Trends in fungal disease in the UK

1
Trends in fungal disease in the UK

• Theresa Lamagni
• Healthcare-Associated Infection Antimicrobial
  Resistance Department
• HPA Centre for Infections

2
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

3
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

4
HPA structure
5
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)

6
measuring the burden of fungal infections

• Fungal 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

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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

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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)

9
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 didnt 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

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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)

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Invasive fungal infections

• Routine (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
12
laboratory surveillance of invasive fungal
infections England 1990-2004
provisional data
13
species distribution of pathogens causing
bloodstream infection England 2004
provisional data
14
laboratory surveillance of invasive candidosis
England 2004
provisional data
15
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 (lt1500g) infants
• 76 of 88 were of extremely low birth weight
  (lt1000g), 2 per 100
• 98 due to Candida species
• one fluconazole-resistant strain identified
• 45 of cases died

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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

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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

18
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)