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Home , Conidiobolus coronatus, Eumycetoma, Pneumocystis jirovecii, Pneumocystis pneumonia

Burden of serious fungal in Jamaica UHSM ¤ 1,2* University Hospital Harish Gugnani , David W Denning of South Manchester NHS Foundation Trust ¤Professor of Microbiology & Epidemiology, St. James School of Medicine, Kralendjik, Bonaire (Dutch Caribbean). 1 LEADING WI The University of Manchester, Manchester Academic Health Science Centre, Manchester, U.K. INTERNATIONAL 2 FUNGAL The University Hospital of South Manchester, (*Corresponding Author) National Centre (NAC) Manchester, U.K. EDUCATION

Background and Rationale The incidence and prevalence of fungal infections in Jamaica is unknown. The first human case of coronatus was discovered in Jamaica (Bras et al. 1965). Cases of and are reported (Fincharn & DeCeulaer 1980, Nicholson et al., 2004; Fletcher et al, 2001). is very frequent in children Chronic pulmonary (East-Innis et al., 2006), because of the population being aspergillosis with (in the left upper lobe) in a 53- predominantly of African ancestry. In a one year study of 665 HIV yr-old, HIV-negative Jamaican male, developing after one infected patients, 46% of whom had CD4 cell counts <200/uL, 23 had year of antitubercular treatment; his baseline IgG pneumocystis and 3 had cryptococcal meningitis (Barrow titer was 741 mg/L (0-40). As a smoker, he also had moderate et al. 2010). We estimated the burden of fungal infections in Jamaica emphysema. from published literature and modelling. Table 1. Estimated burden of fungal disease in Jamaica

Fungal None HIV Respiratory Cancer ICU Total Rate Methods condition /AIDS /Tx burden 100k

We also extracted data from published papers on epidemiology and Oesophageal ? 2,100 - ? - 2,100 77 from the WHO STOP TB program and UNAIDS. Where no data existed, we used specific populations at risk and fungal infection frequencies in Candidaemia - - - 95 41 136 5 Candida - ? - - 20 20 0.75 those populations to estimate national incidence or prevalence. Chronic peritonitis pulmonary aspergillosis (CPA), allergic bronchopulmonary aspergillosis RVVC (4x/year+) 42,885 - - - - 42,885 3,154 ABPA, severe with fungal sensitisation (SAFS) rates were based on asthma and TB rates. Asthma rates (doctor diagnosed asthma) in ABPA - - 13,050 - - 13,050 480 13-14 year olds were taken from Kahwa et al, (BMJ Open, 2012) and SAFS - - 17,225 - - 17,225 633 assumed to relate to adulthood. Other assumptions were based on CPA - - 82 - - 82 11.2 incidence rates reported in the local and international literature. The IA - - - ? ? ? denominator included the overall Jamaican population, number of - - - ? - ? ? CM ? 140 - - - 140 5 patients with HIV/AIDS and respiratory diseases. PCP - 1,120 ? ? - 1,120 41 Histoplasmosis ? ? ? - - ? ? Results Fungal keratitis ? - - - - - ? Tinea capitis ? - - - - ? ? The Jamaican population was estimated to be 2,719,000 million Total burden 42,885+ 3,990+ 30,360 95+ 61+ 77,391+ people (2009), of whom 29% are children (0-14 years) and 11% are estimated >60 years old. The adult asthma population was estimated at 522,000. ABPA = Allergic bronchopulmonary aspergillosis, CM = Cryptococcal meningitis, PCP = Using a 2.5% rate of ABPA based on other studies (Denning et al, pneumonia, IA = Invasive aspergillosis, CPA = Chronic pulmonary aspergillosis, RVVC = Recurrent vaginal candidiasis, SAFS = Severe asthma with fungal sensitisation 2013), Jamaica has 13,000 ABPA cases and 17,225 SAFS cases (480 and, 633/100,000 respectively). Only 98 cases of pulmonary TB were reported in 2011, so chronic pulmonary aspergillosis is probably rare Conclusion with an estimated prevalence of 14 cases after TB (1/100.000), perhaps Using local data and literature, estimates of the incidence or prevalence 15% of the total CPA caseload. An estimated 42,885 women have 4 or of fungal infections, over 75,000 people in Jamaica probably suffer from more attacks of vaginal candidiasis annually (6% women >15 yrs, serious fungal infections each year, most related to asthma, recurrent based on a Nigerian rate) (3,154/100,000 females). Using a common vulvovaginal (RVVC) and HIV infection. Local epidemiological studies are international figure for candidaemia incidence of 5/100,000, 136 cases urgently required to validate or modify these estimates. of candidaemia occur each year, and 20 cases of Candida peritonitis in surgical patients. The burden HIV/AIDS is estimated to be 27,000+ patients, 1.6% of adults of whom (14,000) are not receiving References antiretroviral therapy (CD4 counts <350/uL). Assuming 50% and 15% 1. Bras G. Gordon CC, Emmons, CW Prendegast, KM & Sugar M. (1965) A case of observed in Jamaica; infection with Entomophthoracoronata. Amer. J. trop. Med. Hyg., 14: 141-145. of these patients develop oral or oesophageal candidiasis annually, 2. East-Innis A, Rainford L, Dunwell P, D Barrett-Robinson D, Nicholson AM (2006) The changing pattern of tinea capitis in Jamaica. West Indian Medical J 55: 85-88 6,300 and 2,100 cases respectively would be expected each year. 3. Fincharn AG, DeCeulaer K. (1980) Histoplasmin sensitivity among the cavers in Jamaica. West Indian Med J 29: 22- 27. Assuming 10% of those not on ARVs progress to a life-threatening 4. Fletcher CL, Moore MK, Hay RJ. (2001) Eumycetoma due to Madurellamycetomatis acquired in Jamaica. Br J Dermatol 145:1018-1021. opportunistic infections each year, and that the rate of PCP is 80% and 5. Nicholson AM, Rainford L, Elliott V, Christie CDC (2004). Disseminated histoplasmosis and AIDS at the University Hospital of the West Indies. West Indian Med J 53: 126-30. cryptococcal meningitis (CM) 10%, 1,120 PCP and 140 CM cases would 6. Barrow G, Ckarke TR, Carrington D, Harvey K, Barton EN. (2010). An Analysis of Three Opportunistic Infections in an Outpatient HIV Clinic in Jamaica. West Indian Med J 59: 393-399. be expected in AIDS annually. It wasn't possible to estimate the 7. Kahwa EK, Waldron NK, Younger NO, Edwards NC, Knight-Madden JM, Bailey KA, Wint YB, Lewis-Bell KN. Asthma and allergies in Jamaican children aged 2-17 years: a cross-sectional prevalence survey. BMJ Open. 2012 Jul 12;2(4). burden of histoplasmosis, invasive aspergillosis, mucormycosis, doi:pii: e001132. 8. Denning DW, Pleuvry A, Cole DC. Global burden of allergic bronchopulmonary aspergillosis with asthma and its and fungal keratitis due to paucity of data. complication chronic pulmonary aspergillosis in adults. Med Mycol. 2013 May;51(4):361-70.