Cross-sectional assessment of Angiostrongylus cantonensis transmission risk mediated by invasive apple snails in Jiangsu Province of China

Cross-sectional assessment of Angiostrongylus cantonensis transmission risk mediated by invasive apple snails in Jiangsu Province of China | 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 Cross-sectional assessment of Angiostrongylus cantonensis transmission risk mediated by invasive apple snails in Jiangsu Province of China Qiang Zhang, Fanzhen Mao, Bixian Ni, Jiayao Zhang, Feng Tang, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7316123/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Angiostrongylus cantonensis ( A. cantonensis ), a zoonotic nematode responsible for eosinophilic meningitis, is transmitted mainly through the ingestion of raw or under cooked invasive apple snails. Despite the widespread distribution of these snails in Jiangsu Province of China, systematic assessments of infection risks and public awareness remain limited. This study evaluated the infection status of A. cantonensis in apple snails and investigated public knowledge, attitudes, and practices (KAP) to inform targeted prevention and control strategies. Methods We carried out a cross-sectional study in six prefectural-level cities in Jiangsu during the snails’ peak reproductive season. A total of 732 wild apple snails were collected from different habitats and screened for A. cantonensis larvae by pepsin–HCl digestion and microscopy. 74 local farm markets were inspected for the sale of live or processed apple snails. Simultaneously, a validated knowledge–attitude–practice (KAP) questionnaire was conducted to 630 randomly selected residents. Data analysis employed SPSS for descriptive statistics and multivariate line regression was used to identify predictors of higher scores. Results All wild-caught snails tested negative for A. cantonensis , and no apple snails were found for sale in any market. Overall public knowledge and attitudes were favorable; however, practice gaps were evident: 40.3% of respondents reported not separating raw and cooked utensils, and 78.7% reported snail sighting to authorities, while 22.1% had ever used the Apple Snail Inspector (ASI) mini-program. KAP scores differed significantly among different demographic groups. Multivariable linear regression analysis revealed that age, city of residence, and education level were significant predictors of KAP scores. Conclusions Current infection risk of A. cantonensis infection in Jiangsu appears low, yet the widespread presence of competent apple snails and suboptimal food-handling practices warrant sustained surveillance. Targeted health education programs that address behavioral gaps among older and less-educated residents can further minimize the threat of A. cantonensis introduction and safeguard both public health and ecological security. Angiostrongylus cantonensis Apple snails Knowledge attitude and practice (KAP) Transmission risk Figures Figure 1 Background Angiostrongylus cantonensis ( A. cantonensis ), the rat lungworm first described by Chen in 1935, is now recognized as the leading global cause of human eosinophilic meningitis [ 1 ]. Human infection follows ingestion of third-stage larvae (L3) residing in intermediate hosts and paratenic hosts, or in contaminated agricultural produce, fruits, and potable water [ 2 – 4 ]. After ingestion, the L3 travel from the intestines to the brain, where upon death, the L3 elicit a strong immune response, leading to meningitis and severe neurological symptoms, including headaches, cranial nerve palsies, and, in severe cases, coma or death [ 5 – 7 ]. Originally endemic to Southeast Asia and the Pacific Islands, the parasite has expanded its geographic range to over 30 countries across Asia, Africa, the Americas, Europe, and Australia, driven by rodent migration and global trade [ 6 , 8 ]. In recent years, reported Angiostrongyliasis cases have increased significantly in China [ 9 – 11 ]. Moreover, there have been multiple outbreaks, which pose a serious threat to human health and have attracted urgent public-health attention [ 12 – 15 ]. Human infections are driven largely by culinary habits, particularly the consumption of raw or under-cooked snail meat—fuelled by a growing appetite for exotic or "fresh" dishes. This behavior heightens exposure to L3, facilitating outbreaks of Angiostrongyliasis . In China, invasive apple snails ( Pomacea spp. ) play pivotal roles in transmitting A. cantonensis and virtually all documented outbreaks have been traced to their ingestion [ 15 – 17 ]. Apple snails, now widespread across southern, southwestern, and central China, has been confirmed as a carrier in several provinces [ 18 , 19 ]. Jiangsu Province is abundant in water resources and the invasive apple snail has rapidly spread across Jiangsu, causing severe damage to aquatic ecosystems including farmlands and ponds in recent years [ 20 ]. It has been listed as one of the eight Level 1 controlled species in Jiangsu province's first catalog of invasive alien species. To date, over 1,200 infestation sites have been documented by our real-time monitoring platform—Apple Snail Inspector (ASI) across various aquatic environments including farmlands, park wetlands, and riverine habitats [ 21 ]. Although no autochthonous human Angiostrongyliasis cases have yet been reported in Jiangsu, the confluence of widespread vector presence and risky food behaviors makes sustained monitoring and targeted health education an urgent public-health priority. A recent survey has shown that approximately 26.74% of residents were unable to identify apple snails in Shanghai [ 22 ], and an online survey revealed that 10.6% of respondents would still knowingly eat raw food, despite the risk of parasitic infection [ 23 ]. These gaps between recognition and practice underscores the critical importance of foodborne disease prevention during the annual reproductive peak. The Knowledge, attitudes, and practices (KAP) model is a foundational tool in public health research. It offers a systematic approach to understanding health behaviors, empowering researchers to design impactful interventions and assess their success. KAP surveys play a vital role in this process by assessing the current level of knowledge within a population regarding specific health issues [ 24 ]. By quantitatively analyzing public knowledge, preventive attitudes, and behavioral practices regarding apple snails, cognitive vulnerabilities can be precisely identified. Sustained KAP monitoring not only evaluates the effectiveness of awareness campaigns but also guides the establishment of a community-based "identification-prevention-reporting" through behavior change theories, ultimately forming a closed-loop control system [ 25 ]. Leveraging the Apple Snail Inspector (ASI) platform, we simultaneously conducted A. cantonensis surveillance in selected Jiangsu cities and a population-based KAP survey on apple snail awareness. Findings will be translated into precision interventions: risk-communication campaigns for low-awareness groups, enhanced alerts for those underestimating danger, and behavior-nudging measures to correct unsafe practices. These integrated efforts will effectively reduce the infection risks of A. cantonensis , protect public health and ecological security. Methods Field sampling and detection of apple snails Six prefectural-level cities in Jiangsu (Wuxi, Suzhou, Nantong, Yancheng, Taizhou, and Suqian) were purposively selected to cover the province’s major drainage basins and to coincide with Apple Snail Inspector (ASI) hot-spot data. A minimum of four sampling sites per city were selected (all sites were enrolled if < 4 existed), prioritizing locations with both apple snail infestations and signs of rodent activity. Snails were collected between June and September 2024 (the species’ peak reproductive window) using a combination of dip-netting and gloved hand-picking. At least 25 apple snails were collected per site, with a total sample size reaching ≥ 100 snails for subsequent detection. Snails were transported to the laboratory for microscopic examination using standard digestion techniques and lung-tissue microscopy to detect A. cantonensis larvae [ 26 ]. Market sale status of apple snails During the monitoring period (June and September 2024), field surveys were carried out at a minimum of three markets per site each month. If apple snails were found on sale at these markets, specimens were purchased and subjected to laboratory detection. Population-based KAP survey We developed a 16-item KAP questionnaire tailored to the Jiangsu context (Additional file 1). Then questionnaire content validity was refined through a group meeting with experts in parasitology, epidemiology, health education, and veterinary public health. The final questionnaire comprised three dimensions: (1) Knowledge: 5 items assessing recognition of apple snails, awareness of their health risks, and understanding of preventive measures (correct answer scored 1 and incorrect answer scored 0); (2) Attitude: 4 items evaluating risk perception and willingness to adopt protective behaviors (positive attitude scored 1 and negative attitude scored 0); (3) Practice: 7 items measuring self-reported behaviors related to snail handling, consumption, and reporting (good practice scored 1 and poor practice scored 0). The tool demonstrated high reliability (Cronbach’s α = 0.63) and was validated through pilot testing. The surveys were implemented in communities and schools adjacent to their infestation sites, with a requirement of surveying ≥ 100 respondents per monitoring site. Demographic variables included city of residence, age, gender, education, occupation, and marital status. Statistical analysis Data was reported using a customized Epidata database and entered using a dual-entry verification method by two independent operators. All visualizations were produced using Microsoft Excel 2016. Statistical analyses were performed with SPSS 23.0. Descriptive statistics (mean ± standard deviation, x̄ ± s) summarized KAP scores across subgroups. Intergroup differences were evaluated via independent t-tests and one-way ANOVA. Multivariate linear regression identified predictors of KAP scores, adjusting for covariates such as city of residence, age, education, and occupation. Statistical significance was set at P < 0.05 (two-tailed). Ethical considerations This study was reviewed and approved by the Institutional Ethics Committee of Jiangsu Institute of Parasite Diseases. Written informed consent was obtained from all participants, and data were anonymized to ensure confidentiality. Results No infected apple snails and market sales observed. A total of 732 wild apple snails were collected across the six surveyed cities in Jiangsu Province (Table 1 ): Wuxi (100), Suzhou (135); Nantong(112), Yancheng (160), Taizhou (100), Suqian (125). Laboratory detection revealed no A. cantonensis larvae in any specimen. Concurrently, market inspections across 74 local markets (Wuxi: 12; Suzhou: 12; Nantong: 12; Yancheng: 14; Taizhou: 12; Suqian: 12) found no apple snails offered for sale, indicating effective market regulation and a low risk of human exposure to infected snails in these regions. Table 1 Investigation on the field infection and market sales status of apple snails City Field investigation Market sales investigation Tested samples Positive samples Investigated markets Existence of sales situation Wuxi 100 0 12 0 Suzhou 135 0 12 0 Nantong 112 0 12 0 Yancheng 160 0 14 0 Taizhou 100 0 12 0 Suqian 125 0 12 0 Total 732 0 74 0 Responses of the surveyed population to the KAP questions regarding apple snails A total of 630 questionnaires were collected in this study. In the knowledge aspect, the percentage of correct answers is relatively high (>80% correct on all items), indicating that the public has a certain level of understanding in these areas. Regarding attitudes, most respondents showed a positive attitude with 98.3% of respondents expressed a desire to learn about apple snail hazards, and 97.3% were willing to share relevant knowledge with others. In terms of practices, although a certain number of people separate raw and cooked cutting boards and knives, there is still a significant portion who do not (40.3%). Moreover, only 78.7% respondents would report the discovery of apple snail to authorities and just 22.1% had ever used the Apple Snail Inspector (ASI) platform (Fig. 1 ). KAP scores across demographic subgroups KAP scores showed significant disparities among different demographic groups (Table 2 ). By city ( P < 0.001), Nantong exhibited the highest score (14.10 ± 1.92), while Suqian had the lowest score (12.44 ± 2.20). Gender differences were negligible (males 13.35 ± 1.90 vs. females 13.25 ± 2.15; P = 0.549). Age emerged as a critical factor: individuals aged 40 scored lowest (12.93 ± 2.08) ( P < 0.001). Education level also significantly influenced scores, with higher education (e.g., college graduates: 13.91 ± 1.84) associated with better KAP scores compared to primary education (13.11 ± 2.09) ( P < 0.001). Occupation-based analysis highlighted students (13.83 ± 1.77) and “other” occupations (13.84 ± 1.49) as high-performing groups, whereas farmers scored lowest (12.59 ± 2.12) ( P < 0.001). Marital status further stratified results, with unmarried individuals (13.75 ± 1.90) outperforming married participants (13.12 ± 2.04) ( P < 0.001). Table 2 Comparison of KAP scores in each dimension with different demographic characteristic Characteristics Numbers Knowledge (x̄ ± s) Attitude (x̄ ± s) Practice (x̄ ± s) Total (x̄ ± s) City Wuxi 100 4.51 ± 1.02 3.84 ± 0.37 5.47 ± 1.03 13.82 ± 2.07 Suzhou 100 4.45 ± 1.10 3.74 ± 0.51 5.47 ± 1.05 13.66 ± 1.99 Nantong 105 4.43 ± 1.28 3.88 ± 0.36 5.80 ± 0.58 14.10 ± 1.92 Yancheng 116 4.94 ± 0.30 3.87 ± 0.45 4.86 ± 1.05 13.67 ± 1.25 Taizhou 100 3.38 ± 1.18 3.24 ± 0.57 5.50 ± 1.16 12.12 ± 1.81 Suqian 109 4.15 ± 1.31 3.16 ± 0.72 5.14 ± 1.11 12.44 ± 2.20 F 24.488 44.494 11.471 19.330 P < 0.001 * < 0.001 * < 0.001 * < 0.001 * Gender Male 339 4.39 ± 1.09 3.60 ± 0.62 5.36 ± 1.03 13.35 ± 1.90 Female 291 4.24 ± 1.27 3.65 ± 0.57 5.36 ± 1.09 13.25 ± 2.15 t 1.562 -1.202 0.065 0.599 P 0.119 0.230 0.949 0.549 Age 40 343 4.07 ± 1.27 3.58 ± 0.62 5.28 ± 1.12 12.93 ± 2.08 F 21.522 3.440 4.565 13.793 P < 0.001 * 0.033 * 0.011 * < 0.001 * Education level Primary school and below 230 4.27 ± 1.29 3.61 ± 0.65 5.22 ± 1.05 13.11 ± 2.09 Junior high school 150 4.09 ± 1.29 3.55 ± 0.62 5.10 ± 1.10 12.74 ± 2.09 High school or technical secondary school 99 4.42 ± 0.91 3.67 ± 0.54 5.61 ± 0.99 13.70 ± 1.68 Junior college and above 151 4.56 ± 0.97 3.68 ± 0.51 5.67 ± 0.95 13.91 ± 1.84 F 4.452 1.527 10.975 10.960 P 0.004 * 0.206 < 0.001 * < 0.001 * Occupation Farmer 149 3.95 ± 1.37 3.55 ± 0.63 5.09 ± 1.19 12.59 ± 2.12 Worker 117 4.20 ± 1.18 3.63 ± 0.60 5.32 ± 0.99 13.15 ± 1.96 Medical Worker 58 4.34 ± 1.15 3.57 ± 0.62 5.55 ± 1.13 13.47 ± 2.20 Self-employed 64 4.22 ± 1.24 3.59 ± 0.61 5.33 ± 1.156 13.14 ± 2.38 Student 157 4.78 ± 0.89 3.71 ± 0.59 5.34 ± 0.94 13.83 ± 1.77 Others 85 4.39 ± 0.95 3.62 ± 0.49 5.82 ± 0.76 13.84 ± 1.49 F 8.663 1.308 5.850 7.706 ± 2.02 P < 0.001 * 0.259 < 0.001 * < 0.001 * Marital Status Unmarried 186 4.69 ± 1.00 3.70 ± .59 5.36 ± 0.97 13.75 ± 1.90 Married 444 4.17 ± 1.21 3.59 ± .59 5.36 ± 1.09 13.12 ± 2.04 t 5.542 2.253 -0.002 3.626 P < 0.001 * 0.025 * 0.999 < 0.001 * * Statistically significant. Multivariate predictors of KAP scores Variables with a univariate p -value of total scores below 0.05 were further analyzed using multivariate liner regression analysis to identify key predictors of KAP scores. Three factors remained significant predictors of total KAP score including city of residence (all cities scored higher than the Suqian reference group), younger age and higher education level (Table 3 ), whereas occupations and marital status did not independently predict scores in the adjusted model. Table 3 Multivariate liner regression analysis of the influence of different characteristics on KAP scores Characteristics β Standard error Standardized β P Age -0.030 0.010 -0.307 0.002 * Marital Status (Ref = Married) -0.461 0.372 -0.104 0.216 City (Ref = Suqian) Wuxi 1.214 0.275 0.220 < 0.001 * Suzhou 1.265 0.267 0.229 < 0.001 * Nantong 2.025 0.259 0.374 < 0.001 * Yancheng 1.683 0.263 0.323 < 0.001 * Taizhou 0.609 0.286 0.110 0.034 Education level (Ref = Primary School and Below) Junior high school 0.484 0.226 0.102 0.033 * High school or technical secondary school 1.342 0.288 0.242 < 0.001 * College and above 1.274 0.333 0.270 < 0.001 * Occupation (Ref = Farmer) Worker -0.494 0.292 -0.095 0.091 Medical Worker -0.702 0.377 -0.101 0.063 Self-employed -0.329 0.331 -0.049 0.322 Student 0.057 0.538 0.012 0.915 Others 0.071 0.328 0.012 0.829 * Statistically significant. Discussions The findings of this study provide critical assessment of the current status of A. cantonensis infection risk in Jiangsu Province of China, and couples rigorous ecological surveillance with a detailed behavioral analysis. Although no infected snails or market sales were detected, the pronounced practice gaps revealed by the KAP survey demonstrate that ecological absence does not equate to population safety. The integration of field data and behavioral insights provides policymakers with an evidence-based dual perspective on both ecological and behavioral dimensions to design targeted interventions, strengthen health education. Although invasive apple snails are a significant vector for A. cantonensis [ 27 ], none of 732 wild specimens collected across six cities in Jiangsu carried the parasite. However, the ecological adaptability of apple snails and their widespread distribution in Jiangsu’s water networks necessitate vigilance [ 21 , 28 ]. Multiple provinces adjacent to Jiangsu have documented infections of A. cantonensis in the apple snails [ 29 , 30 ]. The apparent absence in Jiangsu may due to limited sample size, seasonal sampling, or presently unfavorable local ecological conditions [ 31 ]. Additionally, no apple snail sales were found in the 74 surveyed local markets, indicating effective market regulation in these regions, which likely reduces the direct risk of human infection through the consumption of infected snails. However, the morphological overlap between apple snails and Cipangopaludina chinensis [ 32 ] raises the possibility of undetected misidentification during the market surveys. Therefore, continuous surveillance, as recommended by the World Health Organization for neglected tropical diseases, is essential to detect early-stage zoonotic shifts [ 33 ]. The KAP survey results show that the residents in Jiangsu has a relatively high knowledge level of apple snails. This could be attributed to previous health education efforts and increased public awareness of food-borne diseases [ 23 , 34 ]. However, a small proportion of the population remains unaware of apple snail and its associated risk. In terms of attitude, most respondents had a positive attitude, such as a strong willingness to learn about apple snail hazards and disseminate health information, providing a receptive base for future interventions. However, previous research has shown that knowledge does not reliably translate into preventive behaviors, especially when there is a lack of perceived personal risk or motivation [ 35 ]. Although a certain number of households separated raw and cooked cutting boards and knives, 40.3% did not, creating a clear pathway for cross-contamination. This is particularly important given the potential for rapid spread of A. cantonensis through contaminated food and water sources. Moreover, the low reporting rates of apple snail discoveries (78.7% to authorities and 22.1% using ASI) underscore the need for improvement in public participation in surveillance. Demographic disparities in KAP scores were pronounced in this study. Respondents aged < 20, those with higher level education, students, and unmarried individuals generally had higher scores, likely because younger age groups access diverse information channels, and higher education fosters stronger information-seeking and risk-perception skills. In contrast, farmers had the lowest scores, which could be related to their limited access to health education resources and different living and working environments. This is consistent with previous research indicating that education level is a robust determinant of health knowledge and behavior [ 23 , 36 ]. These results highlight the need for differentiated health education strategy. For example, concise, actionable training modules and pictorial materials should be designed specifically for farmers, delivered through village health workers to maximize reach and impact. Multivariate regression analysis identified age, city of residence, and education level as the significant predictors of KAP scores. Furthermore, the significant differences in KAP scores across cities highlight the need for region-specific strategies. Cities with higher KAP scores such as like Nantong, may benefit from reinforcing existing educational programs, while cities with lower scores like Suqian, require more intensive interventions. This approach aligns with the principles of community-based participatory research [ 37 ], which emphasizes the importance of local context in designing effective public health initiatives. Additionally, promoting education based prevention measures, such as incorporating apple snail related knowledge into school curricula and community education programs [ 38 , 39 ], could offer a scalable, education-centered pathway to raise public awareness and convert knowledge into sustained preventive behaviors. This study has several limitations. Firstly, the cross-sectional design precludes causal inferences between KAP factors and infection risks, and longitudinal studies are needed to track behavioral changes after intervention. Secondly, the sample size is insufficient and the sampling focused on urban and peri-urban areas; rural regions with higher agricultural activity may face distinct challenges. Expanding surveillance to remote areas will enhance the representativeness. Finally, while no infections were detected, reliance on microscopic examination in this study may miss low level larval infestations, and integrating molecular techniques such as PCR in future surveys will improve detection sensitivity. Conclusion This study highlights the importance of public awareness and behavior in preventing A. cantonensis infection. Although the parasite was not detected in Jiangsu Province in this survey, the persistent gaps in public knowledge and practices underscore the need for sustained efforts to improve food safety and disease prevention. A sustained, integrated strategy combining real-time surveillance, targeted education tailored to high-risk population, and evidence-based policy measures can safeguard public health in an era of increasing zoonotic threats. Abbreviations A. cantonensis Angiostrongylus cantonensis KAP Knowledge, attitudes, and practices L3 Third-stage larvae ASI Apple snail inspector Declarations Ethics approval and consent to participate This study was approved by the Ethics Review Committee of Jiangsu Institute of Parasite Diseases. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Fundings This work was supported by the Jiangsu Province Capability Improvement Project through Science, Technology, and Education (No. ZDXYS202207) and Jiangsu Provincial Preventive Medicine Association Research Program (Y12023051). Author Contribution YL and QZ conceived and designed the study. QZ wrote the protocol and draft the manuscript. QZ, FM and BN conducted the data gathering. JZ supervised the data processing and analysis. QZ, FT and XG conducted field sampling and laboratory detection. 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Supplementary Files TextS1.docx Additional file 1: Text S1: Questionnaire on knowledge, attitudes, and practices (KAP) regarding apple snails in Jiangsu province Cite Share Download PDF Status: Posted Version 1 posted 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-7316123","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":502534421,"identity":"1515a655-88eb-4c46-9c6f-81d6832d753f","order_by":0,"name":"Qiang Zhang","email":"","orcid":"","institution":"National Health Commission Key Laboratory of Parasitic Disease Control and Prevention","correspondingAuthor":false,"prefix":"","firstName":"Qiang","middleName":"","lastName":"Zhang","suffix":""},{"id":502534424,"identity":"c010c907-3ea2-48f3-9289-0741d5db4910","order_by":1,"name":"Fanzhen Mao","email":"","orcid":"","institution":"National Health Commission Key Laboratory of Parasitic Disease Control and Prevention","correspondingAuthor":false,"prefix":"","firstName":"Fanzhen","middleName":"","lastName":"Mao","suffix":""},{"id":502534428,"identity":"bfac9ade-75cb-4b5d-97f9-a453f542cad5","order_by":2,"name":"Bixian Ni","email":"","orcid":"","institution":"National Health Commission Key Laboratory of Parasitic Disease Control and Prevention","correspondingAuthor":false,"prefix":"","firstName":"Bixian","middleName":"","lastName":"Ni","suffix":""},{"id":502534430,"identity":"6f2b6962-4cde-494a-97cf-7e2c8503c04e","order_by":3,"name":"Jiayao Zhang","email":"","orcid":"","institution":"National Health Commission Key Laboratory of Parasitic Disease Control and Prevention","correspondingAuthor":false,"prefix":"","firstName":"Jiayao","middleName":"","lastName":"Zhang","suffix":""},{"id":502534432,"identity":"73b790fe-847a-4b4d-a953-e3d651018250","order_by":4,"name":"Feng Tang","email":"","orcid":"","institution":"National Health 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Liu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA20lEQVRIiWNgGAWjYHACNiCWqO9nZj5w4MMP4rXYMM5sZ0s8OLOHeC1pjBvO8xgf5mAjQr3B8cPHHvyoOMzMcJjnw2EGHgZ5frEDBLScSUs37DlzmI2xmXfD4QILBsOZsxMIaDmQYybB23aYh5kZqGUGD0OCwW1CWs6/MZP823ZYgo2Z58FhHjZitNzIMZPmbUsz4GHmYSBOi+SNZ+nGMmdsEiSY2QyAgSxB2C9855OPPXxTIZFgf/7w4w8fftjI80sT0KJwAJUvgV85CMg3EFYzCkbBKBgFIx0AAKdnRqbSjeIQAAAAAElFTkSuQmCC","orcid":"","institution":"National Health Commission Key Laboratory of Parasitic Disease Control and Prevention","correspondingAuthor":true,"prefix":"","firstName":"Yaobao","middleName":"","lastName":"Liu","suffix":""}],"badges":[],"createdAt":"2025-08-07 07:53:49","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7316123/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7316123/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89551358,"identity":"c527270b-3d99-4495-84c5-140079fb0250","added_by":"auto","created_at":"2025-08-21 08:24:02","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":66963,"visible":true,"origin":"","legend":"\u003cp\u003eResponses of the surveyed population to the KAP questions about apple snails\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7316123/v1/b9e07964d3cb815263ae88ec.png"},{"id":92375324,"identity":"e7240677-31fc-4a0e-9cca-97a1125f4851","added_by":"auto","created_at":"2025-09-29 04:32:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1130852,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7316123/v1/f301c871-8ca9-4ae9-b1e2-e1409319058c.pdf"},{"id":89551361,"identity":"c6b5ccd2-a049-4cd6-9f06-afe3cdaef514","added_by":"auto","created_at":"2025-08-21 08:24:03","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":15232,"visible":true,"origin":"","legend":"\u003cp\u003eAdditional file 1: Text S1: Questionnaire on knowledge, attitudes, and practices (KAP) regarding apple snails in Jiangsu province\u003c/p\u003e","description":"","filename":"TextS1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7316123/v1/24069ecf440e5643e982174e.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Cross-sectional assessment of Angiostrongylus cantonensis transmission risk mediated by invasive apple snails in Jiangsu Province of China","fulltext":[{"header":"Background","content":"\u003cp\u003e\u003cem\u003eAngiostrongylus cantonensis\u003c/em\u003e (\u003cem\u003eA. cantonensis\u003c/em\u003e), the rat lungworm first described by Chen in 1935, is now recognized as the leading global cause of human eosinophilic meningitis [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Human infection follows ingestion of third-stage larvae (L3) residing in intermediate hosts and paratenic hosts, or in contaminated agricultural produce, fruits, and potable water [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. After ingestion, the L3 travel from the intestines to the brain, where upon death, the L3 elicit a strong immune response, leading to meningitis and severe neurological symptoms, including headaches, cranial nerve palsies, and, in severe cases, coma or death [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Originally endemic to Southeast Asia and the Pacific Islands, the parasite has expanded its geographic range to over 30 countries across Asia, Africa, the Americas, Europe, and Australia, driven by rodent migration and global trade [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In recent years, reported \u003cem\u003eAngiostrongyliasis\u003c/em\u003e cases have increased significantly in China [\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Moreover, there have been multiple outbreaks, which pose a serious threat to human health and have attracted urgent public-health attention [\u003cspan additionalcitationids=\"CR13 CR14\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eHuman infections are driven largely by culinary habits, particularly the consumption of raw or under-cooked snail meat\u0026mdash;fuelled by a growing appetite for exotic or \"fresh\" dishes. This behavior heightens exposure to L3, facilitating outbreaks of \u003cem\u003eAngiostrongyliasis\u003c/em\u003e. In China, invasive apple snails (\u003cem\u003ePomacea spp.\u003c/em\u003e) play pivotal roles in transmitting \u003cem\u003eA. cantonensis\u003c/em\u003e and virtually all documented outbreaks have been traced to their ingestion [\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Apple snails, now widespread across southern, southwestern, and central China, has been confirmed as a carrier in several provinces [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Jiangsu Province is abundant in water resources and the invasive apple snail has rapidly spread across Jiangsu, causing severe damage to aquatic ecosystems including farmlands and ponds in recent years [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. It has been listed as one of the eight Level 1 controlled species in Jiangsu province's first catalog of invasive alien species. To date, over 1,200 infestation sites have been documented by our real-time monitoring platform\u0026mdash;Apple Snail Inspector (ASI) across various aquatic environments including farmlands, park wetlands, and riverine habitats [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Although no autochthonous human \u003cem\u003eAngiostrongyliasis\u003c/em\u003e cases have yet been reported in Jiangsu, the confluence of widespread vector presence and risky food behaviors makes sustained monitoring and targeted health education an urgent public-health priority.\u003c/p\u003e\u003cp\u003eA recent survey has shown that approximately 26.74% of residents were unable to identify apple snails in Shanghai [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], and an online survey revealed that 10.6% of respondents would still knowingly eat raw food, despite the risk of parasitic infection [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. These gaps between recognition and practice underscores the critical importance of foodborne disease prevention during the annual reproductive peak. The Knowledge, attitudes, and practices (KAP) model is a foundational tool in public health research. It offers a systematic approach to understanding health behaviors, empowering researchers to design impactful interventions and assess their success. KAP surveys play a vital role in this process by assessing the current level of knowledge within a population regarding specific health issues [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. By quantitatively analyzing public knowledge, preventive attitudes, and behavioral practices regarding apple snails, cognitive vulnerabilities can be precisely identified. Sustained KAP monitoring not only evaluates the effectiveness of awareness campaigns but also guides the establishment of a community-based \"identification-prevention-reporting\" through behavior change theories, ultimately forming a closed-loop control system [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eLeveraging the Apple Snail Inspector (ASI) platform, we simultaneously conducted \u003cem\u003eA. cantonensis\u003c/em\u003e surveillance in selected Jiangsu cities and a population-based KAP survey on apple snail awareness. Findings will be translated into precision interventions: risk-communication campaigns for low-awareness groups, enhanced alerts for those underestimating danger, and behavior-nudging measures to correct unsafe practices. These integrated efforts will effectively reduce the infection risks of \u003cem\u003eA. cantonensis\u003c/em\u003e, protect public health and ecological security.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eField sampling and detection of apple snails\u003c/h2\u003e\u003cp\u003eSix prefectural-level cities in Jiangsu (Wuxi, Suzhou, Nantong, Yancheng, Taizhou, and Suqian) were purposively selected to cover the province\u0026rsquo;s major drainage basins and to coincide with Apple Snail Inspector (ASI) hot-spot data. A minimum of four sampling sites per city were selected (all sites were enrolled if\u0026thinsp;\u0026lt;\u0026thinsp;4 existed), prioritizing locations with both apple snail infestations and signs of rodent activity. Snails were collected between June and September 2024 (the species\u0026rsquo; peak reproductive window) using a combination of dip-netting and gloved hand-picking. At least 25 apple snails were collected per site, with a total sample size reaching\u0026thinsp;\u0026ge;\u0026thinsp;100 snails for subsequent detection. Snails were transported to the laboratory for microscopic examination using standard digestion techniques and lung-tissue microscopy to detect \u003cem\u003eA. cantonensis\u003c/em\u003e larvae [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eMarket sale status of apple snails\u003c/h3\u003e\n\u003cp\u003eDuring the monitoring period (June and September 2024), field surveys were carried out at a minimum of three markets per site each month. If apple snails were found on sale at these markets, specimens were purchased and subjected to laboratory detection.\u003c/p\u003e\n\u003ch3\u003ePopulation-based KAP survey\u003c/h3\u003e\n\u003cp\u003eWe developed a 16-item KAP questionnaire tailored to the Jiangsu context (Additional file 1). Then questionnaire content validity was refined through a group meeting with experts in parasitology, epidemiology, health education, and veterinary public health. The final questionnaire comprised three dimensions: (1) Knowledge: 5 items assessing recognition of apple snails, awareness of their health risks, and understanding of preventive measures (correct answer scored 1 and incorrect answer scored 0); (2) Attitude: 4 items evaluating risk perception and willingness to adopt protective behaviors (positive attitude scored 1 and negative attitude scored 0); (3) Practice: 7 items measuring self-reported behaviors related to snail handling, consumption, and reporting (good practice scored 1 and poor practice scored 0). The tool demonstrated high reliability (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.63) and was validated through pilot testing. The surveys were implemented in communities and schools adjacent to their infestation sites, with a requirement of surveying\u0026thinsp;\u0026ge;\u0026thinsp;100 respondents per monitoring site. Demographic variables included city of residence, age, gender, education, occupation, and marital status.\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eData was reported using a customized Epidata database and entered using a dual-entry verification method by two independent operators. All visualizations were produced using Microsoft Excel 2016. Statistical analyses were performed with SPSS 23.0. Descriptive statistics (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, x̄ \u0026plusmn; s) summarized KAP scores across subgroups. Intergroup differences were evaluated via independent t-tests and one-way ANOVA. Multivariate linear regression identified predictors of KAP scores, adjusting for covariates such as city of residence, age, education, and occupation. Statistical significance was set at \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 (two-tailed).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eEthical considerations\u003c/h3\u003e\n\u003cp\u003eThis study was reviewed and approved by the Institutional Ethics Committee of Jiangsu Institute of Parasite Diseases. Written informed consent was obtained from all participants, and data were anonymized to ensure confidentiality.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cb\u003eNo infected apple snails and market sales observed.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA total of 732 wild apple snails were collected across the six surveyed cities in Jiangsu Province (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e): Wuxi (100), Suzhou (135); Nantong(112), Yancheng (160), Taizhou (100), Suqian (125). Laboratory detection revealed no \u003cem\u003eA. cantonensis\u003c/em\u003e larvae in any specimen. Concurrently, market inspections across 74 local markets (Wuxi: 12; Suzhou: 12; Nantong: 12; Yancheng: 14; Taizhou: 12; Suqian: 12) found no apple snails offered for sale, indicating effective market regulation and a low risk of human exposure to infected snails in these regions.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eInvestigation on the field infection and market sales status of apple snails\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCity\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eField investigation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003eMarket sales investigation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTested samples\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePositive samples\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eInvestigated markets\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eExistence of sales situation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWuxi\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSuzhou\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e135\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNantong\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e112\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYancheng\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e160\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTaizhou\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSuqian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e125\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e732\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eResponses of the surveyed population to the KAP questions regarding apple snails\u003c/h3\u003e\n\u003cp\u003eA total of 630 questionnaires were collected in this study. In the knowledge aspect, the percentage of correct answers is relatively high (\u0026gt;80% correct on all items), indicating that the public has a certain level of understanding in these areas. Regarding attitudes, most respondents showed a positive attitude with 98.3% of respondents expressed a desire to learn about apple snail hazards, and 97.3% were willing to share relevant knowledge with others. In terms of practices, although a certain number of people separate raw and cooked cutting boards and knives, there is still a significant portion who do not (40.3%). Moreover, only 78.7% respondents would report the discovery of apple snail to authorities and just 22.1% had ever used the Apple Snail Inspector (ASI) platform (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003eKAP scores across demographic subgroups\u003c/h3\u003e\n\u003cp\u003eKAP scores showed significant disparities among different demographic groups (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). By city (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), Nantong exhibited the highest score (14.10\u0026thinsp;\u0026plusmn;\u0026thinsp;1.92), while Suqian had the lowest score (12.44\u0026thinsp;\u0026plusmn;\u0026thinsp;2.20). Gender differences were negligible (males 13.35\u0026thinsp;\u0026plusmn;\u0026thinsp;1.90 vs. females 13.25\u0026thinsp;\u0026plusmn;\u0026thinsp;2.15; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.549). Age emerged as a critical factor: individuals aged\u0026thinsp;\u0026lt;\u0026thinsp;20 scored highest (13.82\u0026thinsp;\u0026plusmn;\u0026thinsp;1.80), while those\u0026thinsp;\u0026gt;\u0026thinsp;40 scored lowest (12.93\u0026thinsp;\u0026plusmn;\u0026thinsp;2.08) (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Education level also significantly influenced scores, with higher education (e.g., college graduates: 13.91\u0026thinsp;\u0026plusmn;\u0026thinsp;1.84) associated with better KAP scores compared to primary education (13.11\u0026thinsp;\u0026plusmn;\u0026thinsp;2.09) (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Occupation-based analysis highlighted students (13.83\u0026thinsp;\u0026plusmn;\u0026thinsp;1.77) and \u0026ldquo;other\u0026rdquo; occupations (13.84\u0026thinsp;\u0026plusmn;\u0026thinsp;1.49) as high-performing groups, whereas farmers scored lowest (12.59\u0026thinsp;\u0026plusmn;\u0026thinsp;2.12) (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Marital status further stratified results, with unmarried individuals (13.75\u0026thinsp;\u0026plusmn;\u0026thinsp;1.90) outperforming married participants (13.12\u0026thinsp;\u0026plusmn;\u0026thinsp;2.04) (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of KAP scores in each dimension with different demographic characteristic\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNumbers\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eKnowledge\u003c/p\u003e\u003cp\u003e(x̄ \u0026plusmn; s)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAttitude\u003c/p\u003e\u003cp\u003e(x̄ \u0026plusmn; s)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePractice\u003c/p\u003e\u003cp\u003e(x̄ \u0026plusmn; s)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003cp\u003e(x̄ \u0026plusmn; s)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWuxi\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.51\u0026thinsp;\u0026plusmn;\u0026thinsp;1.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.84\u0026thinsp;\u0026plusmn;\u0026thinsp;0.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.47\u0026thinsp;\u0026plusmn;\u0026thinsp;1.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e13.82\u0026thinsp;\u0026plusmn;\u0026thinsp;2.07\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSuzhou\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.45\u0026thinsp;\u0026plusmn;\u0026thinsp;1.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.74\u0026thinsp;\u0026plusmn;\u0026thinsp;0.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.47\u0026thinsp;\u0026plusmn;\u0026thinsp;1.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e13.66\u0026thinsp;\u0026plusmn;\u0026thinsp;1.99\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNantong\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e105\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.43\u0026thinsp;\u0026plusmn;\u0026thinsp;1.28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.88\u0026thinsp;\u0026plusmn;\u0026thinsp;0.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.80\u0026thinsp;\u0026plusmn;\u0026thinsp;0.58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e14.10\u0026thinsp;\u0026plusmn;\u0026thinsp;1.92\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYancheng\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e116\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.94\u0026thinsp;\u0026plusmn;\u0026thinsp;0.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.87\u0026thinsp;\u0026plusmn;\u0026thinsp;0.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.86\u0026thinsp;\u0026plusmn;\u0026thinsp;1.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e13.67\u0026thinsp;\u0026plusmn;\u0026thinsp;1.25\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTaizhou\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.38\u0026thinsp;\u0026plusmn;\u0026thinsp;1.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.24\u0026thinsp;\u0026plusmn;\u0026thinsp;0.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.50\u0026thinsp;\u0026plusmn;\u0026thinsp;1.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e12.12\u0026thinsp;\u0026plusmn;\u0026thinsp;1.81\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSuqian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e109\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.15\u0026thinsp;\u0026plusmn;\u0026thinsp;1.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.16\u0026thinsp;\u0026plusmn;\u0026thinsp;0.72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.14\u0026thinsp;\u0026plusmn;\u0026thinsp;1.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e12.44\u0026thinsp;\u0026plusmn;\u0026thinsp;2.20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eF\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24.488\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e44.494\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11.471\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e19.330\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e339\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.39\u0026thinsp;\u0026plusmn;\u0026thinsp;1.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.60\u0026thinsp;\u0026plusmn;\u0026thinsp;0.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.36\u0026thinsp;\u0026plusmn;\u0026thinsp;1.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e13.35\u0026thinsp;\u0026plusmn;\u0026thinsp;1.90\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e291\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.24\u0026thinsp;\u0026plusmn;\u0026thinsp;1.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.65\u0026thinsp;\u0026plusmn;\u0026thinsp;0.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.36\u0026thinsp;\u0026plusmn;\u0026thinsp;1.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e13.25\u0026thinsp;\u0026plusmn;\u0026thinsp;2.15\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.562\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-1.202\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.065\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.599\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.119\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.230\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.949\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.549\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e152\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.77\u0026thinsp;\u0026plusmn;\u0026thinsp;0.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.73\u0026thinsp;\u0026plusmn;\u0026thinsp;0.59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.32\u0026thinsp;\u0026plusmn;\u0026thinsp;0.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e13.82\u0026thinsp;\u0026plusmn;\u0026thinsp;1.80\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e20\u0026ndash;40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e135\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.47\u0026thinsp;\u0026plusmn;\u0026thinsp;1.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.61\u0026thinsp;\u0026plusmn;\u0026thinsp;0.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.60\u0026thinsp;\u0026plusmn;\u0026thinsp;0.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e13.68\u0026thinsp;\u0026plusmn;\u0026thinsp;1.92\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e343\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.07\u0026thinsp;\u0026plusmn;\u0026thinsp;1.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.58\u0026thinsp;\u0026plusmn;\u0026thinsp;0.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.28\u0026thinsp;\u0026plusmn;\u0026thinsp;1.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e12.93\u0026thinsp;\u0026plusmn;\u0026thinsp;2.08\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eF\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21.522\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.440\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.565\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e13.793\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.033\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.011\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEducation level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrimary school and below\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e230\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.27\u0026thinsp;\u0026plusmn;\u0026thinsp;1.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.61\u0026thinsp;\u0026plusmn;\u0026thinsp;0.65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.22\u0026thinsp;\u0026plusmn;\u0026thinsp;1.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e13.11\u0026thinsp;\u0026plusmn;\u0026thinsp;2.09\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJunior high school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e150\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.09\u0026thinsp;\u0026plusmn;\u0026thinsp;1.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.55\u0026thinsp;\u0026plusmn;\u0026thinsp;0.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.10\u0026thinsp;\u0026plusmn;\u0026thinsp;1.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e12.74\u0026thinsp;\u0026plusmn;\u0026thinsp;2.09\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHigh school or technical secondary school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.42\u0026thinsp;\u0026plusmn;\u0026thinsp;0.91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.67\u0026thinsp;\u0026plusmn;\u0026thinsp;0.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.61\u0026thinsp;\u0026plusmn;\u0026thinsp;0.99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e13.70\u0026thinsp;\u0026plusmn;\u0026thinsp;1.68\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJunior college and above\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e151\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.56\u0026thinsp;\u0026plusmn;\u0026thinsp;0.97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.68\u0026thinsp;\u0026plusmn;\u0026thinsp;0.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.67\u0026thinsp;\u0026plusmn;\u0026thinsp;0.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e13.91\u0026thinsp;\u0026plusmn;\u0026thinsp;1.84\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eF\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.452\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.527\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10.975\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e10.960\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.004\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.206\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOccupation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFarmer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e149\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.95\u0026thinsp;\u0026plusmn;\u0026thinsp;1.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.55\u0026thinsp;\u0026plusmn;\u0026thinsp;0.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.09\u0026thinsp;\u0026plusmn;\u0026thinsp;1.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e12.59\u0026thinsp;\u0026plusmn;\u0026thinsp;2.12\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWorker\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e117\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.20\u0026thinsp;\u0026plusmn;\u0026thinsp;1.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.63\u0026thinsp;\u0026plusmn;\u0026thinsp;0.60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.32\u0026thinsp;\u0026plusmn;\u0026thinsp;0.99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e13.15\u0026thinsp;\u0026plusmn;\u0026thinsp;1.96\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedical Worker\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.34\u0026thinsp;\u0026plusmn;\u0026thinsp;1.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.57\u0026thinsp;\u0026plusmn;\u0026thinsp;0.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.55\u0026thinsp;\u0026plusmn;\u0026thinsp;1.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e13.47\u0026thinsp;\u0026plusmn;\u0026thinsp;2.20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSelf-employed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.22\u0026thinsp;\u0026plusmn;\u0026thinsp;1.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.59\u0026thinsp;\u0026plusmn;\u0026thinsp;0.61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.33\u0026thinsp;\u0026plusmn;\u0026thinsp;1.156\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e13.14\u0026thinsp;\u0026plusmn;\u0026thinsp;2.38\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStudent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e157\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.78\u0026thinsp;\u0026plusmn;\u0026thinsp;0.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.71\u0026thinsp;\u0026plusmn;\u0026thinsp;0.59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.34\u0026thinsp;\u0026plusmn;\u0026thinsp;0.94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e13.83\u0026thinsp;\u0026plusmn;\u0026thinsp;1.77\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOthers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.39\u0026thinsp;\u0026plusmn;\u0026thinsp;0.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.62\u0026thinsp;\u0026plusmn;\u0026thinsp;0.49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.82\u0026thinsp;\u0026plusmn;\u0026thinsp;0.76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e13.84\u0026thinsp;\u0026plusmn;\u0026thinsp;1.49\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eF\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.663\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.308\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.850\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e7.706\u0026thinsp;\u0026plusmn;\u0026thinsp;2.02\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.259\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarital Status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnmarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e186\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.69\u0026thinsp;\u0026plusmn;\u0026thinsp;1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.70\u0026thinsp;\u0026plusmn;\u0026thinsp;.59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.36\u0026thinsp;\u0026plusmn;\u0026thinsp;0.97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e13.75\u0026thinsp;\u0026plusmn;\u0026thinsp;1.90\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e444\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.17\u0026thinsp;\u0026plusmn;\u0026thinsp;1.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.59\u0026thinsp;\u0026plusmn;\u0026thinsp;.59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.36\u0026thinsp;\u0026plusmn;\u0026thinsp;1.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e13.12\u0026thinsp;\u0026plusmn;\u0026thinsp;2.04\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.542\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.253\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.002\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3.626\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.025\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.999\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003e*\u003c/sup\u003eStatistically significant.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eMultivariate predictors of KAP scores\u003c/h2\u003e\u003cp\u003eVariables with a univariate \u003cem\u003ep\u003c/em\u003e-value of total scores below 0.05 were further analyzed using multivariate liner regression analysis to identify key predictors of KAP scores. Three factors remained significant predictors of total KAP score including city of residence (all cities scored higher than the Suqian reference group), younger age and higher education level (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), whereas occupations and marital status did not independently predict scores in the adjusted model.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMultivariate liner regression analysis of the influence of different characteristics on KAP scores\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eβ\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eStandard error\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eStandardized\u003cem\u003eβ\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-0.030\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.010\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-0.307\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.002\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarital Status (Ref\u0026thinsp;=\u0026thinsp;Married)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-0.461\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.372\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-0.104\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.216\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCity (Ref\u0026thinsp;=\u0026thinsp;Suqian)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWuxi\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.214\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.275\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.220\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSuzhou\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.265\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.267\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.229\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNantong\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2.025\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.259\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.374\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYancheng\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.683\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.263\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.323\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTaizhou\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.609\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.286\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.110\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.034\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEducation level (Ref\u0026thinsp;=\u0026thinsp;Primary School and Below)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJunior high school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.484\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.226\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.102\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.033\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHigh school or technical secondary school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.342\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.288\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.242\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCollege and above\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.274\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.333\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.270\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOccupation (Ref\u0026thinsp;=\u0026thinsp;Farmer)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWorker\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-0.494\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.292\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-0.095\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.091\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedical Worker\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-0.702\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.377\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-0.101\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.063\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSelf-employed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-0.329\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.331\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-0.049\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.322\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStudent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.057\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.538\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.012\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.915\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOthers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.071\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.328\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.012\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.829\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003e*\u003c/sup\u003eStatistically significant.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussions","content":"\u003cp\u003eThe findings of this study provide critical assessment of the current status of \u003cem\u003eA. cantonensis\u003c/em\u003e infection risk in Jiangsu Province of China, and couples rigorous ecological surveillance with a detailed behavioral analysis. Although no infected snails or market sales were detected, the pronounced practice gaps revealed by the KAP survey demonstrate that ecological absence does not equate to population safety. The integration of field data and behavioral insights provides policymakers with an evidence-based dual perspective on both ecological and behavioral dimensions to design targeted interventions, strengthen health education.\u003c/p\u003e\u003cp\u003eAlthough invasive apple snails are a significant vector for \u003cem\u003eA. cantonensis\u003c/em\u003e [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], none of 732 wild specimens collected across six cities in Jiangsu carried the parasite. However, the ecological adaptability of apple snails and their widespread distribution in Jiangsu\u0026rsquo;s water networks necessitate vigilance [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Multiple provinces adjacent to Jiangsu have documented infections of \u003cem\u003eA. cantonensis\u003c/em\u003e in the apple snails [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. The apparent absence in Jiangsu may due to limited sample size, seasonal sampling, or presently unfavorable local ecological conditions [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Additionally, no apple snail sales were found in the 74 surveyed local markets, indicating effective market regulation in these regions, which likely reduces the direct risk of human infection through the consumption of infected snails. However, the morphological overlap between apple snails and \u003cem\u003eCipangopaludina chinensis\u003c/em\u003e [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] raises the possibility of undetected misidentification during the market surveys. Therefore, continuous surveillance, as recommended by the World Health Organization for neglected tropical diseases, is essential to detect early-stage zoonotic shifts [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe KAP survey results show that the residents in Jiangsu has a relatively high knowledge level of apple snails. This could be attributed to previous health education efforts and increased public awareness of food-borne diseases [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. However, a small proportion of the population remains unaware of apple snail and its associated risk. In terms of attitude, most respondents had a positive attitude, such as a strong willingness to learn about apple snail hazards and disseminate health information, providing a receptive base for future interventions. However, previous research has shown that knowledge does not reliably translate into preventive behaviors, especially when there is a lack of perceived personal risk or motivation [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Although a certain number of households separated raw and cooked cutting boards and knives, 40.3% did not, creating a clear pathway for cross-contamination. This is particularly important given the potential for rapid spread of \u003cem\u003eA. cantonensis\u003c/em\u003e through contaminated food and water sources. Moreover, the low reporting rates of apple snail discoveries (78.7% to authorities and 22.1% using ASI) underscore the need for improvement in public participation in surveillance.\u003c/p\u003e\u003cp\u003eDemographic disparities in KAP scores were pronounced in this study. Respondents aged\u0026thinsp;\u0026lt;\u0026thinsp;20, those with higher level education, students, and unmarried individuals generally had higher scores, likely because younger age groups access diverse information channels, and higher education fosters stronger information-seeking and risk-perception skills. In contrast, farmers had the lowest scores, which could be related to their limited access to health education resources and different living and working environments. This is consistent with previous research indicating that education level is a robust determinant of health knowledge and behavior [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. These results highlight the need for differentiated health education strategy. For example, concise, actionable training modules and pictorial materials should be designed specifically for farmers, delivered through village health workers to maximize reach and impact.\u003c/p\u003e\u003cp\u003eMultivariate regression analysis identified age, city of residence, and education level as the significant predictors of KAP scores. Furthermore, the significant differences in KAP scores across cities highlight the need for region-specific strategies. Cities with higher KAP scores such as like Nantong, may benefit from reinforcing existing educational programs, while cities with lower scores like Suqian, require more intensive interventions. This approach aligns with the principles of community-based participatory research [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], which emphasizes the importance of local context in designing effective public health initiatives. Additionally, promoting education based prevention measures, such as incorporating apple snail related knowledge into school curricula and community education programs [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], could offer a scalable, education-centered pathway to raise public awareness and convert knowledge into sustained preventive behaviors.\u003c/p\u003e\u003cp\u003eThis study has several limitations. Firstly, the cross-sectional design precludes causal inferences between KAP factors and infection risks, and longitudinal studies are needed to track behavioral changes after intervention. Secondly, the sample size is insufficient and the sampling focused on urban and peri-urban areas; rural regions with higher agricultural activity may face distinct challenges. Expanding surveillance to remote areas will enhance the representativeness. Finally, while no infections were detected, reliance on microscopic examination in this study may miss low level larval infestations, and integrating molecular techniques such as PCR in future surveys will improve detection sensitivity.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study highlights the importance of public awareness and behavior in preventing \u003cem\u003eA. cantonensis\u003c/em\u003e infection. Although the parasite was not detected in Jiangsu Province in this survey, the persistent gaps in public knowledge and practices underscore the need for sustained efforts to improve food safety and disease prevention. A sustained, integrated strategy combining real-time surveillance, targeted education tailored to high-risk population, and evidence-based policy measures can safeguard public health in an era of increasing zoonotic threats.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cem\u003eA. cantonensis\u003c/em\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e\u003cem\u003eAngiostrongylus cantonensis\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eKAP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eKnowledge, attitudes, and practices\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eL3\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eThird-stage larvae\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eASI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eApple snail inspector\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cp\u003eThis study was approved by the Ethics Review Committee of Jiangsu Institute of Parasite Diseases.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting interests\u003c/h2\u003e\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFundings\u003c/h2\u003e\u003cp\u003eThis work was supported by the Jiangsu Province Capability Improvement Project through Science, Technology, and Education (No. ZDXYS202207) and Jiangsu Provincial Preventive Medicine Association Research Program (Y12023051).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eYL and QZ conceived and designed the study. QZ wrote the protocol and draft the manuscript. QZ, FM and BN conducted the data gathering. JZ supervised the data processing and analysis. QZ, FT and XG conducted field sampling and laboratory detection. All authors read and approved the final manuscrip\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\u003cp\u003eAll data analyzed during this study are included in this article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRodrigues PS, Gomes SR, Ramos-de-Souza J, Fernandez MA, Maldonado-Junior A, Thiengo SC. Surveillance of land molluscs infected by \u003cem\u003eAngiostrongylus cantonensis\u003c/em\u003e (Nematoda) reveals risk areas for zoonotic eosinophilic meningitis in the State of Rio de Janeiro, Brazil. 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Int J Equity Health. 2020;19:51.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Angiostrongylus cantonensis, Apple snails, Knowledge, attitude, and practice (KAP), Transmission risk","lastPublishedDoi":"10.21203/rs.3.rs-7316123/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7316123/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003e\u003cem\u003eAngiostrongylus cantonensis\u003c/em\u003e (\u003cem\u003eA. cantonensis\u003c/em\u003e), a zoonotic nematode responsible for eosinophilic meningitis, is transmitted mainly through the ingestion of raw or under cooked invasive apple snails. Despite the widespread distribution of these snails in Jiangsu Province of China, systematic assessments of infection risks and public awareness remain limited. This study evaluated the infection status of \u003cem\u003eA. cantonensis\u003c/em\u003e in apple snails and investigated public knowledge, attitudes, and practices (KAP) to inform targeted prevention and control strategies.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe carried out a cross-sectional study in six prefectural-level cities in Jiangsu during the snails\u0026rsquo; peak reproductive season. A total of 732 wild apple snails were collected from different habitats and screened for \u003cem\u003eA. cantonensis\u003c/em\u003e larvae by pepsin\u0026ndash;HCl digestion and microscopy. 74 local farm markets were inspected for the sale of live or processed apple snails. Simultaneously, a validated knowledge\u0026ndash;attitude\u0026ndash;practice (KAP) questionnaire was conducted to 630 randomly selected residents. Data analysis employed SPSS for descriptive statistics and multivariate line regression was used to identify predictors of higher scores.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eAll wild-caught snails tested negative for \u003cem\u003eA. cantonensis\u003c/em\u003e, and no apple snails were found for sale in any market. Overall public knowledge and attitudes were favorable; however, practice gaps were evident: 40.3% of respondents reported not separating raw and cooked utensils, and 78.7% reported snail sighting to authorities, while 22.1% had ever used the Apple Snail Inspector (ASI) mini-program. KAP scores differed significantly among different demographic groups. Multivariable linear regression analysis revealed that age, city of residence, and education level were significant predictors of KAP scores.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eCurrent infection risk of \u003cem\u003eA. cantonensis\u003c/em\u003e infection in Jiangsu appears low, yet the widespread presence of competent apple snails and suboptimal food-handling practices warrant sustained surveillance. Targeted health education programs that address behavioral gaps among older and less-educated residents can further minimize the threat of \u003cem\u003eA. cantonensis\u003c/em\u003e introduction and safeguard both public health and ecological security.\u003c/p\u003e","manuscriptTitle":"Cross-sectional assessment of Angiostrongylus cantonensis transmission risk mediated by invasive apple snails in Jiangsu Province of China","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-21 08:23:57","doi":"10.21203/rs.3.rs-7316123/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"776abc34-3d63-4363-8d07-ced5436eba60","owner":[],"postedDate":"August 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-29T04:23:46+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-21 08:23:57","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7316123","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7316123","identity":"rs-7316123","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}