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  • Nevertheless we believe that the

    2019-05-10

    Nevertheless, we believe that the main findings of our study are robust. We noted a progressive increase in the prevalence of rheumatic Phos-tag Biotin disease with advancing age of children, modelling different prevalence patterns across age groups separately for each study, and pooling estimates within each age group only in a second step, while taking into account the uncertainty of our estimates. Our findings suggest the potential importance of cumulative exposure to streptococcal infections. We noted a prevalence of silent rheumatic heart disease that was several times higher than clinically manifest disease, as previously shown by Marijon and colleagues, among others. Finally, we noted a statistically significant association of prevalence and social inequality. The eradication of rheumatic heart disease in high-income countries was mediated by socioeconomic change. It is a known known that the answer to rheumatic heart disease resides in a reduction of poverty and facilitated access to health care.
    The UK Department for International Development has launched the first ever large-scale effort, KalaCORE, to control visceral leishmaniasis. Funding of up to £26·3 million will be provided to tackle visceral leishmaniasis in south Asia and east Africa, the two endemic regions with more than 85% of the global visceral leishmaniasis cases. Through KalaCORE, more than 250 000 cases are hoped to be treated, averting 55 000 deaths. In east Africa, support will aim to reduce the burden of visceral leishmaniasis, whereas support in south Asia will focus on complementing ongoing national efforts to eliminate visceral leishmaniasis. Greg Matlashewski and colleagues (December, 2014, issue) emphasise research priorities for visceral leishmaniasis elimination, which include the assessment of improved and shorter drug regimens, the role of asymptomatic and post-kala azar dermal leishmaniasis cases in disease epidemiology, and vaccine development. Undoubtedly, these are important research priorities. However, three research areas crucial to the success of operational programmes, such as KalaCORE, are not discussed, and—if omitted—could hamper any substantial progress in the tackling of the visceral leishmaniasis burden worldwide. First, there is no mention of insecticide and drug resistance, both of which are particularly prevalent in the Indian subcontinent. How resistance affects the effect of vector control efforts (ie, insecticide-treated bednets and indoor residual spraying of households with insecticide) and case management in an operational context, and how programme failure relates to actual resistance versus poor programme implementation (eg, suboptimum spraying of households with insecticide or non-compliance of patients to anti-leishmania drugs) are equally important questions. Second, aspects relevant to the surveillance of visceral leishmaniasis are not discussed. Research in this area could—similar to other neglected tropical diseases—include the development of a standardised approach for mapping and surveillance of visceral leishmaniasis to improve our understanding of its distribution and endemicity, which presently relies on passively reported in-country case notifications. Moreover, visceral leishmaniasis is not necessarily a notifiable disease; approaches should be developed and piloted to ensure that all cases of visceral leishmaniasis are detected and reported. Rigorous reporting will become particularly important if transmission intensity decreases (eg, in Nepal and Bangladesh) and elimination becomes a real possibility. Finally, operational research should assess how diagnostic testing could be operationalised in health facilities that already provide services for malaria or tuberculosis; areas sympatric for visceral leishmaniasis and malaria could be prioritised for vector control.
    Hepatitis C virus (HCV) is a global health problem with an estimated 130–150 million people infected and 350 000–500 000 deaths annually, most of which occur in low-income or middle-income countries. As drug prices decrease and new treatments become more affordable, as outlined by Mohga Kamal-Yanni (February issue), there is an opportunity for high-burden countries to prioritise their activities against this disease.