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Keywords:

  • Ningxia Hui Autonomous Region;
  • China;
  • alveolar echinococcosis;
  • cystic echinococcosis;
  • retrospective hospital records;
  • community surveys;
  • public health;
  • socio-economic costs
  • Région Autonome de Ningxia Hui;
  • Chine;
  • échinococcose alvéolaire;
  • échinococcose cystique;
  • records hospitaliers rétrospectifs;
  • étude de communauté;
  • santé publique;
  • coûts socioéconomiques
  • Región Autónoma de Ningxia Hui;
  • China;
  • equinococosis alveolar;
  • equinococosis quística;
  • registros hospitalarios retrospectivos;
  • encuestas comunitarias;
  • salud pública;
  • costes socioeconómicos

Summary

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

A comprehensive study of human echinococcosis (caused by Echinococcus granulosus or E. multilocularis), including assessment of hospital records, community surveys and patient follow-up, was conducted in Ningxia Hui Autonomous Region (NHAR), China. In contrast to hospital records that showed 96% of echinococcosis cases were caused by cystic echinococcosis (CE), 56% of cases detected in active community surveys were caused by alveolar echinococcosis (AE). The AE and CE cases co-existed frequently in the same village, even occurring in the same patient. A serious public health problem caused by echinococcosis was evident in southern NHAR, typified by: a long diagnostic history for both AE and CE (7.5 years) compared with a shorter treatment history (4.7 years); a significant mortality rate (39%) caused by AE in one surveyed village, where patients had no previous access to treatment; family aggregation of CE and AE cases; a high proportion of both AE (62.5%) and CE (58%) in females; a high rate of recurrent surgery (30%) for CE demonstrated by surgical records; and frequent symptomatic recurrences (51%) because of discontinuous or sporadic access to chemotherapy for AE. The disease burden for both human AE and CE is thus very severe among these rural communities in NHAR, and this study provides the first attempt to determine the costs of morbidity and surgical intervention of human CE and AE cases both at the hospital and community level in this setting. This information may be useful for assessing the cost effectiveness of designing effective public health programs to control echinococcosis in this and other endemic areas in China and elsewhere.

Une étude compréhensive de l’échinococcose humaine causée par Echinococcusgranulosus ou E. Multilocularis, incluant des évaluations de records hospitaliers, des études de communautés et des suivis de patients, a été menée dans la région autonome de Ningxia Hui (NHAR) en Chine. Contrairement aux records hospitaliers démontrant 96% de cas d’échinococcose causés par une échinococcose cystique (EC), 56% des cas détectés dans les surveillances actives de la communautéétaient dus à une échinococcose alvéolaire (EA). Les cas d'EC et EA coexistent fréquemment dans le même village et même chez le même patient. Un sérieux problème de santé publique du à l’échinococcose était évident dans le sud de NHAR, caractérisée par: 1) une longue histoire sur le diagnostic des formes EC et EA (7,5 ans) comparée à une courte histoire sur le traitement (4,7 ans), 2) un taux de mortalité important (39%) du à EA dans un des villages étudiés ou les patients au préalable n'avaient pas accès au traitement, 3) un regroupement familial des cas EC et EA, 4) une proportion élevée des deux formes EA (62,5%) et EC (58%) chez les femmes, 5) un taux élevé de chirurgie (30%) pour les formes EC et 6) une fréquente récurrence symptomatologique (51%) due à l'accès sporadique et discontinu au traitement pour l'EA. La charge de morbidité pour les deux formes d’échinococcose est donc très sévère dans ces communautés rurales du NHAR. Cette étude procure la première tentative de détermination des coûts, de la morbidité et de l'intervention chirurgicale des cas d'EC et EA, à la fois au niveau de l'hôpital et dans la communauté dans la région. L'information obtenue pourra être utile pour l’évaluation du rapport coût-efficacité dans le concept de programmes de contrôle effectifs de l’échinococcose dans cette zone et dans d'autres régions endémiques de Chine et d'ailleurs.

Se realizó un estudio extenso sobre la equinococosis humana (por Echinococcusgranulosus o E. multilocularis) en la región autónoma de Ningxia Hui (RANH), China, que incluía la evaluación de registros hospitalarios, encuestas comunitarias y seguimiento de pacientes. En contraste con los registros hospitalarios que mostraban que un 96% de los casos de equinococosis eran causados por equinococosis quística (EQ), 56% de los casos detectados mediante encuestas comunitarias era debido a equinococosis alveolar (EA). Los casos de EQ y EA coexistían con frecuencia en el mismo pueblo e incluso en el mismo paciente. Se evidenció un serio problema de salud pública por equinococosis al sur de RANH, tipificado por: una historia de diagnóstico largo, tanto para EQ como EA (7.5 años), comparado con una historia más corta de tratamiento (4.7 años); una tasa de mortalidad significativa (39%) por EA en uno de los pueblos estudiados en donde los pacientes no habían tenido previo acceso al tratamiento; agregación familiar de los casos de EQ y EA; una alta proporción tanto de EA (62.5%) como de EQ (58%) en mujeres; una tasa alta de cirugía recurrente (30%) para EQ reflejada en los historiales quirúrgicos; y recurrencias sintomáticas frecuentes (51%) por acceso discontinuo o esporádico a la quimioterapia para EA. La carga de enfermedad tanto de EA como EQ es grande en estas comunidades rurales de la RANH. Este estudio aporta un primer ensayo en la determinación de los costes de morbilidad e intervención quirúrgica de casos EQ y EA humana, tanto a nivel hospitalario como comunitario en esta zona. Esta información podría ser útil para evaluar la costo-efectividad de diseñar programas de salud pública efectivos para el control de la equinococosis, en esta y en otras áreas endémicas, tanto dentro como fuera de la China.


Introduction

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Echinococcosis is frequently found in people, livestock and wildlife in north-west China (Vuitton et al. 2003; Craig 2004). Ningxia Hui Autonomous Region (NHAR), situated on the Loess Plateau of central-northern China, is divided by natural geographic features into two main regions, northern and southern NHAR. In southern NHAR inhabitants live either in mountainous areas, or on the Loess Plateau along with their livestock, and this area constitutes a distinct unit in terms of environment, life-style and the educational level of the resident population. No irrigation systems are present, and animal husbandry and agriculture are critically dependent on the environmental and climatic conditions prevailing throughout the year. Consequently, economic and living standards are low. The majority of inhabitants in southern NHAR comprise Hui (Moslem) Chinese, who undertake periodic religion-associated group livestock slaughter without inspection, and carry out extensive sheep farming. Both factors provide highly suitable conditions for the spread of Echinococcus granulosus infection and cystic echinococcosis (CE). Southern NHAR is also recognized as highly endemic for human alveolar echinococcosis (AE), caused by E. multilocularis (Li et al. 1991; Wang et al. 1991; Yang et al. 2005).

Despite the significant public health problems caused by CE and AE in this region, limited data on their public health impact and socio-economic burden are available. As part of an ongoing comprehensive survey for human echinococcosis, a retrospective study of hospital records was conducted that identified a highly endemic focus of CE and AE in NHAR. This revealed a heterogeneous distribution of human AE and CE in the south of the region, especially in the confluent Liu-Pan Mountain area of Xiji, Haiyuan and Guyuan counties (Yang et al. 2005). An ultrasound and serological-based mass screening community study was performed in this endemic focus to determine the true prevalence of human CE and AE (Yang et al. 2006a), with the results enhancing the retrospective hospital study (Yang et al. 2005). Here we describe some epidemiological and clinical features of AE and CE and quantify the resulting socio-economic costs of human echinococcosis in this setting. This information may provide new insights on patient diagnosis, treatment and follow-up in this rural area of China that may inform future control strategies for echinococcosis.

Methods

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Study areas and subjects

Visits were made to seven local county hospitals in Tongxin county and Guyuan prefecture (Xiji, Haiyuan, Pengyang, Longde, Jingyuan and Guyuan counties) in southern NHAR and four other hospitals in Yinchuan, the capital city of NHAR in the north (Figure 1). The files in the surgery sections of each hospital, as well as in departments involved in echinococcosis treatment and diagnosis, were reviewed, with all CE and AE cases being recorded. The majority of cases had local domicile (i.e. the same as the hospital location), but patients came from almost every part of NHAR. A total of 2134 CE and 82 AE cases were documented for the period 1985–2002.

image

Figure 1.  Study areas. The areas covered by the hospital survey are shown by the vertical parallel lines, the community-surveyed areas are shown by horizontal parallel lines, and the overlapping areas are represented by cross-vertical and horizontal lines. The locations of hospitals surveyed (in Yinchuan City and local county hospitals) are shown in bold type.

Download figure to PowerPoint

Based on the hospital records and ‘AE-risk’ landscape profiles (Danson et al. 2003), community survey areas were then selected in the Liu-Pan-Mountainous region comprising Xiji, Guyuan and Longde counties (Figure 1), which we had identified previously with a highly heterogeneous distribution of human echinococcosis (Yang et al. 2005). The community surveys were conducted during 2001–2003. A total of 4773 individuals in 26 communities from 16 townships representing 14.5% of the native community population were actively screened; the sample comprised 2271 females and 2502 males who were predominantly Han (2439 subjects) or Hui (2312 subjects) Chinese.

Retrospective studies based on hospital records

Data on age, sex, domicile, ethnicity, occupation, year of diagnosis, cyst number, cyst location, the number of previous surgical operations for all CE cases, and some AE cases, and type of anti-echinococcosis drug (albendazole or mebendazole) taken (if given) were recorded for each hospital case of echinococcosis for the period 1985–2002. The detailed records of these hospital cases are presented elsewhere (Yang et al. 2005).

Prospective community surveys

After approval by the Ethics Committee of Ningxia Medical College, written consent was obtained from all adults and from parents of minors aged 5 years or older who agreed to participate in the survey. Following completion of a questionnaire, mass screening by ultrasound and serology (Yang et al. 2006a) was performed in the highly endemic echinococcosis focus located in Xiji, Guyuan and Longde. Individuals, including those with a previous CE/AE treatment history, were screened by abdominal ultrasound scan with serological confirmation of abnormal, query or confirmed AE/CE images. Serology was based on antigen B and Em 18 antibody detection by immunoblot analysis and ELISA (Ito et al. 2003). Mass screening procedures and ultrasound classification for AE and CE were in accordance with published recommendations and previous studies (Bartholomot et al. 2002; Macpherson et al. 2003; WHO-IWG 2003).

Criteria for evaluation of echinococcosis cases post-chemotherapy

Modified WHO (1996) criteria were used to evaluate the effectiveness of chemotherapy in patients with echinococcosis in the community surveys including follow-up as follows: (i) successful outcome; lesion disappearance, significant decrease (>50% reduction) in lesion volume, or distinct changes in lesion morphology such as >25% increase in calcification; (ii) improved outcome; evidence of changes in lesion morphology or some alleviation of clinical symptoms; and (iii) unsuccessful outcome; progression of the disease such as increase in volume of the lesion or worsening of clinical symptoms.

Calculation of treatment costs

The hospital case-treatment cost calculations were based on the individual inpatient records. Case-treatment costs during community screening and at follow up were dependent on the local price of albendazole, which was purchased and offered free to echinococcosis patients.

Data analysis

Data from hospital records, interviews/questionnaires, ultrasound scans and serology were put into the Epi-Info program, which is designed for handling epidemiological data in an information sheet format. Data analyses used Epi-Info 3.2 and SPSS 11.5 (Yang et al. 2005).

Results

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Comparison between hospital records and community surveys

A heterogeneous distribution of echinococcosis cases was evident by incidence (ranges 0–13/100 000 for AE/CE combined), obtained from the hospital records, and by prevalence (ranges 0–8.1% for AE and 0–7.4% for CE) obtained from the community surveys. Although the incidence (6/100 000) was almost the same in Guyuan and Xiji counties, the prevalence was 4.5-fold higher in Xiji than in Guyuan (Table 1). The majority of retrospectively recorded hospital cases were caused by CE (96%). In contrast, AE accounted for 56% of cases identified in the mass community surveys. The number of female echinococcosis cases was higher in both the hospital records and community screening surveys, as were cases of Hui ethnicity, compared with Han. The average age of CE cases was lower in the hospital records compared with those identified in the community surveys (Table 1). The occupation of the majority of both CE and AE patients was farming.

Table 1.   A comparison of data obtained from hospital records and community surveys for Ningxia Hui Autonomous Region
ParametersHospital records surveyCommunity survey
  1. AE, alveolar echinococcosis; CE, cystic echinococcosis.

  2. * The hospital survey included data from Guyuan prefecture (Guyuan, Xiji, Haiyuan, Pengyang, Longde and Jingyuan counties) and Tongxin county in southern Ningxia and hospitals in Yinchuan, the capital city of Ningxia in the north; the community survey included data from Xiji, Guyuan and Longde counties.

  3. † Clinical cases included all those recorded from the study hospitals; community cases included all registered patients in the surveyed communities.

  4. ‡ M/F (Av) years = males/females (average age) years.

  5. § Other occupations included: general workers, self-employed, village leaders, teachers, housewives, businessman and butchers in the clinical survey; herdsman, general workers, leaders, businessmen, housewives and teachers in the community survey.

  6. ¶ Incidence (cases/100 000/year).

  7. ** Prevalence (%).

General focus*Seven¶ (0–13) for AE/CE combined3.6** (0–8.1 for AE; 0–7.4 for CE)
GuyuanSix¶ (ratio of AE/CE = 0.05)0.9** (ratio of AE/CE = 2)
XijiSix¶ (ratio of AE/CE = 0.17)4.5** (ratio of AE/CE = 1.25)
Longde0.5¶ (only CE, no AE)0.6** (only CE, no AE)
No. of cases†2124 CE (96%); 82 AE (4%)75 CE (44%); 96 AE (56%)
Gender (F/M)1268/916 for AE/CE combined60/36 for AE; 44/31 for CE
Hui/Han cases1013/776 for AE/CE combined58/38 for AE; 39/36 for CE
Case age range M/F (Av) years‡1–80/3–77 (35/35) years for CE; 21–71/17–70 (44/45) years for AE18–75/25–79 (45/50) years for CE; 23–71/18–73 (48/50) years for AE
Occupation of patients66% farmers (AE/CE combined)91%/95% farmers for CE/AE
12% students (AE/CE combined)1% students for CE only
22% others§ (AE/CE combined)8%/5% others§ for CE/AE
Significant points83% CE cases received radical surgery, 7.3% cases had combined surgery with chemotherapy; there was a 30% re-operation rate. Most AE cases received only chemotherapy and were at an advanced stage of diseaseAverage diagnosis history = 7.5 years. Average treatment history = 4.7 years. 51% recurrences due to curtailed ABZ treatment; 39% deaths due to AE in one village with 3.7% deaths due to CE. Family prevalence of 0–24% for AE and 0–13% for CE

The majority (83%) of CE cases from the hospital survey had received radical surgery with a small group (7.3%) having received a combination of surgery and pre- and post-surgery chemotherapy (albendazole/mebendazole); 6.6% cases had received chemotherapy only. Thirty per cent of CE patients had received repeat operations. Furthermore, the hospital records showed that the majority of AE cases were at an advanced stage, and had received treatment by chemotherapy. The questionnaire data from the community surveys showed that the case-diagnosed history (7.5 years) for both AE and CE was generally longer than the treatment history (4.7 years). Symptom-recurrences occurred in 51% of AE patients due to frequent discontinuous or sporadic access to chemotherapy, mainly because of the high cost of treatment. A major echinococcosis focus (Nanwan village) with a significant mortality rate because of AE (39%) was identified by the hospital records, local information searching and by questionnaire, and a highly heterogeneous range of echinococcosis prevalences (0–24% for AE and 0–13% for CE) was determined in different family groups in this village.

Surgery for CE accounted for 0.4–1% (average 0.7%) of total in-patients in the Second Provincial People's Hospital of NHAR in Guyuan City, where patients mainly came from rural counties within southern NHAR. The organs involved among the hospital records of all surgically confirmed CE patients were predominantly the liver (82.8%) or the lungs (8.1%), and 9.1% of cases involved other organs (abdominal and pelvic cavity, brain, spleen, kidney and mediastinum) or had multiple cysts. The CE was also found in some rare locations such as the thyroid gland, pelvic bone, leg muscle and stomach wall. AE lesions mainly involved the liver only except for one case who also had brain metastases. The main symptoms recorded at consultation were epigastric pain for both CE (71%) and AE (90%). The hospital-based diagnosis predominantly relied on ultrasound (97–99%), with X-ray (30–46%) as the main complementary method. Other more advanced techniques such as computerized tomography (CT) scanning, and histo-pathological examination were available in some of the better-equipped provincial higher-level hospitals (Table 2).

Table 2.   Clinical features of human echinococcosis cases from Ningxia Hui Autonomous Region based on retrospective hospital records*
ParametersCE (%)AE (%)
  1. * Records from the Second Provincial People's Hospital, Guyuan, southern NHAR.

  2. † Other organ: abdominal and pelvic cavity, brain, spleen, kidney and mediastinum. AE lesions mainly involved the liver except for one case who had metastases in the brain.

  3. ‡ Radical surgery accounted for the majority of operations.

  4. § Included all patients receiving surgery, albendazole or combined surgery and albendazole treatment.

Symptoms (epigastria pain)7190
Diagnosis
 Ultrasound9799
 X-ray4630
 CT, pathology99
Lesion location
 Liver82.899.9
 Left2010
 Right6640
 Both1450
 Lung8.1<0.1
 Other organ†9.1<0.1
Treatment method
 Surgery‡861
 Chemotherapy6.698
 Combination7.31
Outcome§
 Cured900
 Improved880
 Worsened117
 No change03
Disease burden
 HospitalizationUS$30–4189 (Mean, $220)US$30–1500 (Mean, $243)

The community screening revealed that more than half of the CE cases (61%) and 34% of AE cases were asymptomatic. Among screened patients, those considered in the early stages of disease accounted for only 21% of subjects for both AE and for CE (Table 3).

Table 3.   Clinical features of human echinococcosis cases from Ningxia Hui Autonomous Region based on data from the community surveys*
ParametersCE (%)AE (%)
  1. CE, cystic echinococcosis; AE, alveolar echinococcosis.

  2. * The majority of cases were detected by ultrasound with a small number of patients at follow-up being diagnosed by CT or X-ray scanning.

  3. † The majority of participants in the community surveys were not assessed for echinococcosis in other organs; this was only undertaken in county hospitals in the follow-up patient group (2% surveyed individuals) – for full details, see text.

  4. ‡ For CE, early stages include T0, T1 and T2, with T3, T4 and T5 being inactive or late stage; for AE, P1 and P2 represent early stage infection and P3 and P4 represent advanced stage.

  5. § Treatment involved use of albendazole only and was limited to 1–2 years.

  6. ¶ Predicted charges for diagnosis and treatment.

Location
 Liver
  Left2814
  Right53.535
  Both1450
  Other organs†3.51
Number
 Single lesion6173
 Multi-lesion1514.5
 No record2412.5
Stage, symptom
 Early‡21 (T0–T2), 10 (sym)21 (P1–P2), 12 (sym)
 Advanced79 (T3–T5), 29 (sym)79 (P3–P4), 54 (sym)
Treatment efficacy§
 Recovered10
 Improved4319
 Stable5656
 Worsened024
 Disease burden¶ US$$220/patient for surgery costs$54 per patient per year for ABZ
 Income/family/pa. <$25051/75 (68)61/96 (64)

Treatment and follow up

Estimations of treatment efficiency for CE demonstrated generally positive outcomes in the hospital inpatient records, with 90% of CE patients considered greatly improved or cured, and 8% improved. On the other hand, the majority of hospitalised AE cases were advanced, and these received only ABZ treatment; the inpatient records showed that the majority (80%) had improved outcomes, with the worse or no-change/stable outcomes being 17% and 3%, respectively (Table 2). Regarding treatment of cases identified during the community surveys, all AE patients and some CE patients who refused, and/or were deemed unsuitable for surgery were offered free ABZ treatment (15–20 mg/kg/day) for at least 6 months. The remaining CE patients were recommended for surgery for removal of their lesions. The efficacy of treatment (with ABZ) was monitored after a 2-year follow-up by ultrasound, which showed that in more than half of the patients (56%) there had been no change in their AE or CE lesions. Of early stage CE (type T1 – simple cyst and type T2 – daughter cysts present) cases, 43% showed improvement in the follow-up indicated by reduction in cyst size and infiltration/opacity of US images.

Socio-economic costs

Hospital diagnosis of both AE and CE relied mainly on ultrasound and/or X-ray. Some cases were skin-tested using the Casoni intradermal test. Among the surgical inpatients, 62% of CE cases remained in hospital for 2 weeks, 23% of them were hospitalized for less than or equal to 10 days, with up to 4 months of hospital stay in complicated cases (ranges from 1 to 125 days). Uncomplicated cases were hospitalized for a mean of 10.8 days while complicated cases required a mean of 75 days. The CE patients required a mean of 40 days as a convalescent period following surgery. The cost of the various tests and radical surgery that led to the diagnosis and treatment of CE ranged from US$30 to $4189 with a mean of US$220 (Table 2).

For AE cases, hospitalization length ranged from 3 to 30 days with a mean of 12 days. The treatment method employed was mainly chemotherapy. The cost of hospitalization ranged from US$30 to $1500 with an average charge of US$243. Patients with advanced stages of AE had no opportunity for radical surgical intervention and therefore lifetime chemotherapy was the only treatment available for these patients. The costs for case diagnosis, treatment and follow-up in the community surveys were covered by Ningxia Medical College; all clinical examinations, ultrasound, serology and ABZ were offered free of charge to all participants. Therefore, the economic costs predicted here are for future patient treatment expenditure. For each CE case, surgical charges were predicted to be at least US$220 (Table 2). Given that the current (2005) market price of a standard bottle of ABZ is US$3 (100 tablets per bottle and 200 mg per tablet), each AE patient would spend at least US$54 per year for regular and continuous chemotherapy (Table 3). Socio-economic data obtained from local government records and questionnaires in the community surveys showed that the majority of the rural population (65%) live at a low-income level (<US$250/family/annum). A high proportion of the echinococcosis patients (64–68%) came from the same low-income group (Table 3).

Discussion

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Analysis of hospital records and community survey findings for human echinococcosis in NHAR showed that the majority of patients had a history of pain and discomfort in the right sub-costal region. The hospital records indicated that the efficiency rate of surgical intervention for CE was high, but if the high repeat operation rate for secondary echinococcosis is taken into consideration, a poorer treatment outcome results. The efficiency of treatment for AE, based on the hospital reports, and the records for the community screened patients and their subsequent follow up, was very poor. Therefore, critical improvements are required for earlier diagnosis of AE and timely surgery to prevent a high incidence of complications. Accordingly, better co-operation between health-workers and surgeons/physicians with regard to earlier diagnosis and treatment of hepatic echinococcosis is needed. Diagnostic imaging techniques (ultrasound and CT scanning) have played a predominant role in improvement of the non-invasive diagnosis of complicated human echinococcosis in China and elsewhere. Ultrasound, especially, is widely practiced in endemic rural areas for community surveys as it is cheap, portable and easy to operate (Bartholomot et al. 2002). In contrast, serology for echinococcosis was not commonly used in most of the hospitals surveyed, especially in rural hospitals, although it is recognized as a very useful complementary or confirmatory method for case detection (Craig et al. 1996, 2003).

Treatment of human echinococcosis requires significant expenditure for the families of patients. Currently in China, public hospitals are financed through three sources: government subsidies, patient fees and drug mark-ups. In township and county hospitals or clinics, only a proportion of staff salaries are covered by the government budget, leaving the remainder to be generated from patient charges. This kind of health-care system has moved attention away from preventive and other public health interventions towards individual clinical care. The result has been a negative impact on public health control programs. From the mid 1980s, user fees were also introduced in some public health programs. However, the budget for health resources is inappropriately spent on high cost equipment and drugs, which results in low use and cost-effectiveness (Liu & Wei 1996). During the past two decades, medical costs in rural clinics in China have increased far in excess of income. The use of high cost technologies and expensive drugs, and the low occupancy rate of hospital beds are some of the critical factors contributing to this cost increase. We have shown that surgical charges have increased threefold during the past 10 years in one of the surveyed hospitals (in the Second Provincial Peoples’ Hospital of NHAR in Guyuan City) in southern NHAR (Yang et al. 2006b). The inequity in health status and access to health care between geographical areas and social groups in NHAR has also increased substantially. Disparities in health status were evident between regions and population groups in the current analysis. Comparing both the highly endemic counties of Guyuan and Xiji, the incidence of human echinococcosis from the hospital records was the same (6/100 000 population) (Yang et al. 2005), but the prevalence in the community survey of Xiji was 4.5-fold higher than that in Guyuan, which suggests that fewer echinococcosis cases are treated in former. As Guyuan is a major city of southern NHAR, health-care facilities are more convenient and of a higher quality than those in poorer, adjacent counties including Xiji. The community surveys thus revealed a very poor healthcare situation and a significant public health problem because of echinococcosis in Xiji. The AE and CE cases often co-existed in the same village, even occurring in the same patient and an unusual clustering of CE and AE cases was identified in Nanwan, one of the villages surveyed in Xiji county (Yang et al. 2006c). The high prevalence of echinococcosis in Xiji is due to the poor socio-economic situation, traditional lifestyles and animal husbandry practices, inadequate hygiene and close relationship with dogs over recent decades.

A high prevalence of asymptomatic patients were found in the community surveys but patient age lagged approximately 10–15 years behind the case-age in the hospital records for CE. This may indicate that different Echinococcus transmission patterns occur between the community study areas and the locations where subjects in the hospital records originated. The distance to a health-care centre for this rural population was also an important issue through its effect on the use of health resources and subsequent treatment for echinococcosis. The majority of AE and CE cases in the community were found by chance in this study and these were at an advanced stage for AE and generally late stage for CE. The reasons may include a long incubation time with non-specific symptoms and/or a heavy economic burden for the families of patients and the entire community. In contrast to CE, AE lesions were more likely to be ignored until they became untreatable because of a longer asymptomatic period followed by more rapid deterioration in health (Craig et al. 2003; McManus et al. 2003; Craig 2004).

Other significant findings of this study, such as the high mortality rate caused by AE, the long diagnosis-history coupled with a short treatment-history among rural patients and the high rate of recurrences, caused by frequent discontinuous chemotherapy, emphasize that echinococcosis is an important public health problem, exacerbated by poor healthcare conditions in this underdeveloped region.

The CE patients may spend large sums of money on hospitalization charges and lose income during periods of post-surgical convalescence. Most individuals with AE are required to take ABZ for the remainder of their lifetime, which also results in decreased income and quality of life. This situation, coupled with lower family income among these rural people, confirms previous reports that the poorest people in the world suffer the greatest burden of infectious disease (Gwatkin & Guillot 1999; Sachs & Steele 2001). This study is the first to attempt to determine the costs of morbidity and surgical intervention because of CE and treatment costs for AE for both inpatients and outpatients in NHAR, China. Similar investigations to this, and that recently described by Budke et al. (2005) of a study in an area in Sichuan Province on the Tibetan Plateau, are required in other echinococcosis-endemic regions of China to provide a broader public health perspective. Such information, based on detailed and continually updated epidemiological data, can be used to assess the cost effectiveness of designing public health programs to control echinococcosis.

We advocate extensive surveys on echinococcosis throughout northwestern China, especially in rural communities. These will enable earlier diagnosis of echinococcosis, thereby improving treatment outcomes, and reveal the true epidemiological picture regarding echinococcosis, with a view to developing and implementing new strategies for future control.

Acknowledgements

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

This work was supported in part by Ningxia Medical College, the University of Queensland, and an NIH/NSF Ecology of Infectious Diseases project on echinococcosis (Two 1565). We are also grateful to Dr Leon Hugo in QIMR for his comments on the MS and Mr Liu Rui-Qi, for his help with the data collection, and all staff at Ningxia Medical College who participated in this program of research.

References

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
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