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Conclusion

Estimating the burden of fungal disease in Vietnam

ResultsBackgroundMethodsThe prevalence of fungal infections in Vietnam is poorly described, and there is no formal surveillance

Fungal infections are of increasing clinical and economic importance world wide, with mortality ranging from 15-50%

We estimated the incidence and prevalence of fungal diseases in Vietnam, using a validated actuarial approachEstimates were based on current reports from Vietnam, epidemiological studies from the local region and global data

Population data were sourced from the General Statistics Office of Vietnam and the WHO World Health Statistics Report

HIV/AIDS related data were sourced from UNAIDS and the Vietnamese Ministry of Health

Prevalence of asthma, Chronic Obstructive Pulmonary Disease (COPD), Tuberculosis (TB), cancer, transplant and intensive care were derived from local and regional data sources, and personal communications

The actuarial approach used was previously described by Denning1J. Beardsley1, D.W. Denning2, N.V. Chau3, N.T.B. Yen4, J.A. Crump5, J.N. Day1Oxford University Clinical Research Unit, Vietnam (jbeardsley@oucru.org). 2. The National Aspergillosis Centre in association with the LIFE program www.LIFE-Worldwide.org, University Hospital of South Manchester and The University of Manchester, UK. 3. Hospital for Tropical Diseases, HCMC, Vietnam. 4. Pham Ngoc Thach Hospital, HCMC, Vietnam 5. University of Otago, New Zealand.M48.8% F 51.2%Gender/Age StructureTotal population 90,796,000

Children22.9%

Female >5017.2%Underlying conditions associated with fungal disease

Pulmonary TB (incidence/yr)Total130,000HIV+9300

HIV/AIDS (est. current cases) 256,845

COPD/Asthma (prevalence)COPD 6.7%Asthma 1.04%

Stem Cell Transplant22.5/ year

Renal Transplant130/ year

Critical Care Beds11,325 nationallyThis is the first attempt to comprehensively describe invasive fungal infections in Vietnam and suggests that the majority of severe disease is due to Aspergillus species, driven by the high incidence of pulmonary TB

The AIDS epidemic highlights opportunistic infections, such as penicilliosis and cryptococcosis. Penicilliosis is a problem unique to South and South East Asia. As the availability of transplants and other immune-modulating therapies increase, the epidemiology of fungal infection is likely to change

These data should be verified by further epidemiological approaches but in the absence of formal surveillance, they provide a useful baseline indication of disease prevalence to inform future research and resource allocation

1. Denning, D. W., Pleuvry, A. & Cole, D. C. Global burden of chronic pulmonary aspergillosis as a sequel to pulmonary tuberculosis. Bull. World Health Organ. 89, 86472 (2011). 2. Park, B. J. et al. Estimation of the current global burden of cryptococcal meningitis among persons living with HIV/AIDS. AIDS 23, 52530 (2009). 3. Kaplan, E. et al. Preventing opportunistic infections in human immunodeficiency virus-infected persons: implications for the developing world. 55, 111 (1996). 4. Le, T. et al. Epidemiology, seasonality, and predictors of outcome of AIDS-associated Penicillium marneffei infection in Ho Chi Minh City, Viet Nam. Clin. Infect. Dis. 52, 94552 (2011). 5. Arendrup, M. C. Epidemiology of invasive candidiasis. Curr. Opin. Crit. Care 16, 44552 (2010). 6. Smith, E. & Orholm, M. Trends and patterns of opportunistic diseases in Danish AIDS patients 1980-1990. Scand. J. Infect. Dis. 22, 66572 (1990). 7. Matee, M. I., Scheutz, F. & Moshy, J. Occurrence of oral lesions in relation to clinical and immunological status among HIV-infected adult Tanzanians. Oral Dis. 6, 10611 (2000). 8. Xu, H. et al. Invasive pulmonary aspergillosis in patients with chronic obstructive pulmonary disease: a case control study from China. Clin. Microbiol. Infect. 18, 4038 (2012). 9. Lortholary, O. et al. Epidemiological trends in invasive aspergillosis in France: the SAIF. (2011). 10. Perkhofer, S. et al. The Nationwide Austrian Aspergillus Registry: a prospective data collection on epidemiology, therapy and outcome of invasive mould infections in immunocompromised and/or immunosuppressed patients. Int. J. Antimicrob. Agents 36, 5316 (2010). 11. Denning, D. W., Pleuvry, A. & Cole, D. C. Global burden of allergic bronchopulmonary aspergillosis with asthma and its complication chronic pulmonary aspergillosis in adults. Med. Mycol. 51, 36170 (2013). 12. Bitar, D. et al. Increasing incidence of zygomycosis (mucormycosis), France, 1997-2006. Emerg. Infect. Dis. 15, 1395401 (2009). 13. Hong Nhung, P. Epidemiology of Fungal Keratitis in North Vietnam. J. Clin. Exp. Ophthalmol. 03, (2012). 14. Foxman, B., Muraglia, R., Dietz, J.-P., Sobel, J. D. & Wagner, J. Prevalence of recurrent vulvovaginal candidiasis in 5 European countries and the United States: results from an internet panel survey. J. Low. Genit. Tract Dis. 17, 3405 (2013). FULL REFERENCES ON REQUESTPopulation density map courtesy of Corinne Thompson, Epidemiologist, OUCRU Vietnam

With refsInfection Total casesRate /100KData SourcesCryptococcal meningitis 1400.15Vietnamese MoH1 / UNAIDS HIV/AIDS2 data and international data on incidence of CM in AIDSPneumocystis pneumonia 6080.67Vietnamese MoH1 / UNAIDS HIV/AIDS2 data and Thai data on incidence of pneumocyctis in AIDS3Penicilliosis 2060.23Published Vietnamese data on incidence of penicilliosis4Candidaemia 4,5405International per population incidence data6Candida peritonitis6810.75Derived from international data on number of cases per case of candidaemia8Oesophageal candidiasis 33,10736International incidence in HIV patients pre and post-ART9, and Vietnamese HIV/AIDS data1,2Allergic bronchopulmonary aspergillosis (ABPA) 23,60726Vietnamese rates of COPD10 and asthma, and international data on incidence of ABPA in these conditions11Severe asthma with fungal sensitisation (SAFS)31,16134International data on incidence of SAFS in asthmatics11Chronic pulmonary aspergillosis (CPA) 55,50961Vietnamese data on COPD10 admissions and AML12, and international data on their relationship to CPA11Mucormycosis 1090.12International incidence dataFungal keratitis 6,3567Results of Vietnamese fungal keratitis epedemiology13 study and personal communications14Recurrent vaginal candidiasis >4/times/year304,024670International incidence estimates15 and Vietnamese population structureTinea capitis 415,301457International incidence estimates16 and Vietnamese population structureEstimated cases1,011,462would need 14 refs!

Simple descriptionInfection Total casesRate /100KEstimation MethodCryptococcal meningitis 1400.15International estimates of CM incidence in AIDS were applied to local HIV epidemiologyPneumocystis pneumonia 6080.67Thai estimates of PCP incidence in AIDS were applied to local HIV epidemiologyPenicilliosis 2060.23Vietnamese estimates of penicilliosis incidence in AIDS were applied to local HIV epidemiologyCandidaemia 4,5405International per population incidence data was applied to local demographic dataCandida peritonitis6810.75Estimated as two cases for every one case of candidaemia, occuring in ICU settingOesophageal candidiasis 33,10736International incidence estimates applied to local HIV epidemiology and treatment coverageAllergic bronchopulmonary aspergillosis (ABPA) 23,60726International estimates of ABPA's association with COPD and asthma were applied to local epidemiology of chronic repiratory diseaseSevere asthma with fungal sensitisation (SAFS)31,16134International estimates of SAFS's association with asthma were applied to local epidemiology of asthmaChronic pulmonary aspergillosis (CPA) 55,50961International estimates of CPA's association with COPD admissions and AML were applied to local epidemiologyMucormycosis 1090.12International per population incidence data was applied to local demographic dataFungal keratitis 6,3567Vietnamese (Hanoian) estimates of fungal keratitis incidence were applied to national demographicsRecurrent vaginal candidiasis >4/times/year304,024670International per population incidence data was applied to local demographic dataTinea capitis 415,301457International per population incidence data was applied to local demographic dataEstimated cases1,011,462

Detailed descriptionInfection Total casesRate /100KEstimation MethodCryptococcal meningitis 1400.153% of new cases of AIDS in Vietnamese HIV patientsPneumocystis pneumonia 6080.6713% of new cases of AIDS in Vietnamese HIV patientsPenicilliosis 2060.234% of new cases of AIDS in Vietnamese HIV patientsCandidaemia 4,54055/100,000 population (3.5/100,000 in ICU patients) Candida peritonitis6810.752 cases for every 1 case of candidaemia in ICU patientsOesophageal candidiasis 33,1073620% of HIV patients not on ARVs and 5% of those on ARVsAllergic bronchopulmonary aspergillosis (ABPA) 23,607262.5% of adult asthmatics and 15% of adults with cysic fibrosisSevere asthma with fungal sensitisation (SAFS)31,1613433% of the most severe 10% of adult asthmaticsChronic pulmonary aspergillosis (CPA) 55,5096122% of cases of cavitatory pulmonary TB plus 2% of non-cavitatory casesMucormycosis 1090.121.2 cases per 1,000,000 populationFungal keratitis 6,35677 cases per 100,000 populationRecurrent vaginal candidiasis >4/times/year304,0246705% of woman over 50Tinea capitis 415,3014572% children 4/times/year6% of women >50 yrs old 14364,829804Tinea capitis 2% of children