A review of cutaneous leishmaniasis in Morocco: A vertical analysisto determine appropriate interventions for control and prevention
Graphical abstract
Introduction
Leishmaniasis is a parasitic disease caused by an intracellular parasite of the genus Leishmania, transmitted to humans by the bite of infected female phlebotomine sand flies (Chaara et al., 2014). The disease is considered the third most important vector-borne disease after malaria and filariasis (Orellano et al., 2013). According to the Global Burden of Disease of the Institute for Health Metrics and Evaluation, the worldwide disability-adjusted life years of leishmaniasis is 3,316,780 / year. Globaly, leishmaniasis includes three clinical entities; visceral leishmaniasis (VL), cutaneous leishmaniasis (CL) and mucocutaneous leishmaniasis (MCL) (Nasir et al., 2014). About three-quarters of incidence cases of leishmaniasis are related to CL (Velez et al., 2009).
CL is a disease with a worldwide distribution; it is endemic in 98 countries with an estimated prevalence of 12 million people. An estimated 500,000–1,000,000 new cases of CL are seen each year, of which only 19–37% of cases are notified to health authorities (Tlamcani and Er Rami, 2014). The disease is a complex disorder that constitutes a major public health concern for the Eastern Mediterranean Regional Office (EMRO). The geographical distribution of CL includes North Africa, West Africa, the Middle East, Central Asia and South America and Central America, from northern Bolivia to Panama (Aoun and Bouratbine, 2014; Pigott et al., 2014). In the Middle East and North Africa CL is endemic in 18 countries (Hotez et al., 2012). This region accounts for the highest burden of CL in the world, with 57% of all cases and more than 100, 000 cases reported annually to WHO by countries in the region. Most cases do not involve a consulting doctor or health professional, therefore the cases are not always notified to health authorities. Therefore, the actual burden of the disease is estimated to be three to five times higher than that reported (Organisation Mondiale de la Santé (OMS), 2014). While typically not fatal, CL results in a profound stigma that affects the social and economic well-being of those affected (Yanik et al., 2004; Hotez, 2008). Morocco is within the endemic region and thus is an important Moroccan public health problem. There are three distinct clinical forms: Cutaneous Leishmania tropica (CLt), Cutaneous Leishmania major (CLm) and CL due to Leishmania infantum (Rioux et al., 1986a, Rioux et al., 1986b; Rioux et al., 1986a; Guilvard et al.,1991). Control of leishmaniasis in Morocco began in 1997 when the National Program of Leishmaniasis Control (NPLC) was established in order to allow the coding of various control measures and an information system to monitor the epidemiological situation in all provinces and prefectures. NPLC control activities are integrated with other activities of ambulatory and hospital health services. The management of this program is entrusted to the Directorate of Epidemiology of Disease Control through the Department of Parasitic Diseases and the Service of Vector Control. In 2009 an evaluation of NPLC was carried out by a WHO expert team commissioned by the Ministry of Health of Morocco to evaluate progress after 12 years of activity (Postigo and Bensalah, 2009). The mission was to assess: (i) the information system at the local, regional and central levels, (ii) the performance of screening and diagnosis and management of the patient, and (iii) the impact of strategies on leishmaniasis control. Despite the implementation of the operational recommendations formulated by WHO experts, the situation of CL worsened with very high numbers of cases (>6000 cases) for both CL forms being reported. Therefore, a strategic response action plan 2010 and 2012 was developed in 2009 to control this disease in Morocco. No significant reduction in the number of cases of CLt was observed until 2013 but reported incidence did stabilize. Reported cases of CLm decreased during the same period (Fig. 2). Another SAP 2013–2016 was then established and in 2015, 2813 cases of CL were recorded; 1859 were attributed to the CLt and 954 to CLm (Fig. 2) (Ministère de la santé du Maroc, 2013a, Ministère de la santé du Maroc, 2013b). Thus, despite the efforts made by the NPLC, it is obvious that CL continues to present challenges to be addressed by the Ministry of Health and raises questions about the performance of the program and the interventions to combat it. In this framework, the general objective of the work reported here is to evaluate the situation of CL in Morocco based on a literature review. We are using the vertical analysis approach defined as a structured analytical method applied to a relatively complex health problem. This strategic method used in public health consists of the identification, description and systematic analysis of a disease. Resulting evidence is used to prioritize interventions expected to solve or reduce the public health problem, in this case, CL in Morocco
Section snippets
Context of country
Morocco is located at the northwestern corner of Africa (Fig. 1). The area of the country is about 710,850 km². Morocco is bordered to the west by the Atlantic Ocean, to the north by the Mediterranean Sea and is separated from Spain by the 14 km of Strait of Gibraltar. It is also bordered to the East by Algeria and Mauritania to the South. Morocco is a country with an arid, semi-arid climate in the major part of the territory. Morocco has a Mediterranean climate characterized by hot dry summers
Incidence and geographic distribution of CL in Morocco
The retrospective analysis of Morocco's NPLC reports between 2004–2015 showed that there was a decrease in the number of incidents of CLm after the implementation of the 2010–2012 strategic action plan (SAP); 537 cases of CLm reported in 2013 and 954 cases in 2015. Moreover, no remarkable reduction in the number of cases of CLt was observed after the introduction of the SAP (2010–2012). Instead, we saw a stabilization of the incidence of this type of Leishmania with 2055 cases reported in 2012 (
Discussion
There is currently no well-defined model for effective control of this disease (Organisation mondiale de la santé (OMS), 2013). In Morocco, CL is a real health problem and is difficult to treat and control. Several factors contribute to this including: i) the number of species and interspecies variants of the parasite, ii) the complexity of parasitic life-cycles and parasite reservoirs, and iii) different geographical distributions of this disease complex.
In this study, we used a literature
Conclusion
The success of a public health program rests not only on the support of government and health care providers, but also on a supportive partnership with the community. The Moroccan government is called upon to support the development and progress of rural communities suffering from socio-economic problems. This emphasizes the integration of the community into NPLC strategies by aiming at a change in the behavior of the population towards hygiene, better use of insecticide-treated nets, and
Funding
This analysis has not received any funding; it is in framework of a Master's Degree in Public Health (MPH) of the first author Dr Majda LABOUDI at the Institute of Tropical Medicine (IMT) Antwerp, Belgium 2014–2015.
Competing interests
The authors declare that they have no competing interests.
Acknowledgments
The author thanks Dr. T. VERDOCK for the supervision of this work and for instructions which enrich our survey. My thanks also go to Miss B. AMEUR, Head of the vector control unit in the Directorate of Epidemiology and Control of Diseases (DELM) in Morocco for information on IMVC and Dr. A. LAAMRANI EL IDRISSI and Dr S BOUHOUT for their valuable assistance in data collection. Finally, we wish to thank Dr. W. GOFF, retired vector borne disease scientist with the United States Department of
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