Knowledge impels action, and action brings change. This adage succinctly captures the fundamental challenge surrounding fungal infections in India. Our public health machinery serving a billion strong population, correctly emphasizes its focus on the colossal burden of tuberculosis, AIDS and malaria.
But it woefully underestimates the fungal foe, which competes equally with tuberculosis and malaria in term of incident cases and mortality. Lack of surveillance mechanisms and definitive data for assessing and monitoring fungal infections in our country have led to this incognizance and indifference among our public health authorities and clinicians, thereby negatively impacting clinical training, diagnostics, therapeutics, innovations and infrastructure development for combating fungal infections.
In terms of numbers, our population of 1.2 billion is plagued by 2.4 million HIV-AIDS patients, 50.7 million diabetics, 31 million TB patients, 12 million COPD patients and 17.5 million cancer patients.
We are witnessing an unprecedented surge in solid organ and hematopoietic stem cell transplants, alcoholic liver disorders and critical-care surgeries. These populations are highly vulnerable to invasive fungi and their sheer quantum reflects the hidden burden of fungal infections. From the limited data available, few examples may depict the burden of invasive fungal infections in our country. Among the three major fungal infections in our hospitals, candidemia rate (300-500 cases/year) at any tertiary care institute (~1500 beds) is more than the candidemia rate of entire
Australia put together. Likewise, an invasive mucormycosis rate of ~50 cases/year seen at most hospitals in India, is more than half of the total mucormycosis cases reported annually from all the
European countries put together. Up to 60% of invasive infections eventually kill the patient, majority of which can be prevented with timely diagnosis and appropriate treatment. To cite another example, fungal ophthalmic infections are a common occurrence in India. In a recent report from Madurai alone, 139 cases of mycotic keratitis were recorded in just three months. In stark contrast South Florida recorded 125 cases over a span of 10 years, and Philadelphia reported only 24 cases over nine years.
Besides these, the average healthy individual also remains prone to several fungi which team in our overcrowded, unhygienic, tropical environs. Fungi thrive in tropical environment. But our challenge with fungal infections goes beyond mere numbers. Majority of our clinicians are poorly trained to recognize and manage these infections; most microbiology labs across the country lack even basic infrastructure and training to provide diagnostic support or monitor antifungal resistance; most antifungal drugs remain prohibitively expensive and out of reach of the poor majority; and hardly any research innovations are forthcoming to tackle this burden.
Information
LIFE is an innovative global consortium which aims to spawn a paradigm shift in tackling fungal infections. Information is the key needed to unlock solutions. Hence we are currently generating evidence-based, valid and comparable estimates of fungal infection burden in India. Given the lack of a formal surveillance system for fungal infections and the attendant shortcomings of a
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surveillance pyramid, we are utilizing 'Burden of Disease' calculations to generate reliable prevalence data. Several decades worth raw data from time-scaled case series, hospital studies, population/community surveys, serological surveys and baseline population data are being analyzed using relevant multipliers, stratifications, and statistical modeling (Monte Carlo algorithms). We are employing international standards recommended by the WHO, the CDC and the ECDC for all our analysis. These burden estimates will offer us several advantages: a) Generate burden data that has been so far unavailable even with the WHO, the CDC and the
ECDC b) Enable direct comparison with other communicable and non-communicable diseases, revealing the relative impact of fungal infections on public health in India c) Provides us a compelling tool to convince public health authorities and the health ministry to allocate resources for combating fungal infections d) Provide us internationally comparable burden estimates critical for aligning global health initiatives
Capacity building
After ascertaining the quantum and ramifications of the challenge fungal infections pose, our ultimate goal is to reduce the attendant morbidity and mortality due to these pathogens. We have organized a multi-pronged strategy to achieve this in a comprehensive and sustainable way. We plan to catalyze a chain-reaction which enables achievements to build upon themselves. We summarize here our action plan.
Communication a) Identify, assess and communicate current and emerging fungal threats. b) Target the three areas of impact which can reduce 66% of morbidity and mortality:
1.
Underlying disease predisposing to fungal infections
2.
Speed of diagnosis
3.
Optimization of therapy c) Sensitize the common man, health care professionals, public health authorities and the health ministry. d) Actively involve largest Indian scientific bodies in mycology (SIHAM) and microbiology (IAMM) to catalyze ideas and proposals planned below.
Clinical Mycology Network & Training
The National Mycology Reference Laboratory at PGIMER, Chandigarh is conducting two training courses every year (one for faculty members and another for technicians) since last seven years and we have helped develop around 71 diagnostic mycology laboratories in the country. Since last three years the Sri Ramachandra University at Chennai has also been conducting one training program every year. But India is vast country and our current efforts are too little to meet the stupendous challenge fungal infections pose. Accordingly we need to: e) Establish a nation-wide Clinical Mycology Network. Designate regional centers of excellence and upgrade existing microbiology labs into a full-fledged network of fungal labs providing primary
(local), specialist and reference lab services. f) The Clinical Mycology Network would aim to foster international standards of diagnostics, surveillance, training, education and research innovations. g) Augment existing training programs, workshops and SOP dissemination already being managed by the national reference lab. Establish field and on-site training programs to train local and specialist lab staff.
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h) Facilitate establishment of official training programs at regional centers of excellence, and fresh posts for trained staff to empower lab networks across the country. i) Promote clinical training in mycology and associate all specialist labs and upwards with minimum one clinician-mycologist.
Diagnostics j) Establish robust diagnostic tools depending on the catchment, capacity and level of the lab and availability of local resources. k) Establish universal availability of microscopy and routine fungal tests. Establish fluorescent microscopy, antigen detection, PCR, validated antifungal susceptibility testing, and therapeutic drug monitoring at specialist and higher labs. l) Develop and establish molecular diagnostics to increase diagnostic reliability and decrease turnover time. m) Develop and establish innovative diagnostic tests which can be implemented in field settings.
Therapeutics n) Prioritizing availability of essential antifungals with national and international support, e.g. cost prohibits even the availability of essential drugs like Amphotericin B and azoles. o) Reassign competing resources and drugs for interlinked diseases like HIV-AIDS and opportunistic mycosis p) Design innovative, cost-effective treatment strategies which can circumvent drug shortfalls and/or non-availability.
Surveillance q) Establish a robust surveillance system to monitor and assess circulating fungal pathogens, levels of antifungal resistance and emerging threats. r) Construct in-built mechanisms to overcome usual points of breakdown in the surveillance pyramid. s) Create a digital network to maintain a perpetually live and accessible surveillance system to utilize its true potential.
Innovation t) Encourage research and innovation in mycology by establishing national and international research consortia u) Boost development of inexpensive but reliable diagnostic tools for field settings and bedside point of care. v) Facilitate development of new therapeutics, by discovery of lead antifungal molecules w) Boost antifungal vaccine development. An area less explored but with great potential.
Outbreak Control
Fungal infection outbreaks are being increasingly reported in India, especially those caused by unusual fungi. And given our overwhelming numbers, most outbreaks afflict people in large numbers. For instance a single fungemia outbreak due to Pichia anomala took a toll on 379 babies. x) Hence we intend to utilize the extensive lab network and surveillance system proposed above to monitor and identify outbreaks and eliminate transmission. Most fungal outbreaks are associated with environmental and architectural breakdown and would require appropriate training and strategies for containing them.
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