The estimated burden of fungal disease in South Africa

Background: With a population of 56.5 million, over 7 million persons living with HIV, one of the highest rates of tuberculosis, and a large proportion of the population living in poverty, South Africa’s fungal disease burden is probably substantial and broad in scope. Objectives: To estimate the burden of fungal disease in South Africa. Methods: Using total and at-risk populations and national, regional, and occasionally global data, we estimated the incidence and prevalence of the majority of fungal diseases in South Africa. Results: Estimates for the annual incidence of HIV-related life-threatening fungal disease include cryptococcal meningitis (8,357 cases), Pneumocystis pneumonia (4,452 cases), and endemic mycoses (emergomycosis, histoplasmosis and blastomycosis with 100, 60, and 10 cases per year, respectively). We estimate 3,885 cases of invasive aspergillosis annually. The annual burden of candidaemia and Candida peritonitis is estimated at 8,257 and 2,972 cases, respectively. The epidemic of pulmonary tuberculosis has probably driven up the prevalence of chronic pulmonary aspergillosis to 99,351 (175.8/100,000), perhaps the highest in the world. Fungal asthma probably affects over 100,000 adults. Mucosal candidiasis is common with an annual prevalence estimated at 1,150,000 and 623,600 oral and oesophageal cases complicating HIV infection alone (estimates in other conditions not made), and over a million women are estimated to be affected by recurrent vulvovagingal candidiasis each year. Tinea capitis in children is common and conservatively estimated at >1,000,000 cases. The inoculation mycoses sporotrichosis, chromoblastomycosis and eumycetoma occur occasionally (with 40, 40, and 10 cases estimated, respectively). Overall, over 4 million South Africans are estimated to have a fungal disease each year (7.1% of the population). Conclusions: Significant numbers of South Africans are estimated to be affected each year by fungal infections, driven primarily by the syndemics of HIV, tuberculosis and poverty. These estimates emphasize the need for better epidemiological data, and for improving the diagnosis and management of these diseases.