Hindawi
BioMed Research International
Volume 2019, Article ID 5327287, 14 pages
https://doi.org/10.1155/2019/5327287
Research Article
Leishmaniasis in Northern Morocco: Predominance of
Leishmania infantum Compared to Leishmania tropica
Maryam Hakkour ,1,2,3 Mohamed Mahmoud El Alem ,1,2
Asmae Hmamouch,2,4 Abdelkebir Rhalem,3 Bouchra Delouane,2 Khalid Habbari,5
Hajiba Fellah ,1,2 Abderrahim Sadak ,1 and Faiza Sebti 2
1
Laboratory of Zoology and General Biology, Faculty of Sciences, Mohammed V University in Rabat, Rabat, Morocco
National Reference Laboratory of Leishmaniasis, National Institute of Hygiene, Rabat, Morocco
3
Agronomy and Veterinary Institute Hassan II, Rabat, Morocco
4
Laboratory of Microbial Biotechnology, Sciences and Techniques Faculty, Sidi Mohammed Ben Abdellah University, Fez, Morocco
5
Faculty of Sciences and Technics, University Sultan Moulay Slimane, Beni Mellal, Morocco
2
Correspondence should be addressed to Maryam Hakkour; maryam.hakkour@gmail.com
Received 24 April 2019; Revised 17 June 2019; Accepted 1 July 2019; Published 8 August 2019
Academic Editor: Elena Pariani
Copyright © 2019 Maryam Hakkour et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
In Morocco, Leishmania infantum species is the main causative agents of visceral leishmaniasis (VL). However, cutaneous
leishmaniasis (CL) due to L. infantum has been reported sporadically. Moreover, the recent geographical expansion of L. infantum
in the Mediterranean subregion leads us to suggest whether the nonsporadic cases of CL due to this species are present. In this
context, this review is written to establish a retrospective study of cutaneous and visceral leishmaniasis in northern Morocco
between 1997 and 2018 and also to conduct a molecular study to identify the circulating species responsible for the recent cases
of leishmaniases in this region. Data concerning leishmaniases cases were collected from the Epidemiology and Disease Control
Directorate from 1997 to 2018. Human samples obtained from peripheral laboratories were examined using PCR-ITS1 method. The
ITS1 products were subjected to digestion with the restriction endonuclease Mn1-I. Between 1997 and 2018, a total of 1,255 cases
of cutaneous and visceral leishmaniasis were recorded in Tangier-Tetouan-Al Hoceima Region, i.e., 1.56% of the reported cases
in Morocco (1,255/80,299). Concerning the geographical study covering the period 2007-2018, 79.5% (105/132) of the sectors were
affected by leishmaniases. The molecular results showed that Humans were found to be infected with the L. infantum species with
a high infection rate compared to L. tropica infection. Moreover, molecular characterization using ITS1 PCR-RFLP showed that the
density of L. infantum was significantly higher (n = 68/81; 84%) than that of L. tropica (n = 13/81; 16%) (P-value 9.894e-10). While
regarding visceral leishmaniasis, L. infantum was the only species responsible of this form. These findings of this study showed the
emergence of L. infantum in Morocco and suggest that this species might be more prevalent than previously thought. Furthermore,
the molecular determination of L. infantum will be helpful for control strategies by taking into consideration the reservoir of this
species.
1. Introduction
Leishmaniasis is a parasitic disease that affects both humans
and animals and is caused by flagellated protozoa belonging
to the genus Leishmania [1]. These unicellular protozoa are
usually transmitted by the bite of female phlebotomine sand
flies (Diptera, Psychodidae) [2]. It is known that more than 20
species of Leishmania infect mammals. They are responsible
for two forms of leishmaniasis depending on the location
of parasites in mammalian tissues, namely, visceral and
cutaneous forms. The outcome of the infection depends on
the species responsible and the immune responses of the host
[3].
Human cutaneous leishmaniasis (CL) is caused by most
Leishmania species of the subgenus Leishmania. In Maghreb
area, including Morocco, three major species responsible for
2
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6∘ 0 0 W
4∘ 0 0 W
N
W
E
M’diq Fahs - Fnideq
Anjra
S
Tetouan
Atlantic
Ocean
Larache
Chefchaouen
35∘ 0 0 N
35∘ 0 0 N
Tangier Assilah
Mediterranean Sea
Al Hoceima
100 50 0 100Km
6∘ 0 0 W
4∘ 0 0 W
Figure 1: The study area.
this disease are Leishmania major, L. tropica, and L. infantum
[4], the latter being more often associated with visceral
leishmaniasis. The transmission is zoonotic for L. major with
a wild animal reservoir [5], and rather anthroponotic for
L. tropica. In fact, the isolation of this species (MON-102
and MON-113) from dog suggests that this mammal (dog)
could be implicated as the secondary reservoir host in the
life cycle of L. tropica. Nevertheless, the few sporadic cases
viscerotropic do not confirm that the dog is the principal
host and the life cycle is zoonotic [6–8]. In some parts of the
Maghreb, L. Killicki has also been proven to be responsible
for zoonotic CL, particularly in Tunisia [9]. Concerning L.
infantum, studies carried out in Maghreb countries isolated
this species from dog suggesting it as the reservoir of this
disease [10].
Regarding visceral leishmaniasis (VL), Leishmania infantum is the single agent responsible for this human form in the
Mediterranean basin [11, 12]. However, Ready et al. suggested
that any parasite responsible for cutaneous leishmaniasis can
visceralize [13] (e.g., Leishmania tropica, which causes CL
cases, has been proven as the agent responsible for human VL
and canine leishmaniasis (CanL) in Turkey [14].
In Morocco, the epidemiological situation of leishmaniasis as well as the distribution of Leishmania species varies.
Two different eco-epidemiological entities have been known
in the past: CL due to L. major also called wet or rural form
and CL due to L. tropica also known as dry or urban form.
However, for L. infantum, it was responsible for sporadic cases
[4]. The recently published work revealed a new distribution
of species by province. Indeed, many studies reported that
CL cases in south-east of Morocco were caused essentially
by L. major but L. tropica is also present [15–17]. However,
in the Southwestern, L. tropica is the only circulating species
[18–20]. In the center of the kingdom, L. tropica is being
the only agent responsible for CL cases in some provinces
[21, 22]. In others, this species was isolated beside few cases of
L. infantum [23, 24]. Approaching north, limited cases of L.
infantum have been also isolated with the presence of major
cases of L. tropica [25].
Nevertheless, epidemiological data on leishmaniases are
missing in the northern region. So, in order to give a general
overview of the new distribution of CL species in Morocco,
it is essential to carry out molecular investigations in the
Northern provinces which have never been started and which
remain until nowadays unknown.
The purpose of this study is to establish epidemiological
data on leishmaniasis in seven provinces located in the
extreme north of Morocco during the 21-year period 19972018 and to characterize the parasite species responsible for
recent cases of leishmaniasis.
2. Material and Methods
2.1. Study Area. This study was established in TangierTetouan-Al Hoceima Region belonging to the northwestern section (35∘ 46 00 N, 5∘ 48 00 W) and concerns Al Hoceima, Chefchaouen, Larache, Tangier-Assilah,
Tetouan, M’diq-Fnidq, and Fahs-Anjra Provinces. This region
is bordered to the north by the Strait of Gibraltar and the
Mediterranean Sea, to the west by the Atlantic Ocean, to the
south-west by the Rabat-Sale-Kenitra Region, to the south
by the Fes-Meknes Region, and to the east by the Oriental
Region (Figure 1). Climatically, this region is characterized by
a Mediterranean climate [26]. Moreover, in terms of tourism,
its exceptional location with its two maritime facades and its
roots in history and cultural diversity predispose it to occupy
a favorite place as a tourist destination.
The Tangier-Tetouan-Al Hoceima Region extends over a
surface of 17,262 km2 (2.43% of the national territory) and
has a total of 3,556,729 inhabitants with a density of 206
inhabitants per km2 [27].
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2.2. Diagnosis
2.2.1. Microscopic Confirmation. The molecular characterization has concerned all smears received in the National Reference Laboratory for Leishmaniasis (NRLL) at the National
Institute of Hygiene (NIH-Rabat, Morocco) between 2016
and 2017 (89/119). The remaining cases were not received
and others were defective. These smears were sent by the
peripheral laboratories in order to confirm and control their
positivity. Only confirmed positive cases were included in this
study.
Concerning 2018, the number of smears received was not
representative compared to the number declared. As a result,
these cases were excluded from the molecular study.
2.2.2. DNA Extraction. The DNA extraction was performed
with the Qiagen Blood and Tissue kit (Hilden, Germany)
respecting the usage protocol provided by the manufacturer
with minor modifications (Proteinase K was incubated for 1H
at a temperature of 56∘ C) [28].
2.2.3. ITS1 PCR-RFLP Analysis. The internal transcribed
spacer (ITS1) region was amplified using the pairs of
primers LITSR (5 -TGATACCACTTATCGCACTT-3 ) and
L5.8S (5 -CTGGATCATTTTCCGATG-3 ). ITS1-PCR products were digested with the restriction endonuclease Mn1I [8, 25, 29, 30]. Reference strains of Leishmania tropica (MHOM/MA/2010/LCTIOK-4), Leishmania infan-tum
(MHOM/MA/1998/LVTA), and Leishmania major (MHOM/
MA/2009/LCER19-09) were used as positive controls.
2.3. Data Collection. In 1997-2018, a total of 1,255 leishmaniases cases were the subject of an epidemiological study. Data
on human cases were obtained from the Epidemiology and
Disease Control Directorate [31]. The data are the result of
passive surveillance based on the notifications recorded by
the medical staff of the provincial laboratories of TangierTetouan-Al Hoceima Region who reported each case to the
Epidemiology Department of the Ministry of Health. The
database contains all patient data, including sex, age, and
place of residence.
The study area is known to be moderately affected by
CL and highly affected by VL as well. In fact, in Morocco,
the provinces considered to be strongly affected by CL
recorded a total of between 10,500 and 1,000 cases during
this period (such as Errachidia Province, Zagora Province,
and Chichaoua Province). Provinces classified as moderately
affected recorded a total between 1,000 and 100 (such as Beni
Mellal Province, Settat Province, and Driouch Province).
Provinces with fewer than 100 cases are considered to be
slightly affected (such as Guercif Province, Agadir Province,
and Tiznit Province) [32]. About visceral form, the provinces
noted more than 100 cases are considered highly infected.
Provinces with 100-10 cases are known to be moderately
affected. Provinces registering less than 10 cases are poorly
affected.
Concerning the geographical study, all data about
autochthonous patients presenting the clinical symptoms of
3
leishmaniasis during 2007-2018 were collected from health
centers and infrastructure services of ambulatory actions
provincial of the study provinces.
2.4. Statistical Analysis. Statistical analysis was performed
using software R version 3.3.3.
3. Results
3.1. Molecular Diagnosis. A total of 89 slides were analyzed
by ITS1 PCR-RFLP. This total is distributed over the seven
Provinces: 38 CL slides in Larache Province, 21 CL/5VL slides
in Al Hoceima Province, 10 CL / 1VL slides in Tetouan
Province, 5 CL slides in Chefchaouen, 3 CL slides in FahsAnjra, 2 CL / 2VL slides in Tangier-Assilah, and 2 CL slides in
Mdiq-Fnidq (Table 1).
The results of this molecular characterization show the
coexistence of L. infantum and L. tropica responsible of
cutaneous form with a predominance of L. infantum species
(P-value 9.894e-10) while L. infantum is the only species
responsible of visceral form (Figure 2) (Table 2).
The distribution of Leishmania species is directly
associated with the presence of sandflies species. Figure 3
summarizes the results of molecular identification in
association with the repartition of sandflies species
[33] according to their bioclimatic stage preferences
(http://www.water.gov.ma/ressources-en-eau/presentationgenerale/).
3.2. Epidemiology of Leishmaniasis in
Tangier-Tetouan-Al Hoceima Region
3.2.1. Temporal Distribution of VL and CL Cases in TangierTetouan-Al Hoceima Region. According to the Moroccan
Ministry of Health, between 1997 and 2018, among the total
declared (1,255) of VL and CL cases, 44.2% (n=555/1,255)
have been noted as VL cases in this region.
Approximately half of the total VL cases (300/555 =
54.05%) were registered in Chefchaouen Province with an
average incidence of 2.86. In Al Hoceima Province, an
average incidence of 2.07 per year of cases were noted
(29.73% (n=165/555)) (Figure 4). As for them, Tetouan
Province, Larache Province, Mdiq-Fnidq Province, TangierAssila Province, and Fahs Anjra Province have registered,
respectively 7.20% (n=40/555), 6.49% (n=36/555), 1.44%
(n=8/555), 0.72% (n=4/555), and 0.36% (n=2/555) of cases.
About CL cases, a total of 700 cases were recorded
and distributed as follows: 32.14% (n=225/700) in Larache
Province, 28.86% (n=202/700) in Al Hoceima Province,
23.28% (n=163/700) in Chefchaouen Province, 10.86%
(n=76/700) in Tetouan Province, 2.43% (n=17/700) in
Tangier-Assila, 1.57% (n=11/700) in Fahs-Anjra Province, and
0.85% (n=6/700) in Mdiq-Fnidq Province (Figure 4).
3.2.2. Geographical Study of Leishmaniasis Cases in TangierTetouan-Al Hoceima Region. The geographical study showed
that 79.5% (105/132) of the sectors were affected by leishmaniasis in this study area between 2007 and 2018.
4
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Table 1: Molecular results of cutaneous and visceral leishmaniasis slides from the most.
Province
Larache
Al Hoceima
Tetouan
Chefchaouen
Sector
Urban/Rural
Ben said
Boujedyane
Bghadda
Zouada
Od Khalkhal
Sahel
Larache Center
Maada
DharRouah
Ayacha
Riassana
Od harti
Zaaroura
Souk Toulba
Ksar Kbir
Souk L’qolla
Laouamra
Bni Arouss
Al Manar
Ksar Bjir
Bni Garfet
Ajdir
Imzouren
Ait Youssef Ouali
Bni Bouayach
Taghzout
Arbaa Taourirt
Bni Abdellah
Izemmouren
Al Hoceima Center
Senada
Boudinar
Arbaa Taourirt
Nekkour
Targuist
Anzagh
Kalabonita
Douar Assammar
Ait ziane
Zinate
Azla
Bni Hsen
Tetouan
Stehat
Chefchaouen Center
R
R
R
R
R
R
U
R
R
R
R
R
R
R
U
R
R
R
R
R
R
U
R
R
R
R
R
R
R
U
R
R
R
R
R
R
R
R
R
R
R
R
U
R
U
Cutaneous form
L. infantum
L. tropica
2
0
1
3
2
0
1
0
1
0
1
0
2
0
1
0
1
0
4
0
5
0
1
0
1
0
2
0
2
0
1
0
1
0
2
0
1
0
1
0
1
1
0
1
5
0
1
0
3
0
0
1
1
0
1
0
1
0
1
0
1
0
1
0
1
0
2
0
1
0
1
3
0
1
0
1
1
0
2
0
1
0
3
0
1
0
0
1
Visceral form
L. infantum
1
1
1
1
1
1
-
Total
2
4
2
1
1
1
2
1
1
4
5
1
1
2
2
1
1
2
1
1
2
1
6
1
3
1
1
1
1
1
1
1
1
2
1
1
1
1
1
4
1
1
1
2
1
1
3
1
1
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Table 1: Continued.
Province
Fahs Anjra
Tanger-Assilah
Mdiq-Fnidq
Sector
Urban/Rural
Anjra
Khmis Anjra
Gzenaya
Mdiq
R
R
Cutaneous form
L. infantum
L. tropica
1
0
1
0
1
0
1
0
1
0
1
1
U
U
Visceral form
L. infantum
2
-
Total
1
1
1
1
1
2
2
R: rural, U: urban.
Table 2: Leishmania species responsible for cutaneous leishmaniasis in the northern region.
Provinces
Larache
Al Hoceima
Tetouan
Chefchaouen
Fahs Anjra
Tanger-Assilah
Mdiq-Fnidaq
Total
L. infantum
34
19
5
4
3
2
1
68
L. tropica
4
2
5
1
0
0
1
13
Total
38
21
10
5
3
2
2
81
P-value
1.135e-06∗
0.00020∗
1
9.894e-10∗
∗ P< 0.001.
1
2
3
4
5
6
7
8
9
10
Lt
Li
276pb 300pb
43pb
Lm
WM
NTC
173pb
109pb
43pb
Figure 2: Application of analysis method ITS1 PCR-RFLP on positive slides of Leishmania in northern region. Lanes 1-8 and 10: L. infantum;
Lanes 9: L. tropica; lane WM, weight marker 100 bp. Positive controls: Lt, L. tropica; Li, L. infantum; Lm, L. major; NTC, negative control.
Regarding visceral leishmaniasis, a percentage of 52.3
(69/132) sectors were affected during this period (Figure 5).
Figure 6 shows a plot number of affected sectors by VL
in each province per year with the majority of cases 80%
(n = 28/35) noted in Al Hoceima Province. In brief, the
spatial distribution of cases during the study period in this
region has shown a remarkable spatial extension of VL within
these provinces. In fact, there is not a concentration and
a prioritization of the sectors on the other. Furthermore,
it is important to note that these sectors are not regularly
affected. Indeed, some sectors have been touched once or
twice during this period and others have been affected yearly
but distributed in different localities of the sector.
Concerning the distribution of cutaneous form, a total of
86 sectors were affected in this region with 65.15% (86/132)
(Figure 7). The highest number of affected sectors were
observed in Larache Province 100% (n= 19/19) followed by
Al Hoceima Province with 77.14% (n= 27/35) of affected
sector. About Chefchaouen Province, 58.82% (n= 20/34) of
the sectors have been touched. Figure 8 shows the number of
affected sectors by CL in each province per year.
3.2.3. Repartition of CL and VL in Relation to Age and
Sex. This study was performed to show the most infected
population in this region. The statistical study about the
distribution of leishmaniasis according to sex has shown
6
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,804792
,081592
,358392
−5
−4
N
W
Fahs -Anjra
Mediterranean Sea
Tangier-Assilah
35,397834
M’diq-Fnideq
Atlantic
Ocean
35,397834
Leishmania tropica
Leishmania infantum
Per−humid climate
Humid climate
Sub−humid climate
Semi−arid climate
Arid climate
Phlebotomus perniciosis
Phlebotomus longicuspis
Phlebotomus sergenti
E
S
,635192
−3
35,855556
35,855556
−5
Tetouan
34,940112
34,940112
Al Hoceima
Chefchaouen
34,482390
,804792
−5
34,482390
Larache
,081592
−5
,358392
−4
,635192
−3
Leishmania tropica
Leishmania infantum
Per-humid climate
Humid climate
Sub-humid climate
Semi-arid climate
Arid climate
Phlebotomus perniciosis
Phlebotomus longicuspis
Phlebotomus sergenti
Figure 3: Molecular results of the circulating species in northern region according to the bioclimatic zone.
there is not a significant difference between genders (Pearson
Chi-square test: 𝜒2 = 0.22314, df = 1, P = 0.6367) with a
slight predominance of leishmaniasis in males (51.23% vs.
48.76% for females; sex-ratio M/F= 1.05). About age group,
49.86% were children under 11 years old. The difference
was statistically significant regarding the other age group
(Pearson Chi-square test: 𝜒2 = 300.82, df = 5, P<2.2e-16)
(Figure 9).
4. Discussion
The region of Tangier-tetouan-Al hoceima, made up of seven
provinces (Tangier-Assilah, Fahs-Anjra, Tetouan, Larache,
Chefchaouen, Al Hoceima, and Mdiaq-Fnidq), is known
to be among the moderately affected regions by leishmaniasis especially the cutaneous form. During the period
1997-2018, 1.56% of the reported cases of leishmaniases in
Morocco were registered in this region (n= 1,255/80,299).
Concerning clinical types, the cutaneous form represented
0.90% (n= 700/78,001) of the reported leishmaniasis cases in
Morocco, whereas the visceral form accounted for 24.15% (n=
555/2,298) [32].
In order to properly intervene in the fight against leishmaniasis in this region, a persistent follow-up of this pathology
is indispensable, in particular the visceral form, which is
considered as a deadly form and which continues to record a
rather large number of cases. The measures of control of this
disease should take into account rapid diagnosis in suspected
clinical cases and treatment of confirmed positive cases,
vector control measures, improvement of hygiene conditions,
and the zoonotic cycle of this form. Unfortunately, the
results showed that these interventions are not yet taken into
consideration.
Regarding the molecular characterization, the identification of DNA from CL slides showed that L. infantum and L.
tropica circulate together in this region with a predominance
of L. infantum (n = 68/81; 84%) (P-value = 6.026e-06),
while L. infantum was the only causal species of VL. On the
other hand, the distribution of these parasites showed that
L. infantum was the only circulating species in Chefchaouen,
Tangier-Assilah, and Fahs-Anjra provinces, while in Larache,
7
45
45
40
40
35
35
30
30
25
25
20
20
15
15
10
10
5
5
Number of VL cases/province
Total cases
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0
0
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Total
Al Hoceima
Chefchaouen
Larache
Tangier-Assilah
Tetouan
Mdiq-Fnidq
Fahs-Anjra
60
50
50
40
40
30
30
20
20
10
10
Number of CL cases/province
Total cases
(a)
60
0
0
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Total
Al Hoceima
Chefchaouen
Larache
Tangier-Assilah
Tetouan
Mdiq-Fnidq
Fahs-Anjra
(b)
Figure 4: Temporal distribution of VL and CL cases. (a) Visceral leishmaniasis cases recorded between 1997 and 2018 in Tangier-Tetouan-Al
Hoceima region. (b) Cutaneous leishmaniasis cases recorded between 1997 and 2018 in Tangier-Tetouan-Al Hoceima Region.
Al Hoceima, and Tetouan, the predominance of L. infantum
beside L. tropica was registered. Indeed, this is the first
identification of this species as the main causative agent of
human cutaneous form of leishmaniasis in this region.
The dominance of L. infantum is no longer surprising. In
fact, this species starts to have a wide extension throughout
the world, including several Mediterranean countries, in
particular Southern Europe, such as the famous foci in
Abruzzi (Italy) [34], and Cukurova region (Turkey) [35].
Also several other epidemiological studies were performed in
North Africa such as Tunisia and Algeria [36, 37].
In Morocco this species was responsible for sporadic cases
in the north of the country [4]. Indeed, the molecular survey
of leishmaniasis in Taza Province showed the existence of
many cases of CL due to L. infantum [23]. The same results
were observed in another study realized in Ouazzane and Sid
Kacem Provinces [25]. Going further, exactly to the south
of the country, a sporadic case of CL due to L. infantum in
Ouarzazate Province was declared [38].
The presence of L. infantum in this region at a high rate
could be explained firstly by the dominance of VL due to
L. infantum in this area. On the other hand, our study area
belongs to humid, subhumid, and semiarid climate located
at an altitude of between 0 and 573m. Indeed, Rioux et al. in
1984 showed that the repartition of different sandflies species
is mostly related to the bioclimatic areas [39]. In addition,
Laqraa et al. in 2015 provided an updated distribution of
leishmaniasis vectors in Morocco according to their bioclimatic and altitudinal preferences [33]. This update showed an
abundance of sandfly species known to be vectors of VL and
CL in this region. These species include Phlebotomus perniciosus, which dominates in the humid, subhumid and semiarid
zones at high altitudes and Phlebotomus longicuspis which is
preponderant in semiarid stages at low altitudes [33, 40]. This
may explain the abundance of this Leishmania species in the
north part of the country, which is characterized by this type
of climate.
The epidemiological study established during the surveyed period showed that peaks in the number of human
CL cases were recorded in three provinces (Larache, Al
Hoceima, and Chefchaouen). The number of cases continues
to increase in the provinces of Larache and Al Hoceima, while
a remarkable decrease is known in Chefchaouen Province.
Moreover, Tetouan Province has recorded a lower number.
However, the epidemiological situation of the visceral form
showed an important geographical extension, especially in
Chefchaouen and Al Hoceima Provinces. Several factors can
explain the increase of the number cases until 2010. Among
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(a)
(b)
Figure 5: Geographical distribution of visceral leishmaniasis in Tangier-Tetouan-Al Hoceima Region (2007-2018). (a) Tangier-Tetouan-Al
Hoceima region and its districts. (b) Geographical distribution of VL cases in Tangier-Tetouan-Al Hoceima Region (2007-2018).
these factors, the active screening is carried out following
the introduction of a response action plan between 2010
and 2016. In addition, this increase can be explained also by
the neighbourship of these provinces with several provinces
already known to be foci of CL and VL such as Ouazzane
[25], Sidi Kacem [25], Taounate [41], and Taza [23]. Also,
the population activities and shifting could also cause this
increase [42]. Moreover, the majority of these cities are
located on a mountainous area that is surrounded by old
unrestored fissured walls, with a nearby spring that provide
daytime resting places for sandflies.
Furthermore, most cases have been reported in rural
and periurban areas. In fact, the provinces of Chefchaouen,
Al Hoceima, and Larache, which recorded the maximum
number of cases, have a relatively low rate of urbanization
(respectively, 12.5%, 32.5%, and 52.5%) [26]. According to
the WHO, the urbanization rate is indicated as a key factor
in the increase of leishmaniasis [43]. The transmission of
leishmaniasis generally occurs in rural areas [44], in which
it could be related to human behavior through humananimal coexistence and the accumulation of animal waste
near homes [45]. Boussaa et al. have confirmed that this factor
has a huge influence on vector populations and consequently
on the epidemiology of the disease. The abundance of
sandflies appears to decrease with increasing urbanization
and some potential vector species may disappear [46]. In
addition, movement population from rural neighboring foci
to periurban areas may increase leishmaniasis cases which
BioMed Research International
9
Chefchaouen
15
10
5
0
15
10
5
0
Fahs-Anjra
15
10
5
0
Larache
Number of sectors
Al Hoceima
15
10
5
0
M’diq-Fnideq
15
10
5
0
Tangier-Assilah
15
10
5
0
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
Tetouan
15
10
5
0
Figure 6: Number of affected sectors by VL depending to years in Tangier-Tetouan-Al Hoceima Region (2007-2018).
are due to the poor quality of life and socioeconomic status
[47, 48]. These factors constitute favorable conditions for the
propagation of reservoir hosts and vectors and consequently
for the spread of leishmaniasis [47].
According to the clinical study of leishmaniasis in
Tangier-Tetouan-Al Hoceima Region, the repartition of CL
and VL in relation to age showed that no age group was
spared from leishmaniasis with the dominance of children
under 9 years old. This dominance could be explained by the
weak immune system and consequently the inability to fight
the Leishmania infection. In addition, this may be due also
to the habits of children who often play near breeding sites
which make them prone to insect bites [49]. Moreover, this
study also shows a predominance of men with leishmaniasis;
this dominance could be explained essentially by the rural
character of the provinces where people’s activities depend
closely to the breeding generally practiced by men.
In addition, the predominance of this cutaneous form
due to L. infantum prompts us to know whether an immune
suppression of the patients with this form can lead to relapses
and develop a visceral form of leishmaniasis. Indeed this
species proved to be an important opportunistic agent with
high rates of relapse and death in patients with acquired
immunodeficiency [50]. Moreover, the emergence of an
anthroponotic cycle of HIV/VL coinfections by sharing
contaminated syringes among intravenous drug users has
been reported [51]. Additionally, it is important to note that
the provisional number of cumulative cases of HIV-AIDS
in Morocco was 12,545 in 2016 according to the Ministry of
Health [52].
Molecular identification of circulating species of Leishmania and knowledge of temporal and spatial distribution
of leishmaniasis cases are essential in order to understand
epidemiology of the diseases [53].
In fact, the transmission cycle of L. infantum is zoonotic;
dogs have been implicated as the main reservoir hosts of
this species. In Morocco, both the MON-1 and MON-24
zymodemes have been isolated from dogs [10, 54]. However,
data on density of dogs and their positivity for L. infantum
in this region are missing. Furthermore, it is important to
mention that rodents may also transmit this parasite of
which L. infantum has been isolated from rodents belonging to the species Rattus norvegicus in Greece and Brazil
[55, 56].
Interestingly, the identification of L. infantum species
causing human cutaneous form in this region will play a
major role in helping and guiding the national leishmaniasis
control program by preventing and taking into consideration
the zoonotic character.
5. Conclusion
The present study concerns both cutaneous and visceral
leishmaniasis prevalence in northern Morocco. Our results
10
BioMed Research International
(a)
(b)
Figure 7: Geographical distribution of cutaneous leishmaniasis in Tangier-Tetouan-Al Hoceima Region (2007-2018). (a) Tangier-Tetouan-Al
Hoceima region and its districts. (b) Geographical distribution of CL cases in Tangier-Tetouan-Al Hoceima Region (2007-2018).
showed that two Leishmania species (L. infantum and L.
tropica) are present in the northern region of Morocco with
a predominance of L. infantum. These findings are consistent
with studies which have shown that L. infantum is the main
agent responsible for VL and CL cases in the Mediterranean
subregion.
The identification of circulating zoonotic L. infantum
species in this region is of great importance since it allows the
determination of transmission cycles. In fact, these funding
will allow us to monitor the health of human and animal
with thinking about “One health” as the potential of closer
cooperation between human and animal health.
Chefchaouen
Fahs-Anjra
Larache
M’diq-Fnideq
Tangier-Assilah
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
Tetouan
20
15
10
5
0
20
15
10
5
0
20
15
10
5
0
20
15
10
5
0
20
15
10
5
0
20
15
10
5
0
20
15
10
5
0
11
Al Hoceima
Number of sectors
BioMed Research International
Figure 8: Number of affected sectors by CL depending to years in Tangier-Tetouan-Al Hoceima Region (2007-2018).
Male
23.0
17.0
Age
Female
50+
16.0
2.0
41-50
12.0
15.0
31-40
23.0
19.0
21-30
26.0
29.0
11-20
85.0
96.0
0-10
82
70
58
46
34
%
22
10
0
9
20
32
44
56
68
80
%
Figure 9: Distribution of leishmaniasis cases in relation to age and sex (2007-2018).
12
BioMed Research International
Abbreviations
CL:
Cutaneous leishmaniasis
VL:
Visceral leishmaniasis
NRLL: National Reference Laboratory of
Leishmaniasis-Rabat
NIH: National Institute of Hygiene-Morocco.
[9]
[10]
Data Availability
The data used to support the findings of this study are
included within the article.
[11]
Conflicts of Interest
The authors declare that they have no competing interests.
[12]
Acknowledgments
[13]
The authors would like to thank the delegates, animators, and
physicians of the provinces studied in this paper for providing
all the necessary information on the samples and the study
area. Also, they send big thanks to MOUNTAJ Sara (PhD
student) and MHIYAOUI Hassan (PhD student) from laboratory of Applied Geosciences Engineering (GAIA), Faculty
of Sciences Aı̈n Chock-Casablanca, for their contribution in
carrying out studies of GIS.
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