CE Incidence in Humans

Data on country-specific annual reported human CE cases were obtained from the Office International des Epizooties (OIE), World Health Organization Handistatus II database for the years 1996–2003 (15). This information was then merged with published case reports from numerous countries and logged into an Excel spreadsheet (Microsoft Corp., Redmond, WA, USA). Type and quality of incidence data varied by country or region; however, most data consisted of annual numbers of detected cases per susceptible population or was converted into this form for analysis purposes. If both an OIE-reported and a literature-based value were available, the larger of the 2 was used. However, if the higher value appeared to be from a survey that evaluated a highly disease-endemic region and was, therefore, not applicable to the entire country, a corresponding adjustment was made. In addition, we assumed that ≈10% of annual cases are not officially diagnosed, and those patients do not receive medical attention because of their socioeconomic status or the subclinical nature of the illness. Based on past studies, this estimate is most likely conservative (12,14). For example, in China, mass ultrasound screening in remote areas has shown high prevalence rates of CE (9). A number of these patients have advanced clinical disease but would not normally have access to treatment because of poverty and distance from medical facilities. Human cases of CE are also systematically underreported by the healthcare establishment, with up to 75% of clinic or hospital-diagnosed cases never recorded in local or national databases or published reports (16,17). Therefore, adjustments were made to account for the substantial underreporting of known treated cases.

CE Prevalence in Livestock

Numbers of annual reported CE cases in slaughtered livestock (sheep, goats, cattle, camels, and swine) for the years 1996–2003 were obtained from the OIE-Handistatus II database (15). This information was merged with abattoir studies performed in numerous countries. If data from both sources were available, the larger of the 2 estimates was used. However, if the higher value appeared to be from a region that was highly disease-endemic and was not appropriate for a countrywide estimate, an adjustment was made. Prevalence per species, for each country, was applied to the estimated number of slaughtered animals per year, with 2004 livestock numbers obtained from the FAOSTAT database (18). The assumption was made that approximately one fourth of sheep and goat populations, one sixth of cattle and camel populations, and the entire swine population would be slaughtered annually, based on estimated average species' lifespan (e.g., approximately one fourth of a country's sheep population would be slaughtered annually, with a typical animal life expectancy of 4 years). Such a general estimate was used because of the large amount of variation in animal production practices between and within countries. As with the human incidence data, the true number that were positive for E. granulosus at slaughter is substantially higher than reported. Therefore, a correction factor was used to estimate true prevalence.

Application of DALYs to Human Incidence Data

The DALY formula (shown below) was applied to global human incidence data.

In this equation, D is a disability weight, β is an age-weighting function parameter, C is an age-weighting correction constant, r is a discount rate, a is age at clinical onset, and L is the duration of disability or time lost because of death (7). Disability weight for CE was assigned a multinomial distribution based on numerous retrospective studies evaluating postoperative outcome (Table 1) (19–24). The percentage of patients projected to improve after surgery was assigned a disability weight of 0.200 (Dutch weight for clinically disease-free cancer) for 1 year, the percentage of patients projected to have substantial postsurgical conditions was assigned a disability of 0.239 (GBD weight for preterminal liver cancer) for 5 years, the percentage of patients projected to have recurrent disease was assigned a disability of 0.809 (GBD weight for terminal liver cancer) for 5 years, and the percentage of patients projected to die postoperatively were assigned a disability of 1 (indicating death) for the remainder of their predicted lifespan (7,25). An assumption was also made that ≈10% of cases are not reported and do not receive medical treatment. These cases were assigned a disability weight of 0.200 (Dutch weight for clinically disease-free cancer) for 10 years (25). For the GBD Study, a standardized life table was used for L (7).

Economic Evaluation of Human-associated Losses

Overall cost per human surgical case was based on findings from previous international studies (Table 2) (11,13,14,26,27). Expenses taken into consideration included diagnostic costs, surgical cost, hospitalization, and postoperative costs. The average cost per surgical patient was shown to be significantly correlated (R² = 0.898, p < 0.05), with the country-specific per capita gross national income (per capita GNI) (Atlas Method) (Table 2). Therefore, the linear regression coefficient was used as a predictor of treatment costs for each disease-endemic country. In addition to medical costs and single-year wage losses, past studies have indicated an average 2.2% postoperative death rate for surgical patients (Table 1). Approximately 6.5% of cases also are assumed to relapse and require a prolonged recovery time (Table 1) (11). Therefore, these outcomes were also taken into account. We assumed that, in addition to surgical cases, ≈10% of cases are not officially diagnosed each year, and those patients never receive treatment. Wage losses for this group were thus taken into consideration. Economic losses in humans were also evaluated, taking into account the nearly 4-fold degree of underreporting of patients who received treatment.

Economic Evaluation of Livestock-associated Losses

Production-based losses attributable to infected sheep, goats, cattle, camels, and pigs were estimated. Losses from liver condemnation, defined as the action of preventing the sale of livers deemed unfit for human consumption (sheep, goats, cattle, pigs, camels), reduction in carcass weight (sheep, goats, cattle), decrease in hide value (sheep, cattle), decrease in milk production (sheep, goats, cattle), and decreased fecundity (sheep, goats, cattle) were taken into account. Only liver-associated losses in camels and pigs are presented since few studies have evaluated production losses from echinococcosis in these species (28). Losses from liver condemnation are assumed to occur since hepatic pathology is associated with infection in swine and camels (29). Losses from liver condemnation were presumed proportional to those used for the analysis of the economic impact of CE in Jordan (12). Decrease in hide value (20%) and decrease in fecundity (11%) were presumed proportional to values suggested by numerous Soviet studies conducted from the 1950s through the 1980s (28). Reductions in carcass weight (2.5%) and milk production (2.5%) were also based on previous reports (30).

Analysis

Spreadsheet models were constructed in Excel to estimate global impact of CE in terms of DALYs and monetary losses. Total disease effects, in DALYs lost or monetary costs, was calculated by summing all of the constituent components. Uncertainty in parameter estimates was modeled by using Monte Carlo techniques (6). Briefly, all parameters were assigned a probability distribution based on the quantity and quality of reported data. Macros were written in Excel to sample across these distributions, with 10,000 iterations of each model calculated. Mean and 95% confidence intervals (CIs) for losses were then determined from these iterations.

Reported global human incidence was assigned a normal distribution, with a standard deviation of 5%. Adjustments were then made to account for the nearly 4-fold degree of underreporting of treated cases believed to occur (16,17). In addition, cases that would not be officially acknowledged had to be accounted for, i.e., cases in persons who never receive treatment in a hospital. We therefore assumed that ≈10% (uniform distribution of 8% to 12%) of cases would not be detected. This estimate is conservative compared to other country-specific estimates (12,14).

The DALY formula was applied to worldwide CE cases in a stochastic manner similar to that used to apply DALYs to echinococcosis cases in a region of western China (10). Mean age of clinical onset (a) was allocated a uniform distribution of 30 to 40 years, established on the basis of various studies (Table 3) (4,9,21,31–34). Numerous and varying reports have indicated the sex of CE-positive persons with women tending to be infected at a higher rate than men. Based on these reports, we assigned a uniform distribution of 50% to 60% of infected persons as female (4,35). Number of DALYs lost, using incidence values corrected and uncorrected for underreporting of surgical incidence, was determined.

Human-associated economic losses were applied in a stochastic manner similar to that used for a region of western China (10). Variability in surgical treatment costs, due to CE, was modeled by using a uniform distribution of 50% to 90% of per capita GNI per country and was weighted by each country's contribution to global human CE incidence (36). Lower income, higher unemployment, or both has been associated with a diagnosis of CE (4,10). Consequently, a decrease in wages earned was assumed, at least for the year of initial diagnosis and treatment. Therefore, all patients were assigned a uniform loss of 50% to 90% of country-specific per capita GNI for 1 year (36). Approximately 6.5% of patients were also assigned a 50%–90% wage loss for 4 additional years because of relapse and prolonged recovery time. In addition, 2.2% of patients were assigned a 100% wage loss until the expected retirement age of 65 due to postsurgical death. A standard 3% discounting rate was applied to all income losses (7). In addition to surgical cases, ≈10% of cases (uniform distribution of 8% to 12%) annually were assumed to not be officially diagnosed. A 25% wage loss for 5 years was consequently assigned to this population. This estimate is conservative and does not take into account income losses attributable to undiagnosed cases with fatal outcomes. Projections were made that assumed the absence and presence of underreporting of surgical incidence (16,17). In addition to using real per capita GNI (Atlas Method), calculations were also performed by using purchasing power parity (ppp) adjusted per capita GNI.

As with human-associated economic losses, livestock-associated losses were applied in a stochastic manner (10). Livestock prices were given uniform distributions of US $30–$60 for sheep, US $15–$30 for goats, US $150–$350 for cattle, US $300–$600 for camels, and US $55–$75 for pigs. Uniform distributions were used because of the large regional variations in prices and assigned in accordance with baseline prices for most affected countries. Production losses were assumed to follow a log-normal distribution; most affected animals were lightly infected, and only a small proportion of animals had severe losses. As with human cases, substantial underreporting of livestock infection was recognized, since official reporting is not mandatory in most countries. Therefore, a uniform correction factor of 1.5 to 2 was used to approximate true economic losses. A large uniform distribution was used because of the lack of information concerning true global prevalence of CE in livestock. This lack will, therefore, be represented in the wide confidence limits obtained.

DALYs

Regional findings for predicted global burden of CE in terms of DALYs lost, with 95% CIs, can be found in Table 4. The most conservative estimate of number of global DALYs lost is 285,407 (95% CI, 218,515–366,133), with no consideration for disease underreporting. Estimated number of global DALYs lost, taking into consideration nonreported surgical cases, is 1,009,661 (95% CI, 862,119–1,175,654).

Human-associated Economic Losses

Findings for predicted regional burden of human CE in economic terms, with 95% CI, can be found in Table 5. Global losses, assuming no underreporting, are estimated at US $193,529,740 (95% CI, $171,567,331–$217,773,513). Losses, adjusted for underreporting, are estimated at US $763,980,979 (95% CI, $676,048,731–$857,982,275). When ppp adjusted per capita GNI is used instead of real per capita GNI, estimated annual overall losses, without correction for underreporting, are US $484,878,359 (95% CI, $432,898,134–US $542,048,125). When corrected for underreporting, annual losses are estimated at US $1,918,318,955 (95% CI, $1,700,574,632–$2,142,268,992) (Table 5).

Livestock-associated Economic Losses

Estimated livestock-associated losses, with 95% CI, can be found in Table 6. Minimal annual losses, assuming liver condemnation alone with no correction for underreporting, is estimated at US $141,605,195 (95% CI, $101,011,553–$183,422,465). However, when losses from additional production factors (decreased carcass weight, decreased milk production, decreased hide value, decreased fecundity) are taken into account, losses range from US $1,249,866,660 (95% CI, $942,356,157 –$1,622,045,957), not taking into account underreporting, up to US $2,190,132,464 (95% CI, $1,572,373,055–$2,951,409,989), when underreporting is considered.