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Estimated Burden of Fungal Infections in Namibia

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Estimated Burden of Fungal Infections in Namibia Journal of Fungi Article Estimated Burden of Fungal Infections in Namibia Cara M. Dunaiski 1,* and David W. Denning 2 1 Department of Health and Applied Sciences, Namibia University of Science and Technology, 13 Jackson Kaujeua Street, Windhoek 9000, Namibia 2 National Aspergillosis Centre, Wythenshawe Hospital and the University of Manchester, Manchester M23 9LT, UK * Correspondence: [email protected]; Tel.: +264 61 207 2891 Received: 30 June 2019; Accepted: 13 August 2019; Published: 16 August 2019 Abstract: Namibia is a sub-Saharan country with one of the highest HIV infection rates in the world. Although care and support services are available that cater for opportunistic infections related to HIV, the main focus is narrow and predominantly aimed at tuberculosis. We aimed to estimate the burden of serious fungal infections in Namibia, currently unknown, based on the size of the population at risk and available epidemiological data. Data were obtained from the World Health Organization (WHO), Joint United Nations Programme on HIV/AIDS (UNAIDS), and published reports. When no data existed, risk populations were used to estimate the frequencies of fungal infections, using the previously described methodology. The population of Namibia in 2011 was estimated at 2,459,000 and 37% were children. Among approximately 516,390 adult women, recurrent vulvovaginal candidiasis ( 4 episodes /year) is estimated to occur in 37,390 (3003/100,000 females). Using a low international ≥ average rate of 5/100,000, we estimated 125 cases of candidemia, and 19 patients with intra-abdominal candidiasis. Among survivors of pulmonary tuberculosis (TB) in Namibia 2017, 112 new cases of chronic pulmonary aspergillosis (CPA) are likely, a prevalence of 354 post-TB and a total prevalence estimate of 453 CPA patients in all. Asthma affects 11.2% of adults, 178,483 people, and so allergic bronchopulmonary aspergillosis (ABPA) and severe asthma with fungal sensitization (SAFS) were estimated in approximately 179/100,000 and 237/100,000 people, respectively. Invasive aspergillosis (IA) is estimated to affect 15 patients following leukaemia therapy, and an estimated 0.13% patients admitted to hospital with chronic obstructive pulmonary disease (COPD) (259) and 4% of HIV-related deaths (108) — a total of 383 people. The total HIV-infected population is estimated at 200,000, with 32,371 not on antiretroviral therapy (ART). Among HIV-infected patients, 543 cases of cryptococcal meningitis and 836 cases of Pneumocystis pneumonia are estimated each year. Tinea capitis infections were estimated at 53,784 cases, and mucormycosis at five cases. Data were missing for fungal keratitis and skin neglected fungal tropical diseases such as mycetoma. The present study indicates that approximately 5% of the Namibian population is affected by fungal infections. This study is not an epidemiological study—it illustrates estimates based on assumptions derived from similar studies. The estimates are incomplete and need further epidemiological and diagnostic studies to corroborate, amend them, and improve the diagnosis and management of these diseases. Keywords: Namibia; HIV/AIDS; fungal infections; opportunistic infections; pulmonary infections 1. Introduction Namibia is a middle-income country in southern Africa, with a population of approximately 2.5 million inhabitants [1]. It consists of five geographical areas: the Central Plateau, the Namib Desert, the Great Escarpment, the Bushveld, and the Kalahari Desert. Together, these areas make Namibia one of the most arid landscapes south of the Sahara. Because of its location between the Namib and Kalahari deserts, the country has the least rainfall in sub-Saharan Africa. J. Fungi 2019, 5, 75; doi:10.3390/jof5030075 www.mdpi.com/journal/jof J. Fungi 2019, 5, 75 2 of 15 J. Fungi 2019, 5, x FOR PEER REVIEW 2 of 15 The climate in Namibia is arid, semi-arid, and subtropical (in the northernmost regions), with a largeThe temperature climate in Namibia range (between is arid, semi-arid, 5 and 20 ◦andC). su Fogbtropical can occur (in the along northernmost the temperate regions), desert with coast. a Thelarge hottest temperature months range of the (between year are January5 and 20and °C).February. Fog can occur Average along daytime the temperate temperatures desert range coast. from The 9hottest to 30 ◦monthsC. During of the the year winter are months,January and May Februa to September,ry. Average temperatures daytime temperatures can fluctuate range from from between 9 to 306 °C. and During 10 ◦C at the night winter to 20 months,◦C in the May day. to Winter Septem daysber, are temperatures generally clear, can cloudless,fluctuate from and sunny.between Frost −6 − canand occur10 °C overat night large to areas20 °C of in the the country day. Winter during da theys are coldest generally months. clear, Overall, cloudless, Namibia and sunny. experiences Frost rainfallcan occur in theover summer, large areas with of limited the country showers during beginning the coldest in October months. and Overall, continuing Namibia until Aprilexperiences [2]. rainfallThe in Namibian the summer, health with system limited has showers a public beginning health service in October run by and the Ministrycontinuing of Healthuntil April and [2]. Social ServicesThe (MoHSS)Namibian and health a relatively system has well-established a public health privateservice healthrun by sectorthe Ministry [3]. Windhoek, of Health theand capital Social cityServices of Namibia, (MoHSS) is theand main a relatively referral centre well-established with generally private good healthhealth services. sector The[3]. WindhoekWindhoek, State the Hospital,capital city illustrated of Nami in Figure1, is Namibia’s main referral hospital. However, these services are deficient in the rural and remote populations of the country. All public pathology is managed by the Namibian Institute of Pathology—approximately 30% of the private healthcare facilities, is also managed by this institution [3]. Figure 1. The Windhoek Central Hospital. Mycotic infections pose an increasing threat to public health forfor severalseveral reasons.reasons. Opportunistic infections such as Pneumocystis pneumonia (PCP), candidiasis, cryptococcosis and aspergillosis are becoming increasinglyincreasingly problematic problematic as theas numberthe numb ofer people of people with weakened with weakened immune immune systems increases,systems particularlyincreases, particularly people with people HIV/ AIDSwith HIV/AIDS or cancer [or4– 8cancer]. In 2017, [4–8]. 8% In of2017, the 8% Namibian of the Namibian population population was HIV positivewas HIV [ 9positive], which [9], is one which of the is one highest of the infection highest rates infection in the rates world in [the10,11 world]. In addition[10,11]. In to addition HIV/AIDS, to NamibiaHIV/AIDS, also Namibia has one also of the has highest one of tuberculosis the highest infectiontuberculosis rates infection in the world, rates with in the 63.5% world, of tuberculosiswith 63.5% casesof tuberculosis being HIV cases positive being [10 ].HIV However, positive there [10]. is Howe a lightver, at the there end is of a the light tunnel. at the According end of the to atunnel. recent studyAccording comparing to a recent Namibia study to comparing nine other Namibia African countriesto nine other and African the United countries States and of America, the United Namibia States hasof America, the highest Namibia percentage has the of HIV-positivehighest percentage patients of awareHIV-positive of their patients status and aware on antiretroviral of their status (ARV) and treatment.on antiretroviral In addition, (ARV) Namibia treatment. also In has addition, the highest Namibia viral suppressionalso has the rate.highest Therefore, viral suppression despite the highrate. HIVTherefore, numbers, despite Namibia the high is on HIV its waynumbers, to epidemic Namibia control is on [its12 way]. to epidemic control [12]. The mostmost noteworthynoteworthy mycotic mycotic infections infections are are opportunistic opportunistic in HIV in /AIDSHIV/AIDS patients. patients. The latest The healthlatest facilityhealth facility census statescensus that states the that availability the availabilit of healthy of services health varies services throughout varies throughout Namibia, providingNamibia, someproviding form some of care form and of support care and services support for services HIV patients. for HIV Thesepatients. care These and supportcare and servicessupport caterservices for opportunisticcater for opportunistic infections infections related to HIV.related However, to HIV. the However, main focus the is main narrow focus and is is narrow predominantly and is aimedpredominantly at tuberculosis. aimed at According tuberculosis. to the According census, only to th 30%e census, of care only and 30% support of care services and support can treat services topical fungalcan treat infections, topical fungal including infections, all hospitals including and 50%all hospitals of sick bays and but50% only of sick 9% bays of clinical but only care 9% and of supportclinical servicecare and facilities support have service at least facilities two medicines have at least to treat two cryptococcosis. medicines to treat Furthermore, cryptococcosis. systemic Furthermore, intravenous treatmentsystemic intravenous for specific fungaltreatment infections for specific are available fungal infections in only two are of available every ten in facilities only two in Namibiaof every ten [3]. facilities
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