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 Centre for Infections

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

7. 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

8. 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 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

10. 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)

11. 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 (<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

16. 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

17. 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)