Preplanned Studies: Cost-effectiveness Assessment of A Smart Health Education Pillbox for Canine Echinococcosis Control During A Cluster-Randomized Trial — Western China, 2023–2024

Introduction: Echinococcosis is a zoonotic parasitic disease that necessitates regular deworming of canines. The efficacy of the conventional manual deworming (CMD) is impeded by geography, the workforce, and severe weather conditions. This study evaluated the effectiveness and cost-effectiveness of the smart health education pillbox (SHEP) compared to CMD in canine echinococcosis control.

Methods: A 12-month cluster randomized trial was conducted across nine endemic Chinese counties, where townships were randomly assigned to either the SHEP or CMD group. The primary outcomes included Echinococcus antigen positivity rates in dog feces, deworming frequency, and cost components. Data analysis was conducted using SPSS 27.0, employing Generalized Estimating Equations (GEE), odds ratios (OR), relative risk (RR), relative risk reduction (RRR), and protective efficacy (1/RR).

Results: SHEP implementation significantly reduced Echinococcus infection risk by 35.45% and demonstrated 1.55-fold higher protective efficacy than CMD. The total deworming costs decreased by 22.62%, with substantial savings in personnel (53.15%), transportation (79.48%), and operational time requirements (30.13%). The proportion of dogs that achieved the target annual deworming frequency (9–12 times) increased from 51.89% to 91.38%, representing a relative improvement of 52.59%.

Conclusion: SHEP, which integrates automated reminders of praziquantel (PZQ) tablet delivery, is a promising tool for diminishing resource utilization and mitigating Echinococcus transmission in endemic areas.

Echinococcosis, a zoonotic parasitic disease designated by the World Health Organization as a neglected tropical disease, manifests predominantly in cystic (CE) and alveolar (AE) forms, caused by Echinococcus granulosus sensu lato and E. multilocularis, respectively. Both forms impose substantial public health burdens, with dogs serving as the definitive hosts for transmission. Despite the nationwide monthly praziquantel (PZQ) deworming initiative for dogs implemented in China in 2006, which led to a decrease in canine fecal antigen prevalence from 4.25% to 0.50% (1–2), persistent operational obstacles such as veterinary workforce shortages, logistical barriers, and financial constraints in remote regions persistently impede consistent deworming coverage and frequency. Surveys have revealed suboptimal deworming frequency (ranging from 21.7%–68.9%) (3–6) as a key factor contributing to sustained high rates of canine infection (ranging from 0.15%–1.60%) (2). These fluctuations in infection rates contribute to ongoing environmental transmission risks. Therefore, there is a need to explore novel approaches to enhance adherence to canine deworming regimens and mitigate environmental contamination.

From 2023 to 2024, a 12-month cluster randomized trial was conducted across nine endemic counties: Xiji County, Ningxia Hui Autonomous Region, Yushu City, Qinghai Province; Emin County, Hejing County, Artux City, Qapqal Xibe Autonomous County, Xinjiang Uygur Autonomous Region; Shangri-La City, Yunnan Province; Tianzhu Xizang Autonomous County, Gansu Province; and Fourth Division, Xinjiang Production and Construction Corps. Within each county, two townships were randomly assigned to interventions: one to the smart health education pillbox (SHEP) group and the other to the conventional manual deworming (CMD) group, with 150 eligible households with dogs randomly selected as study participants in each group. The SHEP group received an automated SHEP reminder and dog owner deworming scheme, where each targeted household received a pre-programmed SHEP and a deworming schedule (e.g., monthly deworming on the 5th day of each month, totaling 12 times annually). On designated deworming days, the SHEP delivered five sequential one-minute reminders combining auditory prompts (“Owner, please administer deworming PZQ chewable tablet to your dog”) and visual cues (flashing red indicator light). Successful completion of all five steps — 1) opening the SHEP lid, 2) removing the PZQ chewable tablets, 3) administering them to the dog, 4) returning unused tablets to the compartment, and 5) closing the lid — is necessary to activate the green light and receive an auditory acknowledgment (“Congratulations! The deworming work has been successfully completed”). Failure to execute all five steps within the scheduled day (e.g., due to dog owner absence) would activate persistent reminders for three consecutive days. In the CMD group, conventional manual deworming procedures were followed in which health workers (veterinarians) from the township or village visited households on scheduled deworming dates to administer door-to-door PZQ chewable tablets. Additionally, stratified training, including canine fecal testing and questionnaire administration, was conducted for all participants across both the SHEP and CMD cohorts.

The primary indicators included the Echinococcus antigen-positive rate in dog feces, deworming frequency, and cost components. Data analysis was conducted using SPSS (version 27.0, IBM Corp., NY, USA), employing Generalized Estimating Equations (GEE), odds ratios (OR), relative risk (RR), relative risk reduction (RRR), and protective efficacy (1/RR). The distribution of deworming frequencies between groups was assessed using the Cochran-Armitage test, employing two-tailed testing, with statistical significance set at P<0.05.

Dog fecal samples were collected twice from each enrolled dog in both groups: at baseline in 2023 and at a 12-month follow-up in 2024. Copro-ELISA was performed at 9 county CDC locations. Baseline fecal testing of 2,643 samples (SHEP group: 1,310; CMD group: 1,333) revealed no significant intergroup variance in Echinococcus antigen positivity (OR=0.86, [95% confidence interval (CI): 0.30, 2.48, P=0.78]. At the 12-month follow-up (2,270 samples: SHEP group, 1,169; CMD group: 1,101), no significant efficacy difference was observed between the two groups (OR=0.74, 95% CI: 0.18, 3.04, P=0.68). Both groups demonstrated significant risk reduction compared to the baseline (SHEP group: OR=0.273, 95% CI: 0.04, 0.96, P=0.048; CMD group: OR=0.30, 95% CI: 0.11, 0.80, P=0.016). GEE accounting for repeated measures and cluster effects (9 counties) indicated that the SHEP group yielded a 35.45% greater risk reduction than the CMD group (RRR=35.45%, 95% CI: –63.78%, –15.21%), with a protective efficacy ratio (1/RR) of 1.55-fold (95% CI: 0.75, 0.97, P=0.046) (Table 1).

At the 12-month follow-up, the deworming frequency in the SHEP group was assessed by enumerating residual PZQ chewable tablets in the SHEP compartments, while in the CMD group, cross-verification of township/village health worker (veterinarian) deworming logs against dog owner interview records was performed. Furthermore, SHEP functionality was monitored, and the annual 12 PZQ tablets were replenished in the SHEP group (each SHEP had a three-year service period). Statistical analysis using the Cochran–Armitage test revealed a significantly higher deworming frequency in the SHEP group than in the CMD group (Z=16.78, P<0.001). All frequency bands showed significant differences (P<0.001), with SHEP achieving a 52.59% increase in high-frequency adherence (9–12 times/year; OR=6.61, 95% CI: 5.41, 8.08) and a 95.35% reduction in low-frequency risk (≤3 times/year, OR=0.036, 95% CI: 0.02, 0.07) (Table 2).

Throughout the study, expenses related to materials, personnel, transportation, and time allocation for the delivery of PZQ chewable tablets were meticulously documented. The SHEP yielded a 22.62% reduction in the overall cost of dog deworming, resulting in annual savings of 53.15% in labor costs, 79.48% in transportation costs, 30.13% in time costs and the commuting efficiency increased by 83.33% (Table 3).