1. Fungal diseases in the UK
David W. Denning
Director, NHS National Aspergillosis Centre
University Hospital of South Manchester
The University of Manchester
President, Global Action Fund for Fungal Infections

2. Fungal infections
Cutaneous i.e. athlete’s foot, ringworm and onychomycosis
Mucosal i.e. oral or vulvovaginal thrush
Chronic fungal infections such as chronic pulmonary aspergillosis
Allergic i.e. allergic fungal sinusitis and allergic bronchopulmonary aspergillosis (ABPA)
Invasive and life-threatening i.e. candidaemia, invasive aspergillosis and cryptococcal meningitis

3. Skin, hair and nails fungal infections
4th most prevalent chronic disease problem after dental caries, tension headache and migraine.
985 million people affected, 14.3% of the global population
* Including fungal complications
Vos et al, Lancet 2012;380:2163

4. Fungal hair infection – tinea capitis
~25% of children in schools all over Africa.
Common in other communities
~200 million children affected – no good UK data
May be disfiguring and painful, certainly affects children’s self esteem
Griseofulvin or fluconazole therapy
Transmissible

5. Cutaneous fungal infections
Ringworm, tinea versicolor, tinea pedis (athlete’s foot), onychomycosis
Very common
Terbinafine, itraconazole, fluconazole and griseofulvin all effective
Transmissible

6. Aspergillus otitis externa
Chronic otitis affects 3-5% of the population ( million)
~10% are fungal in origin, usually A. niger

7. Allergic fungal sinusitis
Chronic rhinitis 10-30% adults in UK
60,000 – 250,000 with allergic fungal rhinosinusitis
Responsive to polyp removal, nasal steroids, saline douches and antibiotics
Antifungals have a minor role

8. Fungal keratitis Implantation disease, often injury related, farmers
~50% of keratitis in LMICs = fungal
Numerous fungal species involved;
Aspergillus and Fusarium predominate
Diagnosis requires microscopy/histopathology + culture
No diagnostic capability in most low resource countries including Africa

9. Fungal keratitis may be increasing in the UK - Moorfields
Ong et al. Am J Ophthamol 2016; 168:227.

10. Sight-threatening infection caused by Fusarium mould74

11. Vulvovaginal candidiasis (VVC)
55% of women have had VVC by mid 20’s
6-9% of women have VVC >4 times per year,
Global estimate of the problem of recurrent VVC is ~137 million women annually (range M) aged years
UK estimate is ~ 1,000,000 affected
Duration of recurrent VVC is highly variable, 1- 2 years commonly, sometimes >8 years.
Denning et al. Lancet Infect Dis In press

12. Other UK health burden statistics:
Meningococcal (meningitis) disease – 805 cases in 2015/16
Malaria – 1,400 cases in 2015
TB – 5,758 cases in 2015
New HIV diagnoses - 6,151 in 2014
Breast cancer - 53,696 in 2013, 11,433 deaths
Multiple sclerosis – 107,000 in 2016
Multiple sources

13. Pegorie et al, J Infect 2017;74:60

14. Risk groups and frequencies of invasive aspergillosis – different test performances
Herbrecht, Ann NY Acad Sci 2012;1271:23

15. Invasive aspergillosis by finished consultant episodes

16. Invasive aspergillosis in lung disease patients - most probably being missed
Pegorie et al, J Infect 2017;74:60

17. Invasive aspergillosis in critical care
Pegorie et al, J Infect 2017;74:60

18. Aspergillus bronchitis
Complicates cystic fibrosis and bronchiectasis
Recurrent infection and/or mucus plugging
Superficial invasion of the bronchial wall.
8,600 UK CF patients, 5,500 adults.
Aspergilus bronchitis affects ~1,500
Non-CF patient burden unclear

19. Pneumocystis pneumonia in the UK – AIDS and non-AIDS [1:3 ratio]
Maini et al, Emerg Infect Dis 2013;10:386

20. Important airborne fungi
Alternaria
Cladosporium
Aspergillus
Rhizopus

21. Common allergen exposures by month
Twaroch et al, Allergy Asthma Immunol Res 2015:7:205

22. Skin prick testing for fungal asthma
Cladosporium +ve
O’Driscoll, unpublished

23. Mean sensitization score (mm)
Fungal allergy is associated with more hospital admissions
Non-Mould allergens No
Hospital
Admission
Single
Multiple
Admissions
20.0
17.5
Mould allergens No
Hospital
Admission
Single
Multiple
Admissions
P= <0.0001
15.0
12.5
Mean sensitization score (mm)
(Mean and 95% CI)
10.0
7.5
5.0
2.5
0.0
O’Driscoll et al, BMC Pulmonary Medicine 2005;5:4

24. 7,104 young adults in 13 countries (11 Europe)
Questionnaires, sensitisation to Alternaria and Cladosporium, assessment of homes, asthma evaluation (metacholine challenge).
New onset asthma (n=355)
Correlation with water damage and mould in the house
Follow up 8.7 ( ) years.
Risk ratio for new asthma = 1.46 (water damage) and 1.3 (indoor moulds).
Norback D, Occup Environ Med 2013;70:

25. ‘Fungal asthma’ in the UK
Pegorie et al, J Infect 2017;74:60