# Epidemiological profile and treatment of cystic echinococcosis hospitalized cases in Morocco between 2011 and 2021

Ilham Benmoujjane, Souad Bouhout, Aicha Mehdioui, Houda Chebli, Meryem Zabarra, Mohammed Akrim, Hassan Chrifi, Touria Benamar

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## To cite this version:

Ilham Benmoujjane, Souad Bouhout, Aicha Mehdioui, Houda Chebli, Meryem Zabarra, et al. Epidemiological profile and treatment of cystic echinococcosis hospitalized cases in Morocco between 2011 and 2021. Clinical Epidemiology and Global Health, 2025, 33, pp.102035. 10.1016/j.cegh.2025.102035. hal-05258231

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Submitted on 15 Sep 2025

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Original article

# Epidemiological profile and treatment of cystic echinococcosis hospitalized cases in Morocco between 2011 and 2021

<figure><img src="image_4.png" /></figure>

Ilham Benmoujjane<sup>a,d,*</sup>, Souad Bouhout<sup>b</sup>, Aicha mehdioui<sup>b</sup>, Houda Chebli<sup>b</sup>, Meryem Zabarra<sup>c,d</sup>, Mohammed Akrim<sup>a</sup>, Hassan Chrifi<sup>a,b</sup>, Touria Benamar<sup>b,d</sup>

## ARTICLE INFO

**Keywords:**

Cystic echinococcosis
Hydatidosis
Epidemiology
Retrospective study
Morocco

## ABSTRACT

**Background/objective:** Cystic Echinococcosis (CE) is a globally spread zoonotic disease. In Morocco, CE is endemic. The objective was to study Morocco's epidemiological profile and management of hospitalized patients with CE.

**Methods:** This research was done retrospectively over 11 years (2011–2021). It included 7385 cases from all regions of Morocco.

**Results:** Between 2011 and 2021, the annual incidence decreased from 4.55 to 1.18 (per 100,000 population). The patients' ages varied from one to 115 years. The sex ratio of women to men was 1.54. Rural areas accounted for 62.96 % of the patients. The diagnostic method commonly used was the ultrasound (67.62 %). The liver (80.85 %) was the most affected organ, followed by the lungs (15.68 %). Type I cysts accounted for 56.35 % of all HC cases. Surgery was performed in 97.33 % of the patients, with 57.01 % being conservative. The outcome was favorable for 98.48 % of the cases. The Average Length of Stay (ALOS) in the hospital for CE patients was 11 days.

**Conclusion:** Significant progress has been made towards achieving the goal of CE eradication by 2030, but Morocco still faces a significant threat due to the high number of hospitalized cases and resulting deaths.

## 1. Introduction

Hydatid disease is a near-cosmopolitan zoonotic disease that prevails in pastoral areas. Central Asia, Mediterranean nations, Eastern Africa, South America, and western China are regions with high endemicity.¹ Each year, it affects more than 1 million people worldwide,² results in around 19,000 deaths each year,³ and is responsible for the loss of 870, 000 disability-adjusted life years (DALYs).⁴ The annual cost of CE, including treatment expenses and lost productivity, is $3 billion.⁵

Due to the high endemicity and severity of the disease, the WHO has established a first road map for 2012–2020 and a second for 2021–2030 to move towards a world free of Neglected Tropical Diseases (NTDs) by 2030, including echinococcosis.

Morocco is considered a country where CE is highly endemic and shows high prevalence in both livestock and humans.⁴ This zoonosis is a

serious public health concern and has a significant socioeconomic impact in Morocco.⁵ According to estimates of Saadi et al., annual average losses due to CE are between 0.06 % and 0.07 % of the national Gross Domestic Product (GDP), average losses in humans range between 16 and 18 million USD annually, and losses related to animal infection range between 53 and 56 million USD annually.⁵

Following the establishment of a national control program for hydatidosis in 2002, the Moroccan health authorities made it mandatory to report CE cases in compliance with Ministerial Decree No. 1020-03 of May 23, and B.O. No. 5122 of July 3, 2003. In 2007, the first interdepartmental strategy to control hydatidosis/echinococcosis was developed, with three key strategic topics: the application of preventive measures, early detection and medical management, and the availability of an appropriate legislative and regulatory arsenal.

The objective of this study is to analyze the epidemiological profile

<footnote><sup>a</sup> National School of Public Health, Morocco</footnote>

<footnote><sup>b</sup> Department of Epidemiology and Disease Control, Ministry of Health and Social Protection, Morocco</footnote>

<footnote><sup>c</sup> Laboratory of Community Health, Preventive Médecine and Hygiene & Laboratory of Biostatistics, Clinical and Epidemiology Research, Department of Public Health, Faculty of Medicine and Pharmacy, Mohammed V University in Rabat, Morocco</footnote>

<footnote><sup>d</sup> Medical Affairs and Strategy Division, Direction of Ibn Sina University Hospital Center, Rabat, 10100, Morocco</footnote>

<footnote>* Corresponding author. National School of Public Health, Morocco.</footnote>

<footnote>E-mail address: ilhambenm@gmail.com (I. Benmoujjane).</footnote>
and management of hospitalized cases of CE.

## 2. Methods

This is a retrospective study covering 11 years (2011–2021). We have used the database of hospitalized CE in Morocco available in the Parasitic Diseases Service at the Epidemiology and Disease Control Department of the Ministry of Health and Social Protection. We examined the distribution by year, origin, age, sex, rural/urban setting, occupation, diagnostic method, location of CE, stage of CE, type of treatment, surgical technique, disease progression, and length of hospital stay.

The annual incidence of CE was calculated using the following formula:

$$I = \frac{\text{Number of new CE cases in the year } X_{*} \times 100 000}{\text{Total population of the year } X} \quad (1)$$

For the total population and by region of each year, we used the database target populations of health programs 2014–2019 and 2020–2026, of the Ministry of Health and Social Protection.

Data preprocessing and analysis were performed using Excel, and the distribution map of CE cases was created using QGIS software.

## 3. Results

### 3.1. Epidemiology of CE

#### 3.1.1. Trend

Overall, 7385 cases of CE were reported in Morocco between 2011 and 2021. The annual distribution of recorded CE cases showed a decrease in the number of cases (1464 in 2011 compared to 433 in 2021), representing a variation of –70%. There has also been a decrease in the incidence of CE (4.55 and 1.18 per 100,000 population in 2011 and 2021, respectively) (Fig. 1).

#### 3.1.2. Geographical distribution

CE cases originated from all regions of Morocco. Between 2011 and 2021, three regions (Rabat-Salé-Kenitra, Marrakech-Safi, and Fès-Meknès) reported 62.39 % of the total recorded cases (Fig. 2).

#### 3.1.3. Characteristics of the patients

The average age of patients hospitalized for CE in Morocco between 2011 and 2021 was 34 years (under a year-115 year) with a standard

deviation of 18.66. The most affected age group was young adults (21–40 years), with 37.13 % of recorded cases. A predominance of females (60.59 %) was observed, with a sex ratio of 1.54 of women to men (Table 1).

The analysis by place of residence reveals a predominance of CE among patients from rural areas (62.96 % of patients are from rural areas compared to only 37.04 % from urban areas) (Table 2).

In our study, the majority of patients hospitalized for CE were unemployed (85.02 %). Farmers, shepherds, and butchers represented 3.71 %, 0.26 %, and 0.08 % respectively (Table 3).

### 3.2. Treatment of CE

#### 3.2.1. Level of medical care

Between 2011 and 2021, the reported cases of CE were distributed as follows: 23.46 % were hospitalized at provincial or prefectural Hospital Centers, 17.65 % at regional hospital centers, and 58.89 % at university hospital centers (Table 4).

#### 3.2.2. Method of diagnosis

In total, 7878 CE diagnostic tests were performed between 2011 and 2021 in various hospitals in Morocco. Ultrasound represented 67.62 % of diagnostic means, followed by CT (15.68 %) and standard radiology (15.07 %). While MRI and serology were rarely used (1.33 % for serology and 0.30 % for MRI) (Table 4).

The proportion of hospitalized patients who received one, two, or three diagnostic tests for CE was 76.02 %, 22.11 %, and 1.87 %, respectively (Table 4).

#### 3.2.3. Cyst localization

In our study, the CE mainly occurred in the liver in 80.85 % of cases, in the lungs in 15.68 %, and in 3.47 % in other organs such as the kidney, spleen, brain, heart, etc. (Table 4). The majority of patients (97.50 %) had involvement of a single organ, compared to only 2.50 % presenting CE affecting several organs (Table 4).

#### 3.2.4. Stage

In our study, type I of CE represented more than half (56.35 %) of the total of CE cases, followed by type II at 21.13 % and type III at 17.43 %. Types IV and V of inactive CE made up 5.09 % of all cases (Table 4).

#### 3.2.5. Modality of treatment

In our analysis, surgical intervention was performed in 97.34 % of

<figure><img src="image_5.png" /><figcaption>Fig. 1. Evolution of the number of hospitalized cases of CE and the annual incidence (per 100,000 population), Morocco, 2011–2021.</figcaption></figure>
<figure><img src="image_6.png" /><figcaption>Fig. 2. Distribution of the number of CE cases by region, Morocco, 2011–2021.</figcaption></figure>

<table><caption>**Table 1**
Distribution by age group and sex of hospitalized CE cases, Morocco, 2011–2021.</caption><thead><tr><th rowspan="2">Age group</th><th colspan="2">Men</th><th colspan="2">Rural</th><th rowspan="2">Total</th><th rowspan="2">Sex ratio</th></tr><tr><th>Women<br>Number</th><th>%</th><th>Number</th><th>%</th></tr></thead><tbody><tr><td>0–10</td><td>356</td><td>45.58 %</td><td>425</td><td>54.42 %</td><td><strong>781</strong></td><td><strong>0.84</strong></td></tr><tr><td>11–20</td><td>580</td><td>53.11 %</td><td>512</td><td>46.89 %</td><td><strong>1092</strong></td><td><strong>1.13</strong></td></tr><tr><td>21–30</td><td>867</td><td>61.75 %</td><td>537</td><td>38.25 %</td><td><strong>1404</strong></td><td><strong>1.61</strong></td></tr><tr><td>31–40</td><td>797</td><td>67.83 %</td><td>378</td><td>32.17 %</td><td><strong>1175</strong></td><td><strong>2.11</strong></td></tr><tr><td>41–50</td><td>694</td><td>65.97 %</td><td>358</td><td>34.03 %</td><td><strong>1052</strong></td><td><strong>1.94</strong></td></tr><tr><td>51–60</td><td>522</td><td>66.58 %</td><td>262</td><td>33.42 %</td><td><strong>784</strong></td><td><strong>1.99</strong></td></tr><tr><td>61–70</td><td>267</td><td>59.33 %</td><td>183</td><td>40.67 %</td><td><strong>450</strong></td><td><strong>1.46</strong></td></tr><tr><td>71–80</td><td>104</td><td>59.43 %</td><td>71</td><td>40.57 %</td><td><strong>175</strong></td><td><strong>1.46</strong></td></tr><tr><td>81–90</td><td>15</td><td>65.22 %</td><td>8</td><td>34.78 %</td><td><strong>23</strong></td><td><strong>1.88</strong></td></tr><tr><td>91–115</td><td>6</td><td>66.67 %</td><td>3</td><td>33.33 %</td><td><strong>9</strong></td><td><strong>2.00</strong></td></tr></tbody><tfoot><tr><td>Total</td><td><strong>4208</strong></td><td><strong>60.59 %</strong></td><td><strong>2737</strong></td><td><strong>39.41 %</strong></td><td><strong>6945</strong></td><td><strong>1.54</strong></td></tr></tfoot></table>

<table><caption>**Table 2**
Evolution of CE cases by place of residence, Morocco, 2011–2021.</caption><thead><tr><th rowspan="2">Year</th><th colspan="2">Urban</th><th colspan="2">Rural</th><th rowspan="2">Total</th></tr><tr><th>Number</th><th>%</th><th>Number</th><th>%</th></tr></thead><tbody><tr><td>2011</td><td>925</td><td>63.18 %</td><td>539</td><td>36.82 %</td><td><strong>1464</strong></td></tr><tr><td>2012</td><td>668</td><td>63.92 %</td><td>377</td><td>36.08 %</td><td><strong>1045</strong></td></tr><tr><td>2013</td><td>465</td><td>63.18 %</td><td>271</td><td>36.82 %</td><td><strong>736</strong></td></tr><tr><td>2014</td><td>391</td><td>62.76 %</td><td>232</td><td>37.24 %</td><td><strong>623</strong></td></tr><tr><td>2015</td><td>280</td><td>60.22 %</td><td>185</td><td>39.78 %</td><td><strong>465</strong></td></tr><tr><td>2016</td><td>277</td><td>68.06 %</td><td>130</td><td>31.94 %</td><td><strong>407</strong></td></tr><tr><td>2017</td><td>330</td><td>66.80 %</td><td>164</td><td>33.20 %</td><td><strong>494</strong></td></tr><tr><td>2018</td><td>196</td><td>62.62 %</td><td>117</td><td>37.38 %</td><td><strong>313</strong></td></tr><tr><td>2019</td><td>212</td><td>65.43 %</td><td>112</td><td>34.57 %</td><td><strong>324</strong></td></tr><tr><td>2020</td><td>119</td><td>56.94 %</td><td>90</td><td>43.06 %</td><td><strong>209</strong></td></tr><tr><td>2021</td><td>164</td><td>51.90 %</td><td>152</td><td>48.10 %</td><td><strong>316</strong></td></tr></tbody><tfoot><tr><td>Total</td><td><strong>4027</strong></td><td><strong>62.96 %</strong></td><td><strong>2369</strong></td><td><strong>37.04 %</strong></td><td><strong>6396</strong></td></tr></tfoot></table>
<table><caption>**Table 3**
Distribution of CE cases by profession, Morocco, 2011–2021.</caption><thead><tr><th>Profession</th><th>Women</th><th>Men</th><th>Total</th><th>%</th></tr></thead><tbody><tr><td>Unemployed</td><td>2221</td><td>1031</td><td><strong>3252</strong></td><td><strong>85.02 %</strong></td></tr><tr><td>Student</td><td>72</td><td>91</td><td><strong>163</strong></td><td><strong>4.26 %</strong></td></tr><tr><td>Farmer</td><td>25</td><td>117</td><td><strong>142</strong></td><td><strong>3.71 %</strong></td></tr><tr><td>Worker</td><td>16</td><td>109</td><td><strong>125</strong></td><td><strong>3.27 %</strong></td></tr><tr><td>Other</td><td>38</td><td>40</td><td><strong>78</strong></td><td><strong>2.04 %</strong></td></tr><tr><td>Employee</td><td>5</td><td>11</td><td><strong>16</strong></td><td><strong>0.42 %</strong></td></tr><tr><td>Shepherd</td><td>5</td><td>5</td><td><strong>10</strong></td><td><strong>0.26 %</strong></td></tr><tr><td>Public worker</td><td>3</td><td>7</td><td><strong>10</strong></td><td><strong>0.26 %</strong></td></tr><tr><td>Part-time worker</td><td>3</td><td>7</td><td><strong>10</strong></td><td><strong>0.26 %</strong></td></tr><tr><td>Trader</td><td>0</td><td>10</td><td><strong>10</strong></td><td><strong>0.26 %</strong></td></tr><tr><td>Housewife</td><td>6</td><td>0</td><td><strong>6</strong></td><td><strong>0.16 %</strong></td></tr><tr><td>Butcher</td><td>1</td><td>2</td><td><strong>3</strong></td><td><strong>0.08 %</strong></td></tr><tr><td>Total</td><td><strong>2395</strong></td><td><strong>1430</strong></td><td><strong>3825</strong></td><td><strong>100 %</strong></td></tr></tbody></table>

<table><caption>**Table 4**
Clinical characteristics and treatment modalities for CE patients, Morocco, 2011–2021.</caption><thead><tr><th>Profession</th><th>Number</th><th>%</th></tr></thead><tbody><tr><td><strong>Level of medical care</strong></td><td></td><td></td></tr><tr><td>Provincial or prefectural hospital centers</td><td>558</td><td>23.46 %</td></tr><tr><td>Regional hospital centers</td><td>420</td><td>17.65 %</td></tr><tr><td>University hospital centers</td><td>1401</td><td>58.89 %</td></tr><tr><td><strong>Method of diagnosis</strong></td><td></td><td></td></tr><tr><td>Ultrasound</td><td>5327</td><td>67.62 %</td></tr><tr><td>CT</td><td>1235</td><td>15.68 %</td></tr><tr><td>Standard radiology</td><td>1187</td><td>15.07 %</td></tr><tr><td>MRI</td><td>24</td><td>0.30 %</td></tr><tr><td>Serology</td><td>105</td><td>1.33 %</td></tr><tr><td><strong>Number of diagnostic tests received</strong></td><td></td><td></td></tr><tr><td>One test</td><td>4916</td><td>76.02 %</td></tr><tr><td>Two tests</td><td>1430</td><td>22.11 %</td></tr><tr><td>Three tests</td><td>121</td><td>1.87 %</td></tr><tr><td><strong>Cyst localization</strong></td><td></td><td></td></tr><tr><td>Liver</td><td>5666</td><td>80.85 %</td></tr><tr><td>Lung</td><td>1099</td><td>15.68 %</td></tr><tr><td>Other organs</td><td>243</td><td>3.47 %</td></tr><tr><td><strong>Number of organs affected</strong></td><td></td><td></td></tr><tr><td>Single organ</td><td>6788</td><td>97.50 %</td></tr><tr><td>Multiple organs</td><td>174</td><td>2.50 %</td></tr><tr><td><strong>Stage of CE</strong></td><td></td><td></td></tr><tr><td>Type I</td><td>2115</td><td>56.35 %</td></tr><tr><td>Type II</td><td>793</td><td>21.13 %</td></tr><tr><td>Type III</td><td>654</td><td>17.43 %</td></tr><tr><td>Type IV</td><td>135</td><td>3.60 %</td></tr><tr><td>Type V</td><td>56</td><td>1.49 %</td></tr><tr><td><strong>Type of treatment</strong></td><td></td><td></td></tr><tr><td>Surgery</td><td></td><td></td></tr><tr><td>Resection of the protruding dome</td><td>3492</td><td>57.01 %</td></tr><tr><td>Pericystectomy</td><td>2039</td><td>33.30 %</td></tr><tr><td>Liver resection</td><td>420</td><td>6.86 %</td></tr><tr><td>Resection of other organs</td><td>10</td><td>0.17 %</td></tr><tr><td>Drug treatment</td><td>160</td><td>2.62 %</td></tr><tr><td>Percutaneous treatment</td><td>3</td><td>0.05 %</td></tr><tr><td><strong>CE surgeries per patient</strong></td><td></td><td></td></tr><tr><td>1</td><td>4823</td><td>94.70 %</td></tr><tr><td>2-4</td><td>261</td><td>5.12 %</td></tr><tr><td>5-7</td><td>9</td><td>0.18 %</td></tr><tr><td><strong>Disease progression</strong></td><td></td><td></td></tr><tr><td>Recovery</td><td>4750</td><td>98.48 %</td></tr><tr><td>Relapse</td><td>62</td><td>1.29 %</td></tr><tr><td>Death</td><td>11</td><td>0.23 %</td></tr></tbody></table>

patients. In these surgically treated patients, surgeons opted for the resection of the protruding dome in 57.01 % of the cases, a pericystectomy in 33.30 %, a liver resection in 6.86 %, and a resection of other organs in 0.17 % (Table 4).

One surgical intervention was effective in 94.70 % of surgically treated patients, while 5.30 % of cases necessitated multiple surgical operations (ranging from two to seven interventions) (Table 4).

For the other types of CE treatment, their frequency remains very low compared to surgical treatment: 2.62 % for drug treatment and 0.05 %

for percutaneous treatment (Table 4).

### 3.2.6. Disease progression

In 98.48 % of patients recovered from CE recovered. The recurrence rate was 1.29 %, while the hospital mortality rate of CE was 0.23 % (Table 4).

### 3.2.7. Average length of stay (ALOS)

Patients with CE stayed in the hospital for an average of 11 days. 81.02 % of them spent less than 15 days there, while 18.74 % required extended hospital stays that occasionally reached 242 days (Fig. 3). The average preoperative period in the ALOS was four days, while the average postoperative period was seven days.

## 4. Discussion

### 4.1. Epidemiology of CE

Hydatidosis is a significant public health concern that is endemic in Morocco. Our study revealed a decrease in the CE incidence from 4.55 to 1.18 (per 100,000 population). This decline had been observed consistently throughout all regions of Morocco. During the study period, the cases were reported mainly from 3 regions: Rabat-Salé-Kénitra, Marrakech-Safi, and Fez-Meknes region, which confirmed the conclusions of Tlamcani.⁶ On the other hand, Guelmim-Oued Noun, Dakhla-Oued Ed-Dahab, and Laayoune-Sakia El Hamra reported very few cases. Other studies showed that the prevalence of CE was 12.6 in Tunisia⁷, and 4.2 in Libya⁸ (per 100,000 population).

The average age of patients hospitalized with hydatid disease in Morocco between 2011 and 2021 was 34 years, with the most common age group being 21–40 years (37 %). This is in line with what is known about hydatidosis as a disease of young adults.⁹ However, the increased prevalence of hydatid cysts in this age group should not be interpreted as a specificity of this group. This is mainly due to the insidious nature of hydatid infection, which can remain asymptomatic for long periods.⁹ The infestation can occur during childhood and only express itself in adulthood.⁹

In this study, we found that women were more likely to contract an infection than men were (sex ratio H/F = 0.39). By Nabah et al.¹⁰ and Derfoufi et al.,¹¹, comparable observations have been made in Morocco. Studies reveal considerable gender disparities in prevalence in the Mediterranean nations, particularly Tunisia and Libya.⁷,¹² This is most likely explained by how women manage and interact with dogs, handle potentially contaminated produce regularly, and engage in agricultural activities.¹³ This raises a woman's risk of coming into contact with a cystic infection.

According to the literature, hydatidosis is a disease that primarily affects rural areas.³ The majority of CE patients in our study are of rural origin, supporting this claim. This is due to the increased exposure that rural residents have to domestic animals and contaminated goods.¹⁴ The hydatidosis/echinococcosis control guidance states that certain occupations, such as farmers, shepherds, and butchers, have a higher risk of developing CE because of the nature of their work.¹⁵ In our analysis, 85 % of victims had reported no profession, while just 4 % of cases came from the high-risk occupations stated above. Findings from a survey carried out in the Tangier-Tetouan-El Hoceima region between 2014 and 2018 by Nabah et al. showed that 67.4 % of participants reported having a job.¹⁰

### 4.2. Treatment of CE

All hospital levels offer care to individuals with CE. To confirm the case, one or more radiological or biological diagnostic methods were applied. Because of its wide availability and high level of reliability, ultrasonography was chosen as the primary medical examination. This is followed by computed tomography (CT), which plays an important role
<figure><img src="image_7.png" /><figcaption>Fig. 3. Distribution of hospitalized patients with CE according to the length of stay, Morocco, 2011–2021.</figcaption></figure>

in the exact topographic diagnosis and counting of cysts, and conventional radiology, which is used to diagnose pulmonary cysts. Magnetic Resonance Imaging (MRI) and serology were rarely used in our study.

Our results concur with those found in the literature,<sup>16,17</sup> which emphasized a preponderance of hepatic CE followed by pulmonary CE concerning the localization of CE. The other locations, such as the kidneys, spleen, brain, and heart, remain very rare. For the multi-visceral location of CE, the Mahboub et al. study found that they are often comprised between 5 % and 7.5 %.<sup>18</sup> In comparison, 3 % of the overall instances in our study involved multi-visceral localization. In other similar studies, the prevalence of multiple hydatidosis was reported at 23 % by Lakhdar et al.<sup>19</sup> and at 28.5 % by Elhamdaoui et al.<sup>20</sup>. According to our study, the liver and lungs were the primary organs impacted in the majority of cases of multi-visceral hydatidosis localization. These findings support Mahboub et al.'<sup>18</sup> findings, which highlighted the preponderance of hepatopulmonary involvement in this form of the disease.

In the majority of CE cases, surgery was used to treat them, according to our study. The usage of conventional surgery, which was long seen to be the best treatment option for simple forms,<sup>21</sup> has decreased globally as a result of medical advancements and minimally invasive therapeutic techniques. Two-thirds of surgical treatments used the conservative approach, which involved resecting the protruding dome. However, this technique has a sizable risk of postoperative complications, such as delayed suppuration, external biliary fistulas, and recurrence,<sup>22</sup> Hydatid disease does not generate immunity, so there is always a risk of reinfection. In our analysis, we discovered that the operations ranged from two to seven surgeries in the few instances where repeated surgery was necessary.

The percutaneous treatment was rarely used in our study, even if it is less invasive, less traumatic, and less expensive compared to traditional surgery, and it can heal patients who were once thought to be inoperable.<sup>23</sup>

For drug treatment, it represented 3 % of total CE treatments. It is prescribed alone only in cases of contraindication to surgery or in inoperable patients.<sup>24</sup> It is most frequently used in combination with surgery or percutaneous treatment.<sup>25</sup>

The WHO listed a fourth treatment option, "watch and wait" which is not reported in the Moroccan CE information system. This option seeks to reduce avoidable risks and expenses for both patients and the healthcare system by choosing to closely monitor CE without performing an immediate intervention, other than in the event of complications or a worsening of the patient's condition. According to the WHO

informal working group on echinococcosis, watch and wait is advised for inactive cysts (Types IV and V), which made up 5 % of the total cases in our study.

The majority of patients experienced a beneficial progression, according to the study's findings. However, this assessment at hospital discharge is premature because difficulties can arise after hospital departure, and CE recurrences are typically reported six months following surgery<sup>26</sup> or even after 10 or 15 years.<sup>21</sup> Our study's recidivism rate was 1.29 %, however, the literature has shown that this rate varies depending on the surgical method used: open surgery has a recurrence rate between 2 % and 10 %, laparoscopy between 0 % and 4.3 %,<sup>21</sup> and percutaneous therapy between 1,6 % and 4 %.<sup>27</sup>

In terms of hospital lethality, it was 0.23 % between 2011 and 2021 for CE. The WHO informal working group on echinococcosis noted in 1996 that the postoperative fatality of CE ranges from 0.5 % to 4.0 %<sup>24</sup> and that this proportion rises if medical or surgical treatment is weak or inadequate. A more recent study of Aribas reported that this percentage varies between 0 % and 2 %,<sup>28</sup> reflecting the advancement of surgical procedures. The lethality of CE in the Khachatryan study was 1.29 %,<sup>29</sup> while in the Ghannouchi et al. study of patients with conservative liver surgery was 1.9 %.<sup>30</sup>

In our analysis, the Average length of stay (ALOS) for CE cases was eleven days. According to the literature, this value varies widely in the studies depending on the affected organ, the stage of CE, and the type of surgery.

## 5. Conclusion

Morocco's national Hydatidosis/echinococcosis program was established twenty years ago, and its strategy was developed sixteen years ago. To accomplish the goals outlined, several actions have been undertaken, including campaigns for screening, improved treatment for CE patients, and promoting public awareness. The information system explored through our study monitors patients of CE admitted to public hospitals, which enables us to provide a picture of the epidemiology of CE in Morocco.

Despite the notable advancements accomplished in the fight against CE, this illness still represents a serious threat to Morocco, highlighted by the high number of hospitalized cases and consequent fatalities. To accomplish the goal of eradicating CE by 2030, it is crucial to have a strong control strategy with an information system that enables the monitoring of all program components, including hospitalizations at the
private sector level, early detection activities at the level of both the private and public sectors, environmental data and animal data.

## Ethical approval

The study presented is based on a secondary analysis of anonymized data concerning hospitalized cases of hydatid cysts in Morocco. These data were provided by the Parasitic Diseases Department of the Directorate of Epidemiology and Disease Control (Ministry of Health and Social Protection of Morocco), as part of the national epidemiological surveillance system.

The database used is fully anonymized, containing no personal identifiers or information that could allow patient identification. It was originally collected for public health purposes, independently of any research project, and its use for epidemiological analyses falls within the scope of the health authorities' surveillance missions.

In accordance with current regulations in Morocco, the use of anonymized surveillance data for research purposes does not require formal ethical approval, as there is no direct interaction with individuals nor processing of identifiable personal data.

For these reasons, no submission to an ethics committee was undertaken.

## Author's contributions

* Ilham Benmoujiane: Study design, methodology development, data analysis, and manuscript writing.

* Dr Souad Bouhout: Providing the KH database and contributing to the manuscript revision.

* Dr Aicha Mehdioui: Data collection and entry, and manuscript revision.

* Dr Houda Chebli: Revision of the manuscript, focusing on improving clarity and ensuring consistency throughout the text.

* Mohammed Akrim: Assistance in the development of the methodology, analysis of the results, and writing of the discussion.

* Meryem Zabarra: Contribution to the revision of the manuscript.

* Dr Hassan Chrifi: Contribution to the revision of the manuscript.

* Touria Benamar: Assistance in the development of the methodology, analysis of the results, and writing of the discussion.

## Funding source

None.

## Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

## Acknowledgment

We would like to express our appreciation to the Epidemiology and Disease Control Directorate for creating an environment conducive to this study. Our thanks also go to all the staff of the Parasitic Diseases Service and the National Centre for Public Health Operations for their sound advice, continued support, and fruitful exchanges. Finally, we would like to thank all the authors of this article for their valuable collaboration and contribution to the successful conduct of this work.

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