Morocco, especially in isolated localities. Rapid diagnostic test-positive lesions can be treated as CL; but when RDT negative, microscopy should be done in a second step. The Se of the RDT can probably be optimized by improving the sampling procedure.

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.