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  • Furthermore an observational cross sectional


    Furthermore, an observational, cross-sectional case-control study used by the authors of 976 children aged 6–10 years, from an area of small towns immersed in the countryside in central Italy, estimated the rate of FAS as between 4 per 1000 and 12 per 1000 people in 2011. These rates cannot in any case be representative of the Italian population, because the study refers to very few individuals belonging to a specific biased suburban, rural area of wine producers.
    We thank Katrine Strandberg-Larsen and colleagues from Denmark and Simona Pichini and colleagues from Italy for their comments on our paper. Both comments underline the immense interest in the related public health problems of alcohol use during pregnancy and fetal alcohol syndrome (FAS). With respect to the comment of Strandberg-Larsen and colleagues from Denmark, the authors question our finding that the prevalence of alcohol use during pregnancy in the WHO European Region was estimated to be the highest among the six WHO regions. According to the latest Global Status Report on Alcohol and Health 2014, however, almost all major alcohol indicators such as prevalence and level of consumption, rates of chronic and heavy episodic drinking, and alcohol use disorders are the highest in this region. Thus, the high prevalence of alcohol use during pregnancy and FAS in the WHO European Region, which exceed global levels, should not come as a surprise. Second, concern raised that our estimated pooled prevalence of alcohol use during pregnancy for Denmark was higher than two recent estimates, which were not included in our meta-analysis because they were published outside of the timeframe covered in our study. However, the study by Iversen and colleagues reported that the proportion of women that disclosed binge drinking, defined as the consumption of at least 60 g of pure alcohol on a single occasion, during early pregnancy was 35%. This is alarming, given that binge drinking is the drinking pattern most strongly causally associated with FAS and fetal alcohol spectrum disorder (FASD). Given that our pooled prevalence estimate was based on any amount of alcohol consumed at any time during pregnancy, the Danish results are actually within the confidence interval of our pooled prevalence for Denmark. Third, Strandberg-Larsen and colleagues indicate that the predicted FAS prevalence for Denmark is high compared with that of the National Danish Patient Registry. As they acknowledge, it norepinephrine bitartrate is well known that record-based ascertainment severely underestimates the true prevalence of FAS and FASD, and active case ascertainment is considered the gold standard. It is for metaphase reason that we excluded any estimates obtained via passive methods from our analysis.
    Access to diagnosis and treatment of a neglected tropical disease is a global challenge, both in endemic and non-endemic countries. Ana Requena-Méndez and colleagues (April, 2017) suggest that screening for Chagas disease in asymptomatic Latin American adults living in Europe is a cost-effective strategy. Mundo Sano—aware of the difficulties that migrants face coming from areas where Chagas disease is endemic in accessing health-care services—has been boosting this strategy in Spain since 2011, and with screening, since 2016. Within the discussion, Requena-Méndez and colleagues pointed out two main challenges in the implementation of Chagas disease screening programmes, among others: legislative differences across Europe and changes in migratory flows. We fully agree with these considerations and have discussed them in relation to Chagas disease screening in Germany, a European country where the scenario could change in the future. We would like to highlight that these differences need to be considered also at a regional level, and not only regarding screening but also treatment. In Spain, the European country with the highest prevalence of Chagas disease, the health-care system legislation varies among the different regions. Since the benznidazole (first-line treatment for Chagas disease) shortage was announced in November 2011, a public–private partnership was established in Argentina to produce a new benznidazole. With the impulse of Mundo Sano, in just over a year (December, 2012), the drug became available again in Spain thanks to its official recognition as a foreign medication by the Spanish Agency of Drugs and Sanitary Products (AEMPS). Patients have to pick the drug up at the hospital or at the regional health service (Foreign Drugs Supply Department), depending on the region where the patient is settled. The price of the drug is also different among Spanish regions. Therefore, because Spain is the only country in Europe with authorised access to benznidazole, this situation could indirectly add new barriers to those seeking Chagas disease screening or treatment, potentially hampering their comprehensive care. Although specific treatment in the chronic phase remains controversial, as Marianela Castillo-Riquelme says, mother-to-child transmission of can be avoided by treating infected women before pregnancy.