Abstract
BACKGROUND: Tuberculosis (TB) is a major health problem in Morocco. This study aims at examining trends in TB in Morocco and identifying TB spatial clusters and TB-associated predictors. METHOD: Country-level surveillance data was exploited. Kendall's correlation test was used to examine trends and an exploratory spatial data analysis was conducted to assess the global and local patterns of spatial autocorrelation in TB rates (Moran's I and local indicator of spatial association [LISA]) at the prefecture/province level. Covariates including living in a prefecture versus living in a province, annual rainfall, annual mean temperature, population density, and AIDS incidence were controlled. An ordinary least squares regression was thus performed and both spatial dependence and heteroscedasticity were assessed. RESULTS: A decrease in TB incidence rate was seen between 1995 and 2014 (Kendall's tau b = - 0.72; P < 0.0001). However, while the period between 2005 and 2014 (10 last years) was considered, TB rate remained stable and as high as 84 per 100 000 population per year (95% CI: 83.7-84.3). The highest incidence rates were seen in Tanger-Assilah, Fez, Tetouen-M'diq Fnidaq, Inezgane Ait Melleoul, and Casablanca. From 2005 to 2014, while TB incidence rate was stable in Fez (P = 0.500), Tetouen-M'diq Fnidaq (P = 0.300), Casablanca (P = 0.500), Mohammadia (P = 0.146), Al Hoceima (P = 0.364), and Guelmim (P = 0.242), an increase in TB incidence rate was seen in Tanger-Assilah (Kendall's tau = 0.49; P = 0.023) and a decrease in Salé (Kendall's tau b = - 0,54; P = 0.014) and Inezgane-Ait Melloul (Kendall's tau b = - 0,67; P = 0.0023). TB is strongly clustered in space (P-values of Moran's I < 0.01). Two distinct spatial regimes that affect TB spatial clustering were identified (east and west). In the east, both annual rainfall (P = 0.003) and AIDS (P = 0.0002) exert a statistically significant effect on TB rate. In the west, only the living area (prefecture versus province) was associated with TB rate (P = 0.048). CONCLUSIONS: New information on TB incidence and TB-related predictors was provided to decision-making and to further pertinent research. Association between annual rainfall and TB may be of interest to be explored elsewhere.