Trends in fungal disease in the UK

Theresa Lamagni

Healthcare-Associated Infection & Antimicrobial Resistance Department

HPA Centre for Infections

overview

Roles, functions and remit of the Health Protection Agency

National surveillance of fungal infections

Trends in invasive fungal infections

invasive candidosis, aspergillosis

Future surveillance developments

the Health Protection Agency

• created in April 2003

• non-governmental public body

• formed out of agencies involved in rapid response to health threats:

Public Health Laboratory Service

Chemical Hazards and Poisons Response Unit

Centre for Applied Microbiology & Research

• National Radiological Protection Board joined in 2005

HPA structure

Centre for Infections

roles and functions of the HPA

Protection of the community against infectious disease & other dangers to health (embodied in the HPA Act, 2004)

•prevention and control of the spread of infectious disease

•advising Department of Health on formulation of policy relating to public health

•research and training in public health

•dissemination of health information to the public and advice to health professionals (e.g. outbreaks & incidents)

•other functions as agreed with the devolved administrations of the UK (Scottish Executive, NAW, DHSS in Northern Ireland)

measuring the burden of fungal infectionsFungal diseases can be divided into three broad groups:

Superficial infections e.g. thrush, ringworm, nail infections

Invasive infections

Allergic fungal disease of the sinuses or chest

Measuring the burden of disease is reliant on ongoing/one-off surveillance programmes

– No ongoing surveillance systems specific to fungal infection

– A number of broad surveillance mechanisms exist of relevance to fungal infections

reliant on clinical or microbiological diagnoses of infection

different methods have different strengths depending on the diagnostic methods employed

surveillance of fungal infections

National surveillance data routine microbiology laboratory reporting

statistical returns

genitourinary medicine statistical returns

Hospital Episode Statistics

death registrations

Ad hoc surveillance projects enhanced surveillance initiatives

Superficial fungal infections

genital candidosis

– although not generally severe, burden associated with genital candidosis (thrush) likely to be substantial

– difficult to obtain good measure of number of cases as a large proportion of sufferers likely to self-medicate (no medical interface)

– statistical returns from genitourinary medicine (GUM) clinics alone recorded over 73,000 attendances for genital candidosis in England in 2003

11% of all diagnoses made in GUM clinics in 2003

ringworm

– common condition, usually not severe but can lead to permanent scarring

– again, difficult to obtain good measure of incidence as a large proportion of sufferers likely to be treated empirically or self-medicate

– recent reports suggest an increase, but robust data lacking

– Hospital Episode Statistics record between 200 – 300 (consultant) episodes of scalp, foot and other ringworm in England per year (1998/9-2003/4)

Invasive fungal infections

invasive candidosis

– generally considered to be the most common invasive fungal infection

– Department of Health Hospital Episode Statistics recorded approx 3000 (consultant) episodes of Candida infection in England (2003/4)

• half not invasive, a third didn’t specify severity

• maximum 1500 invasive candidosis

– Office for National Statistics mortality records identified between 20-30 deaths per annum with candidosis as the underlying cause (2001-3)

– extrapolation of risk estimates from individual studies in specific patient groups

between 4,000 - 5,000 cases of invasive candidosis in UK per annum (D Denning)

however, need to ensure results generalisable and to account for overlapping patient groups

Invasive fungal infections

invasive aspergillosis

– very severe condition, associated with high mortality

– reliable diagnostic tests are lacking, hindering diagnosis

majority of patients are treated empirically on suspicion of disease

– given the diagnostic challenges, difficult to obtain good measure of number of cases

– Department of Health Hospital Episode Statistics recorded 494 (consultant) episodes of aspergillosis in England (2003/4)

– Office for National Statistics mortality records identified 45 deaths with aspergillosis as the underlying cause (2003)

Invasive fungal infectionsRoutine (microbiology) laboratory reporting

system

all public and private microbiology laboratories are invited to report clinically significant isolates to the Communicable Disease Surveillance Centre

laboratories report electronically or on paper to regional offices

all laboratories currently reporting to CDSC (approx 300)

approx. 470,000 reports of any infectious diagnosis received for 2004* (England, Wales, N Ireland)

* provisional data

laboratory surveillance of invasive fungal infections England 1990-2004

* provisional data

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invasive candidosisinvasive aspergillosis

species distribution of pathogens causing bloodstream infection England 2004*

* provisional data

0 2500 5000 7500 10000 12500 15000 17500 20000 22500 25000

AlcaligenesMoraxella

PantoeaListeria

ChlamydiaPeptostreptococcus

MicrococcusBacillus

Morganella morganiiHaemophilus

PropionibacteriumSalmonella

MycoplasmaCorynebacterium

HelicobacterClostridiumCitrobacter

StenotrophomonasSerratia

AcinetobacterBacteroides

CandidaProteus

EnterobacterPseudomonas

KlebsiellaEnterococcusStreptococcus

Escherichia coliStaphylococcus

number of reports

laboratory surveillance of invasive candidosis England 2004*

* provisional data

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0 1-4y 5-9y 10-14y 15-44y 45-64y 65+

age group

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enhance surveillance invasive fungal infections in very low birth weight infants

• BPSU, HPA (CDSC & Mycology Reference Unit), SCIEH, Tayside Institute of Child Health

• enhanced surveillance study measuring incidence, risk factors and outcome

• reports pooled from multiple sources

Preliminary results

– 88 cases observed, 1 per 100 very low birth weight (<1500g) infants

– 76 of 88 were of extremely low birth weight (<1000g), 2 per 100

– 98% due to Candida species

– one fluconazole-resistant strain identified

– 45% of cases died

future developments

Antifungal Susceptibility Surveillance

• concern over emergence of resistance to antifungal treatments

• very few countries monitor national trends in antifungal susceptibility

• important for antifungal treatment selection to be aware of emerging resistance

plan to expand national antibiotic susceptibility surveillance to capture antifungal susceptibility

feasibility work underway

conclusion

fungal infections continue to be a source of substantial health burden in the UK

existing surveillance systems are detecting increases in rates of reports, in particular for invasive candidosis

likely to be accounted for by improved survival of vulnerable patients (increase in number of vulnerable patients)

further supported by changing species distribution for invasive Candida (relative increase in weaker yeast pathogens)

improvements to surveillance systems are warranted for some fungal infections e.g. aspergillosis

acknowledgements

clinicians, microbiologists and other reporters from across the UK

Catherine Keshishian (HPA Centre for Infections)

Georgia Duckworth (HPA Centre for Infections)

Elizabeth Johnson (HPA Mycology Reference Laboratory)