How to Improve Fungal Disease Management Worldwide

In an article published in The Lancet Infectious Diseases, Donald C. Cole, FRCP, from the University of Toronto, Ontario, Canada, and colleagues describe the current state of identification and management of fungal diseases and discuss potential approaches for improving their recognition and treatment.

According to the authors, estimates of the burden of fungal diseases in low-income and middle-income countries made by the Global Action Fund for Fungal Infections (GAFFI) exceed the capability of these countries to manage the burden.

This burden includes neglected tropical diseases such as mycetoma and chromoblastomycosis that cause progressive chronic disfiguring disease, opportunistic fungal infections such as pneumocystis pneumonia in HIV patients, and emerging diseases such as pythiosis.

However, the authors say that fungal disease often goes unrecognized for several reasons, including suboptimal patient and clinician awareness, high patient loads, inadequate clinician training, a low index of diagnostic suspicion, a lack of diagnostic tests to identify certain fungal diseases, poor access to diagnostic tools), and few treatment options. Public health responses to fungal disease are thus rare, they note and typically focus on disease outbreaks and cryptococcal meningitis in AIDS patients.

“These limitations in awareness, diagnosis, and management stem from deficits of the health system in education, provision, and infrastructure,” they stress.

As a consequence, to address these gaps, Dr. Cole and colleagues highlight potential ways to enhance healthcare and public health capabilities in national health systems with international support. In particular, they emphasize 4 core strategies to help accomplish this.

Healthcare providers need education about fungal diseases, they say, but governments, funding agencies, and the World Health Organization (WHO) are not yet ready to prioritize fungal diseases with separate programs for low-income and middle-income countries. The authors therefore suggest incorporating education about fungal diseases into those public health initiatives and programs already established in other important areas such as HIV infection, tuberculosis, antimicrobial resistance, diabetes, chronic respiratory disease, and blindness.

In addition, the authors note the need for improved laboratory capability to detect fungal diseases, with associated surveillance systems. “A mycology reference laboratory, as an integral part of the clinical laboratory network, should ideally be present for every 5—10 million people,” they state. These should be ISO 15189-accredited, and should be equipped to offer specialized diagnostic assays for other laboratories, hold a fungal culture collection, confirm identification and antifungal susceptibility results of unusual fungal isolates, provide technical help with proficiency testing schemes, offer training, and evaluate diagnostic assays. Surveillance of disease is also a cornerstone of public health, Dr. Cole and colleagues note. One way to improve fungal disease surveillance, they suggest, is by integrating it into existing surveillance programs, such as for chronic pulmonary aspergillosis within a tuberculosis control program. In contrast, at the community level, providers can use survey assess disease burden in targeted locations or populations.

And because diagnostic capability without the means of treatment is problematic, they emphasize the need for low-income and middle-income countries to obtain low-cost, high-quality antifungal medicines. However, many of these countries remain challenged to finance, obtain, and distribute the antifungal agents on the WHO Model Lists of Essential Medicines. When selecting antifungal agents, healthcare providers must be aware of their cost, potential associated toxicities and drug—drug interactions, and antifungal resistance.

Dr. Cole and colleagues also stress the need to integrate fungal disease into training for a range of providers such as physicians, nurses, laboratory technicians, and pharmacists. This will improve providers’ awareness, diagnosis, and management of these conditions.

The four focal points of the GAFFI 95—95 by 2025 roadmap are diagnostics, professional education, antifungal agents, and burden of disease data, the authors note.

Governance and financing are key to advancing these, they add, but both require the involvement of multiple stakeholders.

“The guidance starts with national public health agencies or ministries of health convening system stakeholders, including providers and users of the health system,” the authors conclude.

“Ministries of health could potentially be represented by non-governmental organizations engaged in advocacy for access to diagnostics and antifungals, and financing. It would also include relevant clinical or professional and scientific societies who could be involved in guidelines for diagnosis, management, surveillance, and antimicrobial resistant stewardship; and involve representatives of the research community.”

Dr. Parry graduated from the University of Liverpool, England in 1997 and is a board-certified veterinary pathologist. After 13 years working in academia, she founded Midwest Veterinary Pathology, LLC where she now works as a private consultant. She is passionate about veterinary education and serves on the Indiana Veterinary Medical Association’s Continuing Education Committee. She regularly writes continuing education articles for veterinary organizations and journals and has also served on the American College of Veterinary Pathologists’ Examination Committee and Education Committee.