ECONOMIC EFFECTS OF ECHINOCOCCOSIS IN A DISEASE-ENDEMIC REGION OF THE TIBETAN PLATEAU CHRISTINE M. BUDKE,* QIU JIAMIN, WANG QIAN, AND PAUL R. TORGERSON Institute of Parasitology, University of Zürich, Zürich, Switzerland; Sichuan Institute of Parasitic Diseases, Chengdu, Sichuan, People’s Republic of China Abstract. This report attempts to quantify the economic losses due to Echinococcus multilocularis and E. granulosus in Shiqu County, Sichuan, People’s Republic of China, as well as illustrate the cost effectiveness of dog anthelmintic prophylaxis combined with a sheep and goat vaccination program in terms of disability-adjusted life years (DALYs) saved. We evaluated human losses associated with treatment costs and loss of income due to morbidity and mortality, in addition to production losses in livestock due to E. granulosus infection. Annual combined human and animal losses (95% confidence interval) is estimated to reach U.S.$218,676 (U.S.$189,850–247,871) if only liver-related losses in sheep, goats, and yaks are taken into account. This equates to approximately U.S.$3.47 per person annually or 1.4% of per capita gross domestic product. However, total annual losses can be nearly U.S.$1,000,000 if additional livestock pro- duction losses are assumed. Eventual prevention of 65–95% of annual losses due to cystic echinococcosis is suggested with proposed biannual dog anthelmintic prophylaxis and a sheep and goat vaccination program. Prevention of 9–50% of human alveolar echinococcosis-associated losses is suggested based on stochastic models for the current epidemiologic situation. The median estimated cost of the program would be approximately $56,000 per year, which is a fraction of the estimated combined livestock and human financial losses due to the disease. Overall cost for the proposed control program is within the World Health Organization second most cost-effective band of less than U.S.$150 per DALY averted. However, cost per DALY averted would be less than U.S.$25 dollars for the human health sector if cost sharing was implemented between the public health and agricultural sectors based on proportional benefit from control. INTRODUCTION Alveolar echinococcosis (AE) and cystic echinococcosis (CE), which are caused by accidental ingestion of eggs from the cestodes Echinococcus multilocularis and E. granulosus, respectively, result in morbidity and mortality in affected in- dividuals. In addition, infection with these parasites also re- sults in economic losses on the household, community, and national levels. The People’s Republic of China is a country with a population of more than one billion, 84 million of which live in Sichuan Province. China is a developing country with a lower-middle income and an average 2001 gross do- mestic product (GDP) per head of $935 (purchasing power parity GDP per capita of U.S.$4,300). 1 However, the average 2001 per capita GDP for Shiqu County in Sichuan Province was much lower (U.S.$238 purchasing power parity per capita GDP of U.S.$1,095) (Table 1). 1 With such a low income, costs associated with echinococcosis can become a great burden not only for the affected individual and his or her family, but also for the community as a whole. Shiqu County, with an esti- mated prevalence rate of 4.6% and 4.9% for human AE and human CE, respectively, has one of the highest levels of hu- man echinococcosis ever recorded. 2 With a population of 63,000, Shiqu County has been shown to loose approximately 50,000 lifetime prevalence disability-adjusted life years (DALYs) or 1,100 DALYs per year due to human echino- coccosis, resulting in a loss of 0.81 DALY per individual. 2 In addition to DALYs lost, quantifiable financial costs as- sociated with human echinococcosis can be attributed to di- agnostic procedures, surgical and/or chemotherapeutic treat- ment, hospitalization, and economic losses accrued during the convalescent period. Medical costs associated with the surgi- cal treatment of echinococcosis can be expensive in the con- text of local per capita GDP, and travel to one of the larger cities in the region for surgery, namely Kanding, Chengdu, or Xining, is in itself too expensive for most Tibetan herdsmen. Therefore, sole chemotherapeutic treatment with albenda- zole continues to be the most available and least costly means of therapy for the inhabitants of Shiqu County. Economic losses due to lost income during illness, treat- ment, and the convalescent period must be taken into ac- count, as should mortality related loss of income. In addition, economic and social losses associated with undiagnosed and, therefore, untreated cases need to be considered. Animal pro- duction losses must also be evaluated in the case of CE. These include losses from infected sheep, goat, and yak livers, as well as decreased hide value, carcass weight, and reproduc- tion. Currently, the vast majority of expenses attributable to both human echinococcosis and production losses due to live- stock infected with E. granulosus are being absorbed by the local community. This includes infected individuals who have to pay for treatment and lose money due to lost work, as well as local herdsmen who must absorb the costs of decreased livestock production. Due to the public health threat from the local infected dog population, as well as the impact on the local economy, it is suggested that a publicly funded control program be implemented for this region, with the cost of this program shared between the public health and agricultural sectors. The most economically and logistically feasible way to decrease the incidence of human echinococcosis in the Shiqu County region is the practice of deworming local dogs combined with a sheep and goat vaccination program. 3 Prazi- quantel is inexpensive, if purchased in bulk for a control pro- gram, and requires limited effort and technical skill to distrib- ute. A livestock vaccination program would help to decrease E. granulosus prevalence, even though it would not effect the transmission of E. multilocularis. The addition of an educa- tion program would also be beneficial through decreasing the amount of raw offal fed to dogs. 4 Mathematical models have suggested that a combined dog * Address correspondence to Christine M. Budke, Institute of Para- sitology, University of Zürich, Winterthurerstrasse 266a, CH-8057 Zu ¨ rich, Switzerland. E-mail: budke@vetparas.unizh.ch Am. J. Trop. Med. Hyg., 73(1), 2005, pp. 2–10 Copyright © 2005 by The American Society of Tropical Medicine and Hygiene 2