Educational intervention for the awareness improvement and control programme design on Echinococcosis in Izmir, Turkey

Cystic echinococcosis (CE) is an important parasitic disease originated from animals and can be transmitted to other herbivorous animals and humans. The adult tapeworm inhabits in the intestine of some carnivores (called definitive or final hosts), and the larval phase develops in the intermediate hosts, in which humans are included. It is endemic in sheep-raising regions of the world, especially in regions of the Mediterranean littoral and large areas of Europe, such as the Iberian, Balkan, and Italian peninsulas and Turkey. As the disease poses a threat for public health, it is taken under control in developed countries. However, underdeveloped and developing countries still face problems with controlling this disease (Craig et al., 2007, Tamarozzi et al., 2017, Altintas Nuray et al.,2020). Today, CE is included in the group of neglected diseases (WHO 2010).

Cystic echinococcosis is publicly known as “dog cyst”, a fatal and serious disease not only affects livestock husbandry and human health but also brings about economic loss to Izmir province. Turkey is among the countries where this problem still poses a public threat. Although echinococcosis has been recognized in Turkey since 1861, a consistent state policy for disease prevention and control has not been developed and echinococcosis continues to be a major health and economic problem in Turkey. According to some of the local studies, E. granulosus infection in dogs ranges between 0.32 % and 40 %. The prevalence of CE in domestic animals ranges from 3.5 % to 58.6 % has varied widely with geographical location (Altintas, 2003).

In humans, the estimated surgical cases rates ranged from 0.87 to 6.6 per 100,000 inhabitants between 1987 and 1994 (Altintas, 2003). The sero-epidemiological study conducted for the first time in 1999, 3.45 % seropositivity and 291 / 100.000 (6/2055) prevalence were found in 2055 people living in and around Izmir city (Altintas et al., 1999). In other studies conducted in Izmir Province, the number of the cases and the years were found as follow; 591 cases between 1997 and 1998, 840 between 1997 and 2001, and 1.274 cases between 2001 and 2005 (Ertabaklar et al., 2003, Yazar et al., 2008). On the other hand, Turkey’s six provinces (Ankara, Aksaray, Balikesir, Bitlis, Istanbul, Sanliurfa) were screened by ultrasound and 53 of a total 8618 people screened (0.6 %; 1/163) were infected with CE (Tamarozzi et al., 2018). Considering all the results of these surveys approximately one of each 150 – 200 people (0.5 – 0.6 %) can be considered to be infected with CE in Turkey. This is also an indication that one of the most important health problem in Turkey.

This disease has been included within the scope of notifiable diseases since 2005 in Turkey. Newer epidemiologic studies disclosed higher prevalence rates; According to the data of the Ministry of Health; number of annual cases was 408 in 2008, and this number reached 1,867 by the end of 2019. According to this, the morbidity rate reported as 0.57 per 100.000 in 2008 was reported as 2.08 in 2019 (Altintas et al., 2020).

The main reason for facing this public threat in Turkey in such a large scope is because this topic has not yet become a priority for the authorities. The public awareness on this issue is very low, thus people try to protect themselves and their children with hearsay information that are wrong, useless and even sometimes unethical practices such as teaching kids to be afraid of animals or deplacing stray animals from their habitats in residential areas to far. So, CE urgently needs attention both for protecting public health and animal welfare as well as for ending such unethical practices.

Since 1863, many programmes and control measures have been employed in several countries and have had varying outcomes (Jimenez et al., 2002, Craig & Larrieu 2007, Guisantes 2014; Irapedra et al., 2016). The public awareness on this issue one of the most important strategy to make great achievements in controlling the disease and in the reduction of the prevalence in CE. It was recognized that management of information related to the intervention measures and their effectiveness was necessary for the effectiveness of the program. Information for the public concerning the preventative measures that need to be adopted (Jimenez et al., 2002). Health education considered to be one of the most important tools for the control and prevention of CE. It is a multi-disciplinary activity that requires knowledge of medical sciences and of teaching and communication methods (Irabedra et al., 2016).

Exposure of humans to E. granulosus is common due to the lifestyle of the prople who live in close proximity to sheep and dogs. The disease is often seen in women aged between 30 and 50 years who are more likely to be in contact with animals in rural areas (Orsten et al., 2018, Yolasigmaz et al., 2006) such as the chosen districts of Izmir province. Most people live in rural areas and are engaged in animal husbandry in this area. The ignorance about this disease and unsafe practices expose people for be infected, and children are the most vulnerable. And CE poses risk to children who do not pay attention to hygiene and sanitation rules at early ages because this disease especially taken up during childhood and emerged at an older age. According to the records of the Ministry of Health, Izmir province is in fourth place with a total of 680 cases with 131 cases between 2010 and 2014, with 402 cases between 2015 and 2019 (Altintas et al., 2020). So, our study aims to take an initial step towards overcoming this problem by raising awareness and educating children, people and inform authorities. This is the first study on education intervention regarding creating awareness on CE in Izmir Province which includes 10 districts between January 2019 to January 2020.

Cystic echinococcosis is common in people every part of the country but there is very little field work. Human cases are largely based on hospital records, and community-based screening studies are very few. However, with the local studies carried out in certain regions on people, dogs and slaughtered animals in recent years, it has been possible to obtain a little information about the condition of the disease. Although the present number of stray dogs and owned dogs is unknown in Turkey, according to some of the local studies, E. granulosus infection in dogs ranges between 0.32 % and 40 %. The prevalence of CE in domestic animals ranges from 3.5 % to 58.6 % has varied widely with geographical location (Altintas, 2019). But we don’t have any information in the Izmir province yet.

Increased awareness of zoonotic infections has been found to influence the management and control of these diseases (Othieno et al., 2018). Control measures should emphasise health education to encourage periodic trainings which is necessary to help below levels for continued transmission and regulate the slaughter of livestock in abattoirs and farms. People in rural areas need to be educated about proper control measures, such as; reducing transmission of the infection by proper slaughtering, safe waste disposal of infected animals, incineration of infected viscera, provision of safe drinking water, controlling of the dog population and their anti helminthic treatment (Fomda et al., 2015). Health education targets groups which attended to our education trainings that did not professionally concern the problem, such as school children or the public at large.

For E. granulosus the highest prevalence rates among humans and animals occur where livestock production is extensive, where large numbers of dogs are kept, and where dogs have access to carcasses of dead livestock or offal after uncontrolled slaughter (McManus et al., 2003, Babaoğlu et al., 2018). Animal husbandry is a predominant occupation in Turkey. In parts of the country, people make their living by raising animals, especially in central, eastern and southeastern Anatolia. Farming is the main occupation in rural areas thus rural population is at a high risk of acquiring infection. Almost every farmer keeps one or two dogs. Stray dogs are numerous, and prevention and treatment of infection in these dogs is very difficult. Turkey is a secular country; 99 % of the people living in Turkey are Muslims. According to Muslim’s custom, once a year during the sacrificial festival, tens of thousands of sheep and cattle are slaughtered, thus providing the stray dogs to the meat of infected intermediate hosts. Furthermore, livestock are slaughtered for daily meat requirements especially at rural areas (Altintas, 2003). Therefore, although infection control and prevention may seem to be an easy task, it is made very difficult because of the economic and social status of the people. Taking into account the public health perspective, these people are under threat as the nature of their daily life requires close contact with pet and farm animals. Proper education creating awareness and implementation of strict rules regarding disposal of remains of slaughtered animals can help to eliminate this disease. This study helped improving this situation by organising educational events for the rural populations for preventing transmission of the disease.

On the other hand, this study aimed also at raising awareness in the health workers group to help them understand the importance of the problem and how it can be solved by protecting public health while respecting human and animal rights. In addition to raising awareness in this target group, the study was carried out within the action also helped them determine the level of problem in the region, so that they can take decisions guided by information derived from scientific research. This study was conducted to improve the knowledge gaps, and attitudes of the people and health workers about CE infection in these regions. John et al., 2008, which showed that lack of adequate knowledge by health workers on echinococcosis detection was associated with poor management and high prevalence of echinococcosis. The disease is complex and dynamic with an evolving phase and quietly growing cysts. So it is difficult to diagnose, treat and cure. It is also important that more reliable epidemiologic data needed. Our results should be of useful for raising awareness among physicians of the presence of this infection and encourage improvement of case notification and cost benefit analyses in public health interventions.

Cystic echinococcosis is especially taken up during childhood and emerged at an older age. They become exposed to the eggs of the tapeworm after close contact with an infected dog or its contaminated environment. The infected dogs also pass in their feces E. granulosus eggs that adhere to the dogs’ hairs, and pass on to the children who are in the course of playful and intimate contact with the infected dogs. The study suggests that education program for echinococcosis control should be initiated in school children because most infections acquire during childhood. This proposed project helped improving this situation by conducting a series of educational and awareness raising activities for the children such as; brochures, posters and presentations at primary and secondary schools for the children, where families, teachers and school administrations were also invited. In order to raise awareness about CE, we thought that students will inform their family members with the brochures they will take from school to their homes and affect their family members behavior. Feed back with questionarie from childrens and oral feed back from school teachers and from public showed us we had achievement informing them about the disease with our study.

Control programme development has been started to discuss with the authorities from Ministry of Health and Ministry of Agriculture after establishing the Turkish Association of Hydatidology (TAH) in 1999. TAH is the only Non Governmental Organization (NGO) in Turkey that works on “cystic echinococcosis”. Then CE became a “notifiable disease” in 2005 by Ministry of Health. Collaboration among the departments of health, veterinary services and the enviromental agencies is important to take a control of this disease. Awareness programmes should set up a basis for the authorities to adopt corrective and preventive measures to avoid the disease (it can also set up for further and larger scale projects including humans in this field). Cystic echinococcosis continues to constitute a public health problem in endemic rural areas in Turkey. So, there is an urgent need for increasing the public awareness about the disease and to monitor the prevalence. Further studies needed to find out infection prevalence in urban and peri-urban areas.

In addition to the activities described above, Turkish Association of Hydatidology (TAH) have participated in and organised national and international meetings. The Universities in Izmir and other cities (Medical and Veterinary Faculties) to assist in the training of future professionals with better knowledge on the control of CE programme. Ministry of Health and Ministry of Agriculture and Forestry has been initiated in agreement to establih a control programme in 2019. Ministy of Health and Turkish National Committee of Zoonotic Diseases (Cystic Echinococcosis Subcommittee is included) were prepared the Turkey Zoonotic Diseases Action Plan (2019 – 2023). This Action Plan was included 4 objectives; 1) To raise public awareness about zoonotic diseases and prevention, 2) To conduct risk analysis and identify threats related to zoonotic diseases, 3) To develop and ensure the effectiveness of zoonotic diseases diagnostic laboratories throughout the country, 4) Monitoring, evaluation, coordination and planning. But based on the research and studies performed in Turkey fighting against echinococcosis will require a long-term strategy and solution even CE urgently needs attention both for protecting public health and animal welfare. Moreover, this is the first project to create awareness on CE in the Izmir Province, Turkey that covers the big sample-size and different target groups. These activities are mainly aimed to interrupt parasite transmission and ultimately reduce the burden of the disease. Final report derived from the results was sent to the local authorities as well as the Ministry of Health, Ministry of Agriculture and Forestry and Ministry of Education to be used for larger scale projects in this area, including codes of conduct and nationwide control programme.