Fungal Infection Trust Aspergillus Newsletter March 2018
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Highlights of this month...

Accuracy of Fungal Disease Prevalence Estimates from LIFE

The Leading International Fungal Education (LIFE) portal has produced 43 published papers on fungal infection burden estimates. These papers cover fungal infections country by country for over 5.7 billion people.
 
Recently a review by Bongomin et al has collated these figures into a single paper, describing the distribution of an estimated 3,000,000 cases of chronic pulmonary aspergillosis, 223,100 cases of cryptococcal meningitis complicating HIV/aids, ~700,000 cases of invasive candidiasis, ~500,000 cases of Pneumocystis jirovecii pneumonia, ~250,000 cases of invasive aspergillosis, ~100,000 cases of disseminated histoplasmosis, over 10,000,000 cases of fungal asthma and ~1,000,000 cases of fungal keratitis annually. The paper also addresses limitations associated with these estimates, and highlights gaps in the literature.
 
The authors note that although the estimates they describe are a useful way of comparing countries and characterising the burden of fungal infections globally, they do not satisy the need for high quality epidemiological research and systematic surveillance. They also suggest that the gap between estimated burden and recorded cases should be closed for the purpose of improving patient outcomes. 
 
News

The world’s first online Fungal Microscopy course has been developed by experts at The University of Manchester and collaborators worldwide. The modules are free to complete, and successful completion of each module after Module 1 is rewarded with a certificate.
 
The first three modules are aimed at helping doctors, clinical scientists and laboratory technologists across the world to detect different fungi by direct microscopy and  to identify the top 10 most common fungal infections histologically.
 
The final module was released at the beginning of March, and is designed to equip learners with advanced skills in microscopy to identify rare fungal pathogens. 
 
 
Medical Mycology Worldwide is a new website that provides mycology societies around the world with an online platform for news items and discussion. 
 
Societies and groups can set up their own 'page' on the site, following simple video instructions. Participation for societies and members is free, and we're hoping that the site leads to better connectivity within and between groups. 
 
If you have any questions about Medical Mycology Worldwide, or would like advice on setting up a page for your society or group, please get in touch via email: admin@medicalmycologyworldwide.org
Articles
 
The Centre for Disease Control and Prevention recommends that extra infection control measures for Aspergillus are needed for immunocompromised patients in hospitals during buildings works, but standardised guidelines are not available.
 
Hiroyaso Kaya and colleagues investigated an outbreak of invasive aspergillosis (IA) in a haematology ward in Japan. Despite protective measures being taken (including antifungal prophylaxis), three patients contracted IA via their lungs, with two of these infections ultimately being fatal.
 
Even among ward patients who did not develop IA, serum galactomannan rose sharply during construction works. The authors suggest that a spate of such false positives seen during monthly sampling may be a sign that an outbreak is imminent.
 
A partition with sealed windows and HEPA filtration was built between the building works and the patient areas. After the outbreak a negative-pressure unit was added, which appeared to halt the outbreak. The authors note that ceiling demolition is a particularly risky activity.
 
 
Merck’s patent for caspofungin acetate (Cancidas®) expired in March 2017. Three companies have since been granted
approval by the FDA to produce generic versions: Fresenius Kabi USA (for the US), Gland Pharma Ltd, and Mylan Labs Ltd. It is hoped this will reduce prices, giving clinicians more flexibility to tailor treatment regimens to individual patients, especially where drug-drug interactions or comorbidities must be taken into account. Encouraging multiple companies to produce a generic reduces the risk of price gouging, which was seen for flucytosine, a crucial antifungal for treating cryptococcal meningitis. In 2016 it was being sold in the USA for 9000x the price in Europe, costing $28,000 for a 2-week course.
 
However, price is unfortunately not the only consideration in countries where modern antifungals may not even be licensed for use. According to Kneale et al (2016), around 7% of the world’s population lack access to amphotericin B and around 40% lack access to flucytosine for this reason. 
 
 
Fungal keratitis that has not responded to antifungal treatment can be controlled by removing the infected layer(s) of the cornea and replacing it with healthy donor tissue – a procedure known as keratoplasty. Early post-operative treatment with steroids can reduce inflammation and tissue rejection, but can also increase the risk of the infection reoccurring.
 
A new study by Dr Ting Wang and colleagues at the Shandong Academy of Medical Sciences (China) investigated whether the timing of such steroid treatment could be optimised to minimise drawbacks. Topical fluorometholone (0.02%) was initiated 1 week after surgery, instead of the usual 2 weeks.
 
Infection recurrence rates from the Wang group were previously around 6%, and rejection rates as high as 45% have been reported in the literature. In this study, rates were strikingly favourable for both recurrence (1.2%) and rejection (6.8% for penetrating keratoplasty; 0% for lamellar keratoplasty). However, complete removal of fungal hyphae must be ensured when starting early topical steroid therapy.
Reviews

A new review explored the variety of fungal pathogens that can be found in animals. The paper, resulting from contributions from the ISHAM Veterinary Mycology Working Group, also covers mycotoxicoses and antifungal resistance in non-human species.
 
Opportunistic fungal infections covered in this piece include aspergillosis, mucormycosis, candidiasis, and cryptococcosis. Fungal diseases with population-wide effects are also discussed, including chytridiomycosis and bat white-nose syndrome. Public health concerns relating to zoonotic fungal pathogens are also covered, including Microsporum canis and Sporothrix brasiliensis from cats. The threat to humans and animals from mycotoxins including alflatoxins and ochratoxins is discussed.
 
 This paper is a useful introduction to the science of fungal pathogens and agents that affect non-human animals. 
Veterinary

Populations of green turtles (Chelonia mydasare declining because of human activities, beach erosion and pathogenic infections, among other factors. To investigate the possible impact of fungal species on green turtles, a researcher from Hacettepe University in Turkey investigated the fungal diversity of green turtle nests. Dr Candan collected fungal isolates from 25% of nests on the Sogözü beaches in a single nesting season. She found fungal isolates belonging to the genus Aspergillus, as well as Emiricella, Rhizopus, Actinomucor and Apophysomyces. 36.4% of nest sites had fungal contamination.
 
Nests that were contaminated by fungi were significantly less likely to have hatched successfully, compared to uncontaminated nests. This is the first study to investigate fungal species in the nesting site of the Green Turtle, and although fungi are known to limit hatching success in other turtle species, more research is required to confirm a causal link between fungal contamination and hatching success in this species.
 
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Patients & Carers
Patient Meetings

The Aspergillus community/patient group meeting normally meets on the first Friday of each month at the Altounyan Suite, North West Lung Centre, Manchester at 1.30pm BST/GMT. If you can't make it in person, you are welcome to listen in to our Facebook Broadcast

If you want a text reminder when each meeting is approaching (UK only) then send us an email at admin@aspergillus.org.uk with your mobile phone number.
 
For more details see the Patients' Community Newsletter

Skype Meetings

If you would like to listen or chat with fellow patients and a NAC staff member we are running a successful Skype meeting every week! We are a chatty group of 8 - 12 most weeks but we can accommodate up to 24. If you have a computer or smartphone you will be able to join in - just click on https://join.skype.com/nbubWMUM8teC and you will be asked to register, then taken to the group. The Skype meeting is at 11am GMT every Thursday
 
We have recently started running a USA/Worldwide Skype group at 5pm GMT every Thursday, which can be accessed using this link: https://join.skype.com/ffp8FM6UysGf 
 
Join our Facebook Groups
 
Our Aspergillosis Support Facebook Group has over 1000 members and is a safe place to meet and talk to other people with aspergillosis.
 
We also have a Facebook group for carers, friends and family of someone who is affected by the disease - join here
 
To find our regional and international groups, search the following terms within Facebook: 'aspergillosis'; 'aspergillus'; 'ABPA'
Fungal Infection Trust, PO Box 482, Macclesfield, Cheshire SK10 9AR