Cost-effectiveness Analysis of the Integrated Control Strategy for Schistosomiasis Japonica in Lake Region of China: a Jiangling Case Study

Cost-effectiveness Analysis of the Integrated Control Strategy for Schistosomiasis Japonica in Lake Region of China: a Jiangling Case Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Cost-effectiveness Analysis of the Integrated Control Strategy for Schistosomiasis Japonica in Lake Region of China: a Jiangling Case Study Ling-Ling Wu, He-Hua Hu, Xia Zhang, Xiao-Nong Zhou, Tie-Wu Jia, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-168300/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background: Under the condition of low epidemic level and limited funding, it is urgent to carry out health economic evaluation on the integrated schistosomiasis control strategy currently implemented in lake region in order to rationally allocate and utilize health resources and maximize benefits. The objective of this study is to provide reference for understanding the effectiveness of the integrated control strategy and adjusting prevention and control strategies or measures. Methods: The investment in schistosomiasis control and disability adjusted life years （DALYs）caused by schistosomiasis were calculated. Incremental cost-effectiveness ratio (ICER) was conducted through calculating the incremental cost of every additional case averted, the incremental cost of every additional DALY averted through implementation of the integrated schistosomiasis control at different control stages in Jiangling County. Results: The total expenditure for schistosomiasis control in Jiangling County from 2009 to 2019 was 607 million Chinese yuan (CNY). The average annual costs for schistosomiasis prevention and control in stages of morbidity control (2009-2012), transmission control (2013-2016), and transmission interruption (2017-2019) were 41.98 million CNY，90.19 million CNY and 26.06 million CNY respectively. The overall disease burden caused by schistosomiasis presented a downward trend. Meanwhile, the disease burden of advanced cases showed an upward trend with the DALY increased from 943.72 to1031.59 person-years. Most disease burden occurred in the age group over 45 years old (especially the elderly over 60 years old). Taking the morbidity control stage as an analysis control, incremental cost-effectiveness analysis (ICEA) showed that the cost increased by 8505.5 CNY and decreased by 2217.6 CNY respectively to avert one additional case in transmission control stage and transmission interruption stage respectively in Jiangling County. Correspondingly, to avert one additional DALY, the cost increased by 73937.6 CNY and decreased by 21508.6 CNY respectively. Conclusions: As the epidemic declines, the integrated prevention and control strategy is more cost-effective. Surveillance and management on elder population should be strengthened to avert higher diseases burden. Infectious Diseases schistosomiasis integrated control cost-effectiveness DALY ICER Figures Figure 1 Figure 2 Background The implementation of integrated prevention and control strategy focusing on the source of infection to interrupt the transmission of schistosomiasis had strongly accelerated the process of schistosomiasis control in People’s Republic of China (P.R. China) [ 1 ]. Morbidity control (the infection rate of humans and livestock in epidemic villages < 5%) and transmission control (the infection rate of humans and livestock in epidemic villages < 1%) were reached nationwide in 2008 and 2015 respectively [ 2 , 3 ]. By the end of 2019, 95.3% of the epidemic counties in P.R. China had reached the threshold of transmission interruption or elimination according to the national standards [ 4 ]. The endemicity of schistosomiasis had dropped to the lowest level in history. At present, the key areas for schistosomiasis prevention and control in P.R. China are distributed along the middle and lower reaches of the Yangtze River, as well as the areas of Dongting Lake and Poyang Lake. Under the condition of low epidemic level and limited funding, it is urgent to carry out health economic evaluation on the integrated schistosomiasis control strategy currently implemented in lake region in order to rationally allocate and utilize health resources and maximize benefits.[ 5 ] The health economics evaluation refers to the evaluation and selection of alternatives by analyzing the economic effects (cost, effect or input, output) of health planning.[ 6 ] The methods used to evaluate the economic value of disease interventions mainly include cost-effectiveness analysis (CEA), cost-utility analysis (CUA), cost-benefit analysis (CBA) and cost-minimization analysis (CMA). CBA of schistosomiasis is relatively difficult because of the complexity of identifying and quantifying the health benefits of schistosomiasis prevention and control [ 7 , 8 ]. In P.R. China, there have been several studies on the effectiveness of integrated prevention and control strategies for schistosomiasis, but there are few related to cost-effectiveness analyses [ 9 ]. As periodic assessment and analysis of resource utilization are conducive to the optimization of diseases prevention and control [ 10 , 11 ]. We evaluated the cost-effectiveness of the integrated control strategy for schistosomiasis taking Jiangling County as an example due to its heavy endemicity of schistosomiasis in history and well archived data and documents, thus to provide reference for understanding the effectiveness of the integrated control strategy and adjusting diseases prevention and control strategies or measures. Materials And Methods Setting Jiangling county of Hubei Province, a typical marshland and lake region used to be a heavily endemic area of schistosomiasis, locates in the middle reaches of the Yangtze River and near the north bank of the Jingjiang River. It belongs to the hinterland of the four lakes (Long Lake, Three Lakes, Egret Lake, Hong Lake), having rich water system and complex natural environments suitable for snails breeding. Through the implementation of the integrated control strategy for schistosomiasis control, the county has reached the criteria of morbidity control, transmission control and transmission interruption in 2008, 2013 and 2017, respectively [12-14], keeping a low level of schistosomiasis endemicity until now. Data collection Data reflecting the epidemic status of schistosomiasis and costs for schistosomiasis control in Jiangling County from 2009 to 2019 were collected from the perspective of health investors. Data including the number of schistosomiasis cases (acute cases, chronic cases and advanced cases), the snails’ infested area, the infected snails infested areas etc. were collected during 2009-2019. The general demographic information especially the age of each schistosomiasis cases were collected. For schistosomiasis control investment, data reflecting the costs of case detection and treatment, snail control, health education, risk monitoring, livestock elimination and control, toilets modification and integrated management in Jiangling County from 2009 to 2019 were collected [15-18]. The costs of case detection and treatment were composed of the annual costs of questionnaire survey, blood examination, stool examination, treatment against schistosomiasis, involving the costs of subsidies, diagnostic reagents and materials, drug, medical assistance for advanced cases of schistosomiasis and so on. The costs of snail control included the costs for conducting snails’ survey and mollusciciding, involving the costs of subsidies, materials, drug and so on. Health education expenses included the costs for conducting training courses for school students, village cadres and doctors, the costs for preparing and distributing the leaflets, setting the warning signs etc. As for integrated interventions, data reflecting the investment related to schistosomiasis control activities were collected from the departments of agriculture, forestry, water conservancy, transportation and land resources. Data management and statistical analyses Data collected was entered and descriptive analysis was conducted by Microsoft Excel 2016 software. The Disability Adjusted Life Years (DALY) was used to quantify the burden of disease, which was calculated with the life quality method based on disability weight (DW) got from cases’ life quality assessment.[19] The formula was listed as follows [20]: DALYA=YLD+YLL, YLDprev x =Σ Px *DWx, YLL = N*L Where YLD is the years lived with disability, YLL is the years of life lost, YLDprev x is the years lived with disability based on prevalence (prev is the abbreviation of prevalence, x is the grouping variable), Px is the number of cases in the reference population at a specific time. DWx is the disability weight of health outcomes. The DW of different age groups of advanced schistosomiasis cases was calculated as the following criteria: 30-44 years old (0.378), 45-59 years old (0.399), over 60 years old (0.510) [21]. The DW of different age groups of chronic cases of schistosomiasis was standardized as the follows: 5-14 years old (0.095), 15-44 years old (0.159), 45-59 years old (0.207), over 60 years old (0.246) [22]. N is the number of deaths in different age groups and genders; L is the life loss value of each age group, that is, the life expectancy value corresponding to the death age point in the standard life table. For incremental cost-effectiveness analysis (ICEA), the discount formula of the current year was calculated according to formula : Cn' =Cn/(1+r)n[23], where Cn' is the discounted cost ; Cn is the actual cost of each year; r is the discount rate, often using the current bank’s regular interest rate; n is the year. Incremental cost-effectiveness ratio (ICER) was used as the effect indicator [24-26], that was, the incremental cost for each additional case averted and the incremental cost for each additional DALY averted. Results General information of schistosomiasis epidemic situation in Jiangling County From 2009 to 2019, the endemicity of schistosomiasis in Jiangling County presented a downward trend. The number of positives with antibodies against schistosome dropped from 13, 086 in 2009 to 2, 310 in 2019, while the number of stool positives finding Schistosoma japonicum eggs decreased from 2, 158 in 2009 to 0 in 2019. In addition, the number of advanced schistosomiasis cases dropped from 1, 248 in 2009 to 1, 073 in 2019, while no acute schistosomiasis case was reported since 2008 in the county. The snail infested area had declined from 3030.73 hm2 in 2009 to 2718.04 hm2 in 2019, and no infected snail was detected since 2012. Table 1 Changes of schistosomiasis cases and snails’ status in Jiangling County during 2009 to 2019 Year Disease situation Snail situation No. positives of stool exams No. advanced cases of schistosomiasis Snail area(hm 2 ) Area with infected snails(hm 2 ) 2009 2158 1118 3030.73 136.68 2010 1602 1140 3030.23 133.06 2011 1199 1169 3029.53 51.51 2012 573 1180 2875.86 0.00 2013 395 1187 2875.86 0.00 2014 229 1222 2875.86 0.00 2015 74 1233 2728.65 0.00 2016 0 1205 2728.65 0.00 2017 0 1111 2718.10 0.00 2018 0 1098 2718.04 0.00 2019 0 1073 2718.04 0.00 Total 6230 12736 31329.55 321.25 Costs for schistosomiasis control in Jiangling County The overall expenditure for schistosomiasis control in Jiangling County from 2009 to 2019 was 607 million CNY, of which the costs from the land resources department for schistosomiasis control was the largest (336 million), followed by costs for health activities for schistosomiasis control (109 million). Among the investment from health department for schistosomiasis control, costs of snail control, case treatment, cattle disposal and control accounted for 35.3% (3826.15/10855.32), 22.7% (2466.15/10855.32), and 22.6% (2447.60/10855.32) respectively. For investments from other departments, the costs related to land modification, transportation and water conservancy projects accounted for 67.6% (33648.82/60688.43), 13.9% (6911.38 /60688.43) and 10.1% (5050.17/60688.43). From 2009 to 2019, the average annual costs of schistosomiasis prevention and control were 55.17 million CNY. Calculating the costs by the disease control stage, the costs in the stage of morbidity control (2009–2012), transmission control (2013–2016), and transmission interruption (2017–2019) were 41.98 million CNY, 90.19 million CNY and 26.06 million CNY respectively, showing the annual costs of schistosomiasis prevention and control were the lowest after Jiangling County reached the criteria of transmission interruption. (Table 2 ) Table 2 Schistosomiasis control investment in Jiangling Country from 2009 to 2019(CNY 10 000) Expense item 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Total Special funds for health schistosomiasis control Costs of case searching 33.57 39.33 40.67 79.13 70.59 77.81 87.96 39.99 47.23 46.38 39.68 602.33 Costs of case treatment 255.47 244.07 229.69 217.77 217.14 226.21 230.58 236.73 213.54 199.90 195.04 2466.15 Costs of snails’ survey 37.64 39.18 43.42 33.44 38.90 33.31 79.46 80.35 67.59 54.03 54.00 561.32 Costs of mollusciciding 134.00 236.67 710.96 355.30 434.35 319.81 322.98 279.00 397.85 313.36 321.87 3826.15 Costs of health education 11.25 12.76 9.76 10.72 11.08 7.33 5.65 9.81 7.87 9.27 7.65 103.16 Costs of livestock disposal and management 132.00 1376.86 344.56 59.75 101.66 172.99 141.06 18.07 17.68 74.32 8.65 2447.60 Costs of toilets modification 200.01 283.66 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 483.67 Costs of risk monitoring 0.00 0.00 0.00 0.00 0.00 35.55 34.59 46.43 40.17 34.38 31.22 222.34 Others 12.25 21.03 12.96 12.64 17.18 11.52 10.81 11.40 13.85 9.82 9.16 142.62 Subtotal 816.18 2253.56 1392.02 768.75 890.90 884.53 913.08 721.78 805.78 741.46 667.27 10855.32 Costs for integrated control Costs of agricultural projects 60.00 1334.28 478.24 187.09 0.00 304.19 321.58 175.76 217.14 128.64 102.53 3309.45 Costs of forestry projects 0.00 0.00 0.00 328.65 127.58 71.58 131.25 102.69 54.40 49.11 48.03 913.30 Costs of water conservancy projects 72.80 811.44 2104.34 0.00 0.00 501.04 420.01 299.52 242.71 342.14 256.16 5050.17 Costs of transporation projects 216.00 49.88 3098.98 763.31 768.47 232.63 455.01 616.15 150.65 70.39 489.91 6911.38 Costs of land modification projects 0.00 0.00 0.00 2057.94 4116.80 7985.31 10195.78 5840.63 3452.37 0.00 0.00 33648.82 Subtotal 348.80 2195.60 5681.55 3336.98 5012.85 9094.74 11523.64 7034.75 4117.28 590.28 896.64 49833.12 Total 1164.98 4449.16 7073.58 4105.74 5903.75 9979.27 12436.72 7756.54 4923.05 1331.74 1563.90 60688.43 Discounted at 2.25% annual bank interest rate in 2009 Disease burden caused by schistosomiasis in Jiangling County The overall disease burden caused by schistosomiasis presented a downward trend with DALYs decreased from 3178.38 person-years in 2009 to 1497.42 person-years in 2019. Calculating the disease burden by the types of schistosomiasis cases, the DALYs of chronic cases of schistosomiasis presented a downward trend (2234.66 ~ 465.83 person-years), while that of advanced cases showed an upward trend (943.72 ~ 1031.59 person-years) with a small peak in 2017. In addition, the variation trend in total DALYs of schistosomiasis was consistent with that of chronic cases before 2013, but shifted to be consistent with that of advanced cases after 2013. (Fig. 1 ) According to DW, the schistosomiasis cases in Jiangling County from 2009 to 2019 were divided into 4 age groups: 6–14 years old, 15–44 years old, 45–59 years old and ≥ 60 years old. The YLD in the 15–44 and 45–59 age groups presented an obvious downward trend (722.03 ~ 34.28, 1285.41 ~ 295.60 person-years), while fluctuated a little bit in the age group of 60 years old and above, in the range of 460 and 800 person-years. Since 2015, the YLD was mainly concentrated in the age group of 60 years old and above, accounted for 45.8% [43.9% (541.75/1233.77), 45.4% (625.43/1377.00), 47.2% (521.53/1103.92), 43.5% (461.47/1060.85), 49.0% (471.23/962.36)] on average, while the YLD in the age groups of 15–44 years old, under 15 years old accounted for 7.2% [9.3% (114.50/1233.77), 9.2% (126.16/1377.00), 7.0%(77.16/1103.92), 6.8%(71.85/1060.85), 3.6%(34.28/962.36] and 0.0% [0.0% (0.48/1233.77), 0.1% (0.76/1377.00), 0.0%(0.19/1103.92), 0.0%(0.29/1060.85), 0.0%] on average (Fig. 2 ). ICEA of integrated schistosomiasis control Taking the morbidity control stage as an analysis control, ICEA based on the number of schistosomiasis cases showed that the costs increased by 8505.5 CNY and decreased by 2217.6 CNY respectively to avert one additional case in transmission control stage and transmission interruption stage respectively in Jiangling County (Table 3 ). The integrated control strategy was more cost-effective in transmission interruption stage. Table 3 Incremental cost-effectiveness analysis of integrated control strategies in different stages of schistosomiasis-number of cases Stage of schistosomiasis control Annual number of cases per year Average number of cases averted per year Average annual cost (CNY 10 000) Incremental cost (CNY 10 000) ICER(CNY)(incremental cost/average number of cases averted per year Morbidity control stage (2009–2012) 10897.0 — 4198.4 — — Transmission control stage (2013–2016) 5229.3 5667.8 9019.1 4820.7 8505.5 Transmission interruption stage (2017–2019) 3717.3 7179.7 2606.2 -1592.1 -2217.6 — means the control; ICER means incremental cost-effectiveness ratio; CNY means Chinese yuan. Taking the morbidity control stage as an analysis control, ICEA based on the DALY showed that the cost increased by 73937.6 CNY and decreased by 21508.6 CNY respectively to avert one additional DALY in transmission control stage and transmission interruption stage respectively in Jiangling County (Table 4 ). The integrated control strategy was more cost-effective in transmission interruption stage. Table 4 Incremental cost-effectiveness analysis of integrated control strategies in different stages of schistosomiasis- disability adjusted life years Stage of schistosomiasis control Cost (CNY 10 000) Incremental cost (CNY 10 000) DALYs (person-year) DALYs averted (person-year) ICER(CNY) (incremental cost / DALYs averted) Morbidity control stage (2009–2012) 16793.5 — 10257.2 — — Transmission control stage (2013–2016) 36076.3 19282.8 7649.2 2608.0 73937.6 Transmission interruption stage(2017–2019) 7818.7 -8974.8 6084.6 4172.6 -21508.6 — means the control; DALYs means disability adjusted life years; ICER means incremental cost-effectiveness ratio; CNY means Chinese yuan. Discussion The transmission of schistosomiasis is affected by biological, natural and social factors, thus determining that the control of schistosomiasis is a systematic social project, involving many departments, such as agriculture, forestry, water conservancy, land resources etc. Although the integrated control strategy focusing on the source of infection to block the transmission of schistosomiasis has been implemented in P. R. China more than ten years, it’s relatively difficult to carry out a systematic health economic evaluation on the integrated control strategy. The economic evaluation indices of schistosomiasis control measures reported in previous studies were mainly the costs for reducing the infection rate of S. japonicum in residents, livestock, snails, or the costs for reducing the integrated impact index of schistosomiasis. [ 27 – 29 ] However, in current situation, the majority of schistosomiasis cases are advanced cases in P.R. China, featured with a long process of pathological changes and neglected impacts on residents' health. Thus previous evaluation indices were no longer applicable. In our study, the CEA of the integrated control strategy for schistosomiasis was conducted through calculating the indices of DALY and ICER, taking Jiangling County as an example, to explore the burden of schistosomiasis on population more scientifically and comprehensively. The analysis of schistosomiasis investment in different periods in Jiangling County found that the average annual costs of schistosomiasis prevention and control in stages of morbidity control, transmission control and transmission interruption were 41.98 million CNY, 90.19 million CNY and 26.06 CNY respectively, equivalent to the annual per capita investment in schistosomiasis control of 123.08 CNY, 270.27 CNY and 77.29 CNY respectively, if considering the number of average annual resident population(341 100, 333 700, and 337 200 in corresponding periods). Due to the large one-time investment in environmental improvement projects, the overall investment in schistosomiasis control was relatively high [ 30 ], but still reasonable from the perspective of population-based protection through prevention and control activities. The study showed that the investment in schistosomiasis control decreased significantly after Jiangling reached the threshold of transmission interruption. The rising prices of materials and labors may further deepen the gap between investment and actual demand of schistosomiasis control. Because there has been no acute schistosomiasis cases in Jiangling County since 2009, the disease burden only included the DALYs of chronic and advanced schistosomiasis in this study. The DALYs of chronic schistosomiasis was mainly based on YLD caused by schistosomiasis rather than YLL [ 31 ]. In addition, we took the mean value (0.177) as the DW of a few cases as their age information missed in this study. Our study found that the overall disease burden caused by schistosomiasis presented a downward trend. To the opposite, the disease burden of advanced cases showed an upward trend, which can be explained by that YLL of advanced cases increased from 377.40 person-years in 2009 to 535.06 person-years in 2019. Also a small peak was presented in 2017 because 137 advanced cases were dead in that year (137 died cases), resulting in a larger YLL. In addition, the current YLD of schistosomiasis in Jiangling County mainly distributed in the age group of 60 years and over, followed by the age group of 45–59 years. The aging trend of cases was obvious, which was consistent with existing researches [ 32 , 33 ]. With the improvement of treatment quality and strengthening of medical assistance for advanced cases in P.R. China, the life expectancy of advanced cases will extend. As aging is an important factor affecting life quality and disease burden, it is necessary to strengthen dynamic monitoring and management of the elder age group through regular follow-up and healthy education. Early detection of advanced cases and timely interventions when the disease progression was found, are required to avert further deterioration leading to more disease burden. Taking the morbidity control stage as an analysis control, the ICEA of the integrated prevention and control strategy for schistosomiasis in Jiangling County showed that the costs increased by 8505.5 CNY and decreased by 2217.6 CNY respectively to avert one additional case in transmission control stage and transmission interruption stage respectively. Correspondingly, to avert one additional DALY, the costs increased by 73937.6 CNY and decreased by 21508.6 CNY respectively. These results all indicated that the strategy in the transmission interruption stage was the most cost-effective. Although the investment was relatively high in early stage, the disease burden decreased significantly due to the implementation of this strategy. As the endemicity of schistosomiasis declines, this strategy is more cost-effective. Therefore, multiple section collaboration and resource integration should be strengthened further and investments in the schistosomiasis integrated prevention and control should be continued to facilitate the elimination of schistosomiasis. There are some limitations of our study. First, being a retrospective research, a few data are missing because of the large time span. In this paper, the mean substitution was used to deal with the missing value, which may lead to a possible error with the real value, but it’s unavoidable. Second, the investment in human resources and fixed equipment, are not included in the cost calculation due to its complicity of definition, which may impact on the findings. It is suggested to strengthen the recording and archiving of relevant data in the future in order to improve the quality of similar research thus to better guide on-site prevention and control. Conclusions Although the investment was relatively high in early stage of schistosomiasis control, the disease burden decreased significantly due to the implementation of the integrated prevention and control strategy. As the epidemic declines, this strategy is more cost-effective. Thus, multiple section collaboration and resource integration should be strengthened further and investments in the schistosomiasis integrated prevention and control should be continued to facilitate the elimination of schistosomiasis. In addition, the current disease burden of schistosomiasis mainly distributed in the elder age group. Early detection of advanced cases and timely interventions when the disease progression was found, are required to avert further deterioration leading to more disease burden. Abbreviations CEA: Cost-effectiveness analysis; CUA: Cost-utility analysis; CBA: Cost-benefit analysis; CMA: Cost-minimization analysis; DALY: Disability adjusted life years; DW: Disability weight; YLD: Years lived with disability; YLL: Years of life lost; ICEA: Incremental cost-effectiveness analysis; ICER: Incremental cost-effectiveness ratio; S. japonicum: Schistosoma japonicum; P.R. China: People’s Republic of China; CNY: Chinese yuan. Declarations Acknowledgements We thank the staffs for their efforts and assistances in data collection in the Jiangling Station of Schistosomiasis Control. Ethics approval and consent to participate Not applicable. Consent for publication Not applicable. Availability of data and materials All the relevant data generated during this study are included in the manuscript. Competing interests Xiao-Nong Zhou is the Editor-in-Chief of I nfectious Diseases of Poverty . He was not involved in the peer-review or handling of the manuscript. The authors have no other competing interests to disclose. Funding This study was supported by the National Science and Technology Major Project of China ((No. 2018ZX10101002-002) and the National Natural Science Foundation of China (No. 82073619). The funding sources have no role in any aspect of this study. Authors' contributions WLL, ZXN, JTW and XJ conceived and designed the study. WLL, HHH and ZX participated in data collection. WLL WC and HZ carried out the data analyses and wrote the first draft manuscript. WLL and XJ revised the paper. WLL, WC and HZ translated the manuscript. All authors read and approved the final manuscript. References Wang LD. Promotion of strategy transition for national schistosomiasis control programme by implementation of the regulation of schistosomiasis control in China. Chinese Journal of Preventive Medicine. 2006;40(4): 219-220. Hao Y, Zheng H, Zhu R, Guo JG, Wu XH, Wang LY, et al. Schistosomiasis status in People's Republic of China in 2008. 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Bull World Health Organ. 2007;85: 458-465. Department of Disease Control. Schistosomiasis Control Manual, 3rd ed.; Shanghai Science and Technology Press, Shanghai, 2000. p. 263-264. Lo NC, Gurarie D, Yoon N, Coulibaly JT., Bendavid E, Andrews JR., et al. Impact and cost-effectiveness of snail control to achieve disease control targets for schistosomiasis. Proc Natl Acad Sci U S A. 2018;115: E584-E591. Lo NC, Bogoch II, Blackburn BG, Raso G, N'Goran EK, Coulibaly JT. Comparison of community-wide, integrated mass drug administration strategies for schistosomiasis and soil-transmitted helminthiasis: a cost-effectiveness modelling study. The Lancet Global Health. 2015;3: e629-e638. De Neve JW, Andriantavison RL, Croke K, Krisam J, Rajoela VH, Rakotoarivony RA, Rambeloson V, et.al. Health, financial, and education gains of investing in preventive chemotherapy for schistosomiasis, soil-transmitted helminthiases, and lymphatic filariasis in Madagascar: A modeling study. PLoS Negl Trop Dis. 2018;12(12):e0007002. Luo TP, Zhou XN, Qiu ZL. Cost-effectiveness and cost-benefit of integrated schistosomiasis control strategy with emphasis on infectious source control in mountainous areas of Yunnan Province. Chinese Journal of Schistosomiasis Control. 2009;21(2): 93-97. Yang Ya, Li JB, Liu H, Li SD, He Z, Cai B, et al. Cost-effectiveness of comprehensive schistosomiasis control strategy with focus on cattle and sheep removal in Junshan District, Yueyang City. Chinese Journal of Schistosomiasis Control. 2018;30(1): 14-17. Yu Q, Wan XX, Liu Q, Wang ZX, Huang YQ, Guo JG. Cost-effectiveness evaluation and investigation on control measures improvement in areas of schistosomiasis transmission control in hilly regions of mountains Ⅲ. Chinese Journal of Disease Control & Prevention. 2013;17(8): 706-710. Zhang SQ, He JC, Wang TP, Chen GG, Pan XP, Bao JG, et al. Effect of comprehensive schistosomiasis control measures with emphasis on infectious source control carried out in different scale regions. Journal of Tropical Disease and Parasitology.2011;9(3): 63-68. Murray CJL., Salomon J, Lopez A. (2002). Summary measures of population health: concepts, ethics, measurement and applications. Li FY, Tan HZ, Zhou J, Zhou RH, Zhu JH, Cai XT, Ren GH, et al. Analysis of characteristics of medical assistance to advanced schistosomiasis patients in Hunan Province, 2015. Chinese Journal of Schistosomiasis Control. 2017 ;29(3):281-285. Yuan Y, Zhou T. Survey on 202 patients with advanced schistosomiasis in Anqing area in 2017. Journal of Tropical Disease and Parasitology .2018;16(4): 204-206. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 07 Feb, 2021 Reviewers invited by journal 03 Feb, 2021 Editor assigned by journal 02 Feb, 2021 First submitted to journal 27 Jan, 2021 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-168300","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":10497837,"identity":"af6873fd-ddc5-4425-bb37-6613169c4f89","order_by":0,"name":"Ling-Ling Wu","email":"","orcid":"https://orcid.org/0000-0001-7957-731X","institution":"NIPD: National Institute of Parasitic Diseases","correspondingAuthor":false,"prefix":"","firstName":"Ling-Ling","middleName":"","lastName":"Wu","suffix":""},{"id":10497838,"identity":"c63b7975-6f9c-4e44-a42c-3b23b4a77f89","order_by":1,"name":"He-Hua Hu","email":"","orcid":"","institution":"Jiangling Station of Schistosomiasis Control","correspondingAuthor":false,"prefix":"","firstName":"He-Hua","middleName":"","lastName":"Hu","suffix":""},{"id":10497839,"identity":"ecd782c6-f97b-4012-a3f3-42d58bc1c214","order_by":2,"name":"Xia Zhang","email":"","orcid":"","institution":"Jiangling Station of schistosomiasis control","correspondingAuthor":false,"prefix":"","firstName":"Xia","middleName":"","lastName":"Zhang","suffix":""},{"id":10497840,"identity":"a5368de0-a192-4cfa-a398-9a23c3901f52","order_by":3,"name":"Xiao-Nong Zhou","email":"","orcid":"","institution":"NIPD: National Institute of Parasitic Diseases","correspondingAuthor":false,"prefix":"","firstName":"Xiao-Nong","middleName":"","lastName":"Zhou","suffix":""},{"id":10497841,"identity":"152c2fb1-1f5e-4983-b2d1-5b7ff4a8cd79","order_by":4,"name":"Tie-Wu Jia","email":"","orcid":"","institution":"NIPD: National Institute of Parasitic Diseases","correspondingAuthor":false,"prefix":"","firstName":"Tie-Wu","middleName":"","lastName":"Jia","suffix":""},{"id":10497842,"identity":"446ddc52-ede0-48ca-bf6a-fabfc082540b","order_by":5,"name":"Can Wang","email":"","orcid":"","institution":"NIPD: National Institute of Parasitic Diseases","correspondingAuthor":false,"prefix":"","firstName":"Can","middleName":"","lastName":"Wang","suffix":""},{"id":10497843,"identity":"197a5b57-94ab-4380-a083-51fae60dd985","order_by":6,"name":"Zhong Hong","email":"","orcid":"","institution":"NIPD: National Institute of Parasitic Diseases","correspondingAuthor":false,"prefix":"","firstName":"Zhong","middleName":"","lastName":"Hong","suffix":""},{"id":10497844,"identity":"74a86a0f-07b0-489c-a6db-083089c2ca79","order_by":7,"name":"Jing Xu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8UlEQVRIiWNgGAWjYHCChAMMDDYMbAwMBgyMDRIgEQNitKSRpgUEDkNUMjYwENZicCPh4eGCX+fz+KSbNzD83GGRx99+eOMHhpo7OLVIzkhIODyz73Yxm8yxAsbeMxLFEmfSiiUYjj3DqYVfAqiFt+d2YptEjgEzY5tEYsMNHjOgCw/j1MIG0XIOoWU+IS1gW3h+HEBo2UBIi2TPA6AtDcmJbUC/HOwFatkI8kvCMdxaDI7nJH/m+WOXOH9288YHP9vqEucdB4bYhxrcWhgYeBIYGNuANDASD8AFE/BoYGBgByr8A9EyCkbBKBgFowArAAD+2lp6AEfcbwAAAABJRU5ErkJggg==","orcid":"","institution":"NIPD: National Institute of Parasitic Diseases","correspondingAuthor":true,"prefix":"","firstName":"Jing","middleName":"","lastName":"Xu","suffix":""}],"badges":[],"createdAt":"2021-01-28 06:28:03","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-168300/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-168300/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":5747442,"identity":"d898af22-0eb4-4132-80e8-c98a1933dc80","added_by":"auto","created_at":"2021-02-08 18:11:55","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":26462,"visible":true,"origin":"","legend":"Changes of Disability adjusted life years caused by schistosomiasis in Jiangling Country from 2009 to 2019\nNotes: DALYs means disability adjusted life years.","description":"","filename":"Onlinefig1.png","url":"https://assets-eu.researchsquare.com/files/rs-168300/v1/78deeabb0197810175272889.png"},{"id":5747443,"identity":"c4248fd8-94b7-40df-a728-f92ba518036a","added_by":"auto","created_at":"2021-02-08 18:11:55","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":18095,"visible":true,"origin":"","legend":"Changes of Years lived with disability caused by schistosomiasis by age strata in Jiangling Country from 2009 to 2019","description":"","filename":"Onlinefig2.png","url":"https://assets-eu.researchsquare.com/files/rs-168300/v1/77ef8db8e1bef70fbfea8f15.png"},{"id":13657060,"identity":"228e4527-b6bf-4d8b-9f85-2c4c4e2ec54a","added_by":"auto","created_at":"2021-09-17 10:08:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":519108,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-168300/v1/c6757289-fb8b-41e9-990f-9b5456546d7b.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eCost-effectiveness Analysis of the Integrated Control Strategy for Schistosomiasis Japonica in Lake Region of China: a Jiangling Case Study\u003c/p\u003e","fulltext":[{"header":"Background","content":" \u003cp\u003eThe implementation of integrated prevention and control strategy focusing on the source of infection to interrupt the transmission of schistosomiasis had strongly accelerated the process of schistosomiasis control in People\u0026rsquo;s Republic of China (P.R. China) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Morbidity control (the infection rate of humans and livestock in epidemic villages\u0026thinsp;\u0026lt;\u0026thinsp;5%) and transmission control (the infection rate of humans and livestock in epidemic villages\u0026thinsp;\u0026lt;\u0026thinsp;1%) were reached nationwide in 2008 and 2015 respectively [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. By the end of 2019, 95.3% of the epidemic counties in P.R. China had reached the threshold of transmission interruption or elimination according to the national standards [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The endemicity of schistosomiasis had dropped to the lowest level in history. At present, the key areas for schistosomiasis prevention and control in P.R. China are distributed along the middle and lower reaches of the Yangtze River, as well as the areas of Dongting Lake and Poyang Lake.\u003c/p\u003e \u003cp\u003eUnder the condition of low epidemic level and limited funding, it is urgent to carry out health economic evaluation on the integrated schistosomiasis control strategy currently implemented in lake region in order to rationally allocate and utilize health resources and maximize benefits.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] The health economics evaluation refers to the evaluation and selection of alternatives by analyzing the economic effects (cost, effect or input, output) of health planning.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] The methods used to evaluate the economic value of disease interventions mainly include cost-effectiveness analysis (CEA), cost-utility analysis (CUA), cost-benefit analysis (CBA) and cost-minimization analysis (CMA). CBA of schistosomiasis is relatively difficult because of the complexity of identifying and quantifying the health benefits of schistosomiasis prevention and control [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In P.R. China, there have been several studies on the effectiveness of integrated prevention and control strategies for schistosomiasis, but there are few related to cost-effectiveness analyses [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAs periodic assessment and analysis of resource utilization are conducive to the optimization of diseases prevention and control [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. We evaluated the cost-effectiveness of the integrated control strategy for schistosomiasis taking Jiangling County as an example due to its heavy endemicity of schistosomiasis in history and well archived data and documents, thus to provide reference for understanding the effectiveness of the integrated control strategy and adjusting diseases prevention and control strategies or measures.\u003c/p\u003e "},{"header":"Materials And Methods","content":"\u003cp\u003e\u003cstrong\u003eSetting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJiangling county of Hubei Province, a typical marshland and lake region used to be a heavily endemic area of schistosomiasis, locates in the middle reaches of the Yangtze River and near the north bank of the Jingjiang River. It belongs to the hinterland of the four lakes (Long Lake, Three Lakes, Egret Lake, Hong Lake), having rich water system and complex natural environments suitable for snails breeding. Through the implementation of the integrated control strategy for schistosomiasis control, the county has reached the criteria of morbidity control, transmission control and transmission interruption in 2008, 2013 and 2017, respectively [12-14], keeping a low level of schistosomiasis endemicity until now.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData reflecting the epidemic status of schistosomiasis and costs for schistosomiasis control in Jiangling County from 2009 to 2019 were collected from the perspective of health investors.\u003c/p\u003e\n\u003cp\u003eData including the number of schistosomiasis cases (acute cases, chronic cases and advanced cases), the snails\u0026rsquo; infested area, the infected snails infested areas etc. were collected during 2009-2019. The general demographic information especially the age of each schistosomiasis cases were collected. For schistosomiasis control investment, data reflecting the costs of case detection and treatment, snail control, health education, risk monitoring, livestock elimination and control, toilets modification and integrated management in Jiangling County from 2009 to 2019 were collected [15-18]. The costs of case detection and treatment were composed of the annual costs of questionnaire survey, blood examination, stool examination, treatment against schistosomiasis, involving the costs of subsidies, diagnostic reagents and materials, drug, medical assistance for advanced cases of schistosomiasis and so on. The costs of snail control included the costs for conducting snails\u0026rsquo; survey and mollusciciding, involving the costs of subsidies, materials, drug and so on. Health education expenses included the costs for conducting training courses for school students, village cadres and doctors, the costs for preparing and distributing the leaflets, setting the warning signs etc. As for integrated interventions, data reflecting the investment related to schistosomiasis control activities were collected from the departments of agriculture, forestry, water conservancy, transportation and land resources.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData management and statistical analyses\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData collected was entered and descriptive analysis was conducted by Microsoft Excel 2016 software.\u003c/p\u003e\n\u003cp\u003eThe Disability Adjusted Life Years (DALY) was used to quantify the burden of disease, which was calculated with the life quality method based on disability weight (DW) got from cases\u0026rsquo; life quality assessment.[19] The formula was listed as follows [20]:\u003c/p\u003e\n\u003cp\u003eDALYA=YLD+YLL, YLDprev x =\u0026Sigma;\u003cem\u003ePx\u003c/em\u003e*DWx, YLL\u003cstrong\u003e= \u003c/strong\u003e\u003cem\u003eN*L\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWhere YLD is the years lived with disability, YLL is the years of life lost, YLDprev x is the years lived with disability based on prevalence (prev is the abbreviation of prevalence, x is the grouping variable), Px is the number of cases in the reference population at a specific time. DWx is the disability weight of health outcomes. The DW of different age groups of advanced schistosomiasis cases was calculated as the following criteria: 30-44 years old (0.378), 45-59 years old (0.399), over 60 years old (0.510) [21]. The DW of different age groups of chronic cases of schistosomiasis was standardized as the follows: 5-14 years old (0.095), 15-44 years old (0.159), 45-59 years old (0.207), over 60 years old (0.246) [22]. N is the number of deaths in different age groups and genders; L is the life loss value of each age group, that is, the life expectancy value corresponding to the death age point in the standard life table.\u003c/p\u003e\n\u003cp\u003eFor incremental cost-effectiveness analysis (ICEA), the discount formula of the current year was calculated according to formula : Cn' =Cn/(1+r)n[23], where Cn' is the discounted cost ; Cn is the actual cost of each year; r is the discount rate, often using the current bank\u0026rsquo;s regular interest rate; n is the year. Incremental cost-effectiveness ratio (ICER) was used as the effect indicator [24-26], that was, the incremental cost for each additional case averted and the incremental cost for each additional DALY averted.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eGeneral information of schistosomiasis epidemic situation in Jiangling County\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFrom 2009 to 2019, the endemicity of schistosomiasis in Jiangling County presented a downward trend. The number of positives with antibodies against schistosome dropped from 13, 086 in 2009 to 2, 310 in 2019, while the number of stool positives finding Schistosoma japonicum eggs decreased from 2, 158 in 2009 to 0 in 2019. In addition, the number of advanced schistosomiasis cases dropped from 1, 248 in 2009 to 1, 073 in 2019, while no acute schistosomiasis case was reported since 2008 in the county. The snail infested area had declined from 3030.73 hm2 in 2009 to 2718.04 hm2 in 2019, and no infected snail was detected since 2012.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eChanges of schistosomiasis cases and snails\u0026rsquo; status in Jiangling County during 2009 to 2019\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eYear\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eDisease situation\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eSnail situation\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eNo. positives of stool exams\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eNo. advanced cases of schistosomiasis\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eSnail area(hm\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eArea with infected\u003c/p\u003e\n\u003cp\u003esnails(hm\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2009\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2158\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1118\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3030.73\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e136.68\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2010\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1602\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1140\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3030.23\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e133.06\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2011\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1199\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1169\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3029.53\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e51.51\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2012\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e573\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1180\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2875.86\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.00\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2013\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e395\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1187\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2875.86\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.00\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2014\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e229\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1222\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2875.86\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.00\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2015\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e74\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1233\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2728.65\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.00\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2016\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1205\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2728.65\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.00\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2017\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1111\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2718.10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.00\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2018\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1098\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2718.04\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.00\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2019\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1073\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2718.04\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.00\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTotal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6230\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e12736\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e31329.55\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e321.25\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCosts for schistosomiasis control in Jiangling County\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe overall expenditure for schistosomiasis control in Jiangling County from 2009 to 2019 was 607\u0026nbsp;million CNY, of which the costs from the land resources department for schistosomiasis control was the largest (336\u0026nbsp;million), followed by costs for health activities for schistosomiasis control (109\u0026nbsp;million). Among the investment from health department for schistosomiasis control, costs of snail control, case treatment, cattle disposal and control accounted for 35.3% (3826.15/10855.32), 22.7% (2466.15/10855.32), and 22.6% (2447.60/10855.32) respectively. For investments from other departments, the costs related to land modification, transportation and water conservancy projects accounted for 67.6% (33648.82/60688.43), 13.9% (6911.38 /60688.43) and 10.1% (5050.17/60688.43).\u003c/p\u003e\n\u003cp\u003eFrom 2009 to 2019, the average annual costs of schistosomiasis prevention and control were 55.17\u0026nbsp;million CNY. Calculating the costs by the disease control stage, the costs in the stage of morbidity control (2009\u0026ndash;2012), transmission control (2013\u0026ndash;2016), and transmission interruption (2017\u0026ndash;2019) were 41.98\u0026nbsp;million CNY, 90.19\u0026nbsp;million CNY and 26.06\u0026nbsp;million CNY respectively, showing the annual costs of schistosomiasis prevention and control were the lowest after Jiangling County reached the criteria of transmission interruption. (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eSchistosomiasis control investment in Jiangling Country from 2009 to 2019(CNY 10 000)\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eExpense item\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2009\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2010\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2011\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2012\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2013\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2014\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2015\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2016\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2017\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2018\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2019\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eTotal\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"10\" align=\"left\"\u003e\n\u003cp\u003eSpecial funds for health schistosomiasis control\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCosts of case searching\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e33.57\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e39.33\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e40.67\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e79.13\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e70.59\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e77.81\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e87.96\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e39.99\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e47.23\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e46.38\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e39.68\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e602.33\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCosts of case treatment\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e255.47\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e244.07\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e229.69\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e217.77\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e217.14\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e226.21\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e230.58\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e236.73\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e213.54\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e199.90\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e195.04\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2466.15\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCosts of snails\u0026rsquo; survey\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e37.64\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e39.18\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e43.42\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e33.44\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e38.90\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e33.31\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e79.46\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e80.35\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e67.59\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e54.03\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e54.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e561.32\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCosts of mollusciciding\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e134.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e236.67\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e710.96\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e355.30\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e434.35\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e319.81\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e322.98\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e279.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e397.85\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e313.36\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e321.87\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3826.15\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCosts of health education\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11.25\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12.76\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9.76\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10.72\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11.08\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7.33\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5.65\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9.81\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7.87\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9.27\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7.65\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e103.16\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCosts of livestock disposal and management\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e132.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1376.86\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e344.56\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e59.75\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e101.66\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e172.99\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e141.06\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18.07\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e17.68\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e74.32\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8.65\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2447.60\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCosts of toilets modification\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e200.01\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e283.66\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e483.67\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCosts of risk monitoring\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e35.55\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e34.59\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e46.43\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e40.17\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e34.38\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e31.22\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e222.34\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOthers\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12.25\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e21.03\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12.96\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12.64\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e17.18\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11.52\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10.81\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11.40\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13.85\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9.82\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9.16\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e142.62\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSubtotal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e816.18\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2253.56\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1392.02\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e768.75\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e890.90\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e884.53\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e913.08\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e721.78\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e805.78\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e741.46\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e667.27\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10855.32\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"6\" align=\"left\"\u003e\n\u003cp\u003eCosts for integrated control\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCosts of agricultural projects\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e60.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1334.28\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e478.24\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e187.09\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e304.19\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e321.58\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e175.76\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e217.14\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e128.64\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e102.53\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3309.45\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCosts of forestry projects\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e328.65\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e127.58\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e71.58\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e131.25\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e102.69\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e54.40\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e49.11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e48.03\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e913.30\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCosts of water conservancy projects\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e72.80\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e811.44\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2104.34\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e501.04\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e420.01\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e299.52\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e242.71\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e342.14\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e256.16\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5050.17\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCosts of transporation projects\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e216.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e49.88\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3098.98\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e763.31\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e768.47\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e232.63\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e455.01\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e616.15\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e150.65\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e70.39\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e489.91\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6911.38\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCosts of land modification projects\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2057.94\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4116.80\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7985.31\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10195.78\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5840.63\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3452.37\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e33648.82\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSubtotal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e348.80\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2195.60\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5681.55\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3336.98\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5012.85\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9094.74\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11523.64\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7034.75\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4117.28\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e590.28\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e896.64\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e49833.12\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eTotal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1164.98\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4449.16\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7073.58\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4105.74\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5903.75\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9979.27\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12436.72\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7756.54\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4923.05\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1331.74\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1563.90\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e60688.43\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"14\"\u003eDiscounted at 2.25% annual bank interest rate in 2009\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisease burden caused by schistosomiasis in Jiangling County\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe overall disease burden caused by schistosomiasis presented a downward trend with DALYs decreased from 3178.38 person-years in 2009 to 1497.42 person-years in 2019. Calculating the disease burden by the types of schistosomiasis cases, the DALYs of chronic cases of schistosomiasis presented a downward trend (2234.66\u0026thinsp;~\u0026thinsp;465.83 person-years), while that of advanced cases showed an upward trend (943.72\u0026thinsp;~\u0026thinsp;1031.59 person-years) with a small peak in 2017. In addition, the variation trend in total DALYs of schistosomiasis was consistent with that of chronic cases before 2013, but shifted to be consistent with that of advanced cases after 2013. (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\n\u003cp\u003eAccording to DW, the schistosomiasis cases in Jiangling County from 2009 to 2019 were divided into 4 age groups: 6\u0026ndash;14 years old, 15\u0026ndash;44 years old, 45\u0026ndash;59 years old and \u0026ge;\u0026thinsp;60 years old. The YLD in the 15\u0026ndash;44 and 45\u0026ndash;59 age groups presented an obvious downward trend (722.03\u0026thinsp;~\u0026thinsp;34.28, 1285.41\u0026thinsp;~\u0026thinsp;295.60 person-years), while fluctuated a little bit in the age group of 60 years old and above, in the range of 460 and 800 person-years. Since 2015, the YLD was mainly concentrated in the age group of 60 years old and above, accounted for 45.8% [43.9% (541.75/1233.77), 45.4% (625.43/1377.00), 47.2% (521.53/1103.92), 43.5% (461.47/1060.85), 49.0% (471.23/962.36)] on average, while the YLD in the age groups of 15\u0026ndash;44 years old, under 15 years old accounted for 7.2% [9.3% (114.50/1233.77), 9.2% (126.16/1377.00), 7.0%(77.16/1103.92), 6.8%(71.85/1060.85), 3.6%(34.28/962.36] and 0.0% [0.0% (0.48/1233.77), 0.1% (0.76/1377.00), 0.0%(0.19/1103.92), 0.0%(0.29/1060.85), 0.0%] on average (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eICEA of integrated schistosomiasis control \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTaking the morbidity control stage as an analysis control, ICEA based on the number of schistosomiasis cases showed that the costs increased by 8505.5 CNY and decreased by 2217.6 CNY respectively to avert one additional case in transmission control stage and transmission interruption stage respectively in Jiangling County (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). The integrated control strategy was more cost-effective in transmission interruption stage.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eIncremental cost-effectiveness analysis of integrated control strategies in different stages of schistosomiasis-number of cases\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eStage of schistosomiasis control\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eAnnual number of cases per year\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eAverage number of cases averted per year\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eAverage annual cost\u003c/p\u003e\n\u003cp\u003e(CNY 10 000)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eIncremental cost\u003c/p\u003e\n\u003cp\u003e(CNY 10 000)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eICER(CNY)(incremental cost/average number of cases averted per year\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMorbidity control stage\u003c/p\u003e\n\u003cp\u003e(2009\u0026ndash;2012)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10897.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026mdash;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4198.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u0026mdash;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026mdash;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTransmission control stage\u003c/p\u003e\n\u003cp\u003e(2013\u0026ndash;2016)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5229.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5667.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9019.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e4820.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8505.5\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTransmission interruption stage\u003c/p\u003e\n\u003cp\u003e(2017\u0026ndash;2019)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3717.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7179.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2606.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e-1592.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-2217.6\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"7\"\u003e\u0026mdash; means the control; ICER means incremental cost-effectiveness ratio; CNY means Chinese yuan.\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTaking the morbidity control stage as an analysis control, ICEA based on the DALY showed that the cost increased by 73937.6 CNY and decreased by 21508.6 CNY respectively to avert one additional DALY in transmission control stage and transmission interruption stage respectively in Jiangling County (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e). The integrated control strategy was more cost-effective in transmission interruption stage.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab4\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eIncremental cost-effectiveness analysis of integrated control strategies in different stages of schistosomiasis- disability adjusted life years\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eStage of schistosomiasis control\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCost (CNY 10 000)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eIncremental cost (CNY 10 000)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eDALYs\u003c/p\u003e\n\u003cp\u003e(person-year)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eDALYs averted (person-year)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eICER(CNY)\u003c/p\u003e\n\u003cp\u003e(incremental cost / DALYs averted)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMorbidity control stage\u003c/p\u003e\n\u003cp\u003e(2009\u0026ndash;2012)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16793.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026mdash;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10257.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026mdash;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026mdash;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTransmission control stage\u003c/p\u003e\n\u003cp\u003e(2013\u0026ndash;2016)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e36076.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e19282.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7649.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2608.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e73937.6\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTransmission interruption stage(2017\u0026ndash;2019)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7818.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-8974.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6084.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4172.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-21508.6\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"6\"\u003e\u0026mdash; means the control; DALYs means disability adjusted life years; ICER means incremental cost-effectiveness ratio; CNY means Chinese yuan.\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":" \u003cp\u003eThe transmission of schistosomiasis is affected by biological, natural and social factors, thus determining that the control of schistosomiasis is a systematic social project, involving many departments, such as agriculture, forestry, water conservancy, land resources etc. Although the integrated control strategy focusing on the source of infection to block the transmission of schistosomiasis has been implemented in P. R. China more than ten years, it\u0026rsquo;s relatively difficult to carry out a systematic health economic evaluation on the integrated control strategy. The economic evaluation indices of schistosomiasis control measures reported in previous studies were mainly the costs for reducing the infection rate of \u003cem\u003eS. japonicum\u003c/em\u003e in residents, livestock, snails, or the costs for reducing the integrated impact index of schistosomiasis. [\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] However, in current situation, the majority of schistosomiasis cases are advanced cases in P.R. China, featured with a long process of pathological changes and neglected impacts on residents' health. Thus previous evaluation indices were no longer applicable. In our study, the CEA of the integrated control strategy for schistosomiasis was conducted through calculating the indices of DALY and ICER, taking Jiangling County as an example, to explore the burden of schistosomiasis on population more scientifically and comprehensively.\u003c/p\u003e \u003cp\u003eThe analysis of schistosomiasis investment in different periods in Jiangling County found that the average annual costs of schistosomiasis prevention and control in stages of morbidity control, transmission control and transmission interruption were 41.98\u0026nbsp;million CNY, 90.19\u0026nbsp;million CNY and 26.06 CNY respectively, equivalent to the annual per capita investment in schistosomiasis control of 123.08 CNY, 270.27 CNY and 77.29 CNY respectively, if considering the number of average annual resident population(341 100, 333 700, and 337 200 in corresponding periods). Due to the large one-time investment in environmental improvement projects, the overall investment in schistosomiasis control was relatively high [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], but still reasonable from the perspective of population-based protection through prevention and control activities. The study showed that the investment in schistosomiasis control decreased significantly after Jiangling reached the threshold of transmission interruption. The rising prices of materials and labors may further deepen the gap between investment and actual demand of schistosomiasis control.\u003c/p\u003e \u003cp\u003eBecause there has been no acute schistosomiasis cases in Jiangling County since 2009, the disease burden only included the DALYs of chronic and advanced schistosomiasis in this study. The DALYs of chronic schistosomiasis was mainly based on YLD caused by schistosomiasis rather than YLL [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. In addition, we took the mean value (0.177) as the DW of a few cases as their age information missed in this study. Our study found that the overall disease burden caused by schistosomiasis presented a downward trend. To the opposite, the disease burden of advanced cases showed an upward trend, which can be explained by that YLL of advanced cases increased from 377.40 person-years in 2009 to 535.06 person-years in 2019. Also a small peak was presented in 2017 because 137 advanced cases were dead in that year (137 died cases), resulting in a larger YLL. In addition, the current YLD of schistosomiasis in Jiangling County mainly distributed in the age group of 60 years and over, followed by the age group of 45\u0026ndash;59 years. The aging trend of cases was obvious, which was consistent with existing researches [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. With the improvement of treatment quality and strengthening of medical assistance for advanced cases in P.R. China, the life expectancy of advanced cases will extend. As aging is an important factor affecting life quality and disease burden, it is necessary to strengthen dynamic monitoring and management of the elder age group through regular follow-up and healthy education. Early detection of advanced cases and timely interventions when the disease progression was found, are required to avert further deterioration leading to more disease burden.\u003c/p\u003e \u003cp\u003eTaking the morbidity control stage as an analysis control, the ICEA of the integrated prevention and control strategy for schistosomiasis in Jiangling County showed that the costs increased by 8505.5 CNY and decreased by 2217.6 CNY respectively to avert one additional case in transmission control stage and transmission interruption stage respectively. Correspondingly, to avert one additional DALY, the costs increased by 73937.6 CNY and decreased by 21508.6 CNY respectively. These results all indicated that the strategy in the transmission interruption stage was the most cost-effective. Although the investment was relatively high in early stage, the disease burden decreased significantly due to the implementation of this strategy. As the endemicity of schistosomiasis declines, this strategy is more cost-effective. Therefore, multiple section collaboration and resource integration should be strengthened further and investments in the schistosomiasis integrated prevention and control should be continued to facilitate the elimination of schistosomiasis.\u003c/p\u003e \u003cp\u003eThere are some limitations of our study. First, being a retrospective research, a few data are missing because of the large time span. In this paper, the mean substitution was used to deal with the missing value, which may lead to a possible error with the real value, but it\u0026rsquo;s unavoidable. Second, the investment in human resources and fixed equipment, are not included in the cost calculation due to its complicity of definition, which may impact on the findings. It is suggested to strengthen the recording and archiving of relevant data in the future in order to improve the quality of similar research thus to better guide on-site prevention and control.\u003c/p\u003e "},{"header":"Conclusions","content":" \u003cp\u003eAlthough the investment was relatively high in early stage of schistosomiasis control, the disease burden decreased significantly due to the implementation of the integrated prevention and control strategy. As the epidemic declines, this strategy is more cost-effective. Thus, multiple section collaboration and resource integration should be strengthened further and investments in the schistosomiasis integrated prevention and control should be continued to facilitate the elimination of schistosomiasis. In addition, the current disease burden of schistosomiasis mainly distributed in the elder age group. Early detection of advanced cases and timely interventions when the disease progression was found, are required to avert further deterioration leading to more disease burden.\u003c/p\u003e "},{"header":"Abbreviations","content":"\u003cp\u003eCEA: Cost-effectiveness analysis; CUA: Cost-utility analysis; CBA: Cost-benefit analysis; CMA: Cost-minimization analysis; DALY: Disability adjusted life years; DW: Disability weight; YLD: Years lived with disability; YLL: Years of life lost; ICEA: Incremental cost-effectiveness analysis; ICER: Incremental cost-effectiveness ratio; S. japonicum: Schistosoma japonicum; P.R. China: People\u0026rsquo;s Republic of China; CNY: Chinese yuan.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the staffs for their efforts and assistances in data collection in the Jiangling Station of Schistosomiasis Control.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the relevant data generated during this study are included in the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eXiao-Nong Zhou is the Editor-in-Chief of I\u003cem\u003enfectious Diseases of Poverty\u003c/em\u003e. He was not involved in the peer-review or handling of the manuscript. The authors have no other competing interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the National Science and Technology Major Project of China ((No. 2018ZX10101002-002) and the National Natural Science Foundation of China (No. 82073619). The funding sources have no role in any aspect of this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWLL, ZXN, JTW and XJ conceived and designed the study. WLL, HHH and ZX participated in data collection. WLL WC and HZ carried out the data analyses and wrote the first draft manuscript. WLL and XJ revised the paper. WLL, WC and HZ translated the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWang LD. 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Health, financial, and education gains of investing in preventive chemotherapy for schistosomiasis, soil-transmitted helminthiases, and lymphatic filariasis in Madagascar: A modeling study. PLoS Negl Trop Dis. 2018;12(12):e0007002.\u003c/li\u003e\n\u003cli\u003eLuo TP, Zhou XN, Qiu ZL. Cost-effectiveness and cost-benefit of integrated schistosomiasis control strategy with emphasis on infectious source control in mountainous areas of Yunnan Province. Chinese Journal of Schistosomiasis Control. 2009;21(2): 93-97.\u003c/li\u003e\n\u003cli\u003eYang Ya, Li JB, Liu H, Li SD, He Z, Cai B, et al. Cost-effectiveness of comprehensive schistosomiasis control strategy with focus on cattle and sheep removal in Junshan District, Yueyang City. Chinese Journal of Schistosomiasis Control. 2018;30(1): 14-17.\u003c/li\u003e\n\u003cli\u003eYu Q, Wan XX, Liu Q, Wang ZX, Huang YQ, Guo JG. Cost-effectiveness evaluation and investigation on control measures improvement in areas of schistosomiasis transmission control in hilly regions of mountains Ⅲ. Chinese Journal of Disease Control \u0026amp; Prevention. 2013;17(8): 706-710.\u003c/li\u003e\n\u003cli\u003eZhang SQ, He JC, Wang TP, Chen GG, Pan XP, Bao JG, et al. Effect of comprehensive schistosomiasis control measures with emphasis on infectious source control carried out in different scale regions. Journal of Tropical Disease and Parasitology.2011;9(3): 63-68.\u003c/li\u003e\n\u003cli\u003eMurray CJL., Salomon J, Lopez A. (2002). Summary measures of population health: concepts, ethics, measurement and applications.\u003c/li\u003e\n\u003cli\u003eLi FY, Tan HZ, Zhou J, Zhou RH, Zhu JH, Cai XT, Ren GH, et al. Analysis of characteristics of medical assistance to advanced schistosomiasis patients in Hunan Province, 2015. Chinese Journal of Schistosomiasis Control. 2017 ;29(3):281-285.\u003c/li\u003e\n\u003cli\u003eYuan Y, Zhou T. Survey on 202 patients with advanced schistosomiasis in Anqing area in 2017. Journal of Tropical Disease and Parasitology .2018;16(4): 204-206.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"infectious-diseases-of-poverty","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"idop","sideBox":"Learn more about [Infectious Diseases of Poverty](http://idpjournal.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/idop/default.aspx","title":"Infectious Diseases of Poverty","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"schistosomiasis, integrated control, cost-effectiveness, DALY, ICER","lastPublishedDoi":"10.21203/rs.3.rs-168300/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-168300/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eUnder the condition of low epidemic level and limited funding, it is urgent to carry out health economic evaluation on the integrated schistosomiasis control strategy currently implemented in lake region in order to rationally allocate and utilize health resources and maximize benefits. The objective of this study is to provide reference for understanding the effectiveness of the integrated control strategy and adjusting prevention and control strategies or measures. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThe investment in schistosomiasis control and disability adjusted life years （DALYs）caused by schistosomiasis were calculated. Incremental cost-effectiveness ratio (ICER) was conducted through calculating the incremental cost of every additional case averted, the incremental cost of every additional DALY averted through implementation of the integrated schistosomiasis control at different control stages in Jiangling County. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe total expenditure for schistosomiasis control in Jiangling County from 2009 to 2019 was 607 million Chinese yuan (CNY). The average annual costs for schistosomiasis prevention and control in stages of morbidity control (2009-2012), transmission control (2013-2016), and transmission interruption (2017-2019) were 41.98 million CNY，90.19 million CNY and 26.06 million CNY respectively. The overall disease burden caused by schistosomiasis presented a downward trend. Meanwhile, the disease burden of advanced cases showed an upward trend with the DALY increased from 943.72 to1031.59 person-years. Most disease burden occurred in the age group over 45 years old (especially the elderly over 60 years old). Taking the morbidity control stage as an analysis control, incremental cost-effectiveness analysis (ICEA) showed that the cost increased by 8505.5 CNY and decreased by 2217.6 CNY respectively to avert one additional case in transmission control stage and transmission interruption stage respectively in Jiangling County. Correspondingly, to avert one additional DALY, the cost increased by 73937.6 CNY and decreased by 21508.6 CNY respectively. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eAs the epidemic declines, the integrated prevention and control strategy is more cost-effective. Surveillance and management on elder population should be strengthened to avert higher diseases burden.\u003c/p\u003e","manuscriptTitle":"Cost-effectiveness Analysis of the Integrated Control Strategy for Schistosomiasis Japonica in Lake Region of China: a Jiangling Case Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-02-08 18:11:53","doi":"10.21203/rs.3.rs-168300/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2021-02-08T00:00:00+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2021-02-04T00:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2021-02-03T00:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"Infectious Diseases of Poverty","date":"2021-01-27T19:22:51+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"infectious-diseases-of-poverty","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"idop","sideBox":"Learn more about [Infectious Diseases of Poverty](http://idpjournal.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/idop/default.aspx","title":"Infectious Diseases of Poverty","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f5c708c7-62d6-43cb-a971-a98788c1c798","owner":[],"postedDate":"February 8th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":2295856,"name":"Infectious Diseases"}],"tags":[],"updatedAt":"2021-05-20T09:01:35+00:00","versionOfRecord":[],"versionCreatedAt":"2021-02-08 18:11:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-168300","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-168300","identity":"rs-168300","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}