Improving the Cost-efficiency of Preventive Chemotherapy: Impact of New Diagnostics on Stopping Decisions for Control of Schistosomiasis.

BACKGROUND: Control of schistosomiasis (SCH) relies on the regular distribution of preventive chemotherapy (PC) over many years. For the sake of sustainable SCH control, a decision must be made at some stage to scale down or stop PC. These "stopping decisions" are based on population surveys that assess whether infection levels are sufficiently low. However, the limited sensitivity of the currently used diagnostic (Kato-Katz [KK]) to detect low-intensity infections is a concern. Therefore, the use of new, more sensitive, molecular diagnostics has been proposed. METHODS: Through statistical analysis of Schistosoma mansoni egg counts collected from Burundi and a simulation study using an established transmission model for schistosomiasis, we investigated the extent to which more sensitive diagnostics can improve decision making regarding stopping or continuing PC for the control of S. mansoni. RESULTS: We found that KK-based strategies perform reasonably well for determining when to stop PC at a local scale. Use of more sensitive diagnostics leads to a marginally improved health impact (person-years lived with heavy infection) and comes at a cost of continuing PC for longer (up to around 3 years), unless the decision threshold for stopping PC is adapted upward. However, if this threshold is set too high, PC may be stopped prematurely, resulting in a rebound of infection levels and disease burden (+45% person-years of heavy infection). CONCLUSIONS: We conclude that the potential value of more sensitive diagnostics lies more in the reduction of survey-related costs than in the direct health impact of improved parasite control.

Twenty-year economic impacts of deworming.

Estimating the impact of child health investments on adult living standards entails multiple methodological challenges, including the lack of experimental variation in health status, an inability to track individuals over time, and accurately measuring living standards and productivity in low-income settings. This study exploits a randomized school health intervention that provided deworming treatment to Kenyan children, and uses longitudinal data to estimate impacts on economic outcomes up to 20 y later. The effective respondent tracking rate was 84%. Individuals who received two to three additional years of childhood deworming experienced a 14% gain in consumption expenditures and 13% increase in hourly earnings. There are also shifts in sectors of residence and employment: treatment group individuals are 9% more likely to live in urban areas, and experience a 9% increase in nonagricultural work hours. Most effects are concentrated among males and older individuals. The observed consumption and earnings benefits, together with deworming's low cost when distributed at scale, imply that a conservative estimate of its annualized social internal rate of return is 37%, a high return by any standard.

Economic losses caused by the use of low-efficacy anthelmintic drugs in growing heifers.

The aim of this study was to compare the economic revenue related to the use of low- or high-efficacy anthelmintic drugs within suppressive or strategic schemes of treatment in growing heifers. Heifers raised in a semi-intensive grazing system in southern Brazil were used. Levamisole and ivermectin were selected as the high- and the low-efficacy drugs, respectively, based on a previous efficacy test. Subsequently, these drugs were used within strategic (Strat; four times per year) or suppressive (Supp; once a month) treatment regimens in the heifers, and their liveweight and eggs per gram of feces counts were monthly evaluated during a 13-month period. The total costs of the treatments and their cost-benefit ratio in regard to liveweight gain were calculated. Final mean liveweight gains (kg) observed were 126.7 (Strat-Low), 133.6 (Supp-Low), 141.3 (Strat-High), 142.9 (Supp-High), and 125.8 (Control). Treatments with a high-efficacy drug resulted in monetary gains of US$ 19.56 (Strat-High) and US$ 14.98 (Supp-High), but Supp-Low and Strat-Low treatments caused economic losses. Total cost of the efficacy test (US$ 374.79) could be paid by the additional liveweight gain of 20 heifers from the Strat-High group. These results showed that it would be preferable not to treat the heifers against GIN if compared with treating them with a low-efficacy drug. In addition, we showed that the use of four treatments per year with a high-efficacy drug-selected by efficacy test-resulted in a profitable management to control GIN in growing heifers raised in a semi-intensive gazing system in southern Brazil.

Production responses and cost-benefit of long-acting pre-lambing anthelmintic treatment of yearling ewes in two commercial flocks in New Zealand.

AIMS: To investigate the production responses and cost-benefit of administering a controlled-release anthelmintic capsule (CRC) to pregnant yearling ewes prior to lambing. METHODS: Yearling ewes from two commercial sheep flocks (A, n=489; B, n=248) in the North Island of New Zealand were enrolled in the study. Prior to lambing, CRC containing albendazole and abamectin were administered to half the ewes while the other half remained untreated. Ewe liveweights and body condition scores were measured prior to lambing, at weaning and, for Flock B, prior to subsequent mating. Lambs were matched to dams shortly after birth and the weight and number of lamb weaned per ewe were determined. A cost-benefit analysis was undertaken for Flock B considering the increased weight of lamb weaned per ewe, and the weight of ewes at the next mating and the benefit in terms of lambs born. RESULTS: The mean weight at weaning of treated ewes was greater for treated than untreated ewes by 2.76 (95% CI 0.64-4.88) kg in Flock A (p<0.001) and 2.35 (95% CI -0.41-5.12) kg in Flock B (p=0.003); the weight of lamb weaned per ewe was greater for treated than untreated ewes by 1.43 (95% CI -0.71 to -3.49) kg in Flock A (p=0.041) and 3.97 (95% CI 1.59-6.37) kg in Flock B (p<0.001), and ewe liveweight prior to subsequent mating was greater for treated than untreated ewes in Flock B by 4.60 (95% CI 3.6-5.6) kg (p<0.001). There was no difference in the percentage of lambs reared to weaning between treated and untreated ewes in either flock (p>0.8). The overall cost-benefit of treatment for Flock B was NZ$9.44 per treated ewe. CONCLUSIONS AND CLINICAL RELEVANCE: Pre-lambing CRC administration to yearling ewes resulted in increased ewe weaning weights and weight of lamb weaned in both the flocks studied. There was an economic benefit in the one flock where this was assessed.

Knowledge, attitudes, and practices regarding cystic echinococcosis and sheep herding in Peru: a mixed-methods approach.

BACKGROUND: The parasitic disease, cystic echinococcosis (CE), is prevalent in low-income, livestock-raising communities and 2000 new people will be diagnosed this year in South America alone. The disease usually passes from livestock to dogs to humans, making it a zoonotic disease and part of the One Health Initiative. Control of CE has been infamously difficult; no endemic areas of South America have succeeded in maintaining sustainable eradication of the parasite. For the current study, we aimed to gain a better understanding of the knowledge, attitudes, and practices of rural sheep farmers and other community leaders regarding their sheep herding practices and perspectives about a control program for CE. We also hope to identify potential barriers and opportunities that could occur in a control program. The authors conducted Knowledge, Attitude and Practices (KAP) surveys and semi-structured interviews in rural communities in the highlands of Peru. The KAP surveys were administered to 51 local shepherds, and the semi-structured interviews were administered to 40 individuals, including shepherds, community leaders, and health care providers. RESULTS: We found that the shepherds already deworm their sheep at a median of 2 times per year (N = 49, range 2-4) and have a mean willingness-to-pay of U.S. $ 0.60 for dog dewormer medication (N = 20, range = 0.00- $2.00 USD). We were not able to learn the deworming agent or agents that were being used, for neither sheep nor dogs. Additionally, 90% of shepherds slaughter their own sheep (N = 49). We also learned that the main barriers to an effective control program include: lack of education about the cause and control options for CE, accessibility to the distant communities and sparse grazing pastures, and a lack of economic incentive. CONCLUSIONS: Findings suggest it may be feasible to develop an effective CE control program which can be used to create an improved protocol to control CE in the region.

Schistosomiasis in school-age children in Burkina Faso after a decade of preventive chemotherapy.

OBJECTIVE: To assess the impact of a decade of biennial mass administration of praziquantel on schistosomiasis in school-age children in Burkina Faso. METHODS: In 2013, in a national assessment based on 22 sentinel sites, 3514 school children aged 7-11 years were checked for Schistosoma haematobium and Schistosoma mansoni infection by the examination of urine and stool samples, respectively. We analysed the observed prevalence and intensity of infections and compared these with the relevant results of earlier surveys in Burkina Faso. FINDINGS: S. haematobium was detected in 287/3514 school children (adjusted prevalence: 8.76%, range across sentinel sites: 0.0-56.3%; median: 2.5%). The prevalence of S. haematobium infection was higher in the children from the Centre-Est, Est and Sahel regions than in those from Burkina Faso's other eight regions with sentinel sites (P < 0.001). The adjusted arithmetic mean intensity of S. haematobium infection, among all children, was 6.0 eggs per 10 ml urine. Less than 1% of the children in six regions had heavy S. haematobium infections - i.e. at least 50 eggs per 10 ml urine - but such infections were detected in 8.75% (28/320) and 11.56% (37/320) of the children from the Centre-Est and Sahel regions, respectively. Schistosoma mansoni was only detected in two regions and 43 children - i.e. 1 (0.31%) of the 320 from Centre-Sud and 42 (8.75%) of the 480 from Hauts Bassins. CONCLUSION: By mass use of preventive chemotherapy, Burkina Faso may have eliminated schistosomiasis as a public health problem in eight regions and controlled schistosome-related morbidity in another three regions.

Reaching the london declaration on neglected tropical diseases goals for onchocerciasis: an economic evaluation of increasing the frequency of ivermectin treatment in Africa.

BACKGROUND: Recently, there has been a shift in onchocerciasis control policy, changing from prevention of morbidity toward elimination of infection. Switching from annual to biannual ivermectin distribution may accelerate progress toward the elimination goals. However, the settings where this strategy would be cost effective in Africa have not been described. METHODS: An onchocerciasis transmission framework (EpiOncho) was coupled to a disease model in order to explore the impact on disability-adjusted life years averted, program cost, and program duration of biannual ivermectin treatment in different epidemiological and programmatic scenarios in African savannah. RESULTS: While biannual treatment yields only small additional health gains, its benefit is pronounced in the context of the elimination goals, shortening the time frames for and increasing the feasibility of reaching the proposed operational thresholds for stopping treatment. In settings with high precontrol endemicity (and/or poor coverage and compliance), it may not be possible to reach such thresholds even within 50 years of annual ivermectin, requiring adoption of biannual treatment. Our projections highlight the crucial role played by coverage and compliance in achieving the elimination goals. CONCLUSIONS: Biannual ivermectin treatment improves the chances of reaching the 2020/2025 elimination goals, potentially generating programmatic cost savings in settings with high precontrol endemicity. However, its benefit and cost are highly sensitive to levels of systematic noncompliance and, in many settings, it will lead to an increase in costs. Furthermore, it may not always be feasible to implement biannual treatment, particularly in hard-to-reach populations. This highlights the continued need for a macrofilaricide.

An analysis of the costs of Uganda's Child Days Plus: do low costs reveal an efficient program or an underfinanced one?

BACKGROUND: Twice annually, Uganda implements Child Days Plus (CDP), a month-long outreach activity that distributes vitamin A capsules to preschool children and deworms children 6 months to 14 years old. Introduced initially as a temporary, interim strategy, CDP is now a decade old. OBJECTIVE: To assess how well CDP is implemented using an activity-based cost analysis. METHODS: In the absence of a cost-accounting system for CDP, we defined the six major CDP activities as cost centers and identified five important subactivities required to implement a round of CDP. Based on a purposive sample, we conducted a structured interview survey of 59 Ministry of Health facilities, 9 district offices, and national-level CDP staff. RESULTS: Only one-third of the facilities implemented all 11 CDP core activities. The survey revealed that Ministry of Health staff and volunteers are frequently paid substantially less in allowances than they are entitled to for their CDP outreach activities. Viewing these two practices--nonimplementation and less-than-full-reimbursement--as indicators of CDP's underfinancing, we estimate the program is underfinanced by the equivalent of 37% of its 'full implementation" costs. Two-thirds of underfinancing is manifested in nonimplementation and one-third as less-than full-reimbursement. CDP exploits economies of scale and scope and has an average cost per child served of US$0.22. We estimate that it annually saves 367,000 disability-adjusted life-years (DALYs) at an average cost of US$12.5, making it--despite its underfinancing--highly cost-effective. CONCLUSIONS AND RECOMMENDATIONS: Increased CDP funding would enable its vitamin A coverage rate of 58% and its deworming coverage rate of 62% to be increased, thereby increasing its effectiveness and efficiency. CDP should be "relaunched," as part of an effort to improve the structure of the program, set expectations about it, and earmark a minimum of resources for CDP. The Ministry of Health should demonstrate its new, greater commitment to CDP by introducing a program-specific budget line item, increasing CDP's budget allocation, and developing and implementing a training program that identifies the minimum uniform activities required to implement CDP.

Farmers' perception of impacts of bovine trypanosomosis and tsetse fly in selected districts in Baro-Akobo and Gojeb river basins, Southwestern Ethiopia.

BACKGROUND: Trypanosomosis, via causing anaemia, emaciation, production loss and death, is arguably the most important constraint to livestock development in Sub-Saharan countries, including Ethiopia and its impact in Baro-Akobo and Gojeb river basins (endemic areas for tsetse flies) is unknown. This study was carried out from November 2011 to April 2012 to assess farmers' perception on the presence, impact, management and the need of intervention programs of bovine trypanosomosis and tsetse fly in selected districts located in Baro-Akobo and Gojeb river basins, Southwestern Ethiopia. A standardized questionnaire survey was employed to collect the relevant information from the farmers. RESULTS: The result of this study showed that 94.1% of the respondents considered bovine trypanosomosis as an economically important cattle disease which accounted for 64.6% of the total annual deaths in the year 2011/2012. Estimated mean annual financial loss via mortality due to trypanosomosis was reported to be 3501 Ethiopian Birr (US$200)/household. The reported trypanosomosis suggestive signs were consistent with published reports and farmers strongly associated the occurrence of the disease with biting flies (particularly, tsetse fly). Respondents also explained that the seasonality of the disease and its vectors, i.e. May and June are peak risk months of the year. Chemotherapy was reported the major method to combating the problem, mean frequency of treatment being 5.7 times per animal per year. Because of the economic burden of the disease, farmers expressed their strong interest and support for the establishment of intervention program in their area. CONCLUSION: The study revealed that livestock keepers are familiar with bovine trypanosomosis and its vectors as well as its impacts. Thus, trypanosomosis and tsetse control strategies should be integrated with the local communities' participation to minimize the impacts of the disease and its vectors in the area.

Research priorities for helminth infections.

Over a billion people in sub-Saharan Africa, Asia and the Americas are infected with one or more helminth species, causing morbidity that helps maintain the vicious cycle of poverty, decreased productivity, and inadequate socioeconomic development. This report presents an evaluation of current research and challenges in controlling the helminthiases of public health importance, including onchocerciasis, lymphatic filariasis, soil-transmitted helminthiases, schistosomiasis, food-borne trematodiases and taeniasis/cysticercosis. The evaluation covers five major themes--intervention, epidemiology and surveillance, environmental and social ecology, data and modelling, and fundamental biology. Despite the recent demonstrated successes and expansion of tools for the helminthiases outlined here, and the development of some research capacity, the evaluation found major deficiencies in our current control tools, in diagnostics, and in our fundamental knowledge of helminth biology and transmission dynamics, as well as in capacity and policy for health research. Thus the current research issues are summarized here, and opportunities for improving disease control and reducing poverty are identified. Recommendations are presented to inform public health policy, guide implementation programmes, and focus the research community on the needs of disease control and the opportunities for bettering human welfare. This is one of ten disease and thematic reference group reports that have come out of the TDR Think Tank, all of which have contributed to the development of the Global Report for research on Infectious Diseases of Poverty, available at:www.who.int/tdr/stewardship/global_report/en/index.html.

Economic implications of three strategies for the control of taeniasis.

OBJECTIVE: To evaluate the cost-effectiveness of three strategies for the control of taeniasis in a community, in terms of cost per case treated. METHODS: A study was conducted in South India to determine the prevalence of taeniasis by screening stool samples from 653 randomly chosen subjects, for coproantigens. The costs incurred in the project were used to estimate the cost per case screened and treated. A one-way sensitivity analysis was carried out for varying rates of taeniasis, different screening strategies and mass therapy. Further sensitivity analysis was carried out with different manpower and test costs. RESULTS: The rate of taeniasis as detected by ELISA for coproantigen was 3 per 1000 (2 of 653 samples). Our study showed that mass therapy without screening for taeniasis would be the most economical strategy in terms of cost per case treated if field workers are employed exclusively for either mass therapy or screening. For each strategy, costs per case treated are higher at low prevalence of taeniasis, with a sharp rise below 15%. CONCLUSIONS: In places that are endemic for taeniasis and neurocysticercosis, mass therapy or screening for taeniasis should be considered. Screening by stool microscopy is not cost-effective in terms of cost per case of taeniasis treated owing to its low sensitivity. Although the cost per case of taeniasis treated is high at low prevalence of taeniasis for all options, incorporating mass therapy into existing mass drug distribution programmes might prove to be the most cost-effective control strategy.

The cost-effectiveness of schistosomiasis screening and treatment among recently resettled refugees to Canada: an economic evaluation.

BACKGROUND: Many refugees and asylum seekers from countries where schistosomiasis is endemic are infected with the Schistosoma parasite when they arrive in Canada. We assessed, from a systemic perspective, which of the following management strategies by health care providers is cost-effective: testing for schistosomiasis and treating if the individual is infected, treating presumptively or waiting for symptoms to emerge. METHODS: We constructed a decision-tree model to examine the cost-effectiveness of 3 management strategies: watchful waiting, screening and treatment, and presumptive treatment. We obtained data for the model from the literature and other sources, to predict deaths and chronic complications caused by schistosomiasis, as well as costs and net monetary benefit. RESULTS: Presumptive treatment was cost-saving if the prevalence of schistosomiasis in the target population was greater than 2.1%. In our baseline analysis, presumptive treatment was associated with an increase of 0.156 quality-adjusted life years and a cost saving of $405 per person, compared with watchful waiting. It was also more effective and less costly than screening and treatment. INTERPRETATION: Among recently resettled refugees and asylum claimants in Canada, from countries where schistosomiasis is endemic, presumptive treatment was predicted to be less costly and more effective than watchful waiting or screening and treatment. Our results support a revision of the current Canadian recommendations.

The Effect of Drug Pricing on Outpatient Payments and Treatment for Three Soil-Transmitted Helminth Infections in the United States, 2010-2017.

The price of certain antiparasitic drugs (e.g., albendazole and mebendazole) has dramatically increased since 2010. The effect of these rising prices on treatment costs and use of standard of care (SOC) drugs is unknown. To measure the impact of drug prices on overall outpatient cost and quality of care, we identified outpatient visits associated with ascariasis, hookworm, and trichuriasis infections from the 2010 to 2017 MarketScan Commercial Claims and Encounters and Multi-state Medicaid databases using Truven Health MarketScan Treatment Pathways. Evaluation was limited to members with continuous enrollment in non-capitated plans 30 days prior, and 90 days following, the first diagnosis. The utilization of SOC prescriptions was considered a marker for quality of care. The impact of drug price on the outpatient expenses was measured by comparing the changes in drug and nondrug outpatient payments per patient through Welch's two sample t-tests. The total outpatient payments per patient (drug and nondrug), for the three parasitic infections, increased between 2010 and 2017. The increase was driven primarily by prescription drug payments, which increased 20.6-137.0 times, as compared with nondrug outpatient payments, which increased 0.3-2.2 times. As prices of mebendazole and albendazole increased, a shift to alternative SOC and non-SOC drug utilization was observed. Using parasitic infection treatment as a model, increases in prescription drug prices can act as the primary driver of increasing outpatient care costs. Simultaneously, there was a shift to alternative SOC, but also to non-SOC drug treatment, suggesting a decrease in quality of care.

Optimal risk management of human alveolar echinococcosis with vermifuge.

In this study, we develop a bioeconomic model of human alveolar echinococcosis (HAE) and formulate the optimal strategies for managing the infection risks in humans by applying optimal control theory. The model has the following novel features: (i) the complex transmission cycle of HAE has been tractably incorporated into the framework of optimal control problems and (ii) the volume of vermifuge spreading to manage the risk is considered a control variable. With this model, we first obtain the stability conditions for the transmission dynamics under the condition of constant control. Second, we explicitly introduce a control variable of vermifuge spreading into the analysis by considering the associated control costs. In this optimal control problem, we have successfully derived a set of conditions for a bang-bang control and singular control, which are mainly characterized by the prevalence of infection in voles and foxes and the remaining time of control. The analytical results are demonstrated by numerical analysis and we discuss the effects of the parameter values on the optimal strategy and the transmission cycle. We find that when the prevalence of infection in foxes is low and the prevalence of infection in voles is sufficiently high, the optimal strategy is to expend no effort in vermifuge spreading.

Economic analysis of risk of gastrointestinal parasitic infection in cattle in North Eastern States of India.

Gastrointestinal parasitic infection is highly prevalent in the North Eastern States (NEH) of India and accounted for significant economic losses across various livestock species. Productivity of cattle in terms of milk yield was estimated to be considerably higher (3,715, 3,590, and 3,154 L) due to strategic anthelmintic treatment as compare to control group (2,928 L). Based on the probability of occurrence of parasitic infection as well as increase in value of milk production, the possible economic gain at state level has been estimated to be Rs. 46 million, Rs. 35 million, and Rs. 14 million, depending upon the different strategic treatment. The government may take up the program to educate the cattle farmers on strategic management against parasitic infection and simultaneously making available various anthelmintic medicines. This public responsibility of the government to minimize the risk and economic loss due to gastrointestinal parasite infection may reduce the private cost and thereby would increase the social benefits in North Eastern states of India.

Impact of Anthelmintic Price Increases on Practice Patterns of Healthcare Providers Caring for Immigrant and Refugee Populations in the United States.

In the United States, prices of long-established, generic anthelmintic medications have markedly risen. In the past decade, albendazole and mebendazole have increased in price by > 8,000%, whereas praziquantel has increased by > 500%. To determine the effect of these price increases on the practice patterns of healthcare providers, we conducted a cross-sectional electronic survey of clinics in the United States that primarily care for immigrant and refugee patient populations. Among 32 clinics, 53.1% reported that price increases impacted how providers diagnosed and treated helminth infections. A third (34.4%) of clinics reported that price increases have left them unable to treat known helminth infections. Other ways in which price increases impacted practice patterns included prescribing anthelmintics other than albendazole, mebendazole, or praziquantel when possible (34.4%); avoiding screening asymptomatic patients for helminth infections (15.6%); advising patients to acquire medications from another country (15.6%) or the patient's home country (9.4%); reducing anthelmintic dosing regimens to fewer pills (9.4%); and advising patients to purchase medications on the Internet (6.3%). These findings suggest price increases have negatively impacted the diagnosis and treatment of helminth infections in this population, and have resulted in the inability to treat known helminth infections. These findings have significant implications for the morbidity and mortality of infected individuals, as well as for public health in the United States.

Cost of interventions to control schistosomiasis: A systematic review of the literature.

BACKGROUND: Schistosomiasis, a disease caused by blood flukes of the genus Schistosoma, belongs to the neglected tropical diseases. Left untreated, schistosomiasis can lead to severe health problems and even death. An estimated 800 million people are at risk of schistosomiasis and 250 million people are infected. The global strategy to control and eliminate schistosomiasis emphasizes large-scale preventive chemotherapy with praziquantel targeting school-age children. Other tools are available, such as information, education, and communication (IEC), improved access to water, sanitation, and hygiene (WASH), and snail control. Despite available evidence of the effectiveness of these control measures, analyses estimating the most cost-effective control or elimination strategies are scarce, inaccurate, and lack standardization. We systematically reviewed the literature on costs related to public health interventions against schistosomiasis to strengthen the current evidence-base. METHODOLOGY: In adherence to the PRISMA guidelines, we systematically searched three readily available electronic databases (i.e., PubMed, WHOLIS, and ISI Web of Science) from inception to April 2019 with no language restrictions. Relevant documents were screened, duplicates eliminated, specific rules on studies to consider were defined, and the eligible studies fully reviewed. Costs of schistosomiasis interventions were classified in three groups: (i) preventive chemotherapy; (ii) preventive chemotherapy plus an individual diagnostic test to identify at-risk population; and (iii) test-and-treat interventions. PRINCIPAL FINDINGS: Fifteen articles met our inclusion criteria. In general, it was hard to compare the reported costs from the different studies due to different approaches used to estimate and classify the costs of the intervention assessed. Costs varied considerably from one study to another, ranging from US$ 0.06 to US$ 4.46 per person treated. The difference between financial and opportunity costs only played a minimal role in the explanation of the costs' variation, even if delivery costs were two times higher in the analyses including economic costs. Most of the studies identified in our systematic review focused on sub-Saharan African countries. CONCLUSIONS/SIGNIFICANCE: The degree of transparency of most of the costing studies of schistosomiasis interventions found in the current review was limited. Hence, there is a pressing need for strategies to improve the quality of cost analyses, and higher reporting standards and transparency that should be fostered by peer-review journal policies. Cost information on these interventions is crucial to inform resource allocation decisions and those regarding the affordability of scaling-up interventions.

Mathematical Model for Optimal Control of Soil-Transmitted Helminth Infection.

In this paper, we study the dynamics of soil-transmitted helminth infection. We formulate and analyse a deterministic compartmental model using nonlinear differential equations. The basic reproduction number is obtained and both disease-free and endemic equilibrium points are shown to be asymptotically stable under given threshold conditions. The model may exhibit backward bifurcation for some parameter values, and the sensitivity indices of the basic reproduction number with respect to the parameters are determined. We extend the model to include control measures for eradication of the infection from the community. Pontryagian's maximum principle is used to formulate the optimal control problem using three control strategies, namely, health education through provision of educational materials, educational messages to improve the awareness of the susceptible population, and treatment by mass drug administration that target the entire population(preschool- and school-aged children) and sanitation through provision of clean water and personal hygiene. Numerical simulations were done using MATLAB and graphical results are displayed. The cost effectiveness of the control measures were done using incremental cost-effective ratio, and results reveal that the combination of health education and sanitation is the best strategy to combat the helminth infection. Therefore, in order to completely eradicate soil-transmitted helminths, we advise investment efforts on health education and sanitation controls.

[Effect of integrated schistosomiasis control measures in Hunan Province from 2004 to 2019].

OBJECTIVE: To examine the effect of the integrated schistosomiasis control measures in Hunan Province from 2004 to 2019, so as to provide insights into the development of the schistosomiasis elimination strategy. METHODS: The integrated schistosomiasis control measures implemented by the health, agriculture, water resources, forestry, land and resources sectors were retrospectively collected in Hunan Province from 2004 to 2019, and the completion of each measure, cost of control measures, Schistosoma japonicum infections in humans and bovines, and snail status were analyzed each year. An index system for assessing the integrated schistosomiasis control effect was constructed using the Delphi method to calculate the integrated schistosomiasis control effect index. In addition, a cost-effect analysis was performed in terms of the decline in the prevalence of S. japonicum infections in humans and bovines, areas with snails in inner embankments, and areas with infected snails. RESULTS: A total of 7 110 926 500 Yuan were invested into the integrated schistosomiasis control program of Hunan Province from 2004 to 2019. During the 16-year period, a total of 277 437.12 hm2 snail habitats received molluscicidal treatments, 6 927 230 person-times given expanded chemotherapy, 2 116 247 bovine-times given expanded chemotherapy, 954 850 harmless toilets built, 290 359 bovines fenced, 136 666 bovines eliminated, 141 905 machines used to replace bovines, 39 048.63 hm2 water lands improved as dry lands, 724.12 km irrigation regions improved, 3 994 300 populations covered with safe water, 191 102.89 hm2 forests planted and 38 535.27 hm2 lands leveled. The prevalence of S. japonicum infections was 4.29% in humans and 4.48% in bovines in Hunan Province in 2004, with 2 449.37 hm2 snail habitats in inner embankments and 3 423.74 hm2 infected snail areas. In 2019, the prevalence of S. japonicum infections reduced to 0 in both humans and bovines, and areas of snail habitats reduced to 540.92 hm2 (77.92% reductions), while the areas with infected snails reduced to 0. The overall integrated schistosomiasis control effect index appeared a tendency towards a rise over years since 2004, and the integrated schistosomiasis control effect index was 97.35 in 2019; the annual mean costs for a 1% reduction in the prevalence of S. japonicum infections in 100 populations and 100 bovines were 70.11 Yuan and 4 204.78 Yuan, and the annual mean costs for a 1% reduction in the snail areas in inner embankments and infected snail areas were 2 010.20 Yuan and 1 298.09 Yuan, respectively. CONCLUSIONS: The integrated control measures achieve remarkable effectiveness for schistosomiasis control in Hunan Province, with a remarkable decline in the prevalence of S. japonicum infections in humans and bovines and great shrinking of snail areas in inner embankments and infected snail areas. Adequate fund investment is required to improve the integrated schistosomiasis control measures and consolidate the control achievements.

Programmatic implications of the TUMIKIA trial on community-wide treatment for soil-transmitted helminths: further health economic analyses needed before a change in policy.

School-based deworming programmes are currently the main approach used to control the soil-transmitted helminths (STHs). A key unanswered policy question is whether mass drug administration (MDA) should be targeted to the whole community instead, and several trials in this area have been conducted or are currently on-going. A recent well-conducted trial demonstrated that successful community-wide treatment is a feasible strategy for STH control and can be more effective than school-based treatment in reducing prevalence and intensity of hookworm infection. However, we would argue that it is vital that these findings are not taken out of context or over generalised, as the additional health benefits gained from switching to community-wide treatment will vary depending on the STH species and baseline endemicity. Moreover, community-wide treatment will typically be more expensive than school-based treatment. The epidemiological evidence for an additional benefit from a switch to community-wide treatment has yet to be proven to represent "good value for money" across different settings. Further work is needed before changes in policy are made regarding the use of community-wide treatment for STH control, including comprehensive assessments of its additional public health benefits and costs across a range of scenarios, accounting for the presence of alternative treatment delivery platforms.