Human cystic echinococcosis in Morocco: Ultrasound screening in the Mid Atlas through an Italian-Moroccan partnership

<div><p>Background</p><p>Cystic echinococcosis (CE) is a neglected parasitic zoonosis with considerable socioeconomic impact on affected pastoral communities. CE is endemic throughout the Mediterranean, including Morocco, where the Mid Atlas is the most prevalent area for both human and animal infection. The highest hospital annual incidence of human CE is recorded in the provinces of Ifrane and El Hajeb. However, hospital-based statistics likely underestimate the real prevalence of infection, as a proportion of cases never reach medical attention or official records.</p><p>Methodology/Principal findings</p><p>In 2012, a project on clinical management of CE in Morocco was launched with the aims of estimating the prevalence of human abdominal CE in selected rural communes of the above mentioned provinces using ultrasound (US) screening and training local physicians to implement US-based focused assessment and rational clinical management of CE according to the WHO-IWGE Expert Consensus. A total of 5367 people received abdominal US during four campaigns in April-May 2014. During the campaigns, 24 local general practitioners received >24 hours of hands-on training and 143 health education sessions were organized for local communities. We found an overall CE prevalence of 1.9%, with significantly higher values in the rural communes of Ifrane than El Hajeb (2.6% vs 1.3%; p<0.001). CE cysts were predominantly in inactive stage, especially in older age groups. However, active cysts were present also in adults, indicating acquisition of infection at all ages. Province of residence was the only risk factor consistently associated with CE infection.</p><p>Conclusions/Significance</p><p>Our results show a high prevalence and on-going, likely environmental transmission of CE in the investigated provinces of Morocco, supporting the implementation of control activities in the area by national health authorities and encouraging the acceptance and divulgation of diagnosis and treatment algorithms based on imaging for CE at both national and local level.</p></div

Distribution of CE lesions.

<p><b>A.</b> Number of subjects with untreated and previously treated CE cysts (bars; left Y axis) and overall prevalence of CE in the screened population (dotted line; right Y axis) according to gender and age group (X axis). M = males; F = females. Age groups are expressed in years. Three children (aged 3, 8 and 9 years) and 19 adults (aged 81–94 years) were outside the target age range target; none of these subjects were infected with CE. <b>B.</b> Number of hepatic CE cysts in different stages. <b>C.</b> Percentage of CE cyst stages in patients never previously treated for CE within age groups. <b>D.</b> Percentage of CE cyst stages in patients never previously treated for CE within gender groups.</p

Map of Morocco and the survey area.

<p>The survey area is indicated in black. This includes the rural communes of Timahdit and Ain Louh in the province of Ifrane, and the rural communes of Bouderbala and Sebt Jehjouh in the province of El Hajeb, Meknes-Tafilalet region (designated as such until December 2014). Modified from Di Hanhil [Public Domani] Wikimedia Commons.</p

Demographic characteristics distribution of the screened and general population of the investigated provinces.

<p>Three children (aged 3, 8 and 9 years) and 19 adults (aged 81–94 years) were outside the target age range.</p

Examined people and CE cases observed during the screening campaigns.

<p>*One patient reported previous surgery for pulmonary CE.</p

Site characteristics in Old World settings.

<p>Site characteristics in Old World settings.</p

Agreement on key parameters by OWCL and NWCL clinical researchers.

<p>‘Standardized’ criteria are those as proposed in the reference paper Olliaro et al, 2013⁹; ‘updated’ criteria are those resulting from the consultation.</p

Site characteristics in New World settings.

<p>Site characteristics in New World settings.</p