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Burden of Serious Fungal Infections in Jordan

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Burden of Serious Fungal Infections in Jordan Journal of Fungi Article Burden of Serious Fungal Infections in Jordan Jamal Wadi 1,* ID and David W. Denning 2 1 The Medical Center, Jordan Hospital and Medical Center, 29 Adeeb Wahbeh Street, 11118 Amman, Jordan 2 Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester M23 9LT, UK; [email protected] * Correspondence: [email protected]; Tel.: +962-7-77536503 Received: 30 November 2017; Accepted: 16 January 2018; Published: 18 January 2018 Abstract: Objective: To estimate the burden of fungal infections in Jordan for the first time. Material and Methods: Population data was from UN 2011 statistics and TB cases from WHO in 2012. Fewer than 100 patients with HIV were recorded in Jordan in 2013. Approximately 100 renal transplants and eight liver transplants are performed annually. There were 12,233 major surgical procedures in Jordan in 2013, of which 5.3% were major abdominal surgeries; candidemia was estimated in 5% of the population based on other countries, with 33% occurring in the ICU. Candida peritonitis/intra-abdominal candidiasis was estimated to affect 50% of the number of ICU candidemia cases. No adult asthma rates have been recorded for Jordan, so the rate from the Holy Land (8.54% clinical asthma) from To et al. has been used. There are an estimated 49,607 chronic obstructive pulmonary disease (COPD) patients in Jordan, with 64% symptomatic, 25% Gold stage 3% or 4%, and 7% (3472) are assumed to be admitted to hospital each year. No cystic fibrosis cases have been recorded. Literature searches on fungal infections revealed few data and no prevalence data on fungal keratitis or tinea capitis, even though tinea capitis comprised 34% of patients with dermatophytoses in Jordan. Results: Jordan has 6.3 million inhabitants (65% adults, 6% are >60 years old). The current burden of serious fungal infections in Jordan was estimated to affect ~119,000 patients (1.9%), not including any cutaneous fungal infections. Candidemia was estimated at 316 cases and invasive aspergillosis in leukemia, transplant, and COPD patients at 84 cases. Chronic pulmonary aspergillosis prevalence was estimated to affect 36 post-TB patients, and 175 in total. Allergic bronchopulmonary aspergillosis (ABPA) and severe asthma with fungal sensitization (SAFS) prevalence in adults with asthma were estimated at 8900 and 11,748 patients. Recurrent vulvovaginal candidiasis was estimated to affect 97,804 patients, using a 6% rate among women 15–50 years of age. Conclusion: Based on local data and literature estimates of the frequency of mycoses in susceptible populations, at least 1.9% of Jordanians have some form of serious fungal disease. Keywords: mycoses; epidemiology; aspergillosis; candidemia; fungal infections 1. Introduction Jordan and the surrounding region have scanty information on the population prevalence of fungal infections. Jordan is a small country with 6.3 million inhabitants (65% adults, 6% are >60 years old)[1,2]. It is in the Eastern Mediterranean region (Figure1), east of Palestine and west of Iraq and Saudi Arabia, in a relatively moderate climate where populations are mostly concentrated in the mountains, and less populated in the eastern part of the country where desert predominates [3]. This epidemiological modeling study is designed to assess the burden of serious fungal infections in Jordan based on some local data and data obtained from the UN 2011 and WHO 2013 for Jordan. The burden of serious fungal infections, their prevalence, as well as their trends, have not been studied before in Jordan, and the information on this issue continues to be speculative. A study from Jordan by Abu-Elteen and Abdul Malek assessing cutaneous mycosis and their causative species was published in 1999 [4]. J. Fungi 2018, 4, 15; doi:10.3390/jof4010015 www.mdpi.com/journal/jof J. Fungi 2018, 4, 15 2 of 12 J. Fungiby2018 Abu-Elteen, 4, 15 and Abdul Malek assessing cutaneous mycosis and their causative species was2 of 12 published in 1999 [4]. Turkey Syria Lb Iraq Pl i Egypt Saudi Figure 1. Map of Jordan, location in relation to nearby countries, and the world as in the inset Figure 1. Map of Jordan, location in relation to nearby countries, and the world as in the inset (modified (modified from [5]). from [5]). Study of the burden of serious fungal infections using epidemiological surveillance data is rarely Studypossible of worldwide the burden as ofdata serious is scarce fungal but, if infections done, it is mostly using epidemiologicalbased on laboratory surveillance culture and dataautopsy is rarely possibledata worldwide [6]. Studying as datathe fungal is scarce burden but, ifand done, species it is distribution mostly based in ona community laboratory is culture of a principal and autopsy dataimportance [6]. Studying as these the infections fungal burden cause high and morbidity species and distribution mortality, especially in a community in special is risk of groups, a principal such as critically ill ICU patients subjected to several interventions, including many broad-spectrum importance as these infections cause high morbidity and mortality, especially in special risk groups, antibiotics, central venous catheters, total parenteral nutrition, hemodialysis, and ventilators; patients such as critically ill ICU patients subjected to several interventions, including many broad-spectrum with abdominal surgery; cancer patients with neutropenia, hematological diseases, and/or antibiotics,transplants; central patients venous receiving catheters, solid total organ parenteral transplants, nutrition, patients hemodialysis, with different andimmunosuppressive ventilators; patients with abdominalstates, or on surgery; immunosuppressive cancer patients therapy, with neutropenia,and patients hematologicalwith chronic respiratory diseases, and/ordiseases transplants; [7,8]. patientsSummarizing receiving all solid the data organ in any transplants, region, including patients this with region, different empowers immunosuppressive proper nationwide planning states, or on immunosuppressiveto minimize death therapy, and andsuffering patients from with fungal chronic disease, respiratory and can diseases guide [7attending,8]. Summarizing healthcare all the data inprofessionals any region, on including appropri thisate empirical region, empowers approaches proper in complex nationwide patients planning with possible, to minimize probable, death or and sufferingconfirmed from fungalserious disease, fungal infections and can guide[9]. attending healthcare professionals on appropriate empirical approachesOur in current complex study patients depicts with the possible, current state probable, of epidemiological or confirmed knowledge serious fungal and estimates infections the [9 ]. incidence and prevalence of serious fungal infections in Jordan. Our current study depicts the current state of epidemiological knowledge and estimates the incidence2. Materials and prevalence and Methods of serious fungal infections in Jordan. 2. MaterialsWe andcollected Methods data on total and at risk populations. Population data was from UN 2011 statistics and from the WHO in 2012, supported by crudely locally-collected data. Fewer than 100 patients with WeHIV collected were recorded data in on Jordan total andin 2013. at riskApproximatel populations.y 100 Populationrenal transplants data and was eight from liver UN transplants 2011 statistics and fromare performed the WHO annually. in 2012, supportedThere were by12,233 crudely major locally-collected surgical procedures data. in FewerJordan than in 2013, 100 of patients which with HIV were5.3% were recorded major in abdominal Jordan in surgeries; 2013. Approximately candidemia was 100 estimated renal transplants in 5% of the and population eight liver based transplants on are performedother countries, annually. with There33% occurring were 12,233 in ICU. major Candida surgical peritonitis/intra-abdo procedures in Jordanminal in candidiasis 2013, of which was 5.3% wereestimated major abdominal to affect 50% surgeries; of the number candidemia of ICU was cand estimatedidemia cases. in 5% No of adult the populationasthma rates basedhave been on other countries,recorded with for 33% Jordan, occurring so the rate in ICU. in adultsCandida fromperitonitis/intra-abdominal the Holy Land (8.54% clinical candidiasisasthma) from was To estimatedet al. has been used [10]. There are an estimated 49,607 chronic obstructive pulmonary disease (COPD) to affect 50% of the number of ICU candidemia cases. No adult asthma rates have been recorded patients in Jordan [11], with 64% symptomatic, 25% Gold stage 3 or 4 [12], and 7% (3472) are assumed for Jordan, so the rate in adults from the Holy Land (8.54% clinical asthma) from To et al. has been to be admitted to hospital each year. Tuberculosis rates have risen slightly over the last few years and usedwe [10 used]. There the WHO are an 2015 estimated estimates 49,607 for pulmonary chronic obstructiveTB only assuming pulmonary a 10% mortality disease [13]. (COPD) Pulmonary patients in Jordantuberculosis [11], with was 64% assumed symptomatic, to represent 25% 20% Gold of the stage total 3of orchronic 4 [12 pulmonary], and 7% aspergillosis (3472) are assumed cases [14]. to be admittedNo cystic to hospital fibrosis eachcases year.have Tuberculosisbeen recorded. rates Literatu havere searches risen slightly on fungal over infections the last fewrevealed years little and we useddata the WHOand no 2015prevalence
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