ArticlePLOS global public health2026
Spatiotemporal patterns of tuberculosis in urban slums and urban-rural transition zones: evidence from Tétouan, Morocco, 2019-2023.
Article in PLOS global public health, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Tuberculosis (TB) remains a major public health challenge in Morocco. This study analyzed spatiotemporal patterns of TB cases in Tétouan, Morocco using routine surveillance data from 2019-2023 (3,614 cases). Temporal trends and seasonality were assessed using seasonal-trend decomposition, spatial dependence using Global Moran's I and Getis-Ord Gi*; and space-time clustering using Kulldorff's scan statistic. The average annual TB incidence rate was 113 per 100,000 population. Men accounted for 62.94% (2,272/3,614) of cases, with a mean age of 40.0 years (SD 19.1). Pulmonary TB (PTB) represented 56.71% (2,049/3,614) of TB cases, of which 89.87% (1,828/2,034) were bacteriologically confirmed. Notifications declined from 2019 to 2021, coinciding with COVID-19-related service disruptions, followed by a resurgence in 2022-2023. Seasonal peaks were observed mainly in spring and autumn. Spatial analyses identified a persistent high-incidence hotspot in the urban municipality of Tétouan. At the district level, space-time analyses using Monte Carlo permutation tests implemented in SaTScan confirmed significant PTB clustering in urban slum districts, with relative risks (RR) ranging from 1.90 to 2.03 (p < 0.01), suggesting stable reservoirs of TB transmission. Over time, clustering expanded beyond the urban core, with emerging TB hotspots in peri-urban communes (Azla, Zaitoune, and Beni Karrich). At the commune level, Azla and Zaitoune formed the most likely PTB cluster (RR 2.20 during 2022-2023; p < 0.001), while a secondary high-risk cluster was detected in a rural commune (RR up to 3.00; p < 0.01). These findings indicate that slums are entrenched reservoirs of transmission in urban settings, while peri-urban zones are emerging hotspots shaped by urbanization and mobility. Targeted strategies-intensified case detection and social support in slums, mobile diagnostics in peri-urban and rural areas, and seasonally aligned control- combined with routine spatiotemporal surveillance may help reduce geographic inequities and strengthen TB control efforts.
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