Influential medical journal 'The Lancet' has a long history (first published in 1832) of taking on difficult issues in health and politics. In keeping with this traditions it has commissioned a new Global Health Series calling for global action on improving the awareness, diagnosis and treatment of life threatening fungal infections. This is the first time a series on this topic has featured in any journal, but what is the problem that is being addressed?
In the developed world there have been huge strides taken over the last two or three decades such that many more infections are being detected and treated, though still by no means are we diagnosing or successfully treating all. However in many parts of the developing, lower income world there are vulnerable people with fungal infections who receive little or no diagnosis or treatment. Currently 1.5 million people a year that we know of die a preventable death due to fungal infection and over 1 billion people are infected worldwide. Of these it is estimated that aspergillosis (allergic bronchopulmonary aspergillosis (ABPA) or chronic pulmonary aspergillosis (CPA)) accounts for 5 million cases each year.
Part of the reason for this neglect is that many fatal fungal infections are 'hidden' from the statistics that drive awareness and investment. A patient who has HIV or cancer that causes a vulnerability to infection that allowed Aspergillus to grow is likely to be recorded as a death due to HIV or cancer rather than aspergillosis. There is also the possibility that diagnosis of the fungal infection will be missed completely even in developed countries as diagnosis is difficult and requires specialist skills and tests.
Diagnosis is often very slow in the developed world as clear differentials are not available for fungal diseases such as ABPA or CPA. Patients who are referred to the National Aspergillosis Centre in Manchester, UK often relate stories of having respiratory illness for years before finally being referred and subsequently diagnosed with ABPA or CPA. This often results in a poorer outcomes for the patient.
Professors David Denning and Juan Luis Rodriguez Tudela of the University of Manchester have co-ordinated the series and it will take the form of eight new authoritative papers that outline some of the systematic problems that are holding back better care for fungal infections worldwide. The authors of the papers are collectively from all six populated continents of the world giving the series a broad scope of experience.
A broad range of clinical contexts for fungal infection are covered in the series including HIV, cancer, TB, asthma, genetic immunodeficiency and after transplantation and surgery: all common causes or comorbidities of aspergillosis.
In many countries there is insufficient resource in terms of training, staff, diagnostic equipment and access to antifungal drugs to adequately challenge fungal disease. Usefully the International Foundation GAFFI (Global Action Fund for Fungal Infections) has mapped out the availability an cost of some antifungal drugs across the globe in its collection of drug maps. One map reveals that although itraconazole seems widely available, access to itraconazole is very variable as the price in different countries ranges from $0.01 per day in Sri Lanka up to $98.2 per day in Sweden.
In many countries there is no proposal to integrate fungal diseases into the healthcare system at all, or limited monitoring of what is available. To address this Professor Donald Cole of the University of Toronto calls for 'combined health systems and public health approaches' with examples from Mozambique, Kenya, India and South Africa.
The fast emerging problem of antifungal drug resistance accompanied by its spread via environmental sources is a topic along with the need for researching new drugs and especially new antifungal drug classes or different ways to deliver medication is the subject of another article in the series.
Summing up, Professor Denning added:
“The evidence gathered in this article series shows not only the scale of the global problem but also that hundreds of thousands of deaths a year could be avoided."
“The expertise is available, now it just needs government and international action to make it a reality.”
There are nine published papers in this 'Fungal Infections' series as follows:
- 1: Fungal infections in HIV/AIDS
- 2: Candida and invasive mould diseases in non-neutropenic critically ill patients and patients with haematological cancer
- 3: Pulmonary and sinus fungal diseases in non-immunocompromised patients
- 4: Neglected endemic mycoses
- 5: The global problem of antifungal resistance: prevalence, mechanisms, and management
- 6: Immunotherapeutic approaches to treatment of fungal diseases
- 7: Emerging issues, challenges, and changing epidemiology of fungal disease outbreaks
- 8: Improvement of fungal disease identification and management: combined health systems and public health approaches
- COMMENT: Recovery from serious fungal infections should be realisable for everyone