Cystic Echinococcosis: An Impact Assessment of Prevention Programs in Endemic Developing Countries in Africa, Central Asia, and South America
Table 11
Appraisal summary of Article Meeting Inclusion Criteria [39].
Population:
(i) China: pastoral regions of project counties in ten provinces and autonomous regions: Inner Mongolia, Sichuan, Yunnan, Tibet, Shaanxi, Gansu, Qinghai, Ningxia, Xinjiang, and the Xinjiang Production and Construction Corps (ii) Humans: 56.7–79.7 million inhabitants at the county level. 19.3-39.1 million inhabitants at the township level (2004-2014) (iii) Dogs registered: 96, 000 (2004) and 2.69 million (2014)
Sample size:
(i) No sample size provided
Program outputs:
National Cystic Echinococcosis (CE) Control Program (2005): (i) Launched by the Chinese Central Government, National Ministry of Health, in collaboration 13 other ministries (ii) Human patients: ultrasound (US) screening and surgical or medical treatment (albendazole) (iii) Registered dogs: Praziquantel (PZQ) de-worming (8 times per year) (iv) Health education (v) Sanitation improvement
Study design:
Randomized, retrospective cross-sectional study
Program outcomes and/or impact:
Statistical analysis (National Ministry of Health Database 2004–2014): (i) Program economic outcomes: financial costs and working hours to deliver human treatments (ii) Prevalence: human US screening (iii) Human medical and surgical treatment coverage (iv) Behavioral outcomes: de-worming dogs (oral PZQ) coverage
Main findings:
Accumulated financial costs (2004-2014): (i) Total USD$110.67 million: USD$27.0 million for human treatment and registered dog de-worming. 24.4% or 1/4 of the total financial input (ii) Human medical (drug: albendazole) and surgical treatment costs (2004-2014): USD $12.3 million (iii) Dog de-worming (oral PZQ) costs (2004-2014) (after discount): USD $15.8 million (iv) Budgets not keeping pace with increasing demand for human treatments and dog de-worming; 2006-2014 annual and accumulated program costs increased 2840 times for human treatments and 21.8 times for dog de-worming Human work hours to deliver CE surgical and medical treatments: (i) 74, 145 hours (since 2010); 29, 469 unclassified hours (since 2008) (ii) Accumulated total (2011–2012): >10, 000 hours Work hours per patient highest for CE cases: (i) County level hours: 10.2 (CE); 3.9 alveolar echinococcosis (AE); 0.3 (co-infection); 4.4 (unclassified) (ii) Township level hours: 21.8 (CE); 8.5 (AE); 0.6 (co-infection); 7.4 (unclassified) (iii) Treatment (hours): cumulative cases increased 5.7 times for CE cases (2009–2014) (iv) Increased US screening: patient numbers increased 18 times (2004-2014). 1.5 times as many cases diagnosed, which reflected increased surgical operations (3.8× for CE) Human prevalence: (i) CE was responsible for the highest number of cases (2004-2014), compared to AE and co-infection (ii) Most cases were in Western China, in pastoral farming areas with domestic animal populations (e.g., dog feces infect livestock) and sylvatic lifecycles (e.g., foxes or wolves’ feces infect livestock) (iii) Prevalence decreased: 1.08% (2004) to 0.24% (2012). However, prevalence per 100, 000 population rate increased (17× at county level; 10.8x township level) (iv) Total human cases identified by annual US screening (2004-2014) (a) Range 4.8% (959/20, 168) to 18.2% (318/1749) (v) Average rate of patient treatment Increased (2004–2014) (a) 32.4% increase for surgical treatment (b) 81.3% increase for medical treatment Average rate of surgical operations: (i) Pre-program (2005–2006): >10% (ii) Post-program: decreased and remained stable at 5.7% (2007-2012) (95% CI: 5.0-6.9%); 7.4% (2013); 7.6% (2014) Average medical treatments (albendazole): (i) Pre-program: 46.7% (2004) (ii) Post-program: 69.4% (95% CI: 56.8–82.0%) (2007) to 69.1% (2014) Grand total treatment coverage: (i) 64.9% (2004) to 76.7% (95% CI: 67.5–87.9%) (2014). Overall, both surgical and medical treatment coverage increased after program launched (ii) Patients with coinfection (CE and AE) and unclassified cases displayed an annual decreasing trend Dog de-worming: (i) Number of registered dogs de-wormed: 9.6 (2004) increased to 269 (2014); median value 115.0 (95% CI: 83.779–226.0) (ii) De-worming cases (× 10, 000) (2004-2014): 3.7 (2004); 178 (2014). Increased 48 times (iii) Pre-control: 38.2% coverage (2004) (iv) Post-control: 66.2% (2014). Increased coverage 28% (2004-2014) (v) Number of registered dogs increased 28 times (269/9.6) (2004–2014), but de-worming coverage only increased 8 times (2005-2011) or 1.7 times (66.2/38.2) (2004-2014) (vi) Positive correlation between registered dogs and human cases (Spearman’s correlation) Recommendations: (i) Improved control measures for sylvatic cycle (wild canines) (ii) Human clinical case follow-up: patient information and treatment records regularly updated (iii) Improve stray dog management and acknowledge cultural acceptability of culling for population control
Limitations:
(i) Annual number of de-wormed dogs (2012–2014) missing data. Estimation calculation (expectation-maximization (EM) method) used to calculate missing data: only method description/reference was a Wikipedia link, not associated with a webpage (ii) Data only authorized by the National Ministry of Health until 2014 (iii) No information about sample size or collection methods (iv) No distinguishment between stray versus owned dogs (v) No information about de-worming administration methods (vi) Cannot conclude if pre-program and post-program populations similar (vii) In text results stated that de-worming coverage increased 73% (2005-2014). However, data (10.2% (2005) and 66.2% (2014) = 58% increase) (viii) Data reliability: disease surveillance was not performed evenly across endemic regions due to the uneven launching of control programs (ix) Prevalence for human patients and dogs only available from two national surveys (2004 and 2012). However, data was presented outside these dates (e.g., canine cases (2004-2014) and “mean human prevalence” (2008-2014) (x) No controls or significance testing for prevalence changes in correlation to program outputs (e.g., education programs) and outcomes (e.g., behavioral change: improved sanitation methods; PZQ de-worming)
