Cutaneous leishmaniasis in Morocco: psychosocial burden and simplified diagnosis.

Introduction

Cutaneous leishmaniasis (CL) is a neglected tropical disease (NTD) affecting more than one million persons worldwide. In Morocco, reporting over the past decade on average more than 4000 cases per year, CL is considered a public health problem. CL is mainly poverty-related in Morocco. The social representations of CL were never explored, though efficient control requires understanding of people’s perception and community involvement. To fill this gap, and to facilitate early diagnosis of CL, our research aimed to document the psychosocial burden of CL in these regions, and to assess a new diagnostic tool for CL that is appropriate for use in remote endemic areas.

Methods

We first described a major outbreak of CL that took place between 2010 to 2012 in Errachidia province. We documented the intersectoral response measures including environmental management and reservoir control. The reservoir of L. major, a rodent, Meriones shawi, was targeted using strychnine-poisoned wheat baits.

The second part of the thesis documents social representations of CL in Southeastern Morocco, in both L. major and L. tropica areas. In 2015, we conducted qualitative research in a group of high school students living in L. major areas to study their perception of CL. Furthermore, we conducted focus group discussions on CL perception and its psychosocial burden in the adult population in Errachidia and Tinghir provinces. We related our findings on psychosocial burden to those in the international literature by conducting a scoping literature review.

The third part of the thesis assessed the accuracy of a new rapid diagnostic test (RDT) of CL in the real-life conditions of primary health centers. A "phase III" diagnostic accuracy study was performed in a consecutive series of patients with ulcerative skin lesions not older than four months and suggestive of CL. We compared the RDT results with a composite reference standard based on PCR and microscopy.

Results

Between 2004 and 2013, 7099 cases of CL were recorded in Errachidia Province. This outbreak due to L. major left many adolescents with permanent scar tissue on the face or other exposed body parts. Almost 20% of 448 high school students reported a CL lesion and 87% said it could lead to psychological consequences. The indelible CL scars lead to self-stigma and social stigma, 12

and the emergence of adverse psychological effects. Adult participants in the focus groups considered the impact of CL lesions and scars as important. Young women with CL scars in the face are stigmatized and may be rejected for marriage in these communities. People usually try a long list of folk remedies on the active lesions, but none was felt adequate. They expressed a real demand for better treatment. The scoping review confirmed that localized CL is a source of pronounced psychological suffering, stigmatization, and reduction of quality of life in several endemic countries.

In the third part, the RDT showed a sensitivity of 68% [95% CI, 61-74]), a specificity of 94% [95% CI, 91-97]), a positive predictive value of 95% [95% CI, 92-98] and a negative predictive value of 64% [95% CI, 58-70]. Species typing on a subsample of 87 PCR positives using PCR-RFLP and PCR-sequencing identified L. tropica (n=40), L. major (n=35) and L. infantum (n=12). Our findings suggest that this novel RDT for CL is a useful addition to clinical management in Morocco, especially in isolated localities far from provincial laboratories.

Conclusion

The high number of CL cases and related scars in Morocco should mobilize more public health attention to sustain preventive measures against vectors and animal reservoirs. The diagnostic management should be reviewed based on current evidence. We recommend the introduction of the RDT in all endemic CL areas with difficult geographical access and the psychological support of people suffering from CL indelible scars.