Burden of Serious Fungal Infections in China Liping Zhu, Jiqin Wu
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Burden of serious fungal infections in China Liping Zhu, Jiqin Wu. David S. Perlin, David W. Denning Huashan Hospital, Fudan University, Shanghai 200040 China; Public Health Research Institute, Newark, NJ, USA and The University of Manchester in association with the LIFE program at www.LIFE-worldwide.org Introduction The incidence of serous fungal infections has been increasing over the past several decades as a result of the expanding number of immunocompromised patients with risk factors such as HIV infection, transplantation, immunosuppressive therapy, corticosteroid therapy, and broad-spectrum antibiotic medication, etc. Despite the availability of newer and potent antifungal agents, the morbidity and mortality of invasive fungal infections remain high. LIFE Understanding of the burden of fungal infections is crucial to both better disease prevention and treatment. In China, with the largest population in the LEADING world, population-based surveillance on various fungal infections is still lacking. However, data from specific high risk populations and some cities has INTERNATIONAL increasingly been reported. We have attempted to estimate the burden of serious fungal infection in China through literature review. FUNGAL Methods EDUCATION All published epidemiology papers reporting fungal infection rates from China were identified. If few data existed, we used specific populations at risk and fungal infection frequencies in those populations to estimate national incidence or prevalence. Population (2009), HIV (2011) and TB (2011) data were from WHO. Asthma, ABPA and CPA rates were from Denning, Bull WHO 2011, Med Mycol 2013 (ahead of print) and Ma, 2011. COPD admissions were from Tan, Respirology, 2009. Cryptococcal meningitis (CM) estimate in HIV was assumed to be 1 % of late stage HIV patients, and the rate of CM in other cases on the ratios reported by Chen, Mycopathologia, 2012. Pneumocystis jiroveci pneumonia (PCP) rates were based in Hong Kong rates in HIV and in non-HIV on Wang, J Med Microbiol, 2011. Penicillium marneffei infection rate was based in HK data, adjusted for regional differences in HIV prevalence. Tinea capitis rate was on a report from Shanghai (Zhu, Mycopathologia, 2010). Keratitis rate was based on Xu in Qingdao (Chin Med J, 2012). Results Of the 1,363M population, 20% are children (0-14 years) and 12% are >60 years old. 20M Chinese (age 15-50) women are estimated to get recurrent vaginal thrush (4+ times annually). Of the 740,000 estimated HIV positive patients in 2011, 92,227 are not on ARVs (CD4 <350). Of these an estimated 83,000 develop oral thrush, 50,000 oesophageal candidiasis, 461 CM, 16,140 PCP and 1,383 P. marneffei infection. We estimate a 5-year period prevalence of 256,534 CPA cases (assuming 15% annual mortality); 80% from 893,121 cases of pulmonary TB, 20% other conditions. Asthma prevalence in adults is estimated at nearly 20M and assuming 2.5% of asthmatics have ABPA, 491,721 patients with ABPA are likely and 648,300 have severe asthma with fungal sensitisation (SAFS). The rate of candidemia was estimated at 5/100,000 population (68,150 cases) and Candida peritonitis at 19,982 cases. Invasive aspergillosis (IA) in >100,000 haematological patients is estimated at 8,178 cases and in the COPD 154,000 cases (11,9M admissions). IA numbers in renal and liver transplantation and numerous other fungal diseases were not estimated. Number of infections per underlying disorder per year Total Rate Infection None HIV/AIDS Respiratory Cancer/Tx ICU burden /100K Conclusion Oesophageal candidiasis - 50,834 --- 50.834 3.7 Without any national surveys of fungal disease in China, uncertainty Candidaemia --- 20,445 47,705 68,150 5.0 surrounds all these estimates. But the burden of fungal disease is Candida peritonitis - --- 19,082 19.082 1.4 almost certainly one of the greatest in the world. Epidemiological Recurrent vaginal candidiasis (4x/year +) 19.959k - - -- 19.959 2,929 studies are urgently required to validate or modify these estimates. Allergic bronchopulmonary aspergillosis (ABPA) - - 491.721 -- 491.721 36.1 Severe asthma with fungal sensitisation (SAFS) -- 648,300 648,300 47.6 Chronic pulmonary aspergillosis (CPA) -- 265.534 -- 265,534 19.5 Invasive aspergillosis --- 8.178 154,155 162,333 11.9 Mucormycosis -- - 2.726 - 2,726 0.2 corresponding author: Cryptococcal meningitis 922 461 - 922 - 2306 0.17 Dr.Li-ping Zhu. Pneumocystis jiroveci pneumonia (PCP) - 16,140 ? 8.070 - 24,210 1.8 Email:zhulp@ fudan. edu.cn Penicillium marneffei infection ? 1,383 -- - 1,383 0.1 Fungal keratitis 17.038 -_ _ _ 17,038 1.3 Tinea capitis 34.075 -_-- 34,075 2.5 Total burden estimated 20.010k 151.822 1.405,555 37,615 221k 21,829k Belfast Health and Burden of Fungal Infection in Ireland Social Care Trust Eileen Dorgan1, David W. Denning2, Ronan McMullan1 1. Department of Medical Microbiology, Royal Victoria Hospital, Belfast Health and Social Care Trust, Grosvenor Road, Belfast, BT12 6BA 2. The University of Manchester in association with the LIFE program at www.LIFE-worldwide.orq Introduction & Purpose The national figure on critical care beds was obtained form the critical care census Infection Number of infections per underlying disorder per year Total Burden Rate /100K and included just the level 3 beds. Abdominal surgery is used as a marker for None HIV/AIDS Respiratory Cancer/Tx ICU 601 peritoneal candidasis and candidaemia the results for Northern Ireland were Oesophageal candidiasis Fungal Infections are a growing global problem that are difficult to quantify in terms of 601 9.4 obtained from DHSSPSNI Statistics and Research records and the numbers were population affected, mortality, resources used and possible methods of prevention. Currently Candidaemia 275 128 403 6.3 then adjusted to include ROI population. 64 data available on fungal infections worldwide are crude estimates that have not been Candida peritonitis 64 1 standardized. This project attempts to compile data from several countries worldwide that Recurrent Candida Results vaginitis (>4x/year) differ in terms of economic status, health care provision and ethnicity in order to form a better 94,974 94,974 1484 overall picture of the current state of fungal infection globally. Ireland has a population of 6,399,152. Of this, 22% are children under 16 and 8% Allergic 8,961 are women over 60. The rate of recurrent candida vaginitis is between 5-8% of adult bronchopulmonary aspergillosis (ABPA) Methods women; however in populations where a large percentage of women are over 50 this 8,961 140 11,675 may overcall the number of cases and a downward adjustment of 80% is Severe asthma with fungal For the purposes of creating a comparable data set for each country a template was provided sensitisation (SAFS) appropriate7. Therefore it is estimated that 94,974 women in Ireland have recurrent 11,675 182.4 that included demographic data and specific disease related information was gathered. 50 399 Candida vaginitis per year. Invasive aspergillosis 449 7 Relevant published epidemiology describing fungal infection in Ireland was identified. Data Current total HIV/AIDS 7374 Mucormycosis 13 13 0.2 were collected for 2010 from both Northern Ireland (NI) and the Republic of Ireland (ROI) and 3 Ireland has approximately 7,374 Cryptococcal meningitis 3 0 that combined data is presented here. This included some specific assumptions from Proportion of diagnosed cases on ARVs 0.79 people with HIV. There are few Pneumocystis pneumonia 12 38 published data that would allow the directly observed incidence of fungal infection to be used Number of diagnosed cases not receiving ARVS 1549 50 0.8 New cases of AIDS per year 50 AIDS-related opportunistic Chronic pulmonary 196 in conjunction with surrogate markers for fungal infection to estimate the total burden infections with only around 13 Proportion of AIDS cases presenting with PCP 25% aspergillosis 196 3.1 nationally. HIV-positive patients developing Fungal keratitis Proportion of AIDS cases presenting with 6% Pneumocystis pneumonia. Tinea capitis cryptococcal meningitis Population data were obtained from Northern Ireland Research and Statistics Agency and Total burden estimated 94,987 616 20,832 363 591 117,389 Central Statistic Office of Ireland, patients were categorized by age and gender. HIV/AIDS AIDS-related deaths in 2010 12 data for the Republic of Ireland was obtained from World Health Organization (WHO) “People Figure 1. HIV Data in Ireland Pulmonary TB (HIV positives) 20 Figure 4. Summary Table of Results for fungal infections in Ireland living with HIV” report and from the Health Service in Ireland 2011 HIV report. NI data was Among patients with chronic pulmonary Pulmonary TB (HIV negative) 225 gathered from the Public Health Agency (PHA) HIV & STI surveillance report 2011 and a Conclusions aspergillosis (CPA) it is estimated that 25% direct audit of HIV attendances at specialist clinics. It is assumed that 90% of patients with Pulmonary TB total 245 is attributable to TB. We infer an HIV who are not being treated with Anti-retrovirals (ARVs) will develop oral candidiasis and it Most fungal infections are unreported and therefore are impossible to count in approximate prevalence of 196 cases of COPD prevalence (all GOLD stages) 10.1% absolute numbers. To have an impression of the overall fungal burden in Ireland it is is assumed that 20% of patients with HIV not on ARVs and 5% of those on ARVs develop CPA. oesophageal candidiasis. The assumptions for oral candidiasis and oesophageal candidiasis COPD admissions to hospital per 30720 necessary to make some assumptions about the population from known datasets and Using international data, indicating that may artificially elevate the numbers of these conditions in populations where patients are not year published literature. Based on available data approximately 1.9% of Ireland’s typically around 2.5% of adults with asthma receiving ARVs due to having a CD4 count >200 and not fitting clinical criteria that warrants Asthma rate in adults 7.1% population will have a serious fungal infection during one year.