Control of Cutaneous Leishmaniasis Caused by Leishmania Major in South-Eastern Morocco

Tropical Medicine and International Health doi:10.1111/tmi.12543 volume 20 no 10 pp 1297–1305 october 2015

Control of cutaneous leishmaniasis caused by Leishmania major in south-eastern Morocco

Issam Bennis1,2, Vincent De Brouwere2, Btissam Ameur3, Abderrahmane El Idrissi Laamrani3, Smaine Chichaoui4, Sahibi Hamid5 and Marleen Boelaert2

1 National School of Public Health, Rabat, Morocco 2 Institute of Tropical Medicine, Antwerp, Belgium 3 Directorate of Epidemiology and Diseases Control, Ministry of Health, Rabat, Morocco 4 Ministry of Health, Province of Errachidia, Morocco 5 Department of Parasitology, Agronomic and Veterinary Institute Hassan II, Rabat, Morocco

Abstract objective The incidence of cutaneous leishmaniasis (CL) caused by Leishmania major has increased in Morocco over the last decade, prompting the Ministry of Health to take intersectoral response measures including vector and reservoir control. The aim of this article was to describe the CL outbreak response measures taken in the province of Errachidia, where the reservoir of L. major,a sand rat (Meriones shawi), was targeted using strychnine-poisoned wheat baits from 2010 to 2012. method We analysed routine surveillance data and other information using the data of the CL control programme. results We present data on the evolution and the extension of CL in this province as well as the epidemiological proﬁle of the disease. Between 2004 and 2013, 7099 cases of CL were recorded in Errachidia Province, gradually affecting all districts. Our results demonstrate that more women were affected than men and that all age groups were represented. conclusion Errachidia Province was the epicentre of the recent CL outbreak in Morocco. A notable decline in incidence rates was observed after 2011. The outbreak control measures may have contributed to this decline, as well as climatic trends or progressing herd immunity.

keywords cutaneous leishmaniasis, zoonoses, Leishmania major, rodenticide, Morocco

The sand fly Phlebotomus papatasi or a closely related Introduction species is the insect vector [3]. The transmission cycle of Leishmaniasis is a disease caused by protozoa of the genus L. major is complex and requires the presence of a Leishmania, a parasite that infects many mammals includ- rodent reservoir, such as the jird (Meriones spp), the fat ing humans [1] and is transmitted by an insect vector, the sand rat (Psammomys obesus) or the great gerbil (Rhom- phlebotomine sand fly. The clinical spectrum of leishmania- bomys opimus) [5]. Psammomys obesus transmits sis includes cutaneous, mucocutaneous and visceral disease. L. major in most foci between Syria and Saudi Arabia in While the latter is the most serious and fatal if not treated, the east and Morocco in the west [6]. However, in the cutaneous leishmaniasis (CL) causes considerable suffering south of Morocco, M. shawi is the main reservoir [7, 8]. because it can lead to disfiguring scars and social stigma. In Meriones are granivorous and can cause important agri- North Africa and the Middle East, CL usually occurs in cultural damage during their periodic population explo- semi-arid and desert conditions, especially in Afghanistan, sions [9]. Moreover, in Morocco, it seems that Shaw’s Algeria, Iran, Pakistan, Saudi Arabia and Syria [2]. gerbil has adapted to the peridomestic environment In North African countries, CL transmission has been where it feeds on excreta and detritus, thriving close to increasing since the 1980s with the emergence of new garbage pits [8]. The burrows of these rodents provide foci [3]. Both anthroponotic CL, caused by L. tropica, optimal sand fly breeding conditions, as the terrestrial and zoonotic CL (ZCL), caused by L. major, are wide- larvae of Ph. papatasi thrive in moist organic matter. The spread [2]. While the former occurs mostly in urban adult sand fly uses the well-insulated rodent burrows as areas, L. major affects rural populations and is the topic diurnal resting sites [10, 11]. In spring, emergent sand of this article. In North African countries, L. major flies become infected by feeding on infected reservoir belongs almost exclusively to the zymodeme Mon 25 [4]. rodents and transmit L. major to other rodents during

I. Bennis et al. Cutaneous leishmaniasis control in Morocco

subsequent feedings. Humans are an accidental host in 1940s and 1980s in the former Soviet Union as reported this cycle and are usually infected during the sand fly in the literature [24, 25]. Measures for controlling Meri- season in summer/autumn. There is a close temporal ones species were developed initially for agricultural pur- association between the abundance of Ph. papatasi and poses and are mostly based on anticoagulants and zinc the incidence of ZCL [12–14]. In Tunisia, the seasonal phosphide as rodenticides [26]. Guidelines for leishmania- distribution of human ZCL cases showed one major peak sis control published by WHO in 1988 suggested intro- in December, three months after the second peak of ducing poisoned bait in burrow entrances to control the Ph. papatasi abundance [15]. foci where Meriones species is the reservoir host [27]. The first symptoms of ZCL occur 1 to 6 months after Since 2008, an unusual increase in CL cases was the infective sand fly bite and persist until self-healing. observed in the province of Errachidia in Morocco that ZCL lesions usually present as multiple ulcerated and raised growing concern and frustration in the population often superinfected lesions. Presumptive diagnosis of CL is and prompted the local health authorities to take extra con- based on these clinical symptoms, while a parasitological trol measures. An entomological survey conducted in Err- diagnosis remains the reference standard. It includes achidia Province in July 2009 by the National Institute of microscopic examination of Giemsa-stained biopsy smears Hygiene (INH Morocco) had demonstrated the presence of based on the direct identification of amastigote forms with the species Ph. papatasi [28] as well as the reservoir Meri- microscopy, because more sophisticated techniques are ones shawi, but rodent control measures in the province expensive and rarely available in endemic areas [2, 16]. had so far only been taken by the Ministry of Agriculture Spontaneous self-healing often occurs in CL but leaves a (MoA) in the framework of crop protection. From 2010 scar. Depending on the species, this tendency to self-cure onwards, the local health authorities in Errachidia added usually occurs within approximately 2 to 6 months (e.g. the rodent control component to their ZCL outbreak L. major), or 6 to 15 months (e.g. L. tropica) of disease response strategy. This article describes the epidemiological onset [2, 17]. Apart from species, the rate of spontaneous pattern of the recent CL outbreak due to L. major in Err- healing of the lesion depends on factors such as the achidia Province and the results of the control strategy. parasite load, its virulence, the immune response of the host, the location of the lesion and the presence or absence of a bacterial infection [14, 18, 19]. Materials and methods Zoonotic CL cases usually fluctuate in an epidemic Study area cycle with 5- to 10-year intervals [6]. Fluctuating num- bers of cases were attributed either to the cyclic develop- Errachidia Province is located in the Ziz Ghris Valley in ment and loss of herd immunity or to natural disasters the south-east of Morocco, including the Saharan areas, such as floods and famines [20]. There is evidence that plains and highlands at an altitude above 1900 m, and the lack of IFN-gamma allows parasite multiplication covering a surface of 46 000 km2. Errachidia has an arid and progression from infection to disease. Treatment of climate with temperatures between À4 °C and 48 °C, non-healing CL with IFN-gamma resulted in rapid and with large daily and seasonal temperature variations. The complete resolution of lesions [21]. However, the immu- annual mean temperature is 21 °C. Rainfall is scarce and nopathological and immunoprotective mechanisms occur- usually occurs between February and March. The annual ring during CL are difficult to establish without total precipitation is 134 Æ 64 mm [29]. longitudinal studies accounting for the genetic heteroge- The province consists today of seven urban agglomera- neity of human and parasite populations [22]. tions (Errachidia, Erfoud, Goulmima Tinejdad, Moulay The lack of an effective prophylactic vaccine suggests Ali Cherif, Boudnib and Jorf) and 22 rural districts, with that we still do not fully understand the factors that regu- 496 localities (Fig. S1). An administrative reform in 2010 late the induction and maintenance of immunity against redesigned provincial boundaries, and the total popula- Leishmania. Understanding these factors is critical for the tion of the province became 400 422 instead of 564 000 design of an effective vaccine and/or vaccination strategy inhabitants. In this analysis, we have excluded the CL against leishmaniasis [23]. cases recorded in various localities that are no longer part According to the literature, the most effective way to of the province of Errachidia today. control L. major is to combine reservoir and vector control, but the evidence of the effectiveness of this approach Intervention is limited to a small number of case studies [2]. Success stories include the destruction of rodent burrows as rest- The CL control policy of the Ministry of Health (MoH) in ing and breeding sites for Ph. papatasi between the Morocco recommends rodent control as one of the inter-

I. Bennis et al. Cutaneous leishmaniasis control in Morocco

ventions against ZCL, next to screening and treatment of patients, vector control and enhancement of environmental sanitation [30]. All these actions should be supported by health education and intersectoral collaboration. However, in most provinces, local health authorities lack the resources for rodent control and limit themselves to promoting environmental hygiene and some limited insecticide spraying around urban and touristic centres. Contrastingly, the Ministry of Agriculture (MoA) in Morocco actively implements rodent control in the framework of crop protection. The MoA produces the poisoned bait as the use of strychnine is strictly regulated and can be handled only by this Ministry. No strychnine is available in the commercial market. Technical staff of the MoA distribute the poisoned bait to farmers along with instructions for its use. Surveillance of the rodent Figure 1 Poisoned wheat introduced into one burrow (on the population is based on sentinel site surveillance of the left). Colony of Meriones Shawi rodents killed by this technique number of active borrows throughout the year. in Errachidia Province (on the right). In Errachidia Province, because of the alarming CL outbreak, the local health authorities of MoH decided to use rodenticides at home against domestic rats and end 2009 to join forces with the MoA workers in an increase individual and community hygiene, including attempt to control the rodent reservoir. The first joint individual protection measures to avoid insect bites. In control campaign with poisoned baits was conducted addition, complementary measures were introduced by between early December 2009 and end of March 2010, the CIMVC in the seven urban districts and touristic and was from the outset intersectoral, with a strong com- areas of the province. These were vector control of mos- mitment from both MoA and MoH. Technicians from quitoes using insecticide spraying between May and both ministries working in close collaboration supervised August and environmental sanitation around cities and the community workers who applied the baits in the peri- villages involving local communities. domestic environment. This was repeated every year thereafter for three consecutive years. Data collection and analysis In brief, a squad of 2 to 4 control workers with a supervisor was dispatched to the affected village. The This is a retrospective descriptive study of the ZCL epide- workers surveyed the full perimeter around the human miology in Errachidia Province, dating back to the initia- settlement for rodent burrows up to the boundary where tion of epidemiological surveillance in 1998 and palm trees or cultivated fields started. Each active rodent including the intensive control measures started in 2010. hole was treated as follows. A worker wearing protective We analysed routine reports on the control programme’s gloves and gear deposited six to twelve grains of strych- standard preventive measures, as well as anonymised data nine-poisoned wheat about 10 cm inside the burrow from the epidemiological surveillance system and reports using a spoon and the tip of a plastic bottle, under the at the provincial and national level. We consulted the supervision of the team leader. Three days later, all dead central database to cross-check the reporting of cases rodents were disposed of (Figure 1). After 15 to 30 days, among Errachidia residents diagnosed or reported else- the remaining active burrows were counted and poisoned where. Information about laboratory diagnosis was only bait application was repeated up to two times depending available for the period after 2008. The database was on the number of persistent active burrows. This control analysed with the approval of the national health author- operation was repeated for three consecutive years with ities in Morocco (MoH, Directorate of Epidemiology and the same timing. Diseases Control). This intensive campaign was managed as a collabora- We included only native Moroccan residents in rural tion between local authorities, municipalities, MoA and and urban areas of Errachidia Province. The case defini- MoH working together in the Committee of Integrated tion of CL used in this study was the standard MoH defi- Management of Vector Control (CIMVC). Additional nition: any person in an endemic area with at least one measures implemented from February 2010 onwards clinically active skin lesion reported as CL by a health comprised health education messages to encourage people professional [30]. Laboratory confirmation was only

I. Bennis et al. Cutaneous leishmaniasis control in Morocco

sought in the first five cases reported for all newly The outbreak was first recognised as such in 2007 in affected localities. Confirmation was achieved by direct the area of Merzouga in the south-east of the province, microscopic examination of tissue scraping for the detec- in Taous district bordering Algeria (Figure 3), where a tion of amastigote forms. Most of the other cases were total of 94 cases were recorded with an incidence rate clinically diagnosed by medical staff in health centres or (IR) of 2500 cases per 100 000 inhabitants. The follow- by dermatologists in hospitals, because only one clinical ing year, the outbreak spread to the north and west of microbiology laboratory was located in the chief town of the province. By 2010, all areas were affected, and the the province, far from most of the rural areas. overall incidence rate was 869 per 100 000 inhabitants We collected data on age, sex and period of diagnosis in that peak year. Incidence rates ranged between 11 and for each case, which were subsequently anonymised. Data 9382 per 100 000 inhabitants in the rural districts Chorfa entry was performed using Microsoft Office Excel 2013 M’Daghra and Sidi Ali, respectively. and analysed by SPSS Software version 19.1. Epidemio- Between 2010 and 2012, all affected urban and rural logical curves are presented according to the Gregorian district areas in the province were treated with poisoned calendar. We used chi-square tests to compare propor- bait, covering approximately 5000 hectares. In these tions. Quantum GIS Geographic Information System 3 years, 1287 kg of strychnine-poisoned wheat was used. (Open Source Geospatial Foundation Project) was used The total number of active burrows observed before and to design and develop CL distribution maps. after these operations is provided as additional information (Table S1). Initially, the campaign targeted 322 571 active burrows. Although only 80% to 89% of them Results could be treated, after the first round of poisoning in Since the start of the recording of ZCL cases in the prov- 2010, the number of active burrows decreased by 95%. ince of Errachidia in 1998, and up to 2003, 907 cases After the launch of the campaign, we recorded a steep were reported. Between 2004 and 2013, the total number decrease in the number of CL-affected areas, from 28 of cases in the province reached 7099, with a peak num- areas in 2011 to 17 in 2012 and 5 areas in 2013 ber of 3483 cases (49%) in 2010 (Figure 2). Almost all (Figure 3). cases were clinically diagnosed by health centres or hospi- The overall incidence rate was reduced to 9 per tals, but 237 cases were parasitologically confirmed (of a 100 000 inhabitants in 2013 in the affected areas in the total of 303 smear examinations performed) (Table 1). province. However, the city of Errachidia and its neigh-

3500

3000

2500

2000

1500 ANNUAL CASES 1000

500

0 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 YEAR Errachidia district (Annual cases) Other Moroccan districts (Annual cases)

Figure 2 Number cases of zoonotic cutaneous leishmaniasis per year in Errachidia Province and other affected Moroccan provinces between 2004 and 2013.

I. Bennis et al. Cutaneous leishmaniasis control in Morocco

Table 1 Cases of cutaneous leishmaniasis in the province of After the launch of an intensive intersectorial campaign Errachidia between 2004 and 2013 by age group, gender, area in 2010 including for the first time rodent control to tar- of residency, trimester of diagnosis and diagnosis confirmation get the CL reservoir host, we observed a substantial Total reduction in the incidence rate of CL (from 869 to 9/ 100 000 inhabitants per year). However, the observed Cases % decline in the CL incidence rate in Errachidia Province could also be due to the natural cycle of the epidemic, Age groups* [0–10] 1854 26.1 with a decline in incidence when the number of suscepti- [11–20] 2038 28.7 ble persons in the human population has become too [21–30] 971 13.7 low. Climate factors may also play a role in the incidence [31–40] 782 11.0 trend of ZCL [29]. Whereas higher temperature may pos- [41–50] 634 8.9 itively influence the abundance of the sand fly [31, 32], – [51 60] 471 6.6 progressing desertification and lack of humidity could in >60 348 4.9 turn force the rodent population to move to wetter areas Gender Female 4184 58.9 and lead to decreases in incidence [11, 31]. Our data do Male 2915 41.1 not allow to disentangle those effects. Nevertheless, the Area systematic application of poisoned bait in the CL-affected Rural 5940 83.7 areas in Errachidia province has probably contributed to Urban 1159 16.3 the decrease in CL incidence, as it led to a 95% reduc- Diagnosis trimester tion in the number of active rodent burrows in treated Fall 3822 53.8 Winter 2453 34.6 areas, which was sustained for each of the 3 years of the Spring 304 4.3 intervention. The effect observed with this strychnine-poi- Summer 520 7.3 soned bait intervention was more important than that Diagnosis confirmation† observed by others with anticoagulants or zinc phos- Clinical 5250 94.6 phide, a 48% and 58% reduction, respectively [26]. Laboratory 303 5.4 Another intervention in the valley of Turkmenia (Turk- *One missing data. menistan, ex-Soviet Union) in 1941 succeeded in reducing †Data available from 2009. human morbidity from 70% to 0.4% when chloropicrin bait was used in the burrows of large gerbils [25]. In bouring rural areas (Aoufous, Chorfa M’Daghra, Iran, poisoned bait applications led to a less impressive Lkheng), which were not part of the rodent control cam- reduction in cases [26, 33]. A recent overview article paign in 2010, recorded an increase in the number of CL about ZCL trends in Morocco confirmed that the peak cases from 54 in 2010 to 84 cases in 2011 (Table S2). incidence in the country was reached in 2010 with 6444 After the rodent control, intervention was equally applied cases and declined sharply to 2219 cases in 2011 and throughout this area in 2012, and the number of annual 740 cases in 2012 [34]. Errachidia Province was the cases decreased to 12. major contributor to this caseload, accounting for 3483 The maximum caseload was recorded in the fall and or 54% of the total number of cases in the country in early winter season (Figure 4). The rural areas declared 2010 (Figure 2). 83% of all registered cases. All age groups were affected In this Province, the unique feature was the active col- and the average age of cases was 24 Æ 18 years. The most laboration of the local MoH leishmaniasis control pro- affected age group were the 11- to 20-year-olds with 28% gramme with the MoA in implementing the integrated of cases, followed by the age group 0- to 10-year-olds management of vector control (IMVC) strategy into the (26% of cases) (Table 1). Women were more often affected areas. The MoH monitored the outcome of the affected with 59% of the total number of cases. The female strategy very closely, apparently with good results. The predominance of CL cases was present in all age groups, rodenticide strategy we describe has been used in Mor- except in those older than 60 years (Figure 5). occo for crop protection for decades and has been used elsewhere for ZCL control. Detailed knowledge of the animal and vector reservoirs of ZCL in a specific area is Discussion essential to use this chemical method with success. The Our results describe a succession of yearly CL outbreaks rationale for rodent control in an integrated ZCL control in Errachidia Province, resulting in a total of 7099 cases strategy is based on the principle of the momentary between 2004 and 2013, with a peak incidence in 2010. reduction of the rodent population to reduce the infected

I. Bennis et al. Cutaneous leishmaniasis control in Morocco

Number of cases 0 – 0 1 – 5 6 – 10 11 – 20 21 – 40 41 – 80 81 – 160 161 – 320 321 – 640 Cases 2004 Cases 2005 Cases 2006 Cases 2007 Cases 2008

0 50 Km Cases 2009 Cases 2010 Cases 2011 Cases 2012 Cases 2013

Figure 3 Geographic distribution of zoonotic cutaneous leishmaniasis cases in Errachidia Province, between 2004 and 2013.

1 500 Rural_Urban R U

1 000 Number of cases 500

Figure 4 Seasonality pattern of zoonotic cutaneous leishmaniasis cases in Errachidia Province showing cumulative 0 number per month for the period 2004 to Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul 2013, with breakdown by rural and Month of diagnosis urban areas. reservoir [35]. If less sandflies have an infected blood reproduction season of rodents and before the beginning meal, it is expected that less will accidentally contaminate of the sand fly season. Wheat bait is chosen because Mer- humans. Timing of the poisoned bait intervention is iones shawi stores grain reserves in its burrows and sur- essential, because the transmission from rodent to vives on it during winter [36]. humans by the sand flies is most intensive in the summer The reported incidence of CL was higher among women months (May to September), and food habits of rodents than men, although men have a higher exposure level due are seasonal. To be effective, the application of baits to their occupations. In contrast, a higher CL incidence in should take place from December to March, before the men was found in a study in Iran [37] and in the Middle

I. Bennis et al. Cutaneous leishmaniasis control in Morocco

Gender F M

>60 >60

[51–60] [51–60]

[41–50] [41–50] Grp_Age

[31–40] [31–40] Grp_Age [21–30] [21–30]

[11–20] [11–20]

<11 <11 Figure 5 Sex and age distribution of all cases of zoonotic cutaneous leishmaniasis in Errachidia Province from 2004 to 1 000750500 2500 250 500 750 1 000 2013. Cases Cases East [38]. Other studies from Saudi Arabia supported the adverse effects on the ecosystem. There is no clear answer hypothesis that the CL sex ratio is dependent on geo- to these questions, and instead of promoting strychnine- graphic location and cultural patterns [39, 40]. based rodent killing on a large scale in similar contexts, As men in Errachidia generally perceive CL as non- we conclude that more eco-friendly alternatives for reser- severe, this may have led to some under-reporting of voir control are urgently needed. Reservoir control should cases and the true incidence rate may therefore have include environmental surveillance to monitor the expan- been higher than what we report here. Another limita- sion of rodent populations after the rainy seasons as well tion to our study was that cases were mainly ascer- as entomological surveillance to predict ZCL epidemics tained clinically, although in each new area affected the and target the control measures effectively [11]. first suspect cases were systematically confirmed by parasitological exam. Further surveillance thereafter was Conclusion clinical. In addition, the poisoned bait strategy we describe will not work with P. obesus, as they do not It appears that the intersectorial ZCL control strategy feed on grain in the same way as Meriones. Finally, we adopted by the province of Errachidia since 2010 contrib- fully acknowledge that the observed reduction in inci- uted to a quick and major reduction in incidence in the dence cannot be directly attributed to the rodent con- context of the 2004–2013 outbreak. Given there is no trol component, because of the observational nature of vaccine for this disease, more appropriate and less toxic our study, and the fact that the intervention was inte- control measures are desperately needed. Meanwhile, grated in a larger package of control measures. The health authorities should be aware of the rodenticide absence of any control group does not allow establish- approach and use it with caution as a response measure ing a causal effect. in similar contexts of ZCL outbreaks. The application of poisoned grains in the peridomestic environment for ZCL control may be hazardous as there is a lack of clear guidance on the methodology and pre- Acknowledgement cautions to take. Even if no cases of adverse events or We are grateful to Samantha Brunts (Linguapolis, Univer- fatalities of animals or humans have been reported to date sity of Antwerp), who performed English language edit- with the strategy and dose applied, human fatalities have ing and offered useful comments. been reported at doses in excess of 5 to 10 mg per weight in the literature [41]. Moreover, questions can be raised about the environmental impact and sustainability of the References strategy. We have no information about the effect of 1. Gramiccia M, Gradoni L. The current status of zoonotic strychnine on protected species (e.g. Rhombomys opimus, leishmaniases and approaches to disease control. Int J Paras- Hyraxes), about its efficacy in the longer term or about its itol 2005: 35: 1169–1180.

I. Bennis et al. Cutaneous leishmaniasis control in Morocco

2. Reithinger R, Dujardin JC, Louzir H, Pirmez C, Alexander 18. Aytekin S, Ertem M, Yaran O, Aytekin N. Clinico-epidemio- B, Brooker S. Cutaneous leishmaniasis. Lancet Infect Dis logic study of cutaneous leishmaniasis in Diyarbakir Turkey. 2007: 7: 581–596. Dermatol Online J 2006: 12: 14. 3. Aoun K & Bouratbine A. Cutaneous Leishmaniasis in North 19. Calvopina M, Armijos RX, Hashiguchi Y. Epidemiology Africa: a review. Parasite 2014: 21: 14. of leishmaniasis in Ecuador: current status of knowledge-a 4. Pratlong F, Dereure J, Ravel C et al. Geographical distribu- review. Mem Inst Oswaldo Cruz 2004: 99: tion and epidemiological features of Old World cutaneous 663–672. leishmaniasis foci, based on the isoenzyme analysis of 1048 20. Ashford RW. The leishmaniases as emerging and reemerging strains. Tropical Med Int Health 2009: 14: 1071–1085. zoonoses. Int J Parasitol 2000: 30: 1269–1281. 5. Motazedian MH, Mehrabani D, Oryan A, Asgari Q, Karami- 21. Sharma U, Singh S. Immunobiology of leishmaniasis. Indian an M, Kalantari M. Life cycle of cutaneous leishmaniasis in J Exp Biol 2009: 47: 412. Larestan, southern Iran. Arch Clin Infect Dis 2006: 1: 137–143. 22. Louzir H, Aoun K, Spith GF et al. Les leishmanioses vues 6. Postigo JAR. Leishmaniasis in the world health organization au travers du reseau international des Instituts Pasteur. eastern mediterranean region. Int J Antimicrob Agents Medecine/Sciences. 2013: 29: 1151–1160. 2010: 36: S62–S65. 23. Okwor I, Mou Z, Liu D, Uzonna J. Protective immunity 7. Rioux JA, Petter F, Akalay O et al. Meriones shawi (Duver- and vaccination against cutaneous leishmaniasis. Front noy, 1842)[Rodentia, Gerbillidae] a reservoir of Leishmania Immunol 2012: 3: 128. major, Yakimoff and Schokhor, 1914 [Kinetoplastida, Try- 24. Lane RP. The contribution of sandfly control to leishmania- panosomatidae] in South Morocco (author’s transl). CR sis control. Ann Soc Belg Med Trop 1991: 71(Suppl 1): 65– Seances Acad Sci III 1982: 294: 515–517. 74. 8. Rhajaoui M. Human leishmaniases in Morocco: a nosogeo- 25. Saf’janova VM. Leishmaniasis control. Bull World Health graphical diversity. Pathol Biol 2011: 59: 226–229. Organ 1971: 44: 561. 9. Mili AF, Saghrouni F, BenSaid Z, Saadi-BenAoun Y, Guiza- 26. Akhavan AA, Veysi A, Arandian MH et al. Field evaluation ni I & BenSaid M. Retrospective Analysis of Leishmaniasis of phostoxin and zinc phosphide for the control of zoonotic in Central Tunisia: An Update on Emerging Epidemiologi- cutaneous leishmaniasis in a hyperendemic area, central cal Trends. INTECH Open Access Publisher: Croatia, Iran. J Vector Borne Dis 2014: 51: 307. 2012. 27. World Health Organization. Guidelines for Leishmaniasis Con- 10. Mascari TM, Stout RW, Clark JW, Gordon SW, Bast JD, trol at Regional and Subregional Leveles. Parasitic Diseases Foil LD. Insecticide-treated rodent baits for sand fly control. Programme Report. World Health Organization: Geneva, Pestic Biochem Physiol 2013: 106: 113–117. Switzerland, 1988. 11. Toumi A, Chlif S, Bettaieb J et al. Temporal dynamics and 28. INH. Etude des phlebotomes au niveau des provinces d’Err- impact of climate factors on the incidence of zoonotic achidia et Ouarzazates. Institut National d hygiene – Mini- cutaneous leishmaniasis in central Tunisia. PLoS Negl Trop stere de la Sante, Maroc, 2009. Dis 2012: 6: e1633. 29. Bounoua L, Kahime K, Houti L et al. Linking climate to 12. Yaghoobi-Ershadi MR, Akhavan AA, Mohebali M. Monthly incidence of zoonotic cutaneous leishmaniasis (L. major)in variation of Leishmania major MON-26 infection rates in pre-Saharan North Africa. Int J Environ Res Public Health Phlebotomus papatasi (Diptra: Psychodidae) from rodent 2013: 10: 3172–3191. burrows in Badrood area of Iran. Med J Islam Repub Iran 30. Direction de l’Epidemiologie et la Lutte contre les Maladies. 2001: 15: 175–178. Lutte contre les Leishmanioses: Guide des activites. Ministe- 13. Masmoudi A, Hariz W, Marrekchi S, Amouri M, Turki H. re de la Sante, Rabat, Maroc, 2010. Old World cutaneous leishmaniasis: diagnosis and treat- 31. Hunter PR. Climate change and waterborne and vector ment. J Dermatol Case Rep 2013: 7: 31. borne disease. J Appl Microbiol 2003: 94(s1): 37–46. 14. Kubba R, AIGindan Y, ElHassan AM, Omer AHS, Kutty 32. Chaves LF, Pascual M. Climate cycles and forecasts of cuta- MK & Saeed M. Dissemination in cutaneous leishmaniasis. neous leishmaniasis, a nonstationary vector-borne disease. Int J Dermatol 1988: 27: 702–706. PLoS Med 2006: 3: e295. 15. Chelbi I, Derbali M, Al-Ahmadi Z, Zaafouri B, El Fahem A, 33. Yaghoobi-Ershadi MR, Akhavan AA, Zahraei-Ramazani Zhioua E. Phenology of Phlebotomus papatasi (Diptera: AR, Javadian E, Motavalli-Emami M. Field trial for the con- Psychodidae) relative to the seasonal prevalence of zoonotic trol of zoonotic cutaneous leishmaniosis in Badrood, Iran. cutaneous leishmaniasis in central Tunisia. J Med Entomol Ann Saudi Med 2000: 20: 386–389. 2007: 44: 385–388. 34. Tlamcani Z, Er-Rami M. The current status of cutaneous 16. Mouttaki T, Morales-Yuste M, Merino-Espinosa G et al. leishmaniasis in Morocco. Turkiye Parazitol Derg 2014: 38: Molecular diagnosis of cutaneous leishmaniasis and identifi- 5–8. cation of the causative Leishmania species in Morocco by 35. Riyad M, Chiheb S, Soussi-Abdallaoui M. Cutaneous leish- using three PCR-based assays. Parasit Vectors 2014: 7: 420. maniasis caused by Leishmania major in Morocco: still a 17. Dowlati Y. Cutaneous leishmaniasis: clinical aspect. Clin topical question. East Mediterr Health J 2013: 19: Dermatol 1996: 14: 425–431. 495–501.

I. Bennis et al. Cutaneous leishmaniasis control in Morocco

36. Zaime A, Gautier JY. Comparaison des regimes alimentaires 41. Lindsey T, O’Hara J, Irvine R, Kerrigan S. Strychnine over- de trois especes sympatriques de Gerbillidae en milieu saha- dose following ingestion of gopher bait. J Anal Toxicol rien, au Maroc. Revue d’Ecologie 1989: 44: 153–163. 2004: 28: 135–137. 37. Kassiri H, Shariﬁnia N, Jalilian M, Shemshad K. Epidemio- logical aspects of cutaneous leishmaniasis in Ilam province, west of Iran (2000-2007). Asian Pac J Trop Dis 2012: 2: Supporting Information S382–S386. 38. Al-Jawabreh A, Barghuthy F, Schnur LF, Jacobson RL, Additional Supporting Information may be found in the Schonian G, Abdeen Z. Epidemiology of cutaneous leish- online version of this article: maniasis in the endemic area of Jericho, Palestine. East Med- Fig. S1. Maps of the administrative division of districts iterr Health J 2003: 9: 805–815. in Errachidia Province – Kingdom of Morocco. 39. Al-Tawﬁq JA, AbuKhamsin A. Cutaneous leishmaniasis: a 46- Table S1. The number of burrows before and after year study of the epidemiology and clinical features in Saudi operations to control the density of rodent Meriones Arabia (1956-2002). Int J Infect Dis 2004: 8: 244–250. Shawi by subdivision in the Errachidia Province. 40. Amin TT, Al-Mohammed HI, Kaliyadan F, Mohammed BS. Table S2. Distribution of cases and incidence of cuta- Cutaneous leishmaniasis in Al Hassa, Saudi Arabia: epidemiological trends from 2000 to 2010. Asian Pac J Trop Med neous leishmaniasis due to Leishmania major in Errachi- 2013: 6: 667–672. dia Province by districts.

Corresponding Author Issam Bennis, National School of Public Health, Lemfedal Cherkaoui Street, Madinat Al-Irfane, MailBox: 6329, Rabat, Morocco Tel.: +212 661 25 99 01; E-mail: [email protected]