T h e G loba l B u rd en o f Funga l D i s eas es Snigdha Vallabhaneni, Tom Chiller, MD, MPHTM
MD, MPH*,
Rajal K. Mody,
MD, MPH,
Tiffany Walker,
MD,
KEYWORDS Global burden Epidemiology Fungal diseases Candida Cryptococcus Aspergillus Mold Endemic mycoses KEY POINTS Fungal pathogens are emerging as an even more important cause of disease as the number of people with severely immunocompromising conditions, such as HIV, cancer, and organ transplantation, who are at higher risk for fungal diseases, increases. Candida species are the most important cause of serious invasive fungal infections, but infections caused by Cryptococcus, Pneumocystis, invasive molds, and dimorphic molds also contribute to a substantial burden of disease. Systematic surveillance for fungal infections is scarce and is needed to make informed estimates of the global burden of fungal diseases.
INTRODUCTION
Assessment of the global burden and epidemiologic trends of fungal diseases is critical to prioritizing prevention strategies, diagnostic modalities, and therapeutic interventions. The global burden of fungal diseases is increasing, given the expanding number of patients at risk for these infections, including people living with human immunodeficiency virus (PLHIV), transplant recipients, patients with cancer, patients receiving immunomodulators (eg, tumor necrosis factor-a inhibitors), premature neonates, and the elderly. Recent increases in travel and changes in climate may also result in changes in geographic distribution of fungi.
Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Funding Source: No funding source to report. Conflict of Interest: The authors have no relevant conflicts of interest to report. Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA * Corresponding author. Centers for Disease Control and Prevention, 1600 Clifton Road Northeast, Mailstop C-09, Atlanta, GA 30329. E-mail address: [email protected] Infect Dis Clin N Am - (2015) -–http://dx.doi.org/10.1016/j.idc.2015.10.004 0891-5520/15/$ – see front matter Published by Elsevier Inc.
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Quantifying the global burden of fungal diseases is challenging. Fungal diseases are often difficult to diagnose because they manifest with nonspecific symptoms and are not routinely suspected. Diagnosis frequently requires invasive tissue specimens, fungi do not always grow in culture, histopathologic identification is challenging, fungal antibody tests may cross-react, and skin testing for latent infection is generally not available. The most comprehensive estimates of any disease come from surveillance (formal systematic case counts within a specified population). In some parts of the world, limited single institution-based, population-based, or sentinel surveillance for some fungal diseases provides helpful information on trends in the burden of that infection. However, the lack of routine surveillance for most fungal diseases greatly limits the availability of data needed to inform burden estimates. In some cases, administrative health care data documenting hospital discharge diagnoses or registries of patients with fungal diseases have been used in lieu of surveillance.1 Although helpful, these assessments do not capture the full burden of disease. Recent attempts to estimate fungal disease burden have been made using far-reaching extrapolations from limited available data on susceptible populations and prevalence of disease.2 These estimates highlight important data gaps and should be interpreted cautiously. This article reports on distribution, incidence, and prevalence of selected fungal disease, and points out the gaps in knowledge where such data were not available. The review is organized by pathogen and by global region, highlighting the fungal diseases that contribute the most to global morbidity and mortality. YEASTS Candida
Candida bloodstream infection (candidemia) is the most common form of invasive Candida infection and is associated with substantial morbidity and mortality. The incidence of candidemia in the general population and hospitalized and intensive care unit patients has been reported from multiple countries. These estimates vary widely within regions of the same country and over time.3 Representative studies are listed in Table 1.4–14 The reasons for these differences in candidemia incidence are likely multifactorial, including underlying ecology of Candida spp, differences in underlying patient populations, resources available for medical care and training programs, difficulties in implementing hospital infection control programs, and differences in surveillance methodologies.3 Although a plethora of single-institution studies have been reported, only a few countries have conducted geographically widespread surveillance, and in still fewer countries has this been sustained over time to describe trends in candidemia.5,12,15 To truly understand the global burden of candidemia, there is a need for within- and between-country collaborations to systematically study candidemia in different settings. Species distribution of Candida infections in various parts of the world are listed in Box 1.5,8,16–19 The differences in species distribution may relate to local ecology of Candida spp and is important because variation in antifungal susceptibility patterns by species has implications for treatment success. Furthermore, the predominance of some species, such as Candida parapsilosis, signals a need for examination of hospital infection control practices. Invasive infection caused by antifungal-resistant Candida spp is an emerging problem. Fluconazole resistance among Candida albicans isolates is estimated between 0% and 5%, with the highest rate reported in South Africa.20 Fluconazole resistance is a much bigger problem among non-albicans spp and ranges between 5% and
The Global Burden of Fungal Diseases
Table 1 Incidence of candidemia by year, country, and patient population, select studies Candidemia Incidence Year
Country
Per 100,000 Population
Per 10,000 Patient Days
Per 1000 Discharges
1992
USA
9
—
—
4
2008
USA
14
—
—
4
2013
USA
10
—
—
5
1999–2004
Canada
2.9
—
—
6
1995–1999
Finland
2
—
—
7
2004–2012
Norway
3.9
—
—
8
2002–2003
Spain
4.3
—
—
9
2003–2004
Brazil
—
3.7
—
10
1998–2000
USA
—
1.5
—
11
2004–2009
France
—
1.0–1.2
—
12
2010–2011
Asia (25 hospitals across Asia) India
—
—
1.2
13
—
—
6 (per 1000 ICU admission)
14
Ref
65%, with the highest rate reported in Denmark.20 Fluconazole resistance is problematic because it is the only antifungal drug available for treatment of Candida infections in many parts of the world. Echinocandin resistance has also been reported in some settings; in the United States, approximately 6% of Candida glabrata isolates are resistant to echinocandins.5 Cryptococcus
Disseminated Cryptococcus neoformans disease is largely associated with HIV infection. A 2009 study estimated that nearly 1 million cases of cryptococcal meningitis occurred worldwide each year, with more than 600,000 deaths annually.21 More than 700,000 cases were estimated to occur in sub-Saharan Africa annually, where the burden of HIV is also the highest. This study was based on limited published reports of the burden of cryptococcal meningitis at that time, and as such, the estimated range of total infections per year was very wide (371,700–1,544,000). Increased efforts aimed at earlier diagnosis of HIV, rapid antiretroviral treatment initiation, and improved Box 1 Patterns of Candida species distribution C albicans was the leading cause of candidemia worldwide, but its predominance has decreased during the past two decades.5,8 Currently, only about one-third of candidemia in the United States and Western Europe is caused by C albicans; the second leading cause of candidemia is C glabrata followed by C parapsilosis.5 In many regions of the world, C albicans candidemia still predominates, but C tropicalis or C parapsilosis are the second leading cause rather than C glabrata.16,17 In some countries in Asia and South America, C tropicalis is the most common agent and C albicans has dropped to third or fourth in frequency.18,19
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retention in care, along with cryptococcal antigen screening efforts, should reduce the burden of cryptococcal disease in coming years.22 Revised estimates of the burden of cryptococcosis are needed based on current epidemiology. C neoformans infection can also affect patients with immunosuppression resulting from solid organ or bone marrow transplantation, and those receiving short- and long-term treatment with steroids or tumor necrosis factor-a inhibitors,23 but the burden of disease in this population has not been well-reported. Cryptococcus gattii infections are emerging in some areas of the world. C gattii is endemic in Papua New Guinea, Australia, and South America. Starting in the late 1990s, C gattii infections were recognized in British Columbia, Canada (218 cases reported during 1999–2007) and in the US Pacific Northwest since 2004 (approximately 100 cases reported in the United States).24 Unlike C neoformans, which usually affects immunocompromised individuals, C gattii infections can also cause serious disease in immunocompetent hosts. OTHER FUNGUS Pneumocystis jirovecii
Pneumocystis pneumonia (PCP) was a rare disease until the AIDS epidemic began in the early 1980s. PCP became the leading AIDS-defining diagnosis among PLHIV in the United States and Europe. Since the advent of highly active antiretroviral therapy, combined with aggressive PCP prophylaxis with trimethoprim-sulfamethoxazole, the incidence of PCP decreased dramatically in North America and Europe; in one study, incidence decreased from 4.9 cases per 100 person-years to 0.3 cases per 100 person-years among PLHIV between 1995 and 1998.25 Despite this decline, PCP is still an important opportunistic infection among PLHIV in the United States and Europe. Initial reports from developing countries suggested that PCP was a less important cause of morbidity and mortality than tuberculosis and enteric pathogens, but these rates may have been artificially low because of poor access to PCP diagnostic testing and competing risk of death from other opportunistic infections. PCP is also a leading cause of opportunistic infections in HIV-negative persons with malignancies, inflammatory disease, organ transplant recipients, and those receiving prolonged courses of corticosteroids,26 but the burden in this population is unclear. MOLDS Aspergillus
In a multicenter study of invasive fungal infections (IFI) among transplant recipients at 23 US transplant centers during 2001 to 2006, invasive aspergillosis accounted for nearly 20% of all IFIs, second only to invasive candidiasis. The annual incidence of invasive aspergillosis among transplant recipients was 0.65%27,28 and incidence of invasive aspergillosis was highest (3.9%) among hematopoietic stem cell transplant (HSCT) recipients with a matched, unrelated donor.28 A multicenter French study describing trends in IFIs based on hospital discharge data found a 4.4% increase in invasive aspergillosis each year during 2001 to 201029; similar increases have been noted in other parts of the world. Data describing invasive aspergillosis in other parts of the world are sparse. A multicenter Brazilian study of patients with HSCT and hematologic malignancy reported invasive aspergillosis to be the most common IFI, with 6.5% of patients developing the disease.30 Published data on prevalence from most of Asia or Africa are lacking.16 Although the current burden is not known, aspergillosis is likely to increase as resource-limited countries increase organ and bone marrow transplantation.
The Global Burden of Fungal Diseases
Mucormycetes
Although mucormycosis is less common than invasive aspergillosis, its incidence seems to be rising.29 Several studies have shown a rise in the proportion of HSCT recipients developing mucormycosis (8% during 2001–2006 vs 1% in the 1990s) after widespread use of voriconazole prophylaxis to prevent invasive aspergillosis and other fungal infections.31 Although data on mucormycosis are sparse, India contributes substantially to the global burden of this disease. Unlike the United States and Europe, mucormycosis is largely associated with diabetes in India.16 This burden is likely to grow given the rising rates of obesity and diabetes in India and many other parts of the world. Scedosporium
Scedosporium (Pseudallescheria) spp are rare mold pathogens of concern because of echinocandin resistance and variable susceptibility to azoles and high mortality.32 The actual burden of this disease is largely unknown but a single-institution retrospective review from the United States revealed increasing incidence from 0.82 cases per 100,000 inpatient days during 1993 to 1998 to 1.33 cases during 1999 to 2005.33 Fusarium
Invasive infections with Fusarium spp occurs in the setting of severe immunosuppression and mortality ranges from 50% to 80%.34 One prospective study of several transplant centers in the United States noted a cumulative incidence of rare molds, including Fusarium, of 0.25%,27,28 which was significantly lower than the incidence of 2.5% among patients with HSCT and hematologic malignancy reported from eight centers in Brazil.30 The global burden of fusariosis is unknown. ENDEMIC MOLDS Histoplasma capsulatum
The epidemiology of histoplasmosis in the United States has shifted from an HIVrelated disease to one that affects individuals after organ transplantation or chronic immunosuppression from inflammatory conditions,35 and now is the most common transplant-related endemic mycosis in the United States.36 One study evaluating a random sample of US Medicare data reported an incidence of 6.1 cases per 100,000 person-years in the Midwest during 1999 to 2008.37 The actual burden in the United States is unknown outside of a few states because histoplasmosis is not nationally notifiable. In Latin America, histoplasmosis is the most clinically significant endemic mycosis,38 and the most common opportunistic infection among PLHIV, with an incidence reported by one study of 0.15 per 100,000 person-years.39 Histoplasmosis has also been described in China40 and India.41 More than 1200 Thai cases that have been reported to date have mostly occurred among PLHIV.41 African histoplasmosis has been described in Central and Western Africa and Madagascar. More than 200 cases have been reported in the literature from Nigeria, Niger, Senegal, Congo, and Uganda.42 There is no way to estimate the burden of this disease in this region because it has no systematic surveillance. Coccidioides immitis and Coccidioides posadasii
The most reliable burden estimates of coccidioidomycosis are from the United States, where it is a nationally notifiable disease. During 1998 to 2011, the incidence of reported coccidioidomycosis increased substantially in the endemic area from 5.3 to
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42.6 per 100,000.43 Subsequent reports show a decline in incidence since 2011; the reasons for the initial increase and subsequent decline are not clear. These estimates are likely to be gross underestimations of the actual burden because an estimated 60% of those with disease do not seek medical care, and many symptomatic infections go undiagnosed.44 The incidence of disease in Central and South America has not been clearly defined. Skin testing surveys in Mexico found positivity rates between 40% and 90% in certain states,45 indicating a high frequency of exposure to the fungus. Endemic regions have been defined in Mexico, Guatemala, Honduras, Nicaragua, northern Venezuela, northeastern Brazil, Argentina, Bolivia, and Paraguay.38,46 Paracoccidioides brasiliensis
Paracoccidioidomycosis has an endemic zone that extends south from Mexico to Argentina.47 Based on skin testing studies in humans and animals, it is estimated that 50% to 75% of adults in endemic areas have been exposed to the fungus. Brazil, where the disease was first described, has the highest burden of disease, with more than 80% of all cases of paracoccidioidomycosis occurring in six Brazilian states.38 Brazilian data also suggest that the reported incidence of paracoccidioidomycosis is between one and three cases per 100,000 persons living in the endemic areas; in Colombia, the reported incidence is lower at 0.05 to 0.22 per 100,000 persons.48 Blastomyces dermatitidis
The incidence of blastomycosis from certain areas in the United States and Canada, where the disease is reportable, ranges from 0.3 to 41.9 cases per 100,000, with northcentral parts of Wisconsin showing the highest incidence rate.49–51 There were approximately 1000 blastomycosis-related hospitalizations in the United States during 2007 to 2011.1 Again, the true burden in the United States is unknown because of the lack of reporting beyond a few states. Data on the burden of blastomycosis in other parts of the world are not available. Talaromyces (Penicillium) marneffei
Infections with Talaromyces (Penicillium) marneffei are primarily seen as HIVassociated opportunistic infections in Southeast Asia. Although the true incidence of T marneffei is unknown, it was the third most commonly reported opportunistic infection after tuberculosis and cryptococcosis in northern Thailand in the 1990s.52 Eastern India53 and Southern China54 are also endemic for T marneffei. In a retrospective study of the 8000 stored serum samples from Chinese PLHIV during 2004 to 2011, nearly 10% had evidence of T marneffei antigen55; the prevalence of antigen positivity (28%) was higher among those with CD4 counts less than 50 cells/mm3. It remains unclear how these results correlate with the actual burden of infection. OTHER FUNGAL ORGANISMS Organisms Causing Eumycetoma
Mycetoma has a worldwide distribution, but is endemic primarily in tropical and subtropical regions.56 Based on a review of 8000 published cases, Mexico, India, and Sudan seem to carry the highest burden of mycetoma.57,58 Mycetoma has been recognized by the World Health Organization as a neglected tropical disease. It affects many people in the prime of their lives, yet little is known about its incidence, prevalence, diagnosis, or treatment.
The Global Burden of Fungal Diseases
Table 2 Emerging fungal infections Organism
Years First Detected
Global Region to Date
Notes
Ref
Emmonsia spp
2008–2011
South Africa
Finding of a new species of dimorphic fungus that is pathogenic to humans
59
Candida auris
2004–2006
Korea, India, Pakistan, South Africa, Kuwait
Intrinsically resistant to multiple antifungal agents
60
Sporothrix schenckii
1987–present
Brazil
Acquired from contact with cats (in addition to inoculation after contact with plants)
61
Azole-resistant Aspergillus fumigatus
—
Multiple regions including in Europe, Japan, India, Iran
Clinical and environmental A fumigatus found to be azole-resistant; possibly linked to fungicide use in agriculture
62
Emerging Pathogens
Newly emerging fungal pathogens are described each year, as fungal species not previously known to cause disease are recognized as agents of opportunistic infections in high-risk patients. Several recently described emerging fungal pathogens are listed in Table 259–62 along with their significance and implications. Many other established and emerging fungal organisms are not included in this review. Infections caused by yeast, such as Trichosporon, and rare molds, such as Exserohilum, Bipolaris, and Sarocladium, are conditions that are relevant in certain susceptible populations, but the burden of these conditions is not known. SUMMARY
Fungal diseases cause considerable morbidity and mortality globally, but their burden is largely undetermined. The prevalence of invasive Candida infection has been the best-studied of all fungal diseases. Several population-based estimates describe rates of candidemia, especially in North America and Europe. Nevertheless, it is difficult to estimate the worldwide burden of this disease because of major data gaps from Africa and some parts of Asia. Estimates of the global burden of cryptococcal disease, which is probably the next best-studied fungal disease, have been attempted but relied on limited data from a few settings.21 Regional burden estimates for other diseases, such as histoplasmosis and coccidioidomycosis, exist but lack of data from other endemic areas makes global burden estimation challenging. In general, lack of surveillance data, especially in the developing world, makes calculating reliable burden estimates very challenging. Establishing the incidence and prevalence of infection through institution of surveillance systems is critical to understand disease burden and to describe emerging fungal threats and antimicrobial resistance. Developing much needed, long-term, sustainable, surveillance programs for fungal diseases should be a priority. To begin with, efforts to improve the diagnosis and recognition of fungal infections are paramount. Focusing surveillance activities on populations at risk (candidemia in intensive care unit patients, mold infections in transplant recipients, and so forth) may help narrow the scope of surveillance programs and
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reduce cost. Developing better noninvasive and reliable diagnostic tools for fungal diseases will facilitate laboratory diagnosis and thereby increase case detection and reporting to surveillance. Such information serves as a foundation for appropriate, targeted, and measurable prevention and control efforts. REFERENCES
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The Global Burden of Fungal Diseases
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33. Lamaris GA, Chamilos G, Lewis RE, et al. Scedosporium infection in a tertiary care cancer center: a review of 25 cases from 1989-2006. Clin Infect Dis 2006; 43(12):1580–4. 34. Dignani MC, Anaissie E. Human fusariosis. Clin Microbiol Rev 2004;10(Suppl 1): 67–75. 35. Myint T, Al-Hasan MN, Ribes JA, et al. Temporal trends, clinical characteristics, and outcomes of histoplasmosis in a tertiary care center in Kentucky, 2000 to 2009. J Int Assoc Provid AIDS Care 2014;13(2):100–5. 36. Kauffman CA, Freifeld AG, Andes DR, et al. Endemic fungal infections in solid organ and hematopoietic cell transplant recipients enrolled in the TransplantAssociated Infection Surveillance Network (TRANSNET). Transpl Infect Dis 2014;16(2):213–24. 37. Baddley JW, Winthrop KL, Patkar NM, et al. Geographic distribution of endemic fungal infections among older persons, United States. Emerg Infect Dis 2011; 17(9):1664–9. 38. Colombo AL, Tobon A, Restrepo A, et al. Epidemiology of endemic systemic fungal infections in Latin America. Med Mycol 2011;49(8):785–98. 39. Nacher M, Adenis A, Adriouch L, et al. What is AIDS in the Amazon and the Guianas? Establishing the burden of disseminated histoplasmosis. Am J Trop Med Hyg 2011;84(2):239–40. 40. Pan B, Chen M, Pan W, et al. Histoplasmosis: a new endemic fungal infection in China? Review and analysis of cases. Mycoses 2013;56(3):212–21. 41. Antinori S. Histoplasma capsulatum: more widespread than previously thought. Am J Trop Med Hyg 2014;90(6):982–3. 42. Gugnani HC, Muotoe-Okafor F. African histoplasmosis: a review. Rev Iberoam Micol 1997;14(4):155–9. 43. CDC. Increase in reported coccidioidomycosis—United States, 1998–2011. MMWR Morb Mortal Wkly Rep 2013;62(12):217–21. 44. Chang DC, Anderson S, Wannemuehler K, et al. Testing for coccidioidomycosis among patients with community-acquired pneumonia. Emerg Infect Dis 2008; 14(7):1053–9. 45. Padua y Gabriel A, Martinez-Ordaz VA, Velasco-Rodreguez VM, et al. Prevalence of skin reactivity to coccidioidin and associated risks factors in subjects living in a northern city of Mexico. Arch Med Res 1999;30(5):388–92. 46. Brown J, Benedict K, Park BJ, et al. Coccidioidomycosis: epidemiology. Clin Epidemiol 2013;5:185–97. 47. Queiroz-Telles F, Escuissato DL. Pulmonary paracoccidioidomycosis. Semin Respir Crit Care Med 2011;32(6):764–74. 48. Restrepo A, McEwen JG, Castan˜eda E. The habitat of Paracoccidioides brasiliensis: how far from solving the riddle? Med Mycol 2001;39(3):233–41. 49. Morris SK, Brophy J, Richardson SE, et al. Blastomycosis in Ontario, 1994-2003. Emerg Infect Dis 2006;12(2):274–9. 50. Benedict K, Roy M, Chiller T, et al. Epidemiologic and ecologic features of blastomycosis: a review. Curr Fungal Infect Rep 2012;6:327–35. 51. Reed KD, Meece JK, Archer JR, et al. Ecologic niche modeling of Blastomyces dermatitidis in Wisconsin. PLoS One 2008;3(4):e2034. 52. Supparatpinyo K, Khamwan C, Baosoung V, et al. Disseminated Penicillium marneffei infection in southeast Asia. Lancet 1994;344(8915):110–3. 53. Ranjana KH, Priyokumar K, Singh TJ, et al. Disseminated Penicillium marneffei infection among HIV-infected patients in Manipur state, India. J Infect 2002; 45(4):268–71.
The Global Burden of Fungal Diseases
54. Zheng J, Gui X, Cao Q, et al. A clinical study of acquired immunodeficiency syndrome associated Penicillium marneffei infection from a non-endemic area in China. PLoS One 2015;10(6):e0130376. 55. Wang YF, Xu HF, Han ZG, et al. Serological surveillance for Penicillium marneffei infection in HIV-infected patients during 2004-2011 in Guangzhou, China. Clin Microbiol Infect 2015;21(5):484–9. 56. Ahmed AOA, van Leeuwen W, Fahal A, et al. Mycetoma caused by Madurella mycetomatis: a neglected infectious burden. Lancet Infect Dis 2004;4(9):566–74. 57. Bonifaz A, Tirado-Sa´nchez A, Caldero´n L, et al. Mycetoma: experience of 482 cases in a single center in Mexico. PLoS Negl Trop Dis 2014;8(8):e3102. 58. van de Sande WW. Global burden of human mycetoma: a systematic review and meta-analysis. PLoS Negl Trop Dis 2013;7(11):e2550. 59. Kenyon C, Bonorchis K, Corcoran C, et al. A dimorphic fungus causing disseminated infection in South Africa. N Engl J Med 2013;369(15):1416–24. 60. Chowdhary A, Anil Kumar V, Sharma C, et al. Multidrug-resistant endemic clonal strain of Candida auris in India. Clin Microbiol Infect 2014;33(6):919–26. 61. Freitas DF, Valle AC, da Silva MB, et al. Sporotrichosis: an emerging neglected opportunistic infection in HIV-infected patients in Rio de Janeiro, Brazil. PLoS Negl Trop Dis 2014;8(8):e3110. 62. Vermeulen E, Lagrou K, Verweij PE. Azole resistance in Aspergillus fumigatus: a growing public health concern. Curr Opin Infect Dis 2013;26(6):493–500.
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MD, MPH*,
Rajal K. Mody,
MD, MPH,
Tiffany Walker,
MD,
KEYWORDS Global burden Epidemiology Fungal diseases Candida Cryptococcus Aspergillus Mold Endemic mycoses KEY POINTS Fungal pathogens are emerging as an even more important cause of disease as the number of people with severely immunocompromising conditions, such as HIV, cancer, and organ transplantation, who are at higher risk for fungal diseases, increases. Candida species are the most important cause of serious invasive fungal infections, but infections caused by Cryptococcus, Pneumocystis, invasive molds, and dimorphic molds also contribute to a substantial burden of disease. Systematic surveillance for fungal infections is scarce and is needed to make informed estimates of the global burden of fungal diseases.
INTRODUCTION
Assessment of the global burden and epidemiologic trends of fungal diseases is critical to prioritizing prevention strategies, diagnostic modalities, and therapeutic interventions. The global burden of fungal diseases is increasing, given the expanding number of patients at risk for these infections, including people living with human immunodeficiency virus (PLHIV), transplant recipients, patients with cancer, patients receiving immunomodulators (eg, tumor necrosis factor-a inhibitors), premature neonates, and the elderly. Recent increases in travel and changes in climate may also result in changes in geographic distribution of fungi.
Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Funding Source: No funding source to report. Conflict of Interest: The authors have no relevant conflicts of interest to report. Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA * Corresponding author. Centers for Disease Control and Prevention, 1600 Clifton Road Northeast, Mailstop C-09, Atlanta, GA 30329. E-mail address: [email protected] Infect Dis Clin N Am - (2015) -–http://dx.doi.org/10.1016/j.idc.2015.10.004 0891-5520/15/$ – see front matter Published by Elsevier Inc.
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Quantifying the global burden of fungal diseases is challenging. Fungal diseases are often difficult to diagnose because they manifest with nonspecific symptoms and are not routinely suspected. Diagnosis frequently requires invasive tissue specimens, fungi do not always grow in culture, histopathologic identification is challenging, fungal antibody tests may cross-react, and skin testing for latent infection is generally not available. The most comprehensive estimates of any disease come from surveillance (formal systematic case counts within a specified population). In some parts of the world, limited single institution-based, population-based, or sentinel surveillance for some fungal diseases provides helpful information on trends in the burden of that infection. However, the lack of routine surveillance for most fungal diseases greatly limits the availability of data needed to inform burden estimates. In some cases, administrative health care data documenting hospital discharge diagnoses or registries of patients with fungal diseases have been used in lieu of surveillance.1 Although helpful, these assessments do not capture the full burden of disease. Recent attempts to estimate fungal disease burden have been made using far-reaching extrapolations from limited available data on susceptible populations and prevalence of disease.2 These estimates highlight important data gaps and should be interpreted cautiously. This article reports on distribution, incidence, and prevalence of selected fungal disease, and points out the gaps in knowledge where such data were not available. The review is organized by pathogen and by global region, highlighting the fungal diseases that contribute the most to global morbidity and mortality. YEASTS Candida
Candida bloodstream infection (candidemia) is the most common form of invasive Candida infection and is associated with substantial morbidity and mortality. The incidence of candidemia in the general population and hospitalized and intensive care unit patients has been reported from multiple countries. These estimates vary widely within regions of the same country and over time.3 Representative studies are listed in Table 1.4–14 The reasons for these differences in candidemia incidence are likely multifactorial, including underlying ecology of Candida spp, differences in underlying patient populations, resources available for medical care and training programs, difficulties in implementing hospital infection control programs, and differences in surveillance methodologies.3 Although a plethora of single-institution studies have been reported, only a few countries have conducted geographically widespread surveillance, and in still fewer countries has this been sustained over time to describe trends in candidemia.5,12,15 To truly understand the global burden of candidemia, there is a need for within- and between-country collaborations to systematically study candidemia in different settings. Species distribution of Candida infections in various parts of the world are listed in Box 1.5,8,16–19 The differences in species distribution may relate to local ecology of Candida spp and is important because variation in antifungal susceptibility patterns by species has implications for treatment success. Furthermore, the predominance of some species, such as Candida parapsilosis, signals a need for examination of hospital infection control practices. Invasive infection caused by antifungal-resistant Candida spp is an emerging problem. Fluconazole resistance among Candida albicans isolates is estimated between 0% and 5%, with the highest rate reported in South Africa.20 Fluconazole resistance is a much bigger problem among non-albicans spp and ranges between 5% and
The Global Burden of Fungal Diseases
Table 1 Incidence of candidemia by year, country, and patient population, select studies Candidemia Incidence Year
Country
Per 100,000 Population
Per 10,000 Patient Days
Per 1000 Discharges
1992
USA
9
—
—
4
2008
USA
14
—
—
4
2013
USA
10
—
—
5
1999–2004
Canada
2.9
—
—
6
1995–1999
Finland
2
—
—
7
2004–2012
Norway
3.9
—
—
8
2002–2003
Spain
4.3
—
—
9
2003–2004
Brazil
—
3.7
—
10
1998–2000
USA
—
1.5
—
11
2004–2009
France
—
1.0–1.2
—
12
2010–2011
Asia (25 hospitals across Asia) India
—
—
1.2
13
—
—
6 (per 1000 ICU admission)
14
Ref
65%, with the highest rate reported in Denmark.20 Fluconazole resistance is problematic because it is the only antifungal drug available for treatment of Candida infections in many parts of the world. Echinocandin resistance has also been reported in some settings; in the United States, approximately 6% of Candida glabrata isolates are resistant to echinocandins.5 Cryptococcus
Disseminated Cryptococcus neoformans disease is largely associated with HIV infection. A 2009 study estimated that nearly 1 million cases of cryptococcal meningitis occurred worldwide each year, with more than 600,000 deaths annually.21 More than 700,000 cases were estimated to occur in sub-Saharan Africa annually, where the burden of HIV is also the highest. This study was based on limited published reports of the burden of cryptococcal meningitis at that time, and as such, the estimated range of total infections per year was very wide (371,700–1,544,000). Increased efforts aimed at earlier diagnosis of HIV, rapid antiretroviral treatment initiation, and improved Box 1 Patterns of Candida species distribution C albicans was the leading cause of candidemia worldwide, but its predominance has decreased during the past two decades.5,8 Currently, only about one-third of candidemia in the United States and Western Europe is caused by C albicans; the second leading cause of candidemia is C glabrata followed by C parapsilosis.5 In many regions of the world, C albicans candidemia still predominates, but C tropicalis or C parapsilosis are the second leading cause rather than C glabrata.16,17 In some countries in Asia and South America, C tropicalis is the most common agent and C albicans has dropped to third or fourth in frequency.18,19
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retention in care, along with cryptococcal antigen screening efforts, should reduce the burden of cryptococcal disease in coming years.22 Revised estimates of the burden of cryptococcosis are needed based on current epidemiology. C neoformans infection can also affect patients with immunosuppression resulting from solid organ or bone marrow transplantation, and those receiving short- and long-term treatment with steroids or tumor necrosis factor-a inhibitors,23 but the burden of disease in this population has not been well-reported. Cryptococcus gattii infections are emerging in some areas of the world. C gattii is endemic in Papua New Guinea, Australia, and South America. Starting in the late 1990s, C gattii infections were recognized in British Columbia, Canada (218 cases reported during 1999–2007) and in the US Pacific Northwest since 2004 (approximately 100 cases reported in the United States).24 Unlike C neoformans, which usually affects immunocompromised individuals, C gattii infections can also cause serious disease in immunocompetent hosts. OTHER FUNGUS Pneumocystis jirovecii
Pneumocystis pneumonia (PCP) was a rare disease until the AIDS epidemic began in the early 1980s. PCP became the leading AIDS-defining diagnosis among PLHIV in the United States and Europe. Since the advent of highly active antiretroviral therapy, combined with aggressive PCP prophylaxis with trimethoprim-sulfamethoxazole, the incidence of PCP decreased dramatically in North America and Europe; in one study, incidence decreased from 4.9 cases per 100 person-years to 0.3 cases per 100 person-years among PLHIV between 1995 and 1998.25 Despite this decline, PCP is still an important opportunistic infection among PLHIV in the United States and Europe. Initial reports from developing countries suggested that PCP was a less important cause of morbidity and mortality than tuberculosis and enteric pathogens, but these rates may have been artificially low because of poor access to PCP diagnostic testing and competing risk of death from other opportunistic infections. PCP is also a leading cause of opportunistic infections in HIV-negative persons with malignancies, inflammatory disease, organ transplant recipients, and those receiving prolonged courses of corticosteroids,26 but the burden in this population is unclear. MOLDS Aspergillus
In a multicenter study of invasive fungal infections (IFI) among transplant recipients at 23 US transplant centers during 2001 to 2006, invasive aspergillosis accounted for nearly 20% of all IFIs, second only to invasive candidiasis. The annual incidence of invasive aspergillosis among transplant recipients was 0.65%27,28 and incidence of invasive aspergillosis was highest (3.9%) among hematopoietic stem cell transplant (HSCT) recipients with a matched, unrelated donor.28 A multicenter French study describing trends in IFIs based on hospital discharge data found a 4.4% increase in invasive aspergillosis each year during 2001 to 201029; similar increases have been noted in other parts of the world. Data describing invasive aspergillosis in other parts of the world are sparse. A multicenter Brazilian study of patients with HSCT and hematologic malignancy reported invasive aspergillosis to be the most common IFI, with 6.5% of patients developing the disease.30 Published data on prevalence from most of Asia or Africa are lacking.16 Although the current burden is not known, aspergillosis is likely to increase as resource-limited countries increase organ and bone marrow transplantation.
The Global Burden of Fungal Diseases
Mucormycetes
Although mucormycosis is less common than invasive aspergillosis, its incidence seems to be rising.29 Several studies have shown a rise in the proportion of HSCT recipients developing mucormycosis (8% during 2001–2006 vs 1% in the 1990s) after widespread use of voriconazole prophylaxis to prevent invasive aspergillosis and other fungal infections.31 Although data on mucormycosis are sparse, India contributes substantially to the global burden of this disease. Unlike the United States and Europe, mucormycosis is largely associated with diabetes in India.16 This burden is likely to grow given the rising rates of obesity and diabetes in India and many other parts of the world. Scedosporium
Scedosporium (Pseudallescheria) spp are rare mold pathogens of concern because of echinocandin resistance and variable susceptibility to azoles and high mortality.32 The actual burden of this disease is largely unknown but a single-institution retrospective review from the United States revealed increasing incidence from 0.82 cases per 100,000 inpatient days during 1993 to 1998 to 1.33 cases during 1999 to 2005.33 Fusarium
Invasive infections with Fusarium spp occurs in the setting of severe immunosuppression and mortality ranges from 50% to 80%.34 One prospective study of several transplant centers in the United States noted a cumulative incidence of rare molds, including Fusarium, of 0.25%,27,28 which was significantly lower than the incidence of 2.5% among patients with HSCT and hematologic malignancy reported from eight centers in Brazil.30 The global burden of fusariosis is unknown. ENDEMIC MOLDS Histoplasma capsulatum
The epidemiology of histoplasmosis in the United States has shifted from an HIVrelated disease to one that affects individuals after organ transplantation or chronic immunosuppression from inflammatory conditions,35 and now is the most common transplant-related endemic mycosis in the United States.36 One study evaluating a random sample of US Medicare data reported an incidence of 6.1 cases per 100,000 person-years in the Midwest during 1999 to 2008.37 The actual burden in the United States is unknown outside of a few states because histoplasmosis is not nationally notifiable. In Latin America, histoplasmosis is the most clinically significant endemic mycosis,38 and the most common opportunistic infection among PLHIV, with an incidence reported by one study of 0.15 per 100,000 person-years.39 Histoplasmosis has also been described in China40 and India.41 More than 1200 Thai cases that have been reported to date have mostly occurred among PLHIV.41 African histoplasmosis has been described in Central and Western Africa and Madagascar. More than 200 cases have been reported in the literature from Nigeria, Niger, Senegal, Congo, and Uganda.42 There is no way to estimate the burden of this disease in this region because it has no systematic surveillance. Coccidioides immitis and Coccidioides posadasii
The most reliable burden estimates of coccidioidomycosis are from the United States, where it is a nationally notifiable disease. During 1998 to 2011, the incidence of reported coccidioidomycosis increased substantially in the endemic area from 5.3 to
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42.6 per 100,000.43 Subsequent reports show a decline in incidence since 2011; the reasons for the initial increase and subsequent decline are not clear. These estimates are likely to be gross underestimations of the actual burden because an estimated 60% of those with disease do not seek medical care, and many symptomatic infections go undiagnosed.44 The incidence of disease in Central and South America has not been clearly defined. Skin testing surveys in Mexico found positivity rates between 40% and 90% in certain states,45 indicating a high frequency of exposure to the fungus. Endemic regions have been defined in Mexico, Guatemala, Honduras, Nicaragua, northern Venezuela, northeastern Brazil, Argentina, Bolivia, and Paraguay.38,46 Paracoccidioides brasiliensis
Paracoccidioidomycosis has an endemic zone that extends south from Mexico to Argentina.47 Based on skin testing studies in humans and animals, it is estimated that 50% to 75% of adults in endemic areas have been exposed to the fungus. Brazil, where the disease was first described, has the highest burden of disease, with more than 80% of all cases of paracoccidioidomycosis occurring in six Brazilian states.38 Brazilian data also suggest that the reported incidence of paracoccidioidomycosis is between one and three cases per 100,000 persons living in the endemic areas; in Colombia, the reported incidence is lower at 0.05 to 0.22 per 100,000 persons.48 Blastomyces dermatitidis
The incidence of blastomycosis from certain areas in the United States and Canada, where the disease is reportable, ranges from 0.3 to 41.9 cases per 100,000, with northcentral parts of Wisconsin showing the highest incidence rate.49–51 There were approximately 1000 blastomycosis-related hospitalizations in the United States during 2007 to 2011.1 Again, the true burden in the United States is unknown because of the lack of reporting beyond a few states. Data on the burden of blastomycosis in other parts of the world are not available. Talaromyces (Penicillium) marneffei
Infections with Talaromyces (Penicillium) marneffei are primarily seen as HIVassociated opportunistic infections in Southeast Asia. Although the true incidence of T marneffei is unknown, it was the third most commonly reported opportunistic infection after tuberculosis and cryptococcosis in northern Thailand in the 1990s.52 Eastern India53 and Southern China54 are also endemic for T marneffei. In a retrospective study of the 8000 stored serum samples from Chinese PLHIV during 2004 to 2011, nearly 10% had evidence of T marneffei antigen55; the prevalence of antigen positivity (28%) was higher among those with CD4 counts less than 50 cells/mm3. It remains unclear how these results correlate with the actual burden of infection. OTHER FUNGAL ORGANISMS Organisms Causing Eumycetoma
Mycetoma has a worldwide distribution, but is endemic primarily in tropical and subtropical regions.56 Based on a review of 8000 published cases, Mexico, India, and Sudan seem to carry the highest burden of mycetoma.57,58 Mycetoma has been recognized by the World Health Organization as a neglected tropical disease. It affects many people in the prime of their lives, yet little is known about its incidence, prevalence, diagnosis, or treatment.
The Global Burden of Fungal Diseases
Table 2 Emerging fungal infections Organism
Years First Detected
Global Region to Date
Notes
Ref
Emmonsia spp
2008–2011
South Africa
Finding of a new species of dimorphic fungus that is pathogenic to humans
59
Candida auris
2004–2006
Korea, India, Pakistan, South Africa, Kuwait
Intrinsically resistant to multiple antifungal agents
60
Sporothrix schenckii
1987–present
Brazil
Acquired from contact with cats (in addition to inoculation after contact with plants)
61
Azole-resistant Aspergillus fumigatus
—
Multiple regions including in Europe, Japan, India, Iran
Clinical and environmental A fumigatus found to be azole-resistant; possibly linked to fungicide use in agriculture
62
Emerging Pathogens
Newly emerging fungal pathogens are described each year, as fungal species not previously known to cause disease are recognized as agents of opportunistic infections in high-risk patients. Several recently described emerging fungal pathogens are listed in Table 259–62 along with their significance and implications. Many other established and emerging fungal organisms are not included in this review. Infections caused by yeast, such as Trichosporon, and rare molds, such as Exserohilum, Bipolaris, and Sarocladium, are conditions that are relevant in certain susceptible populations, but the burden of these conditions is not known. SUMMARY
Fungal diseases cause considerable morbidity and mortality globally, but their burden is largely undetermined. The prevalence of invasive Candida infection has been the best-studied of all fungal diseases. Several population-based estimates describe rates of candidemia, especially in North America and Europe. Nevertheless, it is difficult to estimate the worldwide burden of this disease because of major data gaps from Africa and some parts of Asia. Estimates of the global burden of cryptococcal disease, which is probably the next best-studied fungal disease, have been attempted but relied on limited data from a few settings.21 Regional burden estimates for other diseases, such as histoplasmosis and coccidioidomycosis, exist but lack of data from other endemic areas makes global burden estimation challenging. In general, lack of surveillance data, especially in the developing world, makes calculating reliable burden estimates very challenging. Establishing the incidence and prevalence of infection through institution of surveillance systems is critical to understand disease burden and to describe emerging fungal threats and antimicrobial resistance. Developing much needed, long-term, sustainable, surveillance programs for fungal diseases should be a priority. To begin with, efforts to improve the diagnosis and recognition of fungal infections are paramount. Focusing surveillance activities on populations at risk (candidemia in intensive care unit patients, mold infections in transplant recipients, and so forth) may help narrow the scope of surveillance programs and
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reduce cost. Developing better noninvasive and reliable diagnostic tools for fungal diseases will facilitate laboratory diagnosis and thereby increase case detection and reporting to surveillance. Such information serves as a foundation for appropriate, targeted, and measurable prevention and control efforts. REFERENCES
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The Global Burden of Fungal Diseases
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The Global Burden of Fungal Diseases
54. Zheng J, Gui X, Cao Q, et al. A clinical study of acquired immunodeficiency syndrome associated Penicillium marneffei infection from a non-endemic area in China. PLoS One 2015;10(6):e0130376. 55. Wang YF, Xu HF, Han ZG, et al. Serological surveillance for Penicillium marneffei infection in HIV-infected patients during 2004-2011 in Guangzhou, China. Clin Microbiol Infect 2015;21(5):484–9. 56. Ahmed AOA, van Leeuwen W, Fahal A, et al. Mycetoma caused by Madurella mycetomatis: a neglected infectious burden. Lancet Infect Dis 2004;4(9):566–74. 57. Bonifaz A, Tirado-Sa´nchez A, Caldero´n L, et al. Mycetoma: experience of 482 cases in a single center in Mexico. PLoS Negl Trop Dis 2014;8(8):e3102. 58. van de Sande WW. Global burden of human mycetoma: a systematic review and meta-analysis. PLoS Negl Trop Dis 2013;7(11):e2550. 59. Kenyon C, Bonorchis K, Corcoran C, et al. A dimorphic fungus causing disseminated infection in South Africa. N Engl J Med 2013;369(15):1416–24. 60. Chowdhary A, Anil Kumar V, Sharma C, et al. Multidrug-resistant endemic clonal strain of Candida auris in India. Clin Microbiol Infect 2014;33(6):919–26. 61. Freitas DF, Valle AC, da Silva MB, et al. Sporotrichosis: an emerging neglected opportunistic infection in HIV-infected patients in Rio de Janeiro, Brazil. PLoS Negl Trop Dis 2014;8(8):e3110. 62. Vermeulen E, Lagrou K, Verweij PE. Azole resistance in Aspergillus fumigatus: a growing public health concern. Curr Opin Infect Dis 2013;26(6):493–500.
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