Burden of serious fungal infections in India

Publication summary

In the absence of robust global and national surveillance systems for fungal diseases, estimates built from a variety of data sources can help to provide a country-wide picture of fungal infection incidence and prevalence. National estimates of fungal disease burden can allow prioritization of resources and policies, given that the type and prevalence of fungal infections vary substantially depending on geography, the proportion of people at risk of infection and severe disease, and socioeconomic characteristics. India is home to nearly 1.4 billion people, more than a quarter of whom are under the age of 15, and it’s estimated that about 2.35 million people in India are living with HIV. This data modeling study, accompanied by a  literature review of 434 articles, aims to estimate the burden of serious fungal infections—aspergillosis, mucormycosis, candidiasis, and fungi that cause neglected tropical and other skin diseases—across India, including infection incidence and prevalence in people living with HIV. Based on their estimates, the authors conclude that more than 57 million people across India are affected by fungal diseases.

Who this is for

• Healthcare policymakers at the national and state levels in India
• Clinicians working in India, especially with patients at increased risk of fungal infection

Key findings

Aspergillosis

• Invasive aspergillosis. The annual incidence of invasive aspergillosis in India is an estimated 250,900 cases, including 79,100 to 239,000 cases in people with chronic obstructive pulmonary disease; 1,885 cases in people with lung cancer; and 7,040 cases in people with leukemia, lymphoma, or transplantation. Invasive aspergillosis was estimated to have accounted for 2,360 deaths from AIDS in 2020.
• Chronic pulmonary aspergillosis. The annual incidence of chronic pulmonary aspergillosis is an estimated 212,502 cases, including 42,766 deaths in the year following diagnosis. About 90% of the chronic pulmonary aspergillosis burden is associated with pulmonary tuberculosis, and the authors estimate that the total prevalence is about 1.7 million cases.
• Allergic bronchopulmonary aspergillosis. The prevalence of allergic bronchopulmonary aspergillosis in adults who have severe asthma with fungal sensitization is an estimated 1 million to 2.8 million cases.
• Chronic fungal rhinosinusitis. The prevalence of chronic fungal rhinosinusitis, based on limited data, is an estimated 1.5 million cases.

Mucormycosis

The researchers estimate that the annual incidence of mucormycosis across India is about 195,000 cases.

Candidiasis

• Candidemia. Models estimated that the annual incidence of candidemia across India is 188,035. Given the low sensitivity of blood cultures for identifying invasive candidiasis, however, the researchers assert that the true annual incidence of candidemia is closer to 470,000 cases. Candida tropicalis is likely responsible for about 42% of cases, while Candida albicans and Candida auris account for an estimated 21% and 5.3%, respectively.
• Candida peritonitis. The annual prevalence of Candida peritonitis in people with end-stage renal disease in India is estimated to be 85 cases.
• Intra-abdominal candidiasis. Post-surgical intra-abdominal candidiasis is estimated to account for 18,775 cases per year in intensive care units.
• Recurrent vulvovaginal candidiasis. The annual prevalence of recurrent vulvovaginal candidiasis is estimated to be 24,370,566 cases.
• Esophageal candidiasis. The annual incidence of esophageal candidiasis is approximately 266,612 cases in people living with HIV.

Pneumocystis pneumonia

The researchers estimated that Pneumocystis pneumonia affects 58,378 patients in India, 25,686 of whom are living with HIV.

Cryptococcal meningitis

The annual incidence of cryptococcal meningitis is estimated to be 11,526 cases, 9,682 of which occur in people living with HIV.

Talaromycosis

The authors estimate that 2,825 people living with HIV in India are affected by talaromycosis.

Histoplasmosis

Citing unavailable data and regional variation in disease occurrence, the authors were unable to estimate histoplasmosis incidence and prevalence. 

Neglected tropical or other skin diseases

The prevalence of tinea capitis, which overwhelmingly affects children and people living in poverty, is estimated to be 25,053,332 cases, although this assumes that data primarily collected from Kolkata are applicable to the rest of the country. The estimated annual prevalence of fungal keratitis, which can cause blindness, is 1,017,182 cases. Data were insufficient to estimate incidence or prevalence of sporotrichosis, mycetoma, and chromoblastomycosis.

Limitations and recommendations

The authors note that, because estimates were built off of available data, they may over- or underestimate incidence and prevalence in some instances. In measurements of serious infections, such as candidemia, a shortage of intensive care unit beds may lead to underestimates of the number of infections that require critical care. The authors recommend that the new estimates and future studies of fungal infection burden across India lead to improvements in surveillance and access to fungal diagnostic tests.