The Monetary Burden of Cystic Echinococcosis in Iran
Majid Fasihi Harandi1,2*, Christine M. Budke3, Sima Rostami2
1Research Center for Modeling in Health, Kerman University of Medical Sciences, Kerman, Iran, 2Department of Parasitology, School of Medicine, Kerman University of
Medical Sciences, Kerman, Iran, 3Department of Veterinary Integrative Biosciences, College of Veterinary and Biomedical Sciences, Texas A&M University, College Station,
Texas, United States of America
Cystic echinococcosis (CE) is a globally distributed parasitic infection of humans and livestock. The disease is of significant
medical and economic importance in many developing countries, including Iran. However, the socioeconomic impact of the
disease, in most endemic countries, is not fully understood. The purpose of the present study was to determine the
monetary burden of CE in Iran. Epidemiological data, including prevalence and incidence of CE in humans and animals, were
obtained from regional hospitals, the scientific literature, and official government reports. Economic data relating to human
and animal disease, including cost of treatment, productivity losses, and livestock production losses were obtained from
official national and international datasets. Monte Carlo simulation methods were used to represent uncertainty in input
parameters. Mean number of surgical CE cases per year for 2000–2009 was estimated at 1,295. The number of asymptomatic
individuals living in the country was estimated at 635,232 (95% Credible Interval, CI 149,466–1,120,998). The overall annual
cost of CE in Iran was estimated at US$232.3 million (95% CI US$103.1–397.8 million), including both direct and indirect
costs. The cost associated with human CE was estimated at US$93.39 million (95% CI US$6.1–222.7 million) and the annual
cost associated with CE in livestock was estimated at US$132 million (95% CI US$61.8–246.5 million). The cost per surgical
human case was estimated at US$1,539. CE has a considerable economic impact on Iran, with the cost of the disease
approximated at 0.03% of the country’s gross domestic product. Establishment of a CE surveillance system and
implementation of a control program are necessary to reduce the economic burden of CE on the country. Cost-benefit
analysis of different control programs is recommended, incorporating present knowledge of the economic losses due to CE
Citation: Fasihi Harandi M, Budke CM, Rostami S (2012) The Monetary Burden of Cystic Echinococcosis in Iran. PLoS Negl Trop Dis 6(11): e1915. doi:10.1371/
Editor: Paul Torgerson, University of Zurich, Switzerland
Received January 15, 2012; Accepted October 5, 2012; Published November 29, 2012
Copyright: ? 2012 Fasihi Harandi et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: Funding was provided by Vice-Chancellor for Education and the Research Center for Modeling in Health, Kerman University of Medical Sciences,
Kerman, Iran under a small grant scheme, grant No. 90-167. The funder had no role in study design, data collection and analysis, decision to publish, or
preparation of the manuscript.
Competing Interests: The authors have declared that no competing interests exist.
* E-mail: firstname.lastname@example.org
Cystic echinococcosis (CE), a chronic disease caused by the
larval form of the tapeworm Echinococcus granulosus, is one of the
most important helminth-associated zoonoses globally [1,2]. The
parasite’s domestic life cycle involves livestock and dogs as the
primary intermediate and definitive hosts, respectively. Canids
harboring adult E. granulosus worms excrete eggs into the
environment, where intermediate hosts become infected through
ingestion of the eggs. Humans can also act as aberrant
intermediate hosts if they ingest infective parasite eggs either
through contaminated food or directly from an infected canid. A
cystic larval form (metacestode) gradually develops, most com-
monly in the liver or lungs. However, other organs can also be
affected. Clinical signs typically develop as a result of this space-
occupying lesion exerting pressure on surrounding tissues.
Rupture of the cyst and spillage of the contents may cause
anaphylactic shock and secondary CE. In many parts of the world,
including Iran, surgery remains the treatment of choice for most
individuals suffering from CE .
Cystic echinococcosis is a cosmopolitan zoonosis, with highly
endemic areas especially prevalent in regions of South America,
North Africa, China, and the Middle East . Iran is an important
endemic focus of CE where several species of intermediate host are
commonly infected with E. granulosus . High infection preva-
lences, with different strains of E. granulosus, have been reported in
various domestic livestock including sheep (5.1%–74.4%), goats
(2%–20%), cattle (3.5%–38.3%), buffalo (11.9%–70%), and
camels (25.7%–59.3%) [4,5,6]. Between 5% and 45% of dogs is
reported to be infected with E.granulosus in different provinces of
Iran (reviewed in ). Human CE cases are also regularly reported
from medical centers in different parts of the country and the
incidence of CE is estimated 1.18-3 per 100,000 populations in
different regions .
Recently, the World Health Organization (WHO) included CE
in a subgroup of selected Neglected Tropical Diseases (NTDs) to
be addressed within its 2008–2015 strategic plan for control of
NTDs [8,9]. The WHO recommends that the impact of zoonotic
infections be assessed before implementation of any control
measure [10,11]. Costs associated with CE have been shown to
have a great impact on affected individuals, their families, and the
community as a whole [12,13]. Monetary losses due to CE have
been estimated for Uruguay , Wales , Jordan , Tunisia
, Turkey , Spain , Peru  and for a highly endemic
area of the Tibetan plateau [21,22]. In addition, the non-monetary
burden of CE has been assessed for a highly endemic region of
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China and globally utilizing the disability adjusted life year
Although CE is assumed to be a significant public health and
economic problem in Iran, the extent of its socioeconomic impact
is not fully understood. Economic losses due to CE in ruminants
have been previously estimated in three provinces of Iran
(Khuzestan, North Khorasan, and Ardabil) [24,25,26]. However,
these studies were not concerned with human CE and used
potentially biased methods to estimate livestock-related losses.
Accurate assessment of the disease burden is crucial to raise
awareness of decision-makers and to prioritize use of limited
resources to provide timely preventive measures [27,28]. The
purpose of the present study is to estimate the monetary burden of
CE in Iran using existing country-level data on human and animal
Materials and Methods
Human epidemiological data
Population data for Iran for 2010 were extrapolated from the
2006 population census, with 71.8% of the population living in
urban areas . Due to a lack of surveillance data, the number of
CE patients, by age and gender, that underwent surgery between
2000 and 2009 in 34 referral hospitals in seven of the country’s
most populous provinces (representing 51.4% of the total
population) was collected to determine average annual surgical
incidence. In total, 5,993 CE surgeries were identified over this 10-
year period. For the remaining 23 provinces, data from individual
scientific reports were used when available [30,31,32,33]. For
those provinces with no data, information from neighboring
provinces with similar socioeconomic status was applied. Based on
these sources, an annual number of 1,295 CE surgeries was
calculated. All CE recurrences with re-operations were regarded as
new surgical cases. Approximately 80% of surgical CE cases in
Iran are treated in public hospitals, with the remaining 20%
treated in private hospitals. Only surgical cases of CE were
included in this study due to a lack of data on cases that seek
treatment, but that are treated medically. In order to estimate the
number of undiagnosed or asymptomatic cases of CE in Iran, data
on ultrasound prevalence of CE (1.2% and 0.2%) were used
(Table 1) [34,35]. Lengths of hospital stay and mortality rates were
based on available literature (Table 1).
Livestock epidemiological data
The livestock species primarily involved in the domestic cycle of
CE in Iran are sheep, goats, cattle, buffalo, and camels. Data for
livestock populations and annual numbers of slaughtered animals
were obtained from official government reports (Table 2) .
The low percentage of the total sheep and goat population
slaughtered annually (12.8% and 8.5%, respectively) may reflect
the practice of slaughtering outside of abattoirs. To account for
home slaughtering, losses were also evaluated assuming that
slaughter rates are twice what are reported at the abattoirs,
assuming a mean of 1.25 offspring per ewe/doe per year. Milk,
wool, and hide/skin production values were based on either
Statistical Center of Iran (SCI) reports or United Nation’s Food
and Agriculture Organization (FAO) FAOSTAT data [29,36].
Livestock prevalence data were obtained from abattoir-based
studies available from the literature. Only studies where a
researcher confirmed the presence of CE cysts were included
because abattoir-reported cases are not considered reliable in Iran.
Prevalence data obtained from 3 or more studies were combined
for cattle, sheep, and goats using a meta-analysis for proportions in
R statistical data analysis software, ver. 2.12.0 (META package
version 1.6-1; by Guido Schwarzer) (Table 2) . Due to the
limited available data for buffalos, a meta-analysis could not be
performed for this species. Therefore, the mean prevalence from
two studies on CE in buffalo in Iran (12.4% and 11.9%) was used
Human economic data
Costs associated with direct and indirect losses associated with
human surgical CE were assessed. Direct costs included cost of
surgery, hospital accommodation, diagnostic imaging, clinical
laboratory and histopathology testing, and drug costs in both
public and private hospitals. The Puncture Aspiration Injection
Re-aspiration (PAIR) technique, which is widely used in other
parts of the world, is rarely used in Iran. Therefore, the procedure
was not costed in this study. Unit costs of services were obtained
from official tariffs established by the Iranian Ministry of Health
and Medical Education . Service costs were calculated by
multiplying the unit cost of an individual parameter by its
frequency in the course of disease. Expert attending surgeons from
Afzalipour Medical Center in Kerman, Iran were asked to
estimate the frequency of common CE-associated procedures and
services when these data were not available elsewhere.
Indirect costs associated with human CE included lost wages
due to work absenteeism during hospitalization and recovery, due
to time off to stay with a child with CE, and due to CE-related
mortality. Income data for urban and rural populations were
obtained from official reports of the CBI. Gender specific wage
data were not available for Iran or its neighboring countries.
Therefore, based on studies conducted in other regions, it was
assumed that women earn approximately 0.70 times as much as
men . Breakdown of wages by age was also not available for
Iran. Therefore, it was assumed that this breakdown would also be
similar to the findings from other studies . Unemployment
figures were based on SCI data. Productivity for females who do
not work outside of the home was assumed to be equivalent to
30% of the daily income of an officially employed female of the
same age group .
Cystic echinococcosis (CE), caused by the tapeworm
Echinococcus granulosus, is a zoonotic infection that occurs
worldwide. The adult parasite resides in the small
intestines of dogs and the cyst form can develop in the
liver and lungs of both humans and livestock. CE causes
medical, veterinary, and economic losses in endemic areas.
However, data on the economic consequences of CE are
lacking. The present study estimated the monetary burden
of CE in Iran. We used epidemiological and economic
information to estimate direct and indirect costs of human
and livestock CE in the country. Costs associated with
human CE included the costs of surgery and hospital
services in addition to lost wages due to work absenteeism
during hospitalization and recovery. Costs associated with
CE in livestock included losses due to condemnation of
livers and lungs during carcass inspections, decreased
carcass weight, reproductive losses, and reductions in milk
and other animal products. We estimated the overall
annual cost of CE in Iran at US$232.25 million, with the cost
of the disease estimated to be approximately 0.03% of the
country’s gross domestic product. Implementation of a
control program is necessary to reduce the economic
burden of CE on Iran.
Burden of Echinococcosis in Iran
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