Breaking the cycle: Determinants and opportunities for sustainable control of cystic echinococcosis.

Cystic echinococcosis (CE) remains one of the most persistent neglected zoonoses despite profound knowledge of the life cycle of Echinococcus granulosus sensu lato and the availability of well-established control tools. Persistence of CE is driven by interacting barriers, i.e., rapid reinfection of dogs, continued access of dogs to infected offal and carcasses, informal slaughter, suboptimal surveillance feedback, fragmented institutional responsibility, and misaligned economic incentives. These constraints are especially evident in sheep-farming and agro-pastoral systems, where dogs, livestock, household practices, and rural economies remain closely connected. Effective control requires a One Health approach that combines repeated praziquantel treatment of dogs, safe management of offal and carcasses, inspected slaughter, livestock surveillance, community engagement, and management of owned, semi-owned, and free-roaming dogs. This Chapter examines the underlying factors that challenge eradication of CE from many endemic settings. Particular attention is given to prevention, health education, and edutainment, since CE control primarily depends on achieving change in a small number of high-risk practices that are often normalized in daily pastoral life. Sardinia and comparable Mediterranean settings are used to illustrate how persistent sheep infection, fertile cysts, working-dog ecology, informal slaughter, incomplete dog prophylaxis, and governance gaps sustain endemic transmission even where the disease is well recognized. The Chapter argues that CE persistence reflects failures of continuity, traceability, and field delivery; durable control therefore depends on the organization of dog management, slaughter systems, surveillance, and community action as much as on parasitology.