br Tuberculosis remains a global emergency
Tuberculosis remains a global emergency and continues to present major public health challenges worldwide. The actual global burden of tuberculosis can only be estimated because no accurate data are available from national country programmes from of high tuberculosis endemic countries. The WHO 2014 annual tuberculosis report estimates that 3·3 million women developed active tuberculosis in 2013, resulting in 510 000 deaths, 180 000 (35%) in those who were HIV-infected. Tuberculosis is one of the top causes of death in women of reproductive age and is a common non-obstetric cause of maternal mortality. Untreated, tuberculosis in pregnancy can have a mortality of up to 40%. Active tuberculosis disease in HIV-infected pregnant women increases the risk of maternal mortality by nearly 300%. The exact magnitude of the global prevalence of tuberculosis in pregnant women remains undefined and requires definition. Accurate diagnosis of tuberculosis in pregnancy is difficult because the symptoms and signs of pregnancy overlap with those of tuberculosis and other infectious and non-communicable diseases. Thus, unless there is a high degree of clinical awareness and availability of tuberculosis diagnostic tests, many cases of active tuberculosis in pregnancy are easily missed and remain undiagnosed and unreported. WHO estimates that 3 million active tuberculosis cases are missed annually and need to be found, and it Merimepodib is probable that large numbers of pregnant women with active tuberculosis are being missed. In this issue of , Jordan Sugarman and colleagues present their analyses of data lending further support in terms of further estimates to the growing consensus and international concern over the long-neglected issue of tuberculosis in pregnancy. Using publicly accessible country level estimates of demographic and epidemiological parameters from 217 countries, they derived estimates of the number of pregnant women with active tuberculosis. Although they point out the inherent weaknesses of their approach, they used indicators of health system access and data for performance of diagnostic tests to estimate that, globally in 2011, there were 216 500 (95% uncertainty range 192 100–247 000) pregnant women with active tuberculosis, of which the Africa (89 400 cases; 41%) and South-East Asia (67 500; 31%) WHO regions had the largest numbers. Sugarman and colleagues\' assessment of the potential effect of several tuberculosis diagnostic tests used with different levels of health-care access adds further to previous calls for the introduction of proactive screening for tuberculosis in pregnant women at whichever health-care facility they present, with rapid diagnostic tests to diagnose tuberculosis which would otherwise remain undetected and untreated. Several important scientific and operational issues of current health services relating to the specific issue of tuberculosis in pregnancy arise from Sugarman and colleagues\' study, which need to be addressed by governments and funders to provide optimum tuberculosis care for pregnant women.
Over the past 10 years, the number of studies on the burden of rheumatic heart disease in developing countries has substantially increased. These studies range from echocardiographic screening surveys of the prevalence of rheumatic heart disease in school children, to studies of incidence and progression, to investigations of the pathogenesis of the disease. The systematic review and meta-analysis of prevalence studies of rheumatic heart disease by Martina Rothenbühler and colleagues in is a timely summary of a decade of renewed focus by the international community on a neglected disease of poverty. Rothenbühler and colleagues sought to assess the effect of different screening methods (ie, auscultation echocardiography) on estimated prevalence of rheumatic heart disease among children and adolescents in endemic regions of the world. Of the 37 populations included, 17 were from Asia, nine Africa, seven Oceania, three Latin America, and one Europe. The pooled prevalence of rheumatic heart disease detected by cardiac auscultation was 2·9 per 1000 people (95% CI 1·7–5·0) and by echocardiography it was 12·9 per 1000 people (8·9–18·6), with substantial heterogeneity between individual reports for both screening tests (=99·0% and =94·9%, respectively). The previously reported association between social inequality expressed by the Gini coefficient and prevalence of rheumatic heart disease was also confirmed by Rothenbühler and colleagues (p=0·0002). The prevalence of clinically silent rheumatic heart disease (21·1 per 1000 people, 95% CI 14·1–31·4) was about seven to eight times higher than that of clinically manifest disease (2·7 per 1000 people, 1·6–4·4). As has been reported by others, prevalence progressively increased with advancing age, from 4·7 per 1000 people (95% CI 0·0–11·2) in 5-year-old children, to 21·0 per 1000 people (6·8–35·1) in 16-year-old adolescents, and the estimated overall incidence was 1·6 per 1000 people (95% CI 0·8–2·3) and was constant across age categories (range 2·5, 95% CI 1·3–3·7 in 5-year-old children to 1·7, 0·0–5·1 in 15-year-old adolescents). Unlike others who have noted a female preponderance in rheumatic heart disease prevalence, no sex-related differences in prevalence of rheumatic heart disease were found (p=0·829).