leishmaniasis in northern morocco: predominance of...

Research ArticleLeishmaniasis in Northern Morocco Predominance ofLeishmania infantum Compared to Leishmania tropica

MaryamHakkour 123 MohamedMahmoud El Alem 12

Asmae Hmamouch24 Abdelkebir Rhalem3 Bouchra Delouane2 Khalid Habbari5

Hajiba Fellah 12 Abderrahim Sadak 1 and Faiza Sebti 2

1Laboratory of Zoology and General Biology Faculty of Sciences Mohammed V University in Rabat Rabat Morocco2National Reference Laboratory of Leishmaniasis National Institute of Hygiene Rabat Morocco3Agronomy and Veterinary Institute Hassan II Rabat Morocco4Laboratory of Microbial Biotechnology Sciences and Techniques Faculty Sidi Mohammed Ben Abdellah University Fez Morocco5Faculty of Sciences and Technics University Sultan Moulay Slimane Beni Mellal Morocco

Correspondence should be addressed to Maryam Hakkour maryamhakkourgmailcom

Received 24 April 2019 Revised 17 June 2019 Accepted 1 July 2019 Published 8 August 2019

Academic Editor Elena Pariani

Copyright copy 2019 Maryam Hakkour et al This is an open access article distributed under the Creative Commons AttributionLicense which permits unrestricted use distribution and reproduction in any medium provided the original work is properlycited

In Morocco Leishmania infantum species is the main causative agents of visceral leishmaniasis (VL) However cutaneousleishmaniasis (CL) due to L infantum has been reported sporadically Moreover the recent geographical expansion of L infantumin the Mediterranean subregion leads us to suggest whether the nonsporadic cases of CL due to this species are present In thiscontext this review is written to establish a retrospective study of cutaneous and visceral leishmaniasis in northern Moroccobetween 1997 and 2018 and also to conduct a molecular study to identify the circulating species responsible for the recent casesof leishmaniases in this region Data concerning leishmaniases cases were collected from the Epidemiology and Disease ControlDirectorate from 1997 to 2018 Human samples obtained from peripheral laboratories were examined using PCR-ITS1 methodTheITS1 products were subjected to digestion with the restriction endonuclease Mn1-I Between 1997 and 2018 a total of 1255 casesof cutaneous and visceral leishmaniasis were recorded in Tangier-Tetouan-Al Hoceima Region ie 156 of the reported casesin Morocco (125580299) Concerning the geographical study covering the period 2007-2018 795 (105132) of the sectors wereaffected by leishmaniases The molecular results showed that Humans were found to be infected with the L infantum species witha high infection rate compared to L tropica infection Moreover molecular characterization using ITS1 PCR-RFLP showed that thedensity of L infantum was significantly higher (n = 6881 84) than that of L tropica (n = 1381 16) (P-value 9894e-10) Whileregarding visceral leishmaniasis L infantum was the only species responsible of this formThese findings of this study showed theemergence of L infantum in Morocco and suggest that this species might be more prevalent than previously thought Furthermorethe molecular determination of L infantum will be helpful for control strategies by taking into consideration the reservoir of thisspecies

1 Introduction

Leishmaniasis is a parasitic disease that affects both humansand animals and is caused by flagellated protozoa belongingto the genus Leishmania [1] These unicellular protozoa areusually transmitted by the bite of female phlebotomine sandflies (Diptera Psychodidae) [2] It is known that more than 20species of Leishmania infect mammals They are responsible

for two forms of leishmaniasis depending on the locationof parasites in mammalian tissues namely visceral andcutaneous forms The outcome of the infection depends onthe species responsible and the immune responses of the host[3]

Human cutaneous leishmaniasis (CL) is caused by mostLeishmania species of the subgenus Leishmania In Maghrebarea including Morocco three major species responsible for

HindawiBioMed Research InternationalVolume 2019 Article ID 5327287 14 pageshttpsdoiorg10115520195327287

2 BioMed Research International

Al HoceimaChefchaouenLarache

Tetouan

Tangier

EW

S

N

-Assilah

Fahs -Anjra

Mrsquodiq -Fnideq Mediterranean Sea

Atlantic Ocean

100 50 0 100Km

6∘00W 4

∘00W

6∘00W 4

∘00W

35∘0

0N

35∘00

N

Figure 1 The study area

this disease are Leishmania major L tropica and L infantum[4] the latter being more often associated with visceralleishmaniasis The transmission is zoonotic for L major witha wild animal reservoir [5] and rather anthroponotic forL tropica In fact the isolation of this species (MON-102and MON-113) from dog suggests that this mammal (dog)could be implicated as the secondary reservoir host in thelife cycle of L tropica Nevertheless the few sporadic casesviscerotropic do not confirm that the dog is the principalhost and the life cycle is zoonotic [6ndash8] In some parts of theMaghreb L Killicki has also been proven to be responsiblefor zoonotic CL particularly in Tunisia [9] Concerning Linfantum studies carried out in Maghreb countries isolatedthis species from dog suggesting it as the reservoir of thisdisease [10]

Regarding visceral leishmaniasis (VL) Leishmania infan-tum is the single agent responsible for this human form in theMediterranean basin [11 12] However Ready et al suggestedthat any parasite responsible for cutaneous leishmaniasis canvisceralize [13] (eg Leishmania tropica which causes CLcases has been proven as the agent responsible for humanVLand canine leishmaniasis (CanL) in Turkey [14]

In Morocco the epidemiological situation of leishmani-asis as well as the distribution of Leishmania species variesTwo different eco-epidemiological entities have been knownin the past CL due to L major also called wet or rural formand CL due to L tropica also known as dry or urban formHowever forL infantum it was responsible for sporadic cases[4] The recently published work revealed a new distributionof species by province Indeed many studies reported thatCL cases in south-east of Morocco were caused essentiallyby L major but L tropica is also present [15ndash17] Howeverin the Southwestern L tropica is the only circulating species[18ndash20] In the center of the kingdom L tropica is beingthe 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 Linfantum have been also isolated with the presence of majorcases of L tropica [25]

Nevertheless epidemiological data on leishmaniases aremissing in the northern region So in order to give a generaloverview of the new distribution of CL species in Moroccoit is essential to carry out molecular investigations in theNorthern provinces which have never been started andwhichremain until nowadays unknown

The purpose of this study is to establish epidemiologicaldata on leishmaniasis in seven provinces located in theextreme north of Morocco during the 21-year period 1997-2018 and to characterize the parasite species responsible forrecent cases of leishmaniasis

2 Material and Methods

21 Study Area This study was established in Tangier-Tetouan-Al Hoceima Region belonging to the northwest-ern section (35∘ 461015840 0010158401015840 N 5∘ 481015840 0010158401015840 W) and con-cerns Al Hoceima Chefchaouen Larache Tangier-AssilahTetouanMrsquodiq-Fnidq and Fahs-Anjra ProvincesThis regionis bordered to the north by the Strait of Gibraltar and theMediterranean Sea to the west by the Atlantic Ocean to thesouth-west by the Rabat-Sale-Kenitra Region to the southby the Fes-Meknes Region and to the east by the OrientalRegion (Figure 1) Climatically this region is characterized bya Mediterranean climate [26] Moreover in terms of tourismits exceptional location with its two maritime facades and itsroots in history and cultural diversity predispose it to occupya favorite place as a tourist destination

The Tangier-Tetouan-Al Hoceima Region extends over asurface of 17262 km2 (243 of the national territory) andhas a total of 3556729 inhabitants with a density of 206inhabitants per km2 [27]

BioMed Research International 3

22 Diagnosis

221 Microscopic Confirmation Themolecular characteriza-tion has concerned all smears received in the National Ref-erence Laboratory for Leishmaniasis (NRLL) at the NationalInstitute of Hygiene (NIH-Rabat Morocco) between 2016and 2017 (89119) The remaining cases were not receivedand others were defective These smears were sent by theperipheral laboratories in order to confirm and control theirpositivityOnly confirmedpositive caseswere included in thisstudy

Concerning 2018 the number of smears received was notrepresentative compared to the number declared As a resultthese cases were excluded from the molecular study

222 DNA Extraction The DNA extraction was performedwith the Qiagen Blood and Tissue kit (Hilden Germany)respecting the usage protocol provided by the manufacturerwithminormodifications (Proteinase Kwas incubated for 1Hat a temperature of 56∘C) [28]

223 ITS1 PCR-RFLP Analysis The internal transcribedspacer (ITS1) region was amplified using the pairs ofprimers LITSR (51015840-TGATACCACTTATCGCACTT-31015840) andL58S (51015840-CTGGATCATTTTCCGATG-31015840) ITS1-PCR prod-ucts were digested with the restriction endonuclease Mn1-I [8 25 29 30] Reference strains of Leishmania trop-ica (MHOMMA2010LCTIOK-4) Leishmania infan-tum(MHOMMA1998LVTA) and Leishmania major (MHOMMA2009LCER19-09) were used as positive controls

23 Data Collection In 1997-2018 a total of 1255 leishmani-ases cases were the subject of an epidemiological study Dataon human cases were obtained from the Epidemiology andDisease Control Directorate [31] The data are the result ofpassive surveillance based on the notifications recorded bythe medical staff of the provincial laboratories of Tangier-Tetouan-Al Hoceima Region who reported each case to theEpidemiology Department of the Ministry of Health Thedatabase contains all patient data including sex age andplace of residence

The study area is known to be moderately affected byCL and highly affected by VL as well In fact in Moroccothe provinces considered to be strongly affected by CLrecorded a total of between 10500 and 1000 cases duringthis period (such as Errachidia Province Zagora Provinceand Chichaoua Province) Provinces classified as moderatelyaffected recorded a total between 1000 and 100 (such as BeniMellal Province Settat Province and Driouch Province)Provinces with fewer than 100 cases are considered to beslightly affected (such as Guercif Province Agadir Provinceand Tiznit Province) [32] About visceral form the provincesnoted more than 100 cases are considered highly infectedProvinces with 100-10 cases are known to be moderatelyaffected Provinces registering less than 10 cases are poorlyaffected

Concerning the geographical study all data aboutautochthonous patients presenting the clinical symptoms of

leishmaniasis during 2007-2018 were collected from healthcenters and infrastructure services of ambulatory actionsprovincial of the study provinces

24 Statistical Analysis Statistical analysis was performedusing software R version 333

3 Results

31 Molecular Diagnosis A total of 89 slides were analyzedby ITS1 PCR-RFLP This total is distributed over the sevenProvinces 38 CL slides in Larache Province 21 CL5VL slidesin Al Hoceima Province 10 CL 1VL slides in TetouanProvince 5 CL slides in Chefchaouen 3 CL slides in Fahs-Anjra 2 CL 2VL slides in Tangier-Assilah and 2 CL slides inMdiq-Fnidq (Table 1)

The results of this molecular characterization show thecoexistence of L infantum and L tropica responsible ofcutaneous form with a predominance of L infantum species(P-value 9894e-10) while L infantum is the only speciesresponsible of visceral form (Figure 2) (Table 2)

The distribution of Leishmania species is directlyassociated with the presence of sandflies species Figure 3summarizes the results of molecular identification inassociation with the repartition of sandflies species[33] according to their bioclimatic stage preferences(httpwwwwatergovmaressources-en-eaupresentation-generale)

32 Epidemiology of Leishmaniasis inTangier-Tetouan-Al Hoceima Region

321 Temporal Distribution of VL and CL Cases in Tangier-Tetouan-Al Hoceima Region According to the MoroccanMinistry of Health between 1997 and 2018 among the totaldeclared (1255) of VL and CL cases 442 (n=5551255)have been noted as VL cases in this region

Approximately half of the total VL cases (300555 =5405) were registered in Chefchaouen Province with anaverage incidence of 286 In Al Hoceima Province anaverage incidence of 207 per year of cases were noted(2973 (n=165555)) (Figure 4) As for them TetouanProvince Larache Province Mdiq-Fnidq Province Tangier-Assila Province and Fahs Anjra Province have registeredrespectively 720 (n=40555) 649 (n=36555) 144(n=8555) 072 (n=4555) and 036 (n=2555) of cases

About CL cases a total of 700 cases were recordedand distributed as follows 3214 (n=225700) in LaracheProvince 2886 (n=202700) in Al Hoceima Province2328 (n=163700) in Chefchaouen Province 1086(n=76700) in Tetouan Province 243 (n=17700) inTangier-Assila 157 (n=11700) in Fahs-Anjra Province and085 (n=6700) in Mdiq-Fnidq Province (Figure 4)

322 Geographical Study of Leishmaniasis Cases in Tangier-Tetouan-Al Hoceima Region The geographical study showedthat 795 (105132) of the sectors were affected by leishma-niasis in this study area between 2007 and 2018


Table 1 Molecular results of cutaneous and visceral leishmaniasis slides from the most

Province Sector UrbanRural Cutaneous form Visceral form TotalL infantum L tropica L infantum

Larache

Ben said R 2 0 - 2Boujedyane R 1 3 - 4Bghadda R 2 0 - 2Zouada R 1 0 - 1

Od Khalkhal R 1 0 - 1Sahel R 1 0 - 1

Larache Center U 2 0 - 2Maada R 1 0 - 1

DharRouah R 1 0 - 1Ayacha R 4 0 - 4Riassana R 5 0 - 5Od harti R 1 0 - 1Zaaroura R 1 0 - 1

Souk Toulba R 2 0 - 2Ksar Kbir U 2 0 - 2Souk Lrsquoqolla R 1 0 - 1Laouamra R 1 0 - 1Bni Arouss R 2 0 - 2Al Manar R 1 0 - 1Ksar Bjir R 1 0 - 1Bni Garfet R 1 1 - 2

Al Hoceima

Ajdir U 0 1 - 1Imzouren R 5 0 1 6

Ait Youssef Ouali R 1 0 - 1Bni Bouayach R 3 0 - 3Taghzout R 0 1 - 1

Arbaa Taourirt R 1 0 - 1Bni Abdellah R 1 0 - 1Izemmouren R 1 0 - 1

Al Hoceima Center U 1 0 - 1Senada R 1 0 - 1Boudinar R 1 0 - 1

Arbaa Taourirt R 1 0 - 1Nekkour R 2 0 - 2Targuist R 1 0 - 1Anzagh R - - 1 1

Kalabonita R - - 1 1Douar Assammar R - - 1 1

Ait ziane R - - 1 1

Tetouan

Zinate R 1 3 - 4Azla R 0 1 - 1

Bni Hsen R 0 1 - 1- 1 0 - 1

Tetouan U 2 0 - 2- 1 0 - 1- - - 1 1

Chefchaouen- - 3 0 - 3

Stehat R 1 0 - 1Chefchaouen Center U 0 1 - 1


Table 1 Continued


Fahs AnjraAnjra R 1 0 - 1

Khmis Anjra R 1 0 - 1- 1 0 - 1

Tanger-AssilahGzenaya U 1 0 - 1

- 1 0 - 1- - - 2 2

Mdiq-Fnidq Mdiq U 1 1 - 2R rural U urban

Table 2 Leishmania species responsible for cutaneous leishmaniasis in the northern region

Provinces L infantum L tropica Total P-valueLarache 34 4 38 1135e-06lowastAl Hoceima 19 2 21 000020lowastTetouan 5 5 10 1Chefchaouen 4 1 5 -Fahs Anjra 3 0 3 -Tanger-Assilah 2 0 2 -Mdiq-Fnidaq 1 1 2 -Total 68 13 81 9894e-10lowastlowast Plt 0001

1 2 NTCWMLmLiLt1098765432276pb 300pb 173pb43pb 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 infantumLanes 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 523(69132) sectors were affected during this period (Figure 5)Figure 6 shows a plot number of affected sectors by VLin each province per year with the majority of cases 80(n = 2835) noted in Al Hoceima Province In brief thespatial distribution of cases during the study period in thisregion has shown a remarkable spatial extension of VLwithinthese provinces In fact there is not a concentration anda prioritization of the sectors on the other Furthermoreit is important to note that these sectors are not regularlyaffected Indeed some sectors have been touched once ortwice during this period and others have been affected yearlybut distributed in different localities of the sector

Concerning the distribution of cutaneous form a total of86 sectors were affected in this region with 6515 (86132)(Figure 7) The highest number of affected sectors wereobserved in Larache Province 100 (n= 1919) followed byAl Hoceima Province with 7714 (n= 2735) of affectedsector About Chefchaouen Province 5882 (n= 2034) ofthe sectors have been touched Figure 8 shows the number ofaffected sectors by CL in each province per year

323 Repartition of CL and VL in Relation to Age andSex This study was performed to show the most infectedpopulation in this region The statistical study about thedistribution of leishmaniasis according to sex has shown


Mediterranean Sea

Atlantic Ocean

Al Hoceima

Chefchaouen

Larache

Tetouan

Tangier-Assilah

Fahs -Anjra

Mrsquodiq-Fnideq

Perminushumid climateHumid climateSubminushumid climateSemiminusarid climateArid climate

minus3635192minus4358392minus5081592minus5804792


Phlebotomus sergentiPhlebotomus longicuspisPhlebotomus perniciosis

Leishmania infantumLeishmania tropica

34482390

34940112

35397834

35855556

34482390

34940112

35397834

35855556

S

E

N

W

Per-humid climateHumid climateSub-humid climateSemi-arid climateArid climate



Figure 3 Molecular results of the circulating species in northern region according to the bioclimatic zone

there is not a significant difference between genders (PearsonChi-square test 1205942 = 022314 df= 1 P = 06367) with aslight predominance of leishmaniasis in males (5123 vs4876 for females sex-ratio MF= 105) About age group4986 were children under 11 years old The differencewas statistically significant regarding the other age group(Pearson Chi-square test 1205942= 30082 df= 5 Plt22e-16)(Figure 9)

4 Discussion

The region of Tangier-tetouan-Al hoceima made up of sevenprovinces (Tangier-Assilah Fahs-Anjra Tetouan LaracheChefchaouen Al Hoceima and Mdiaq-Fnidq) is knownto be among the moderately affected regions by leishma-niasis especially the cutaneous form During the period1997-2018 156 of the reported cases of leishmaniases inMorocco were registered in this region (n= 125580299)Concerning clinical types the cutaneous form represented090 (n= 70078001) of the reported leishmaniasis cases in

Morocco whereas the visceral form accounted for 2415 (n=5552298) [32]

In order to properly intervene in the fight against leishma-niasis in this region a persistent follow-up of this pathologyis indispensable in particular the visceral form which isconsidered as a deadly form and which continues to record arather large number of cases The measures of control of thisdisease should take into account rapid diagnosis in suspectedclinical cases and treatment of confirmed positive casesvector controlmeasures improvement of hygiene conditionsand the zoonotic cycle of this form Unfortunately theresults showed that these interventions are not yet taken intoconsideration

Regarding the molecular characterization the identifica-tion of DNA from CL slides showed that L infantum and Ltropica circulate together in this region with a predominanceof L infantum (n = 6881 84) (P-value = 6026e-06)while L infantum was the only causal species of VL On theother hand the distribution of these parasites showed thatL infantum was the only circulating species in ChefchaouenTangier-Assilah and Fahs-Anjra provinces while in Larache


0

5

10

15

20

25

30

35

40

45

0

5

10

15

20

25

30

35

40

45

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Num

ber of VL casesprovince

Tota

l cas

es

Total Al Hoceima Chefchaouen Larache Tangier-Assilah Tetouan Mdiq-Fnidq Fahs-Anjra

(a)

0

10

20

30

40

50

60

0

10

20

30

40

50

60

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018


Num

ber of CL casesprovinceTo

tal c

ases

(b)

Figure 4 Temporal distribution of VL and CL cases (a) Visceral leishmaniasis cases recorded between 1997 and 2018 in Tangier-Tetouan-AlHoceima region (b) Cutaneous leishmaniasis cases recorded between 1997 and 2018 in Tangier-Tetouan-Al Hoceima Region

Al Hoceima and Tetouan the predominance of L infantumbeside L tropica was registered Indeed this is the firstidentification of this species as the main causative agent ofhuman cutaneous form of leishmaniasis in this region

The dominance of L infantum is no longer surprising Infact this species starts to have a wide extension throughoutthe world including several Mediterranean countries inparticular Southern Europe such as the famous foci inAbruzzi (Italy) [34] and Cukurova region (Turkey) [35]Also several other epidemiological studies were performed inNorth Africa such as Tunisia and Algeria [36 37]

InMorocco this specieswas responsible for sporadic casesin the north of the country [4] Indeed the molecular surveyof leishmaniasis in Taza Province showed the existence ofmany cases of CL due to L infantum [23] The same resultswere observed in another study realized in Ouazzane and SidKacem Provinces [25] Going further exactly to the southof the country a sporadic case of CL due to L infantum inOuarzazate Province was declared [38]

The presence of L infantum in this region at a high ratecould be explained firstly by the dominance of VL due toL infantum in this area On the other hand our study areabelongs to humid subhumid and semiarid climate locatedat an altitude of between 0 and 573m Indeed Rioux et al in

1984 showed that the repartition of different sandflies speciesis mostly related to the bioclimatic areas [39] In additionLaqraa et al in 2015 provided an updated distribution ofleishmaniasis vectors in Morocco according to their biocli-matic and altitudinal preferences [33]This update showed anabundance of sandfly species known to be vectors of VL andCL in this regionThese species includePhlebotomus pernicio-sus which dominates in the humid subhumid and semiaridzones at high altitudes and Phlebotomus longicuspis which ispreponderant in semiarid stages at low altitudes [33 40]Thismay explain the abundance of this Leishmania species in thenorth part of the country which is characterized by this typeof climate

The epidemiological study established during the sur-veyed period showed that peaks in the number of humanCL cases were recorded in three provinces (Larache AlHoceima and Chefchaouen) The number of cases continuesto increase in the provinces of Larache andAlHoceima whilea remarkable decrease is known in Chefchaouen ProvinceMoreover Tetouan Province has recorded a lower numberHowever the epidemiological situation of the visceral formshowed an important geographical extension especially inChefchaouen and Al Hoceima Provinces Several factors canexplain the increase of the number cases until 2010 Among


(a)

(b)

Figure 5 Geographical distribution of visceral leishmaniasis in Tangier-Tetouan-Al Hoceima Region (2007-2018) (a) Tangier-Tetouan-AlHoceima 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 followingthe introduction of a response action plan between 2010and 2016 In addition this increase can be explained also bythe neighbourship of these provinces with several provincesalready known to be foci of CL and VL such as Ouazzane[25] Sidi Kacem [25] Taounate [41] and Taza [23] Alsothe population activities and shifting could also cause thisincrease [42] Moreover the majority of these cities arelocated on a mountainous area that is surrounded by oldunrestored fissured walls with a nearby spring that providedaytime resting places for sandflies

Furthermore most cases have been reported in ruraland periurban areas In fact the provinces of ChefchaouenAl Hoceima and Larache which recorded the maximum

number of cases have a relatively low rate of urbanization(respectively 125 325 and 525) [26] According tothe WHO the urbanization rate is indicated as a key factorin the increase of leishmaniasis [43] The transmission ofleishmaniasis generally occurs in rural areas [44] in whichit could be related to human behavior through human-animal coexistence and the accumulation of animal wastenear homes [45] Boussaa et al have confirmed that this factorhas a huge influence on vector populations and consequentlyon the epidemiology of the disease The abundance ofsandflies appears to decrease with increasing urbanizationand some potential vector species may disappear [46] Inaddition movement population from rural neighboring focito periurban areas may increase leishmaniasis cases which


Al H

oceima

ChefchaouenFahs-A

njraLarache

Mrsquodiq-Fnideq

Tangier-Assilah

Tetouan

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

1510

50

1510

50

1510

50

1510

50

1510

50

1510

50

1510

50

Num

ber o

f sec

tors

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 thepropagation of reservoir hosts and vectors and consequentlyfor the spread of leishmaniasis [47]

According to the clinical study of leishmaniasis inTangier-Tetouan-Al Hoceima Region the repartition of CLand VL in relation to age showed that no age group wasspared from leishmaniasis with the dominance of childrenunder 9 years old This dominance could be explained by theweak immune system and consequently the inability to fightthe Leishmania infection In addition this may be due alsoto the habits of children who often play near breeding siteswhich make them prone to insect bites [49] Moreover thisstudy also shows a predominance of men with leishmaniasisthis dominance could be explained essentially by the ruralcharacter of the provinces where peoplersquos activities dependclosely to the breeding generally practiced by men

In addition the predominance of this cutaneous formdue to L infantum prompts us to know whether an immunesuppression of the patients with this form can lead to relapsesand develop a visceral form of leishmaniasis Indeed thisspecies proved to be an important opportunistic agent withhigh rates of relapse and death in patients with acquiredimmunodeficiency [50] Moreover the emergence of ananthroponotic cycle of HIVVL coinfections by sharingcontaminated syringes among intravenous drug users hasbeen reported [51] Additionally it is important to note that

the provisional number of cumulative cases of HIV-AIDSin Morocco was 12545 in 2016 according to the Ministry ofHealth [52]

Molecular identification of circulating species of Leish-mania and knowledge of temporal and spatial distributionof leishmaniasis cases are essential in order to understandepidemiology of the diseases [53]

In fact the transmission cycle of L infantum is zoonoticdogs have been implicated as the main reservoir hosts ofthis species In Morocco both the MON-1 and MON-24zymodemes have been isolated from dogs [10 54] Howeverdata on density of dogs and their positivity for L infantumin this region are missing Furthermore it is important tomention that rodents may also transmit this parasite ofwhich L infantum has been isolated from rodents belong-ing to the species Rattus norvegicus in Greece and Brazil[55 56]

Interestingly the identification of L infantum speciescausing human cutaneous form in this region will play amajor role in helping and guiding the national leishmaniasiscontrol program by preventing and taking into considerationthe zoonotic character

5 Conclusion

The present study concerns both cutaneous and visceralleishmaniasis prevalence in northern Morocco Our results


(a)

(b)

Figure 7 Geographical distribution of cutaneous leishmaniasis in Tangier-Tetouan-Al Hoceima Region (2007-2018) (a) Tangier-Tetouan-AlHoceima 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 Ltropica) are present in the northern region of Morocco witha predominance of L infantum These findings are consistentwith studies which have shown that L infantum is the mainagent responsible for VL and CL cases in the Mediterraneansubregion

The identification of circulating zoonotic L infantumspecies in this region is of great importance since it allows thedetermination of transmission cycles In fact these fundingwill allow us to monitor the health of human and animalwith thinking about ldquoOne healthrdquo as the potential of closercooperation between human and animal health


201510

50

201510

50

201510

50

201510

50

201510

50

201510

50

201510

50

Num

ber o

f sec

tors

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

Al H

oceima

ChefchaouenFahs-A

njraLarache

Mrsquodiq-Fnideq

Tangier-Assilah

Tetouan

Figure 8 Number of affected sectors by CL depending to years in Tangier-Tetouan-Al Hoceima Region (2007-2018)

Male Age Female

50+

41-50

31-40

21-30

11-20

0-10

230

170

120

230

260

850 960

290

190

150

20

160

0 806856443220982 102234465870

Figure 9 Distribution of leishmaniasis cases in relation to age and sex (2007-2018)


Abbreviations

CL Cutaneous leishmaniasisVL Visceral leishmaniasisNRLL National Reference Laboratory of

Leishmaniasis-RabatNIH National Institute of Hygiene-Morocco

Data Availability

The data used to support the findings of this study areincluded within the article

Conflicts of Interest

The authors declare that they have no competing interests

Acknowledgments

The authors would like to thank the delegates animators andphysicians of the provinces studied in this paper for providingall the necessary information on the samples and the studyarea Also they send big thanks to MOUNTAJ Sara (PhDstudent) and MHIYAOUI Hassan (PhD student) from lab-oratory of Applied Geosciences Engineering (GAIA) Facultyof Sciences Aın Chock-Casablanca for their contribution incarrying out studies of GIS

References

[1] J Dedet ldquoLeishmanies leishmanioses Biologie clinique ettherapeutiquerdquo Encyclopedie Medico-Chirurgicale MaladiesInfectieuses vol 8 no 506 pp 10-11 2001

[2] R Killick-Kendrick ldquoThe biology and control of phlebotominesand fliesrdquo Clinics in Dermatology vol 17 no 3 pp 279ndash2891999

[3] M TM Roberts ldquoCurrent understandings on the immunologyof leishmaniasis and recent developments in prevention andtreatmentrdquoBritishMedical Bulletin vol 75-76 no 1 pp 115ndash1302005

[4] M Rhajaoui ldquoHuman leishmaniases in Morocco a nosogeo-graphical diversityrdquo Pathologie Biologie vol 59 no 4 pp 226ndash229 2011

[5] J Rioux F Petter O Akalay G Lanotte A Ouazzani MSeguignes et al ldquoMeriones shawi (Duvernoy 1842) (Roden-tia Gerbillidae) reservoir de Leishmania major Yakimoff etSchokhor 1914 (Kinetoplastida Trypanosomatidae) dans le Sudmarocainrdquo Comptes Rendus de lrsquoAcademie des Sciences vol 294pp 515ndash517 1982

[6] F Pratlong J Rioux J Dereure et al ldquoLeishmania tropica auMaroc IV mdash Diversite isozymique intrafocale rdquo Annales deParasitologie Humaine et Comparee vol 66 no 3 pp 100ndash1041991

[7] M Lemrani R Nejjar and F Pratlong ldquoA new Leishmaniatropica zymodememdashcausative agent of canine visceral leishma-niasis in Northern Moroccordquo Annals of Tropical Medicine andParasitology vol 96 no 6 pp 637-638 2002

[8] J Derreure A Saddiki and A Martini ldquoLeishmania tropica auMaroc Role du vecteur de Psergenti A propos de 89 isolatsrdquo

Annales de Parasitologie Humaine et Comparee vol 66 no 3pp 96ndash99 1991

[9] K Jaouadi J Depaquit N Haouas et al ldquoTwenty-four newhuman cases of cutaneous leishmaniasis due to Leishmaniakillicki in Metlaoui southwestern Tunisia probable role ofPhlebotomus sergenti in the transmissionrdquoActa Tropica vol 122no 3 pp 276ndash283 2012

[10] R Benikhlef Z Harrat M Toudjine A Djerbouh S Bendali-Braham and M Belkaid ldquoDetection of Leishmania infantumMON-24 in the dogrdquo Medecine Tropicale Revue du Corps deSante Colonial vol 64 no 4 pp 381ndash383 2004

[11] F Pratlong P Lami C Ravel Y Balard J Dereure G Serreset al ldquoGeographical distribution and epidemiological featuresof Old World Leishmania infantum and Leishmania donovanifoci based on the isoenzyme analysis of 2277 strainsrdquo Parasitol-ogy vol 140 pp 423ndash434 2013

[12] M Mniouil H Fellah F Amarir et al ldquoEpidemiological char-acteristics of visceral leishmaniasis in Morocco (1990ndash2014) anupdaterdquo Acta Tropica vol 170 pp 169ndash177 2017

[13] P D Ready ldquoEpidemiology of visceral leishmaniasisrdquo Journal ofClinical Epidemiology vol 6 no 1 pp 147ndash154 2014

[14] S O Toz G Culha F Y Zeyrek et al ldquoA real-time ITS1-PCRbased method in the diagnosis and species identification ofleishmania parasite from human and dog clinical samples inTurkeyrdquo PLOS Neglected Tropical Diseases vol 7 no 5 2013

[15] M Ait Kbaich I Mhaidi A Ezzahidi et al ldquoNew epidemiolog-ical pattern of cutaneous leishmaniasis in two pre-Saharan aridprovinces southern Moroccordquo Acta Tropica vol 173 pp 11ndash162017

[16] E A Mohamed Mahmoud S Faiza M Lemine et al ldquoGeo-graphical distribution and new situation of leishmania speciesafter the control of cutaneous leishmaniasis foci in errachidiaprovinceMorocco in 2014rdquoBioMedResearch International vol2016 Article ID 8642373 7 pages 2016

[17] A Hmamouch M M El Alem M Hakkour et al ldquoCirculatingspecies of Leishmania at microclimate area of BoulemaneProvince Morocco impact of environmental and human fac-torsrdquo Parasites amp Vectors vol 10 no 1 2017

[18] M M El Alem M Hakkour A Hmamouch et al ldquoRiskfactors and prediction analysis of cutaneous leishmaniasis dueto Leishmania tropica in Southwestern Moroccordquo InfectionGenetics and Evolution vol 61 pp 84ndash91 2018

[19] A Fatima S Faiza F Hajiba et al ldquoEpidemiological charac-teristics of a new focus of cutaneous leishmaniasis caused byLeishmania tropica in Settat Moroccordquo Acta Tropica vol 150pp 116ndash121 2015

[20] M Rhajaoui F Sebti H Fellah et al ldquoIdentification ofthe causative agent of cutaneous leishmaniasis in Chichaouaprovince Moroccordquo Parasite vol 19 no 1 pp 81ndash84 2012

[21] H Arroub S Hamdi M Ajaoud K Habbari and M LemranildquoEpidemiologic study and molecular detection of Leishmaniaand sand fly species responsible of cutaneous leishmaniasis inFoum Jamaa (Azilal Atlas of Morocco)rdquo Acta Tropica vol 127no 1 pp 1ndash5 2013

[22] S Faiza H Asmae A Fatima et al ldquoMolecular epidemiologicalstudy of cutaneous leishmaniasis in Beni Mellal and Fquih BenSaleh provinces inMoroccordquoActa Tropica vol 149 pp 106ndash1122015

[23] M Hakkour A Hmamouch M M El Alem et al ldquoNewepidemiological aspects of visceral and cutaneous leishmaniasisin Taza Moroccordquo Parasites amp Vectors vol 9 no 1 2016


[24] H Asmae A Fatima F Hajiba et al ldquoCoexistence of Leish-mania tropica and Leishmania infantum in Sefrou provinceMoroccordquo Acta Tropica vol 130 no 1 pp 94ndash99 2014

[25] H El Miri C Faraj O Himmi et al ldquoCutaneous leishmaniasisin Ouazzane and Sidi Kacem provinces Morocco (1997-2012)rdquoBulletin de la Societe de Pathologie Exotique vol 109 no 5 pp376ndash380 2016

[26] HCP Monographie de la region Tanger-Tetouan-Al Hoceima2015 fileCUsersAdminDownloadsMONOGRAPHIEDE LA REGION DE TANGER TETOUAN fr (3)pdf

[27] HCP Vue drsquoensemble de la Region Tanger-Tetouan-AlHoceima Haut Commissariat au Plan 2017 httpswwwhcpmaregion-tangerVue-d-ensemble-de-la-Region-Tanger-Te-touan-Al-Hoceima a149html

[28] M A Mahdy H M Al-Mekhlafi A M Al-Mekhlafi et alldquoMolecular characterization of leishmania species isolated fromcutaneous leishmaniasis in Yemenrdquo PLoS ONE vol 5 no 9Article ID e12879 pp 1ndash4 2010

[29] A Al-Jawabreh L Schnur A Nasereddin J SchwenkenbecherZ Abdeen F Barghuthy et al ldquoThe recentemergence of Leish-mania tropica in Jericho (Ariha) and its environs a classical-focus of Leishmania majorrdquo Tropical Medicine amp InternationalHealth vol 9 pp 1ndash5 2004

[30] G Schonian ANasereddin NDinse et al ldquoPCRdiagnosis andcharacterization of Leishmania in local and imported clinicalsamplesrdquoDiagnosticMicrobiology and InfectiousDisease vol 47no 1 pp 349ndash358 2003

[31] DELM Programme de Lutte contre les Leishmanioses 2000[32] MMHMM of H Sante en chiffres (edition 2017 en cours) 2016

httpwwwsantegovmaPublicationsEtudes enquetePagesdefaultaspx

[33] E Laqraa M Elkohli E Adlaoui and C Faraj ldquoLesphlebotomes du Marocrdquo Bulletin de lrsquoInstitut NationaldrsquoHygiene vol 3 p 4 2015

[34] M Gramiccia L Gradoni and E Pozio ldquoLeishmania infantumsensu lato as an agent of cutaneous leishmaniasis in Abruzziregion (Italy)rdquo Transactions of the Royal Society of TropicalMedicine and Hygiene vol 81 no 2 pp 235ndash237 1987

[35] J Votypka O E Kasap P Volf P Kodym and B AltenldquoRisk factors for cutaneous leishmaniasis in Cukurova regionTurkeyrdquo Transactions of the Royal Society of Tropical Medicineand Hygiene vol 106 no 3 pp 186ndash190 2012

[36] M BenSaid S Guerbouj F Saghrouni A Fathallah-Mili andI Guizani ldquoOccurrence of Leishmania infantum cutaneousleishmaniasis in central Tunisiardquo Transactions of the RoyalSociety of TropicalMedicine andHygiene vol 100 no 6 pp 521ndash526 2006

[37] K Aoun and A Bouratbine ldquoCutaneous leishmaniasis in NorthAfrica a reviewrdquo Parasite vol 21 pp 14ndash23 2014

[38] A ElHamouchi R EjghalMHida andM Lemrani ldquoIntraspe-cific genetic variability in a population ofMoroccan Leishmaniainfantum revealed by PCR-RFLP of kDNA minicirclesrdquo ActaTropica vol 169 pp 142ndash149 2017

[39] J Rioux P Rispail G Lanotte and J Lepart ldquoRelationsPhlebotomes-bioclimats en ecologie des leishmanioses Corol-laires epidemiologiques Lrsquoexemple du Marocrdquo Bulletin de laSociete Botanique de France Actualites Botaniques vol 131 no2ndash4 pp 549ndash557 2014

[40] J Rioux ldquoEco-epidemiologie des leishmanioses auMaroc Bilande 30 ans de cooperation Direction de lEpidemiologie et deLutte contre les Maladiesrdquo Bulletin Epidemiologique vol 37 pp2ndash10 1999

[41] J Rioux J Mahjour M Gallego J Dereure J Perieres ALaamrani et al ldquoLeishmaniose cutanee humaine a Leishmaniainfantum MON-24 au Marocrdquo Bulletin de la Societe Francaisede Parasitologie vol 14 no 2 pp 179ndash183 1996

[42] WHO Report on Global Surveillance of Epidemic-prone Infec-tious Diseases ndash Leishmaniasis 2000 httpwwwwhointcsrresourcespublicationsCSR ISR 2000 1leishen

[43] WHO ldquoUrbanization An increasing risk factor for Leishmani-asisrdquo The Weekly Epidemiological Record vol 77 pp 365ndash3722002

[44] WHO Leishmaniasis 2017 httpwwwwhointmediacentrefactsheetsfs375en

[45] W d Nunes S R Araujo and C M Calheiros ldquoEpidemiolog-ical profile of leishmaniasis at a reference service in the stateof Alagoas Brazil from January 2000 to september 2008rdquo TheBrazilian Journal of Infectious Diseases vol 14 no 4 pp 342ndash345 2010

[46] S Boussaa B Pesson and A Boumezzough ldquoPhlebotominesandflies (Diptera Psychodidae) of Marrakech city MoroccordquoAnnals of Tropical Medicine and Parasitology vol 101 no 8 pp715ndash724 2007

[47] R Reithinger M Mohsen and T Leslie ldquoRisk factors foranthroponotic cutaneous leishmaniasis at the household levelin Kabul Afghanistanrdquo PLOS Neglected Tropical Diseases vol4 no 3 Article ID e639 2010

[48] M A Ghatee I Sharifi A A Haghdoost et al ldquoSpatial cor-relations of population and ecological factors with distributionof visceral leishmaniasis cases in southwestern Iranrdquo Journal ofVector Borne Diseases vol 50 no 3 pp 179ndash187 2013

[49] H Arroub A Alaoui M Lemrani and K Habbari ldquoCuta-neous leishmaniasis in foum jamaa (Azilal Morocco) micro-environmental and socio-economical risk factorsrdquo Journal ofAgriculture and Social Sciences vol 8 pp 6ndash10 2012

[50] J Alvar P Aparicio A Aseffa et al ldquoThe relationship betweenleishmaniasis and AIDS the second 10 yearsrdquo Clinical Microbi-ology Reviews vol 21 no 2 pp 334ndash359 2008

[51] I Cruz M A Morales I Noguer A Rodrıguez and J AlvarldquoLeishmania in discarded syringes from intravenous drugusersrdquoThe Lancet vol 359 no 9312 pp 1124-1125 2002

[52] DELM Bulletin drsquoEpidemiologie et de Sante Publique 2017httpswwwsantegovmaPublicationsBullten pidmiologiqueBullettin-DELMpdf

[53] G Schonian L Schnur M El Fari et al ldquoGenetic heterogeneityin the species Leishmania tropica revealed by different PCR-based methodsrdquo Transactions of the Royal Society of TropicalMedicine and Hygiene vol 95 no 2 pp 217ndash224 2001

[54] J Rioux G Lanotte F Petter J Dereure O Akalay F Pratlonget al ldquoLes Leishmanioses cutanees du bassin Mediterraneenoccidental De lidentification enzymatique a lanalyse eco-epidemiologique Lexemple de trois foyers tunisienmarocain et francais IMEEErdquo Montpellier Applicationseco-epidemiologiques pp 365ndash395 1986

[55] Y Ozbel I BalciogluM Olgen F Simsek S Toz H Ertabaklaret al ldquoSpatial distribution of phlebotomine sand flies in theAydin Mountains and surroundings the main focus of cuta-neous Papadogiannakis E Spanakos G Kontos V MenounosPG Tegos N Vakalis N Molecular detection of Leishmaniainfantum in wild rodents (Ratt)rdquo Zoonoses Public Health vol57 pp e23ndashe25 2010


[56] F O Lara-Silva R A Barata E M Michalsky et al ldquoRattusnorvegicus (Rodentia Muridae) Infected by Leishmania (Leish-mania) infantum (syn Le chagasi) in Brazilrdquo BioMed ResearchInternational vol 2014 Article ID 592986 7 pages 2014

Hindawiwwwhindawicom

International Journal of

Volume 2018

Zoology

Hindawiwwwhindawicom Volume 2018

Anatomy Research International

PeptidesInternational Journal of



Journal of Parasitology Research

GenomicsInternational Journal of


Hindawi Publishing Corporation httpwwwhindawicom Volume 2013Hindawiwwwhindawicom

The Scientific World Journal

Volume 2018


BioinformaticsAdvances in

Marine BiologyJournal of



Neuroscience Journal


BioMed Research International

Cell BiologyInternational Journal of



Biochemistry Research International

ArchaeaHindawiwwwhindawicom Volume 2018


Genetics Research International


Advances in

Virolog y Stem Cells International



Enzyme Research



MicrobiologyHindawiwwwhindawicom

Nucleic AcidsJournal of

Volume 2018

Submit your manuscripts atwwwhindawicom


Al HoceimaChefchaouenLarache

Tetouan

Tangier

EW

S

N

-Assilah

Fahs -Anjra

Mrsquodiq -Fnideq Mediterranean Sea

Atlantic Ocean

100 50 0 100Km

6∘00W 4

∘00W

6∘00W 4

∘00W

35∘0

0N

35∘00

N

Figure 1 The study area

this disease are Leishmania major L tropica and L infantum[4] the latter being more often associated with visceralleishmaniasis The transmission is zoonotic for L major witha wild animal reservoir [5] and rather anthroponotic forL tropica In fact the isolation of this species (MON-102and MON-113) from dog suggests that this mammal (dog)could be implicated as the secondary reservoir host in thelife cycle of L tropica Nevertheless the few sporadic casesviscerotropic do not confirm that the dog is the principalhost and the life cycle is zoonotic [6ndash8] In some parts of theMaghreb L Killicki has also been proven to be responsiblefor zoonotic CL particularly in Tunisia [9] Concerning Linfantum studies carried out in Maghreb countries isolatedthis species from dog suggesting it as the reservoir of thisdisease [10]

Regarding visceral leishmaniasis (VL) Leishmania infan-tum is the single agent responsible for this human form in theMediterranean basin [11 12] However Ready et al suggestedthat any parasite responsible for cutaneous leishmaniasis canvisceralize [13] (eg Leishmania tropica which causes CLcases has been proven as the agent responsible for humanVLand canine leishmaniasis (CanL) in Turkey [14]

In Morocco the epidemiological situation of leishmani-asis as well as the distribution of Leishmania species variesTwo different eco-epidemiological entities have been knownin the past CL due to L major also called wet or rural formand CL due to L tropica also known as dry or urban formHowever forL infantum it was responsible for sporadic cases[4] The recently published work revealed a new distributionof species by province Indeed many studies reported thatCL cases in south-east of Morocco were caused essentiallyby L major but L tropica is also present [15ndash17] Howeverin the Southwestern L tropica is the only circulating species[18ndash20] In the center of the kingdom L tropica is beingthe 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 Linfantum have been also isolated with the presence of majorcases of L tropica [25]

Nevertheless epidemiological data on leishmaniases aremissing in the northern region So in order to give a generaloverview of the new distribution of CL species in Moroccoit is essential to carry out molecular investigations in theNorthern provinces which have never been started andwhichremain until nowadays unknown

The purpose of this study is to establish epidemiologicaldata on leishmaniasis in seven provinces located in theextreme north of Morocco during the 21-year period 1997-2018 and to characterize the parasite species responsible forrecent cases of leishmaniasis

2 Material and Methods

21 Study Area This study was established in Tangier-Tetouan-Al Hoceima Region belonging to the northwest-ern section (35∘ 461015840 0010158401015840 N 5∘ 481015840 0010158401015840 W) and con-cerns Al Hoceima Chefchaouen Larache Tangier-AssilahTetouanMrsquodiq-Fnidq and Fahs-Anjra ProvincesThis regionis bordered to the north by the Strait of Gibraltar and theMediterranean Sea to the west by the Atlantic Ocean to thesouth-west by the Rabat-Sale-Kenitra Region to the southby the Fes-Meknes Region and to the east by the OrientalRegion (Figure 1) Climatically this region is characterized bya Mediterranean climate [26] Moreover in terms of tourismits exceptional location with its two maritime facades and itsroots in history and cultural diversity predispose it to occupya favorite place as a tourist destination

The Tangier-Tetouan-Al Hoceima Region extends over asurface of 17262 km2 (243 of the national territory) andhas a total of 3556729 inhabitants with a density of 206inhabitants per km2 [27]


22 Diagnosis










3 Results












Larache






Al Hoceima







Ait ziane R - - 1 1

Tetouan


Bni Hsen R 0 1 - 1- 1 0 - 1

Tetouan U 2 0 - 2- 1 0 - 1- - - 1 1




Table 1 Continued



Khmis Anjra R 1 0 - 1- 1 0 - 1


- 1 0 - 1- - - 2 2





43pb






Mediterranean Sea

Atlantic Ocean

Al Hoceima

Chefchaouen

Larache

Tetouan

Tangier-Assilah

Fahs -Anjra

Mrsquodiq-Fnideq






34482390

34940112

35397834

35855556

34482390

34940112

35397834

35855556

S

E

N

W






4 Discussion






0

5

10

15

20

25

30

35

40

45

0

5

10

15

20

25

30

35

40

45

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Num


Tota

l cas

es


(a)

0

10

20

30

40

50

60

0

10

20

30

40

50

60

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018


Num


tal c

ases

(b)









(a)

(b)






Al H

oceima

ChefchaouenFahs-A

njraLarache

Mrsquodiq-Fnideq

Tangier-Assilah

Tetouan

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

1510

50

1510

50

1510

50

1510

50

1510

50

1510

50

1510

50

Num

ber o

f sec

tors









5 Conclusion



(a)

(b)





201510

50

201510

50

201510

50

201510

50

201510

50

201510

50

201510

50

Num

ber o

f sec

tors

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

Al H

oceima

ChefchaouenFahs-A

njraLarache

Mrsquodiq-Fnideq

Tangier-Assilah

Tetouan


Male Age Female

50+

41-50

31-40

21-30

11-20

0-10

230

170

120

230

260

850 960

290

190

150

20

160

0 806856443220982 102234465870



Abbreviations



Data Availability




Acknowledgments


References






























































Volume 2018

Zoology











Volume 2018

















Advances in




Enzyme Research





Volume 2018



22 Diagnosis










3 Results












Larache






Al Hoceima







Ait ziane R - - 1 1

Tetouan


Bni Hsen R 0 1 - 1- 1 0 - 1

Tetouan U 2 0 - 2- 1 0 - 1- - - 1 1




Table 1 Continued



Khmis Anjra R 1 0 - 1- 1 0 - 1


- 1 0 - 1- - - 2 2





43pb






Mediterranean Sea

Atlantic Ocean

Al Hoceima

Chefchaouen

Larache

Tetouan

Tangier-Assilah

Fahs -Anjra

Mrsquodiq-Fnideq






34482390

34940112

35397834

35855556

34482390

34940112

35397834

35855556

S

E

N

W






4 Discussion






0

5

10

15

20

25

30

35

40

45

0

5

10

15

20

25

30

35

40

45

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Num


Tota

l cas

es


(a)

0

10

20

30

40

50

60

0

10

20

30

40

50

60

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018


Num


tal c

ases

(b)









(a)

(b)






Al H

oceima

ChefchaouenFahs-A

njraLarache

Mrsquodiq-Fnideq

Tangier-Assilah

Tetouan

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

1510

50

1510

50

1510

50

1510

50

1510

50

1510

50

1510

50

Num

ber o

f sec

tors









5 Conclusion



(a)

(b)





201510

50

201510

50

201510

50

201510

50

201510

50

201510

50

201510

50

Num

ber o

f sec

tors

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

Al H

oceima

ChefchaouenFahs-A

njraLarache

Mrsquodiq-Fnideq

Tangier-Assilah

Tetouan


Male Age Female

50+

41-50

31-40

21-30

11-20

0-10

230

170

120

230

260

850 960

290

190

150

20

160

0 806856443220982 102234465870



Abbreviations



Data Availability




Acknowledgments


References






























































Volume 2018

Zoology











Volume 2018

















Advances in




Enzyme Research





Volume 2018





Larache






Al Hoceima







Ait ziane R - - 1 1

Tetouan


Bni Hsen R 0 1 - 1- 1 0 - 1

Tetouan U 2 0 - 2- 1 0 - 1- - - 1 1




Table 1 Continued



Khmis Anjra R 1 0 - 1- 1 0 - 1


- 1 0 - 1- - - 2 2





43pb






Mediterranean Sea

Atlantic Ocean

Al Hoceima

Chefchaouen

Larache

Tetouan

Tangier-Assilah

Fahs -Anjra

Mrsquodiq-Fnideq






34482390

34940112

35397834

35855556

34482390

34940112

35397834

35855556

S

E

N

W






4 Discussion






0

5

10

15

20

25

30

35

40

45

0

5

10

15

20

25

30

35

40

45

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Num


Tota

l cas

es


(a)

0

10

20

30

40

50

60

0

10

20

30

40

50

60

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018


Num


tal c

ases

(b)









(a)

(b)






Al H

oceima

ChefchaouenFahs-A

njraLarache

Mrsquodiq-Fnideq

Tangier-Assilah

Tetouan

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

1510

50

1510

50

1510

50

1510

50

1510

50

1510

50

1510

50

Num

ber o

f sec

tors









5 Conclusion



(a)

(b)





201510

50

201510

50

201510

50

201510

50

201510

50

201510

50

201510

50

Num

ber o

f sec

tors

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

Al H

oceima

ChefchaouenFahs-A

njraLarache

Mrsquodiq-Fnideq

Tangier-Assilah

Tetouan


Male Age Female

50+

41-50

31-40

21-30

11-20

0-10

230

170

120

230

260

850 960

290

190

150

20

160

0 806856443220982 102234465870



Abbreviations



Data Availability




Acknowledgments


References






























































Volume 2018

Zoology











Volume 2018

















Advances in




Enzyme Research





Volume 2018



Table 1 Continued



Khmis Anjra R 1 0 - 1- 1 0 - 1


- 1 0 - 1- - - 2 2





43pb






Mediterranean Sea

Atlantic Ocean

Al Hoceima

Chefchaouen

Larache

Tetouan

Tangier-Assilah

Fahs -Anjra

Mrsquodiq-Fnideq






34482390

34940112

35397834

35855556

34482390

34940112

35397834

35855556

S

E

N

W






4 Discussion






0

5

10

15

20

25

30

35

40

45

0

5

10

15

20

25

30

35

40

45

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Num


Tota

l cas

es


(a)

0

10

20

30

40

50

60

0

10

20

30

40

50

60

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018


Num


tal c

ases

(b)









(a)

(b)






Al H

oceima

ChefchaouenFahs-A

njraLarache

Mrsquodiq-Fnideq

Tangier-Assilah

Tetouan

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

1510

50

1510

50

1510

50

1510

50

1510

50

1510

50

1510

50

Num

ber o

f sec

tors









5 Conclusion



(a)

(b)





201510

50

201510

50

201510

50

201510

50

201510

50

201510

50

201510

50

Num

ber o

f sec

tors

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

Al H

oceima

ChefchaouenFahs-A

njraLarache

Mrsquodiq-Fnideq

Tangier-Assilah

Tetouan


Male Age Female

50+

41-50

31-40

21-30

11-20

0-10

230

170

120

230

260

850 960

290

190

150

20

160

0 806856443220982 102234465870



Abbreviations



Data Availability




Acknowledgments


References






























































Volume 2018

Zoology











Volume 2018

















Advances in




Enzyme Research





Volume 2018



Mediterranean Sea

Atlantic Ocean

Al Hoceima

Chefchaouen

Larache

Tetouan

Tangier-Assilah

Fahs -Anjra

Mrsquodiq-Fnideq






34482390

34940112

35397834

35855556

34482390

34940112

35397834

35855556

S

E

N

W






4 Discussion






0

5

10

15

20

25

30

35

40

45

0

5

10

15

20

25

30

35

40

45

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Num


Tota

l cas

es


(a)

0

10

20

30

40

50

60

0

10

20

30

40

50

60

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018


Num


tal c

ases

(b)









(a)

(b)






Al H

oceima

ChefchaouenFahs-A

njraLarache

Mrsquodiq-Fnideq

Tangier-Assilah

Tetouan

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

1510

50

1510

50

1510

50

1510

50

1510

50

1510

50

1510

50

Num

ber o

f sec

tors









5 Conclusion



(a)

(b)





201510

50

201510

50

201510

50

201510

50

201510

50

201510

50

201510

50

Num

ber o

f sec

tors

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

Al H

oceima

ChefchaouenFahs-A

njraLarache

Mrsquodiq-Fnideq

Tangier-Assilah

Tetouan


Male Age Female

50+

41-50

31-40

21-30

11-20

0-10

230

170

120

230

260

850 960

290

190

150

20

160

0 806856443220982 102234465870



Abbreviations



Data Availability




Acknowledgments


References






























































Volume 2018

Zoology











Volume 2018

















Advances in




Enzyme Research





Volume 2018



0

5

10

15

20

25

30

35

40

45

0

5

10

15

20

25

30

35

40

45

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Num


Tota

l cas

es


(a)

0

10

20

30

40

50

60

0

10

20

30

40

50

60

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018


Num


tal c

ases

(b)









(a)

(b)






Al H

oceima

ChefchaouenFahs-A

njraLarache

Mrsquodiq-Fnideq

Tangier-Assilah

Tetouan

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

1510

50

1510

50

1510

50

1510

50

1510

50

1510

50

1510

50

Num

ber o

f sec

tors









5 Conclusion



(a)

(b)





201510

50

201510

50

201510

50

201510

50

201510

50

201510

50

201510

50

Num

ber o

f sec

tors

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

Al H

oceima

ChefchaouenFahs-A

njraLarache

Mrsquodiq-Fnideq

Tangier-Assilah

Tetouan


Male Age Female

50+

41-50

31-40

21-30

11-20

0-10

230

170

120

230

260

850 960

290

190

150

20

160

0 806856443220982 102234465870



Abbreviations



Data Availability




Acknowledgments


References






























































Volume 2018

Zoology











Volume 2018

















Advances in




Enzyme Research





Volume 2018



(a)

(b)






Al H

oceima

ChefchaouenFahs-A

njraLarache

Mrsquodiq-Fnideq

Tangier-Assilah

Tetouan

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

1510

50

1510

50

1510

50

1510

50

1510

50

1510

50

1510

50

Num

ber o

f sec

tors









5 Conclusion



(a)

(b)





201510

50

201510

50

201510

50

201510

50

201510

50

201510

50

201510

50

Num

ber o

f sec

tors

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

Al H

oceima

ChefchaouenFahs-A

njraLarache

Mrsquodiq-Fnideq

Tangier-Assilah

Tetouan


Male Age Female

50+

41-50

31-40

21-30

11-20

0-10

230

170

120

230

260

850 960

290

190

150

20

160

0 806856443220982 102234465870



Abbreviations



Data Availability




Acknowledgments


References






























































Volume 2018

Zoology











Volume 2018

















Advances in




Enzyme Research





Volume 2018



Al H

oceima

ChefchaouenFahs-A

njraLarache

Mrsquodiq-Fnideq

Tangier-Assilah

Tetouan

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

1510

50

1510

50

1510

50

1510

50

1510

50

1510

50

1510

50

Num

ber o

f sec

tors









5 Conclusion



(a)

(b)





201510

50

201510

50

201510

50

201510

50

201510

50

201510

50

201510

50

Num

ber o

f sec

tors

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

Al H

oceima

ChefchaouenFahs-A

njraLarache

Mrsquodiq-Fnideq

Tangier-Assilah

Tetouan


Male Age Female

50+

41-50

31-40

21-30

11-20

0-10

230

170

120

230

260

850 960

290

190

150

20

160

0 806856443220982 102234465870



Abbreviations



Data Availability




Acknowledgments


References






























































Volume 2018

Zoology











Volume 2018

















Advances in




Enzyme Research





Volume 2018



(a)

(b)





201510

50

201510

50

201510

50

201510

50

201510

50

201510

50

201510

50

Num

ber o

f sec

tors

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

Al H

oceima

ChefchaouenFahs-A

njraLarache

Mrsquodiq-Fnideq

Tangier-Assilah

Tetouan


Male Age Female

50+

41-50

31-40

21-30

11-20

0-10

230

170

120

230

260

850 960

290

190

150

20

160

0 806856443220982 102234465870



Abbreviations



Data Availability




Acknowledgments


References






























































Volume 2018

Zoology











Volume 2018

















Advances in




Enzyme Research





Volume 2018



201510

50

201510

50

201510

50

201510

50

201510

50

201510

50

201510

50

Num

ber o

f sec

tors

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

Al H

oceima

ChefchaouenFahs-A

njraLarache

Mrsquodiq-Fnideq

Tangier-Assilah

Tetouan


Male Age Female

50+

41-50

31-40

21-30

11-20

0-10

230

170

120

230

260

850 960

290

190

150

20

160

0 806856443220982 102234465870



Abbreviations



Data Availability




Acknowledgments


References






























































Volume 2018

Zoology











Volume 2018

















Advances in




Enzyme Research





Volume 2018



Abbreviations



Data Availability




Acknowledgments


References






























































Volume 2018

Zoology











Volume 2018

















Advances in




Enzyme Research





Volume 2018







































Volume 2018

Zoology











Volume 2018

















Advances in




Enzyme Research





Volume 2018


leishmaniasis in northern morocco: predominance of...

Documents