Knowledge, attitudes and practices regarding echinococcosis in Xizang Autonomous Region, China

Pictorial review of hepatic echinococcosis: Ultrasound imaging and differential diagnosis

Echinococcosis is a zoonotic disease caused by parasites belonging to the genus Echinococcus that primarily affect the liver. The western plateau and pastoral areas of China are high-risk regions for hepatic cystic echinococcosis and hepatic alveolar echinococcosis (HAE). The high late mortality rate associated with HAE underscores the critical need for early diagnosis to improve cure rates and mitigate the disease burden in endemic areas. Currently, the World Health Organization recommends ultrasonography as the preferred initial screening method for hepatic echinococcosis. However, distinguishing between specific types of lesions, such as those of hepatic cystic echinococcosis and HAE, and other focal liver lesions is challenging. To address this issue, contrast-enhanced ultrasound is recommended as a tool to differentiate solid and cysto-solid hepatic echinococcosis from other focal liver lesions, significantly enhancing diagnostic accuracy. In this comprehensive review, we discuss the progression of hepatic echinococcosis and detail the imaging features of various types of echinococcosis using conventional, contrast-enhanced, and intraoperative ultrasound techniques. Our objective is to provide robust imaging evidence and guidance for early diagnosis, clinical decision making, and postoperative follow-up in regions with high disease prevalence.

Global, Regional and National Burden of Human Cystic Echinococcosis from 1990 to 2019: A Systematic Analysis for the Global Burden of Disease Study 2019

BACKGROUND

Cystic echinococcosis (CE) is a neglected tropical parasitic disease that poses huge disease, social and economic burdens worldwide; however, there has been little knowledge on the global morbidity, mortality and disability-adjusted life years (DALYs) of CE until now. This study aimed to collect the most up-to-date data about the global, regional and national disease burden due to CE from 1990 to 2019 and to project trends in the next 10 years.

METHODS

We measured the global, regional and national morbidity, mortality and DALYs of CE from 1990 to 2019 based on the Global Burden of Disease Study 2019 (GBD 2019) data, and we examined the correlation between socioeconomic development levels and the disease burden of CE. In addition, the disease burden due to CE was projected from 2020 to 2030.

RESULTS

The age-standardized incidence rate (ASIR) of CE reduced from 2.65/105 [95% UI: (1.87/105 to 3.7/105)] in 1990 to 2.6/105 [95% UI: (1.72/105 to 3.79/105)] in 2019 (EAPC = -0.18%). The number of deaths, DALYs, age-standardized mortality rate (ASMR) and age-standardized DALY rate due to CE all showed a tendency to decline from 1990 to 2019. A higher disease burden of CE was measured in women than in men in 2019. There was a significant difference in the ASMR of CE by region according to the socio-demographic index (SDI), and lower burdens of CE were estimated in high-SDI regions. The global ASIR of CE is projected to decline from 2020 to 2030; however, the ASMR and age-standardized DALY rate are projected to rise.

CONCLUSIONS

The global burden of CE remains high, and it is recommended that more health resources are allocated to low-SDI regions, women and the elderly aged 55 to 65 years to reduce the disease burden of CE.

Knowledge, awareness and practice regarding cystic echinococcosis in Algeria: A cross-sectional survey among the general population

Cystic echinococcosis (CE) is a parasitic zoonotic disease with a widespread occurrence, particularly in developing countries. Known as a neglected disease, it is highly prevalent in Algeria with a significant public health concern and substantial financial losses. The objectives of this study was to explore knowledge and awareness and practice of the Algerian population regarding this disease. A cross-sectional online-based survey was conducted between July 15 and September 25, 2022 using a self-administered questionnaire targeting all Algerian people of more than 18 years of age. Out of the total respondents, 87.7% have ever heard of CE with livestock rearing connection (OR:2.550, CI 95% OR: 1.108-5.870) and educational level (OR:3.826, CI 95% OR: 1.599-9.156) as the main factors associated with the level of awareness. Regarding their knowledge, results showed dispersing notions about the disease. The majority (84.8%) were aware of the zonnotic nature of the disease while only 49.6% knew that CE is caused by parasitic disease. Also, 83.3% were knowledgeable of the role of contaminated offal in the contamination of dogs which are considered as the main source of contamination of humans (65.19%). Regarding their practices, even home slaughtering was common (92.96%), some positive attitudes were prevalent where most of the participants declared washing vegetable before consumption (97.41%) and washing their hands after touching a dog (91.11%). Also, 68.29% among the dog owners declared that deworming their pets. This study has revealed that despite the high level of awareness and some positive attitudes, the level of knowledge about CE among the Algerian public has shown some gaps related to the epidemiology of the disease. These results could be helpful for the awareness campaigns programmers in their missions through focusing their efforts on raising the level of knowledge for the items that have shown a lack of understand which will be of great importance in the strategy of CE elimination.

Revealing novel cytb and nad5 genes-based population diversity and benzimidazole resistance in Echinococcus granulosus of bovine origin

Cystic echinococcosis (CE) is a neglected zoonotic disease caused by Echinococcus granulosus (sensu stricto). The parasite affects a wide range of livestock and wild animals. In this study, the population diversity of the Echinococcus species was investigated based on mitochondrial cytochrome b (cytb) and NADH dehydrogenase subunit 5 (nad5) genes. In addition to this, β-tubulin gene isoforms of Echinococcus granulosus were amplified to determine the resistance against benzimidazoles. For this purpose, 40 cyst samples from cattle (n = 20) and buffaloes (n = 20) were collected from the main abattoir of Sialkot. DNA extraction was performed using Qiagen Blood and Tissue Kits. Amplification was performed through PCR. Each amplicon was confirmed by GelRed™ stained agarose gel (2%). Samples were sequenced in a DNA analyzer and viewed for any misread nucleotide by using MEGA (v.11). Corrections in nucleotide sequence and multiple sequence alignment were made through the same software. NCBI-BLAST was used for sample specific sequences to identify them as belonging to a particular species. Diversity indices were estimated using DnaSP (v.6) while phylogenetic analysis was inferred using the Bayesian method using MrBayes (v.1.1). β-tubulin gene isoforms sequence analysis was performed to find out the candidate gene causing benzimidazole resistance. All 40 isolates were found positive for E. granulosus. BLAST-based searches of sequences of each isolate for each gene (nad5 and cytb) confirmed their maximum similarity with the G1 genotype. Overall, high haplotype diversity (Hd nad5 = 1.00; Hd cytb = 0.833) and low nucleotide diversity (π nad5 = 0.00560; π = cytb = 0.00763) was identified based on diversity indices. For both the genes, non-significant values of Tajima's D (nad5 = -0.81734; cytb = -0.80861) and Fu's Fs (nad5 = -1.012; cytb = 0.731) indicate recent population expansion. Bayesian phylogeny-based results of nad5 and cytb sequences confirmed their genotypic status as distinct from other Echinococcus species. This study shed light on the status of benzimidazole resistance in Echinococcus granulosus for the very first time from Pakistan. The findings of this study will significantly add in the information available on genetic diversity of Echinoccous granulosus based on cytb and nad5 genes sequences.

Attitude and awareness of Algerian university students about cystic echinococcosis: A cross-sectional study

Cystic echinococcosis is a neglected tropical parasitic disease affecting both humans and animals with considerable socioeconomic impact on affected pastoral and poor communities. CE is endemic in the Mediterranean basin, including Algeria posing a real threat for either animal and public health. This study was conducted to evaluate the level of awareness and knowledge of Algerian university students about this disease and to describe their attitude toward some risky practices. Results showed that despite that a high number of students (76.1%) have heard about CE, their level of knowledge is however medium (63.3%) especially among students of non medical and life sciences specialties. The gaps of knowledge concerns especially the life cycle of the parasite even they are aware about the association of dogs (43.7%) and sheep (59.4%) and considered that dogs are the main source of contamination of humans (58.1%) through contaminated foods (45%) or direct contact with their faeces (44.5%). Regarding their practice, a good level was shown since washing vegetables (99.2%) and washing hands after touching a dog (97.9%) and dogs deworming (82%) were common. These results highlight the need to improve knowledge about the transmission cycle of the parasite through awareness campaign targeting students which could be helpful in CE eradication.

How climate, landscape, and economic changes increase the exposure of Echinococcus Spp

BACKGROUND

Echinococcosis is a global enzootic disease influenced by different biological and environmental factors and causes a heavy financial burden on sick families and governments. Currently, government subsidies for the treatment of patients with echinococcosis are only a fixed number despite patients' finical income or cost of treatment, and health authorities are demanded to supply an annual summary of only endemic data. The risk to people in urban areas or non-endemic is increasing with climate, landscape, and lifestyle changes.

METHODS

We conducted retrospective descriptive research on inpatients with human echinococcosis (HE) in Lanzhou hospitals and analyzed the healthcare expenditure on inpatient treatment and examined the financial inequalities relating to different levels of gross domestic product. The livestock losses were also estimated by infection ratio. The occurrence records of Echinococcus spp. composed of hospitalized patients and dogs infected in the Gansu province were collected for Ecological niche modeling (ENM) to estimate the current suitable spatial distribution for the parasite in Gansu province. Then, we imported the resulting current niche model into future global Shared Socioeconomic Pathways scenarios for estimation of future suitable habitat areas.

RESULTS

Between 2000 to 2020, 625 hospitalized HE patients (51% men and 49% women) were identified, and 48.32 ± 15.62 years old. The average cost of hospitalization expenses per case of HE in Gansu Province was ￥24,370.2 with an increasing trend during the study period and was negative with different counties' corresponding gross domestic product (GDP). The trend of livestock losses was similar to the average cost of hospitalization expenses from 2015 to 2017. The three factors with the strongest correlation to echinococcosis infection probability were (1) global land cover (GLC, 56.6%), (2) annual precipitation (Bio12, 21.2%), and (3) mean temperature of the Wettest Quarter (Bio12, 8.5% of variations). We obtained a robust model that provides detail on the distribution of suitable areas for Echinococcus spp. including areas that have not been reported for the parasite. An increasing tendency was observed in the highly suitable areas of Echinococcus spp. indicating that environmental changes would affect the distributions.

CONCLUSION

This study may help in the development of policies for at-risk populations in geographically defined areas and monitor improvements in HE control strategies by allowing targeted allocation of resources, including spatial analyses of expenditure and the identification of non-endemic areas or risk for these parasites, and a better comprehension of the role of the environment in clarifying the transmission dynamics of Echinococcus spp. Raising healthcare workers' and travelers' disease awareness and preventive health habits is an urgent agenda. Due to unpredictable future land cover types, prediction of the future with only climatic variables involved needs to be treated cautiously.

Assessment of risk, landscape epidemiology and management strategies to combat alveolar echinococcosis in the rural communities of Hunza, Pakistan

Background

Human alveolar echinococcosis (AE) is a neglected zoonotic disease. Prevalence of AE in humans is reported in Pakistan as a result of poor economic and sanitary conditions, close proximity to wildlife and limited knowledge of AE. Studies on the prevalence and transmission of AE have been limited, especially for rural Pakistan. The study objectives were to identify knowledge, attitudes and practices relating to AE, to determine awareness of the disease, and to identify knowledge about possible risk factors of infections involving the landscape epidemiological attributes of rural villages in Hunza, one of the districts of Gilgit-Baltistan, a region of Pakistan that borders China.

Methods

A community-based cross-sectional study was conducted among the general population of Hunza to establish the level of awareness, knowledge, attitudes, practices, landscape epidemiology, and disease management and control relating to AE in rural areas of Hunza. Data were collected by questionnaire.

Results

A total of 387 questionnaires was received. Statistical analysis showed that the population's knowledge about the disease was poor. The attitudes and practices of the participants indicated that their risk of infection was low. Knowledge of landscape epidemiology of the disease was poor but knowledge about AE disease management was good. The attitudes of residents toward disease treatment and control strategies were positive, although the overall knowledge of participants about prevention of infection was poor.

Conclusion

Knowledge of AE is poor among the residents of Hunza, Pakistan. Our study demands continued and strengthened awareness of the changes to lifestyle and practices associated with AE, not only in the study locality but throughout other areas of Pakistan.

Societal drivers of human echinococcosis in China

BACKGROUND

Echinococcosis is a parasitic zoonotic disease that threatens human health and economic development. In China, 370 counties are endemic for echinococcosis. Qinghai-Tibet Plateau has the most patients and people at risk. Therefore, analyzing the societal factors related to susceptibility to the disease is critical for efficient prevention and control of echinococcosis.

METHODS

The demographic characteristics and lifestyle of echinococcosis cases were clustered using K-means cluster analysis to determine the main factors of risk of echinococcosis.

RESULTS

Middle-aged and young people as well as those with a low education level and herdsmen are at risk of contracting echinococcosis. Nomadism, domestic and feral dogs in the surrounding environment, and drinking heavily polluted natural surface water are the main behavioral risk factors. The cystic echinococcosis (CE) and alveolar echinococcosis (AE) cluster analysis focused on female, middle-aged, and young people, winter settlement and summer nomadism, and domestic and feral dogs in the surrounding environment. There were significant differences in lifestyle between Qinghai-Tibet Plateau cases and non-Qinghai-Tibet-Plateau cases.

CONCLUSION

According to the distribution of cases and CE and AE, this study identified the factors of risk of echinococcosis in the Qinghai-Tibet Plateau and non-Qinghai-Tibet Plateau. Adapted control techniques appropriate for the various epidemic areas should be established to serve as a reference for echinococcosis prevention.

Echinococcus multilocularis protoscoleces enhance glycolysis to promote M2 Macrophages through PI3K/Akt/mTOR Signaling Pathway

Alveolar Echinococcosis (AE) is a zoonotic parasitic disease caused by Echinococcus multilocularis, but its pathogenesis remains unclear. The primary objective of this study is to explore whether Echinococcus multilocularis protoscoleces (PSCs) regulate macrophage polarization and glucose metabolism by PI3K/Akt/mTOR signaling pathway. We found that large numbers of CD68⁺ macrophages gathered in close liver issue from the lesion in AE patients. PSCs preferentially differentiated into M2 macrophages and the expressions of HK1, PFKL, PKM2, PI3K, Akt, p-Akt, mTOR and p-mTOR increased. The above results show that Echinococcus multilocularis protoscoleces enhance glycolysis to promote M2 macrophages through PI3K/Akt/mTOR signaling pathway.

Geographic distribution and prevalence of human echinococcosis at the township level in the Tibet Autonomous Region

Background

Echinococcosis, a zoonotic parasitic disease, is caused by larval stages of cestodes in the Echinococcus genus. Echinococcosis is highly prevalent in ten provinces/autonomous regions of western and northern China. In 2016, an epidemiological survey of Tibet Autonomous Region (TAR) revealed that the prevalence of human echinococcosis was 1.66%, which was much higher than the average prevalence in China (0.24%). Therefore, to improve on the current prevention and control measures, it is important to understand the prevalence and spatial distribution characteristics of human echinococcosis at the township level in TAR.

Methods

Data for echinococcosis cases in 2018 were obtained from the annual report system of echinococcosis of Tibet Center for Disease Control and Prevention. Diagnosis had been performed via B-ultrasonography. The epidemic status of echinococcosis in all townships in TAR was classified according to the relevant standards of population prevalence indices as defined in the national technical plan for echinococcosis control. Spatial scan statistics were performed to establish the geographical townships that were most at risk of echinococcosis.

Results

In 2018, a total of 16,009 echinococcosis cases, whose prevalence was 0.53%, were recorded in 74 endemic counties in TAR. Based on the order of the epidemic degree, all the 692 townships were classified from high to low degrees. Among them, 127 townships had prevalence rates ≥ 1%. The high prevalence of human echinococcosis in TAR, which is associated with a wide geographic distribution, is a medical concern. Approximately 94.65% of the villages and towns reported echinococcosis cases. According to spatial distribution analysis, the prevalence of human echinococcosis was found to be clustered, with the specific clustering areas being identified. The cystic echinococcosis primary cluster covered 88 townships, while that of alveolar echinococcosis’s covered 38 townships.

Conclusions

This study shows spatial distributions of echinococcosis with different epidemic degrees in 692 townships of TAR and high-risk cluster areas at the township level. Our findings indicate that strengthening the echinococcosis prevention and control strategies in TAR should directed at townships with a high prevalence and high-risk clustering areas.

Graphical Abstract

Advances in research on echinococcoses epidemiology in China

Echinococcoses are serious zoonotic diseases in China's vast, western and north-western pastoral areas that has one of the highest prevalence in the world. The two most common forms, cystic echinococcosis (CE) and alveolar echinococcosis (AE), are co-epidemic in some areas causing a grave threat to people's health and economic development. Echinococcus spp. are transmitted through domestic, sylvatic and mixed cycles involving many kinds of host. Successful transmission requires a favourable environment for the growth of the parasites and survival of their eggs, while the unique customs and religious beliefs in the endemic areas pose a challenge to the prevention and control of these parasites. Based on previous epidemiological studies, this paper reviews the particular factors affecting the transmission of Echinococcus parasites in China, with a focus on biological (parasite genotype and the species, age, sex and density of hosts), environmental (landscape and climate) and social (age, gender, ethnicity, education, occupation, life style, cultural customs, living conditions and hygiene practices of humans in the endemic areas). These three factors interact with each other and jointly determine the parasites' transmission intensity, the study of which supports the formulation of the strategies and measures that are significant for control of these infections.