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    • In the context of our present work

    2019-06-26

    In the context of our present work that uses total community treatment with azithromycin for yaws eradication, we would support an empirical approach to treatment. Azithromycin is effective for treatment of both and , so our mass treatment should be effective for both causes of skin ulcer. isolates from skin infections in Samoa were susceptible to azithromycin, with minimum inhibitory concentrations of 0·012 mg/L. Furthermore, the tissue half-life of azithromycin is such that protection against reinfection with either organism should continue for many weeks after treatment. In well controlled studies, a 1 g dose of azithromycin protected against experimental infection for a mean period of about 2 months. Because development of macrolide resistance requires only a single base-pair mutation, we agree with Sally Roberts and Susan Taylor that surveillance to monitor the appearance of resistance mutations is essential. After mass treatment, in the setting of active case detection for identification of new yaws cases, a test such as LAMP might be useful. Although the WHO-endorsed DPP Syphilis Screen and Confirm Assay (Chembio, USA) allows improved determination of the yaws serological status of the patient in the field, molecular assays must be used as an adjunct to serology because of the very high level of seropositivity in at-risk populations. Molecular assays should be used as a quality control measure, and for cases that could be seropositive but have lesions caused by agents other than yaws. Selection of appropriate settings and the rational use of serological and molecular tests during the yaws eradication project must be addressed through appropriate policy design that includes the routine practice of the health worker.
    In a yaws-endemic area, Oriol Mitjà and colleagues show that causes skin ulcers in about 7% of children. In the context of empirical therapy, this important work underscores the need to periodically assess assumptions about epidemiology. was thought to be exclusively transmitted by abrasions that occur during sexual intercourse. In human inoculation experiments, 10 CGK733 did not infect intact skin, but as few as one bacterium delivered by a puncture wound caused infection. The high prevalence of skin ulcers could be due to minor trauma and contact between infected children or a clone of that can penetrate intact skin. 64% of the villagers infected with were male. In experimental infection, men were twice as likely as women to develop pustules, and there was no immunity to reinfection; sex and an absence of immunity might contribute biologically to the prevalence of skin ulcers. Single-dose azithromycin prevented infection from weekly inoculation for nearly 2 months. If strains are susceptible, mass treatment of yaws with azithromycin could treat and prevent infection. Mitjà and colleagues speculate that syndromic management of genital ulcers drove into the paediatric population. Most genital strains are susceptible to only quinolones, macrolides, and third-generation cephalosporins. Penicillin is used empirically to treat skin ulcers in the south Pacific; so far, all cutaneous isolates have been β-lactamase negative. The cutaneous strains might be older clone(s) of that flew under the empirical radar.
    We completely agree with Madhukar Pai and colleagues that a complete and patient-centric solution to tuberculosis control should be delivered with dignity and compassion. India\'s Revised National Tuberculosis Control Programme (RNTCP), which was recognised as one of the best-run tuberculosis control programmes in the world, has only been able to provide 27% of patients with multidrug-resistant tuberculosis with treatment, which is worrisome. Pai and colleagues vouch for patient-centric solutions for complete treatment. However, they do not emphasise the fact that most of India\'s population is served by the public health system, with varied quality of services delivered. The scope for the tuberculosis control programme has been increasing from 2006 when the whole country was immunised, and there was a drive to strengthen the programme in the areas of tuberculosis and HIV co-endemicity, drug-resistant tuberculosis, tuberculosis–diabetes, and tuberculosis notification, without any major modification to the available human resources. The degree of integration expected from the general health system by the RNTCP was not fully achieved; the onus of treatment of a patient with tuberculosis always remained with the RNTCP, rather than the health system. We urge that the public health system in the country is augmented with new workforce strategies and policies to retain human resources and deliver appropriate care to the community. The proportion of gross domestic product spent on health is a meagre 4·1% in India, whereas developed countries, such as the USA, spend more than 17·1% on health care.