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www.thelancet.cominfection Vol 13 June 2013 555 Conclusions A pressing need exists for improved access in rural Africa to microbiological tests for severe and treatable neurological infections. There is reason for optimism, with advances in the past 10 years leading to promising rapid diagnostic tests for human African trypano- somiasis and cryptococcal meningoencephalitis that need little infrastructure or skill. For other diseases— eg, syphilis—highly accurate fi eld-validated rapid diagnostic tests are available, but their role in diagnosis of disease with neurological involvement is yet to be established. For others still—eg, tuberculosis— advances in research have not yet yielded validated instruments for diagnosis of neurological disease. After decades of low prioritisation of diagnostic laboratories in health-care delivery structures for low-resource settings, 136 the renewed push for elimination or eradication of diseases such as malaria and schistosomiasis has put a new focus on diagnostics. For clinicians with patients suspected of having a neuro- logical infection, these new diagnostic tests will need to be incorporated into validated diagnosis–treatment pathways based on evidence. Rapid diagnostic tests for malaria and HIV have revolutionised the care of these diseases, and the time has come for rapid diagnostic tests for other severe and treatable infections to be made available in the regions where they are most needed. Contributors CPY and EB conceived the Review, proposed the approach for selecting priority conditions, and took primary responsibility for the literature review and writing the fi rst draft. MAM organised the 3-day expert workshop where information from the review was discussed and validated. All authors wrote sections or provided feedback and advice according to their areas of expertise, and extensively reviewed all drafts. Acknowledgments This work is part of the NIDIAG network Collaborative Project supported by the European Commission under the Health Cooperation Work Programme of the 7th Framework Programme, Grant Agreement 260260. An early version of this work was presented as an oral communication at the 7th European Congress on Tropical Medicine and International Health Barcelona, Spain, Oct 3–6, 2011. Confl icts of interest We declare that we have no confl icts of interest. References 1 WHO. Working to overcome the global impact of neglected tropical diseases: the fi rst WHO report on neglected tropical diseases. Geneva: World Health Organization, 2010. 2 WHO. The global burden of disease: 2004 update. Geneva: World Health Organization, 2008. 3 WHO, WFN. Atlas: country resources for neurological disorders 2004. http:www.who.intmental_healthneurologyneurogy_atlas_ lr.pdf accessed Dec, 31 2011. 4 Urdea M, Penny LA, Olmsted SS, et al. Requirements for high impact diagnostics in the developing world. Nature 2006; 444 suppl 1: 73–79. 5 Hotez PJ, Kamath A. Neglected tropical diseases in sub-Saharan Africa: review of their prevalence, distribution, and disease burden. PLoS Negl Trop Dis 2009; 3: e412. 6 Simarro P, Diarra A, Ruiz Postigo J, Franco J, Jannin J. The human African trypanosomiasis control and surveillance programme of the World Health Organization 2000–2009: the way forward. PLoS Negl Trop Dis 2011; 5: e1007. 7 Mitashi P, Hasker E, Lejon V, et al. Human African trypanosomiasis diagnosis in fi rst-line health services of endemic countries, a systematic review. PLoS Negl Trop Dis 2012; 6: e1919. 8 Birbeck GL. Neurologic disease in a rural Zambian hospital. Trop Doct 2001; 31: 82–85. 9 Bower JH, Asmera J, Zebenigus M, Sandroni P, Bower SM, Zenebe G. The burden of inpatient neurologic disease in two Ethiopian hospitals. Neurology 2007; 68: 338–42. 10 Winkler AS, Mosser P, Schmutzhard E. Neurological disorders in rural Africa: a systematic approach. Trop Doct 2009; 39: 102–04. 11 Jarvis JN, Meintjes G, Williams A, Brown Y, Crede T, Harrison TS. Adult meningitis in a setting of high HIV and TB prevalence: fi ndings from 4961 suspected cases. BMC Infect Dis 2010; 10: 67. 12 Cohen DB, Zijlstra EE, Mukaka M, et al. Diagnosis of cryptococcal and tuberculous meningitis in a resource-limited African setting. Trop Med Int Health 2010; 15: 910–17. 13 Blum J, Schmid C, Burri C. Clinical aspects of 2541 patients with second stage human African trypanosomiasis. Acta Trop 2006;

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14 Pai NP, Vadnais C, Denkinger C, Engel N, Pai M. Point-of-care testing for infectious diseases: diversity, complexity, and barriers in low- and middle-income countries. PLoS Med 2012; 9: e1001306. 15 D’Acremont V, Kahama-Maro J, Swai N, Mtasiwa D, Genton B, Lengeler C. Reduction of anti-malarial consumption after rapid diagnostic tests implementation in Dar es Salaam: a before-after and cluster randomized controlled study. Malar J 2011; 10: 107. 16 WHO. Guidelines for the treatment of malaria, 2nd edn. Geneva: World Health Organization, 2010: 1–194. 17 Yansouni CP, Bottieau E, Chappuis F, et al. Rapid diagnostic tests for a coordinated approach to fever syndromes in low-resource settings. Clin Infect Dis 2012; 55: 610–11. 18 Chappuis F, Alirol E, d’Acremont V, Bottieau E, Yansouni CP. Rapid diagnostic tests for non-malarial febrile illness in the tropics. Clin Microbiol Infect 2013; published online Jan 17. doi: 10.11111469- 0691.12154. 19 Nash TE, Garcia HH. Diagnosis and treatment of neurocysticercosis. Nat Rev Neurol 2011; 7: 584–94. 20 Jackson AC. Rabies in the critical care unit- diagnostic and therapeutic approaches. Can J Neurol Sci 2011; 38: 689–95. 21 Verdonck K, González E, Van Dooren S, Vandamme A-M, Vanham G, Gotuzzo E. Human T-lymphotropic virus 1: recent knowledge about an ancient infection. Lancet Infect Dis 2007; 7: 266–81. 22 WHO. World malaria report 2012. Geneva: World Health Organization; 2012. 23 Murray CJ, Rosenfeld LC, Lim SS, et al. Global malaria mortality between 1980 and 2010: a systematic analysis. Lancet 2012; 379: 413–31. 24 Taylor SM, Messina JP, Hand CC, et al. Molecular malaria epidemiology: mapping and burden estimates for the Democratic Republic of the Congo, 2007. PLoS One 2011; 6: e16420. Search strategy and selection criteria We searched PubMed for articles published from Jan 1, 1990, to Dec 31, 2012, with the MeSH headings “Central Nervous System Infections”, “Clinical Laboratory Techniques”, “Point- of-Care Systems”, “Serologic Tests”, “Diagnosis”, “Africa”, “Developing Countries”, and combining them with searches for the specifi c pathogens discussed in the text. We identifi ed other reports of the epidemiology of neurological infections in central Africa by searching the Archives Collection of the Institute of Tropical Medicine, Antwerp, Belgium, and our personal fi les. Furthermore, relevant information from the review was discussed and validated at a 3-day expert workshop at the London School of Hygiene and Tropical Medicine UK, held on Sept 20–23, 2011. We reviewed the reports identifi ed from these searches. We included articles written in English, French, Spanish, Dutch, or German. 556 www.thelancet.cominfection Vol 13 June 2013 25 Feachem RG, Phillips AA, Hwang J, et al. Shrinking the malaria map: progress and prospects. Lancet 2010; 376: 1566–78. 26 O’Meara WP, Mangeni JN, Steketee R, Greenwood B. Changes in the burden of malaria in sub-Saharan Africa. Lancet Infect Dis 2010;

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