One of the recommended control methods to reduce leishmaniasis transmission is the use of long lasting insecticide nets (LLINs). However, recent studies in Morocco show that their effect on cutaneous leishmaniasis (CL) incidence was minor.

Aim: This study was conducted to identify the factors that might explain this low impact; mainly ownership and use after distribution.

Subject and methods: The study involved fourteen localities covered by LLINs and was based on a households (HH) survey, which utilized a simple random sampling design. Interviews were done during May-June 2012, with each head of randomly selected HH using a questionnaire. Data were analyzed by using the normal test for the comparison of proportions and the student test for comparison of means.

Results: In the fourteen localities, LLINs ownership was good: 94.4 % (62-100). On average, each household received 3.2 LLINs. The proportions of individuals sleeping under LLINs was very low (34.3%) with no significant difference between both sexes. Results of the study support the conclusion that the low impact of LLINs intervention is due to their low usage by the population.

Conclusion: There is a need to strengthen the communication with community to improve the use of nets and assure an effective impact on leishmaniasis transmission..

Faraj C, Adlaoui E, Herrak T, Wahabi R, Kaddaf M, et al. (2017) Estimation of Long-Lasting Insecticidal Bednets usage in 14 Cutaneous Leishmaniasis Endemic Areas in Morocco. Ann Community Med Pract 3(1): 1018.

• Cutaneous leishmaniasis
• Control
• LLINs
• Coverage
• Usage
• Morocco

LLINs: Long Lasting Insecticide Nets; CL: Cutaneous Leishmaniasis; HH: Household

Cutaneous Leishmaniases (CL) remainas a major health issue in Morocco [1,2]. Two forms are described; anthroponotic and zoonotic leishmaniasis. The zoonotic forms are caused by Leishmania major and L. infantum [3]. Leishmania major is endemic in the south and the east of the country where its vector, Phlebotomus papatasi and its reservoir host, Meriones shawi, are prevalent [4,5]. CL caused by L. infantum has been described mainly in the north of the country [6-9]. The anthroponotic CL, prevalent in the center and the north of the country [3,10], is due to L. tropica and transmitted by Ph. Sergenti [11,12]. Major epidemics of CL have occurred in Morocco recently, with 8000 cases nationwide in 2010 [10]. In 2011 and 2012, the Moroccan Ministry of Health reported respectively 4319 and 2990 cases caused by both L. major and L. tropica. Control measures against leishmaniasis rely on case management, rodent reservoir control in zoonotic foci, and vector control in anthroponotic foci. Vector control methods have historically relied mainly on environmental management. In addition, focal indoor residual spraying with DDT or synthetic pyrethroids and use of bednets has been conducted in some transmission foci.

Between 2010-2015, a nationwide study was conducted in 42 localities belonging to eight leishmaniasis endemic provinces to compare the effectiveness of long lasting insecticide treated bednets and indoor residual spraying for the control of cutaneous leishmaniasis in Morocco [13]. Results of this study revealed that the impact of LLINs on leishmaniasis transmission was weak with a non-significant reduction in CL incidence.

Hence, the current study was conducted to identify the factors that might explain this low impact. It is about a household survey conducted in fourteen localities where long lasting insecticide nets (LLIN) were distributed to determine their availability and use after distribution. This paper describes the methodology and results of this survey.

The study was a cross-sectional household survey using a simple random sampling design. The sampling involved fourteen localities covered by LLINs. These localities are belonging to five provinces: Azilal, Tinghir, Essaouira, Moulay Yacoub, and Chichaoua (Figure 1). Characteristics of these localities are summarized in (Table 1). The nets were distributed door to door to the target localities to cover all sleeping areas. In these localities, kids are used to sleep near each other’s. Therefore, two people bed net could cover up to four kids.

Data collection

The study was based on a households (HH) survey conducted in the14 localities during May-June of year 2012. Interviews were done with each head of HH using a questionnaire, which was pre-tested and adapted to the local characteristics of each locality.

The questionnaire was divided into four sections including HH demographic characteristics, knowledge on CL and attitudes adopted to prevent disease transmission, knowledge on bed nets, nets owned by the HH and their use. The questionnaire was used by trained healthcare professionals.

In each locality, an alphabetical list of HH was established. 10 % of them were randomly selected to answer the questionnaire. The choice of the HH was made by using a simple random sampling with interval. The first HH to keep for the survey was randomly selected from the HH list. Next HH were selected after every 10 HH count. Each selected HH was visited at home and the head of HH or an adult person acting on behalf of him was interviewed.

Data processing and analysis

The information collected from the survey forms was entered by creating a data entry form under the Census and Survey Processing System (CSPro), a public domain software package developed and supported by the U.S. Census Bureau and used for entering, editing, tabulating, and disseminating census and survey data.

All the information is then centralized in an Excel file. Frequencies and means of responses were computed to describe the basic characteristics of HH in each locality. We used the normal test for the comparison of proportions and the student test for comparison of means. The tests are significant if p <0.05 [14].

Main indicators used for data analysis are:

- Net coverage: the total number of nets relative to the total number of sleeping units.

- Net usage: proportion of family members who slept under LLINs the previous night.

(Table 1) showed that 6714 LLINs has been distributed to the population living in the localities involved in this study.

The coverage rate was 100% for eight localities. The lowest rates are in the province of Azilal in the localities Iaatarne (62%) and Ait Ouariane (71%). These low coverage rates are mainly explained by the absence of heads of HH and their families at the time of the distribution and during the catch-up sessions.

A random sample of 299 HH from the 14 localities involved in the study was selected to determine the availability and usage rate of nets.

100% of the 299 households surveyed, received LLINs. The average number of LLINs received is 3.2 LLINs per household (Table 2).

The use rate was very low in almost all the localities of the study, except in two localities; Ait Ouariane and Timolite in Azilal province where the rates of usage were satisfactory; respectively 98 and 84 %. Overall, only 34% of the study population reported using a net at the time of the survey, with an equal usage by both sexes. The normal test-U showed that there is no-significant difference between both sexes (p=0.57).

The present household survey is particularly interesting because it is the first report describing bednets ownership and usage in CL-endemic areas in Morocco in particular and in the old world in general. To our knowledge there is no publication related to the LLINs coverage and utilization for CL prevention. Studies on this subject are so far mainly performed on bednets use for malaria in Africa [15-19] and visceral leishmaniasis in the Indian subcontinent [20].

These survey findings show that even if the average coverage was up to 94 %, the proportion of individuals sleeping under LLINs was low (34%), possibly, because the perceived risk of CL is small and because of L. tropica CL is a non-invalidating disease.

This low uses of LLINs could be also explained by the low knowledge on the importance of bednets use, in spite of the effort made to heighten the awareness of the population by Health officers. Therefore, it is possible that the low levels of LLIN use compromised the efficacy of the LLIN intervention.

To achieve a high proportion of people using the nets during the CL transmission season, a behavior change is needed. More investigations to determine factors inducing low LLIN use in endemics areas are very important before any new introduction of the LLINs in CCL endemics areas in Morocco.

Table 1: Characteristics of localities involved in the study.

Table 2: LLIN ownership and usage by locality.

Results of the study support the conclusion that the low impact of LLINs intervention on CL incidence is due to their low usage rates by the population.

Our results indicate that LLINs interventions need to be strengthening by communication with community using LLIN to improve their use and assure an effective impact of the intervention on CL incidence. A communication strategy should be developed taking into account the factors that motivate a family to appropriately use bednets and should accompany the net distribution.

The authors wish to extend their sincere thanks to the staff of Ministry of health Delegations of Azilal, Tinghir, Chichaoua, Essaouira and MoulayYacoub for their kind assistance in the fieldwork. This investigation received financial assistance from WHO/GEF. Project ID No: EMDCD 1004953.

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