Effectiveness over 10 years (2004-2014) of the echinococcosis control progamme in China: Impact on humans and dogs population

A national control program for echinococcosis has been in effect since 2005 in China. This program has applied a comprehensive strategy, and good control results have been achieved. The objective of this study is focusing on the effectiveness of the programme with two indices, including patients treatment and registered dogs deworming, in endemic areas of echincoccosis control over the period of 10 years (2004-2014) in China. The study was conducted in the pastoral and farming-pastoral regions of project counties in 10 provinces and autonomous regions, a database was established that included demography at county and township levels, grouping available patients into those subjected to surgery and those receiving drug treatment after population screening. Information was given regarding the diagnosis (CE, AE, co-infection or unclassified) and the number of registered dogs and that of those dewormed. All statistical analyses were performed using SPSS software version 18 (SPSS Institute, Chicago, IL, USA). The results are shown as percentages with the corresponding 95% confidence intervals (95% CIs). The situation with respect to humans and dogs were described using epidemiological descriptive analyses and the direct costs calculated after discount. dogs during the program Echinococcus intermediate and definitive ultrasonography simple, safe and reliable screening for internal cysts. Importantly, relatively safe and effective . The data in this study demonstrate that the grand total person-hours spent on surgical interventions and treatment (including postoperative treatment) was 76.6% of the corresponding grand total proportion for the year of 2014, which was 1.2-fold compared to 2005. These results show a high disease burden in terms of DALYs in the endemic areas, which indicates that echinococcosis is a serious threat in parts of China. However, the patient numbers increased 18-fold in 2014 compared to 2004, while the prevalence per 100,000 population rate increased 17-fold at the county level and 10.8 times at the township level during the same time. Moreover, 1.5 as many new cases were found, and the cumulative cases (expressed in person-hours) for surgical operations increased 4.2 times, which was 3.8 times the value for CE and 8.1 times the value for AE. For treatment (expressed in person-hours), the cumulative cases increased 5.7 times the value for the CE cases and 3.3 times the value for the AE cases for the last 5 years (2009-2014) compared to the former 5 years (2004-2008). In addition, increases of 0.6 times co-infection with surgical interventions and 0.5 times the co-infection cases with treatment for the last 3 years (2012- 2014) were sustained compared to the former 3 years (2010-2011). For the unclassified cases, the cumulative cases were 13.7 times the value obtained with respect to surgical interventions and 6.3 times the value obtained for treatment for the last 4 years (2011- 2014) compared to the former 3 years (2008-2010). and the unclassified cases treated during an additional 3-year period decreased by one-half. The results indicate that patients with co-infection and unclassified cases display an annual decreasing trend. Moreover, the patient treatments varied widely due to improvement of the diagnostic accuracy through ultrasound screening for the entire exposed

disease is under control and has been eliminated in all endemic areas of China. Based on the results obtained through this study, we recommend that more attention should be paid to controlling stray dogs during the ongoing program period. Keywords: Control progamme; Effectiveness, Echinococcosis, humans and dogs Background Echinococcosis (hydatid disease) is one of the 17 neglected tropical diseases (NTDs) recognized by the World Health Organization (WHO) and its continued spread is a severe public health concern (1).
Echinococcosis is mainly endemic in areas of central, eastern and western Asia, South America, Oceania and southern, northern and eastern Africa. Infection in humans/livestock/small mammals is caused by the larval stage of the parasite. Canines (i.e. dogs, foxes, and wolves) are the definitive hosts and play a key role in the transmission and dissemination of the adult stage of this tapeworms belonging to genus Echinococcus. The two most important zoonotic species, E. granulosus (the causative agent of cystic echinococcosis -CE) and E. multilocularis (the causative agent of alveolar echinococcosis -AE), are a serious threat to over 1 million people and responsible for over US$ 3 billion in expenses every year. Expressed in global disability-adjusted life years (DALYs), losses of between 0.3-1million DALYs for CE and 0.65 million DALYs for AE, respectively, have been reported (2)(3)(4)(5).China has a high prevalence of human CE and one of the highest prevalence levels of human AE, accounting for 40% of global DALYs lost worldwide (5,6,8,11). Both diseases are widely endemic in the pastoral and farming-pastoral regions of Inner Mongolia, Sichuan, Yunnan, Tibet, Shaanxi, Gansu, Qinghai, Ningxia, and Xinjiang provinces (autonomous regions) covering 350 counties, with120,000 people infected and 50 million people estimated at risk according to the national prevalence survey of echinococcosis initiated by the National Health and Family Planning Commission in 2012 (13).
Notably, canine infectious sources in wild environments in the above endemic areas play important roles in the transmission dynamics of both diseases (7,9,10,12). A national program for echinococcosis control with comprehensive approaches was launched in 2005. This program has developed well, particularly thanks to the national control action plan (2010)(2011)(2012)(2013)(2014)(2015) implemented by the Chinese Central Government, as evidenced by the human echinococcosis prevalence rate, which has shown a remarkable decrease from 1.08% in 2004 to 0.24% in 2012 (13)(14). The key measures were monthly praziquantel oral treatment (reported to have 99.9% efficacy by WHO) of registered dogs in addition to large-scale human surgical interventions and oral treatment in the endemic regions (1). Clearly, control of CE and AE will have important economic consequences. An evaluation of the costs of the human intervention and deworming of the dog population is essential and should be part of any program aimed at the control of parasitic zoonoses (15). The objective of this study was to assess progress and costs for the national echinococcosis control program at the central government level over a 10-year period up to 2014. This assessment includes a comprehensive, epidemiological description and a cost analysis with estimates for human and dog interventions in the endemic areas of China for the period 2004-2014. Due to the limitation of data confidentiality, we only collected data approved by the National Health and Family Planning Commission up to 2014, so the four years data after that were not covered. Moreover, although the national control programme was led by National Health and Family Planning Commission, the livestock management and vaccination were the responsibility of the Ministry of Agriculture and the outcomes will depend on their reports. In addition, the national surveillance system for echinococcosis was established in 2016, as there were hardly any historical data for analysis to fully reflect the prevalence or incidence for patients and dogs, except for the two national surveys in 2004 and 2012.

Study area
The study was conducted in the pastoral and farming-pastoral regions of project counties in 10

Data collection
All data were obtained in the form of echinococcosis control statistics from the disease-endemic areas approved by the National Health and Family Planning Commission for each year of the 10-year period.
Data involving patient privacy were not involved. Based on the collected information, a database was established that included demography at county and township levels, grouping available patients into those subjected to surgery and those receiving drug treatment after population screening.
Information was given regarding the diagnosis (CE, AE, co-infection or unclassified) and the number of registered dogs and that of those dewormed. The situation with respect to humans and dogs were described using epidemiological descriptive analyses and the direct costs calculated after discount. these rates were stable over the whole study period (Table. 1, Figure.           and ultrasonography is regarded as a simple, safe and reliable diagnostic tool for screening for internal cysts. Importantly, relatively safe and effective chemotherapy is available (21,22).
The data in this study demonstrate that the grand total person-hours spent on surgical interventions and treatment (including postoperative treatment) was 76.6% of the corresponding grand total According to the mean prevalence rate at the county and township level, more diagnosed patients will be reported with a higher prevalence following a large-scale population screening; however, the characteristics of the co-infection cases and the unclassified cases treated during an additional 3-year period decreased by one-half. The results indicate that patients with co-infection and unclassified cases display an annual decreasing trend. Moreover, the patient treatments varied widely due to improvement of the diagnostic accuracy through ultrasound screening for the entire exposed population in high-risk areas. Therefore, patient diagnosis and management, including surgery and proportion narrowed by 70% with respect to annual or accumulated gaps, which is in accordance with the annual increase of the cost for patients and anti-parasite treatment of registered dogs. Notably, a strong relationship exists between patients and dogs, which means that there is a high risk that humans ingest parasite eggs directly through contact with infectious dogs or indirectly from contaminated environments. Studies also reveal that E. granulosus eggs remain viable and infective after 41 months that include warm summer and cold winter conditions (1,4,7,9).
In this study, we found that a positive correlation (R=0.97, P <0.01) between registered dogs with the available patients after Spearman's correlation analysis of the present data. Currently, the management of stray dogs is particularly difficult in some regions where cultural acceptance is prevalent, several studies indicate that distribution of anthelmintic baits against wild and stray definitive hosts results in significant reductions in AE prevalence, particularly if innovative bait delivery is used (30-,32,). According to WHO reports regarding endemic regions, the human prevalence rates for CE can reach more than 50 per 100,000 person-years with prevalence levels as high as 5%-10% worldwide; similar rates have been reported in regions of western China (1,8,33,34).

Conclusion
China has a high prevalence of human cystic echinococcosis (CE) and one of the highest prevalence Declarations edited the manuscript. All authors read and approved the final manuscript.

Funding
This study was supported by the National Key Research and Development Program of China (No.

2016YFC1200500) and the Project of Ganzi Tibetan Autonomous Prefecture Station for Echinococcosis
Control, China CDC.

Availability of data and materials
The supporting data in this paper are included in the context.

Ethics approval and consent to participate
The study has been reviewed and approved by the Ethical Review Board of National Institute of Parasitic Diseases. The study does not involve the use of any animal or human samples.

Consent for publication
All participants consented for publication.   Change of coverage rate for registered dog deworming for the period 2004-2014