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Aksoy E, Yildirim E, Ozmen I, Yilmaz NO, Karaman AK, Takir H, Ozbaki F, Agca M, Berk A. Clinical Features, Treatment Outcome and Potential risk Factors for Recurrence Among Patients with Chronic Pulmonary Aspergillosis in a Resource-limited Setting: A Retrospective Observational Study. Mycopathologia 2024; 189:76. [PMID: 39172211 DOI: 10.1007/s11046-024-00884-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 08/09/2024] [Indexed: 08/23/2024]
Abstract
OBJECTIVE To evaluate the clinical characteristics and treatment outcomes of patients with chronic pulmonary aspergillosis (CPA) and to determine risk factors for disease recurrence. METHODS A total of 43 patients with CPA (mean ± SD age: 61.4 ± 10.5 years, 83.7% were males) were included in this retrospective study. Data on demographic, clinical and disease-related characteristics, galactomannan (GM) test positivity in bronchoalveolar lavage (BAL) samples, histopathological diagnosis, imaging (CT) findings and CPA forms, antifungal therapy, recurrence rate and time to recurrence were recorded. RESULTS Chronic obstructive pulmonary disease (COPD;76.7%) was the leading predisposing factor, and the aspergillus nodule (37.2%) was the most prevalent CPA form.GM test positivity was noted in 89.7% (35/39) of BAL samples. Median duration of voriconazole treatment was 180 days. CPA recurrence was noted in 14.0% of patients, while the comorbid tuberculosis sequela (66.7% vs. 16.2%, p = 0.02) and mild immunosuppressive disorder (100.0% vs. 51.4%, p = 0.032) were significantly more common in patients with recurrence vs. those without recurrence. Recurrence rate was 50.0% (3 of 6 patients) in patients with simple aspergilloma, and ranged from 0.0% to 25.0% in those with other CPA forms. Treatment duration and time to recurrence ranged 70-270 days and 1.1-37 months, respectively in simple aspergilloma, while they were ranged 150-180 days and 30-43.3 months, respectively in other CPA forms. CONCLUSIONS Our findings indicate the importance of considering CPA in differential diagnosis in patients with predisposing conditions, and emphasize the tuberculosis sequela, immunosuppressive disorder and the certain CPA forms managed with shorter duration of antifungal therapy (i.e., simple aspergilloma) as the potential risk factors of CPA recurrence.
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Affiliation(s)
- Emine Aksoy
- Clinics of Chest Diseases, University of Health Sciences, Istanbul Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey.
| | - Elif Yildirim
- Clinics of Chest Diseases, University of Health Sciences, Istanbul Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ipek Ozmen
- Clinics of Chest Diseases, University of Health Sciences, Istanbul Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Nermin Ozer Yilmaz
- Clinics of Infectious Diseases, University of Health Sciences, Istanbul Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ahmet Kursat Karaman
- Clinics of Radiology, University of Health Sciences, Istanbul Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Huriye Takir
- Clinics of Chest Diseases, University of Health Sciences, Istanbul Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Fatma Ozbaki
- Clinics of Chest Diseases, University of Health Sciences, Istanbul Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Meltem Agca
- Clinics of Chest Diseases, University of Health Sciences, Istanbul Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Aysegul Berk
- Clinics of Chest Diseases, University of Health Sciences, Istanbul Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
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Bekele A, Alayande BT, Gulilat D, White RE, Tefera G, Borgstein E. A plea for urgent action: Addressing the critical shortage of cardiothoracic surgical workforce in the COSECSA region. World J Surg 2024. [PMID: 38972978 DOI: 10.1002/wjs.12278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 06/24/2024] [Indexed: 07/09/2024]
Abstract
BACKGROUND The College of Surgeons of East, Central, and Southern Africa (COSECSA) comprises 14 countries, many of which currently grapple with an increasing burden of cardiothoracic surgical (CTS) diseases. Health and economic implications of unaddressed CTS conditions are profound and require a robust regional response. This study aimed to define the status of CTS specialist training in the region (including the density of specialists, facilities, and active training posts), examine implications, and proffer recommendations. METHODS A desk review of COSECSA secretariat documents and program accreditation records triangulated with information from surgical societies was performed in May 2022 and September 2023 as part of education quality improvement. A modified nominal group process involving contextual experts was used to develop a relevant action framework. RESULTS Only 6 of 14 (43%) of COSECSA countries offered active training programs with annual intake of only 18 trainees. Significant training gaps existed in Burundi, Botswana, Malawi, Rwanda, South Sudan, Zambia, and Zimbabwe. Country specialist density ranged from 1 per 400,000 (Namibia) to 1 per 8,000,000 (Ethiopia). Overall, the region had 0.2 CTS specialists per million population as compared with 7.15 surgeons per million in High-Income Countries. Surgical education experts proposed an action framework to address the training crisis including increasing investments in CTS education, establishing regional centers of excellence, retention incentives and opportunities for women, and leveraging international partnerships. CONCLUSION Proactive investments in infrastructure, human resources, training, and collaborative efforts by national governments, regional intergovernmental organizations, and international partners are critical to expanding regional CTS training.
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Affiliation(s)
- Abebe Bekele
- College of Surgeons for East, Central and Southern Africa Secretariat, Arusha, Tanzania
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
| | - Barnabas Tobi Alayande
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Dereje Gulilat
- Department of Surgery, Addis Ababa University, School of Medicine, Addis Ababa, Ethiopia
| | | | - Girma Tefera
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Eric Borgstein
- University of Malawi College of Medicine, Blantyre, Malawi
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Osaigbovo II, Govender NP, Jordan AM, Bongomin F, Meya DB, Kanyua A, Mashedi OM, Koffi D, Loyse A, Sturny-Leclère A, Gangneux JP, Denning DW, Chiller T, Cornely OA, Oladele RO. The Nairobi Declaration 2023: A commitment to address deadly yet neglected fungal diseases in Africa. Med Mycol 2024; 62:myad141. [PMID: 38154488 DOI: 10.1093/mmy/myad141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 12/21/2023] [Accepted: 12/27/2023] [Indexed: 12/30/2023] Open
Abstract
On May 30th and 31st, 2023, delegates representing various African subregions, together with global representatives from the International Society of Human and Animal Mycology (ISHAM), the European Confederation of Medical Mycology (ECMM), the United States Centre for Disease Control and Prevention (CDC), and Global Action for Fungal Infections (GAFFI), convened in Nairobi, Kenya under the aegis of the Pan African Mycology Working Group, a working group of ISHAM. The meeting objectives were, amongst others, to deliberate on a continental response to the World Health Organisation Fungal Priority Pathogen List and facilitate interaction between global and regional leaders. Country delegates and international speakers addressed Africa's fungal disease burden; capacity for diagnosis and management; ongoing surveillance; knowledge gaps and trends in invasive fungal diseases such as Candida auris, mucormycosis, aspergillosis, and Acquired Immune Deficiency Syndrome (AIDS)-related mycoses; and current laboratory practice. During the technical sessions, expert panels deliberated on establishing and financing of national/regional surveillance networks for mycoses; establishing and sustaining African-led collaborations; expanding on existing laboratory and point-of-care diagnostic capacity as well as planning a mycology reference laboratory service and network in Africa. The meeting also highlighted successful African-led collaborations, capacity building, and clinical trial initiatives. The meeting conclusions informed the resolutions of the Nairobi Declaration calling for improved awareness; strong collaborations between clinical and laboratory teams across Africa; improved fungal disease surveillance within the continent; access to antifungals and diagnostics; and leveraging qualified human resources for mycology present within and outside Africa to facilitate trainings, collaborations, and exchanges.
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Affiliation(s)
- Iriagbonse I Osaigbovo
- Department of Medical Microbiology, School of Medicine, College of Medical Sciences, University of Benin, Benin City, Nigeria
| | - Nelesh P Govender
- National Institute for Communicable Diseases, a Division of the National Health Laboratory Service, School of Pathology, University of the Witwatersrand, Johannesburg, South Africa
| | - Alexander M Jordan
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, United States of America
| | - Felix Bongomin
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Alice Kanyua
- Department of Pathology and Laboratory Medicine, Aga Khan University, Nairobi, Kenya
| | | | - David Koffi
- Institut Pasteur de Côte d'Ivoire, Abidjan, Cote d'Ivoire
| | - Angela Loyse
- Division of Infection and Immunity Research Institute, St George's University of London, London, United Kingdom
| | - Aude Sturny-Leclère
- Institut Pasteur, Universite Paris Cite, National Reference Center for Invasive Mycoses and Antifungals, Translational Mycology research group, Mycology Department, F-75015, Paris, France
| | - Jean-Pierre Gangneux
- CHU de Rennes, University of Rennes, INSERM, Irset (Institut de recherche en santé, environnement et travail) - UMR_S 1085, Rennes, France
| | - David W Denning
- Manchester Fungal Infection Group, Division of Evolution, Infection and Genomics, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, United Kingdom
| | - Tom Chiller
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, United States of America
| | - Oliver A Cornely
- Department of Internal Medicine, European Diamond Excellence Center of Medical Mycology, University Hospital Cologne, Cologne, Germany
| | - Rita O Oladele
- Department of Medical Microbiology and Parasitology, Faculty of Basic Medical Sciences, College of Medicine, University of Lagos, Lagos, Nigeria
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Bongomin F, Kwizera R, Namusobya M, van Rhijn N, Andia-Biraro I, Kirenga BJ, Meya DB, Denning DW. Re-estimation of the burden of serious fungal diseases in Uganda. Ther Adv Infect Dis 2024; 11:20499361241228345. [PMID: 38328511 PMCID: PMC10848809 DOI: 10.1177/20499361241228345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 01/09/2024] [Indexed: 02/09/2024] Open
Abstract
Background It is of utmost importance to monitor any change in the epidemiology of fungal diseases that may arise from a change in the number of the at-risk population or the availability of local data. Objective We sought to update the 2015 publication on the incidence and prevalence of serious fungal diseases in Uganda. Methods Using the Leading International Fungal Education methodology, we reviewed published data on fungal diseases and drivers of fungal diseases in Uganda. Regional or global data were used where there were no Ugandan data. Results With a population of ~45 million, we estimate the annual burden of serious fungal diseases at 4,099,357 cases (about 9%). We estimated the burden of candidiasis as follows: recurrent Candida vaginitis (656,340 cases), oral candidiasis (29,057 cases), and esophageal candidiasis (74,686 cases) in HIV-infected people. Cryptococcal meningitis annual incidence is estimated at 5553 cases, Pneumocystis pneumonia at 4604 cases in adults and 2100 cases in children. For aspergillosis syndromes, invasive aspergillosis annual incidence (3607 cases), chronic pulmonary aspergillosis (26,765 annual cases and 63,574 5-year-period prevalent cases), and prevalence of allergic bronchopulmonary aspergillosis at 75,931 cases, and severe asthma with fungal sensitization at 100,228 cases. Tinea capitis is common with 3,047,989 prevalent cases. For other mycoses, we estimate the annual incidence of histoplasmosis to be 646 cases and mucormycosis at 9 cases. Conclusion Serious fungal diseases affect nearly 9% of Ugandans every year. Tuberculosis and HIV remain the most important predisposition to acute fungal infection necessitating accelerated preventive, diagnostic, and therapeutic interventions for the management of these diseases.
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Affiliation(s)
- Felix Bongomin
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda
- Manchester Fungal Infection Group, Division of Evolution, Infection and Genomics, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Richard Kwizera
- Infectious Diseases Institute, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Martha Namusobya
- Department of Clinical Epidemiology and Biostatistics, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Norman van Rhijn
- Manchester Fungal Infection Group, Division of Evolution, Infection and Genomics, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | | | - Bruce J. Kirenga
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - David B. Meya
- Infectious Diseases Institute, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - David W. Denning
- Manchester Fungal Infection Group, CTF Building, The University of Manchester, Grafton Street, Manchester M13 9NT, UK
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Bongomin F, Olum R, Kibone W, Namusobya M, van Rhijn N, Denning DW. Prevalence of chronic pulmonary aspergillosis along the continuum of pulmonary tuberculosis care: A protocol for a living systematic review and meta-analysis. PLoS One 2023; 18:e0294634. [PMID: 38100446 PMCID: PMC10723662 DOI: 10.1371/journal.pone.0294634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/05/2023] [Indexed: 12/17/2023] Open
Abstract
INTRODUCTION Chronic pulmonary aspergillosis (CPA) is a debilitating disease estimated to affect over 3 million people worldwide. Pulmonary tuberculosis (PTB) is the most significant risk factor for CPA. However, the true burden of CPA at the time of PTB diagnosis, during, and after PTB treatment remains unknown. In this paper, we present a protocol for a living systematic review aimed at estimating the current burden of CPA along the continuum of PTB care. MATERIALS AND METHODS We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) guidelines to formulate this protocol, which is registered with the International Prospective Register of Systematic Reviews (PROSPERO: CRD42023453900). We will identify primary literature through various electronic databases, including CINAHL, Ovid MEDLINE, MEDLINE (PubMed), EMBASE, Google Scholar, Cochrane Database of Systematic Reviews, and African Journal Online. The search will encompass articles from inception to December 31st, 2023, using medical subject heading search terms "pulmonary tuberculosis" AND "chronic pulmonary aspergillosis". Two reviewers will independently assess titles, abstracts, and full texts for eligibility using the Covidence web-based software. The eligible studies will comprise original observational research that reports on the prevalence of CPA diagnosed in individuals with PTB, based on established criteria, without language or geographic restriction. We intend to exclude single case reports and case series with fewer than 10 participants, as well as review articles, guidelines, and letters to the editors. Cochrane Risk of Bias Tools (ROB2 and ROBINS-I) will used to assess study quality and risk of bias and the quality of the evidence will be rated using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool. Our data syntheses will encompass meta-analysis and meta-regression, conducted using STATA version 18 and R- Studio version 4.0.2. This systematic review will be updated every 3-5 years as more data emerges. CONCLUSIONS The findings of this proposed systematic review will summarize the available evidence on the occurrence of CPA, at the time of PTB diagnosis, during and after PTB treatment. The study results have the potential to guide healthcare policies regarding screening for CPA, enhance clinical decision-making, and catalyse further research into understanding the interplay between PTB and CPA. By shedding light on the current burden of CPA along the continuum of PTB care, we aspire to contribute to the betterment of patient care, disease management, and global health outcomes. PROSPERO REGISTRATION CRD42023453900.
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Affiliation(s)
- Felix Bongomin
- Manchester Fungal Infection Group, Division of Evolution, Infection and Genomics, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda
| | - Ronald Olum
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Winnie Kibone
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda
| | - Martha Namusobya
- Department of Epidemiology and Biostatistics, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Norman van Rhijn
- Manchester Fungal Infection Group, Division of Evolution, Infection and Genomics, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - David W. Denning
- Manchester Fungal Infection Group, Division of Evolution, Infection and Genomics, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
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Bongomin F, Ekeng BE, Kwizera R, Salmanton-García J, Kibone W, van Rhijn N, Govender NP, Meya DB, Osaigbovo II, Hamer DH, Oladele R, Denning DW. Fungal diseases in Africa: Closing the gaps in diagnosis and treatment through implementation research and advocacy. J Mycol Med 2023; 33:101438. [PMID: 38358796 PMCID: PMC11103624 DOI: 10.1016/j.mycmed.2023.101438] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 10/12/2023] [Accepted: 10/18/2023] [Indexed: 02/16/2024]
Abstract
Fungal diseases impose an escalating burden on public health in Africa, exacerbated by issues such as delayed diagnosis, inadequate therapy, and limited access to healthcare resources, resulting in significant morbidity and mortality. Effectively tackling these challenges demands a comprehensive approach encompassing research, training, and advocacy initiatives. Recent clinical mycology surveys conducted by Global Action for Fungal Infection (GAFFI) and the European Confederation of Medical Mycology/International Society for Human and Animal Mycology (ECMM/ISHAM) have underscored gaps in fungal diagnostics and the availability and accessibility of antifungal therapy in Africa. The World Health Organization (WHO) Fungal Priority Pathogens List (FPPL) identifies fungi of critical or high importance to human health, providing a roadmap for action and highlighting the urgent need for prioritizing fungal diseases and developing targeted interventions within the African context. To enhance diagnosis and treatment, it is imperative to invest in comprehensive training programs for healthcare workers across all levels and disciplines. Equipping them with the necessary knowledge and skills will facilitate early detection, accurate diagnosis, and appropriate management of fungal infections. Moreover, implementation science research in medical mycology assumes a pivotal role in bridging the gap between knowledge and practice. By identifying the barriers and facilitators that influence the adoption of diagnostic techniques and public health interventions, tailored strategies can be formulated to improve their implementation within healthcare settings. Advocacy plays a critical role in raising awareness regarding the profound impact of fungal diseases on public health in Africa. Engaging policymakers, healthcare providers, researchers, industry experts and communities underscore the importance of addressing these diseases and galvanize efforts for change. Substantial investment in surveillance, research and development specifically focused on fungal diseases is indispensable for advancing our understanding of local epidemiology, developing effective interventions, and ultimately improving patient outcomes. In conclusion, closing the gaps in diagnosing and treating fungal diseases in Africa demands concerted research and advocacy initiatives to ensure better healthcare delivery, reduced mortality rates, and improved public health outcomes.
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Affiliation(s)
- Felix Bongomin
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, P.O. Box 166, Gulu, Uganda; Manchester Fungal Infection Group, Division of Evolution, Infection and Genomics, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom.
| | - Bassey E Ekeng
- Department of Medical Microbiology and Parasitology, University of Calabar Teaching Hospital, Calabar, Nigeria
| | - Richard Kwizera
- Translational Research Laboratory, Department of Research, Infectious Diseases Institute, College of Health Sciences, Makerere University, P.O Box 22418, Kampala, Uganda
| | - Jon Salmanton-García
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Institute of Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany; University of Cologne, Faculty of Medicine, and University Hospital Cologne, Department I of Internal Medicine, Excellence Center for Medical Mycology (ECMM), Cologne, Germany; German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Winnie Kibone
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, P.O. Box 166, Gulu, Uganda
| | - Norman van Rhijn
- Manchester Fungal Infection Group, Division of Evolution, Infection and Genomics, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Nelesh P Govender
- National Institute for Communicable Diseases, a Division of the National Health Laboratory Service and School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - David B Meya
- Infectious Diseases Institute, Department of medicine, College of Health Sciences, Makerere University, P.O Box 22418, Kampala, Uganda
| | - Iriagbonse I Osaigbovo
- Department of Medical Microbiology, School of Medicine, College of Medical Sciences, University of Benin, Benin 300213, Nigeria
| | - Davidson H Hamer
- Department of Global Health, Boston University School of Public Health, Boston, United States; Section of Infectious Diseases, Boston University Chobanian & Avedisian School of Medicine, Boston, United States of America; National Emerging Infectious Disease Laboratory, Boston, United States; Center for Emerging Infectious Diseases Policy & Research, Boston University, Boston, MA, United States
| | - Rita Oladele
- Department of Medical Microbiology and Parasitology, Faculty of Basic Medical Sciences, College of Medicine, University of Lagos, Lagos 101017, Nigeria
| | - David W Denning
- Manchester Fungal Infection Group, Division of Evolution, Infection and Genomics, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
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Truda VSS, Falci DR, Porfírio FMV, de Santos DWDCL, Junior FIO, Pasqualotto AC, Puga FG, Bollela VR, Junior JNA, Ferreira PRA, Colombo AL. A contemporary investigation of burden and natural history of aspergillosis in people living with HIV/AIDS. Mycoses 2023. [PMID: 37045744 DOI: 10.1111/myc.13589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 04/01/2023] [Accepted: 04/02/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND Untreated HIV infection can lead to profound immunosuppression and increase susceptibility of people living with HIV/AIDS (PLHA) to aspergillosis. OBJECTIVES Reporting the burden and natural history of aspergillosis documented in PLHA admitted in five medical centres in Brazil. PATIENTS AND METHODS Clinical, epidemiological and laboratory data were collected in all sequential cases of proven or probable aspergillosis documented in PLHA hospitalised in five medical centres between 2012 and 2020. RESULTS We enrolled 25 patients ageing between 23 and 58 years (mean = 39) including 11 patients with invasive aspergillosis (IA) and 14 with chronic pulmonary aspergillosis (CPA). The prevalence rate of aspergillosis was 0.1% of 19.616 PLHA. Overall, 72.7% of patients with IA exhibited CD4 < 100 cells/mL and 42.8% of patients with CPA exhibited CD4 count >200 cells/mL. Most patients had a history of tuberculosis, especially those with CPA (85.7%). IA was documented after a mean of 16.5 days of hospitalisation, mainly in critically ill patients exposed to corticosteroids and broad-spectrum antibiotics. In the CPA group, a positive culture (71.4%) and radiological alterations were the most frequent findings supporting their diagnosis. Episodes of IA were mostly documented by tissue biopsies. Crude mortality rates were 72.7% and 42.8% in patients with IA and CPA, respectively. CONCLUSIONS Despite being considered an unusual complication in PLHA (0.1%), IA should be considered in patients with profound immunosuppression and pneumonia refractory to conventional therapy. CPA should be investigated in PLHA with chronic deterioration of pulmonary function and previous diagnosis of tuberculosis.
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Affiliation(s)
| | - Diego Rodrigues Falci
- Infectious Disease Department, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | | | | | | | - Alessandro Comaru Pasqualotto
- Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Brazil
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil
| | - Fernanda Guioti Puga
- Divisions of Clinical Immunology, Emergency, Infectious Diseases and Intensive Care Unit, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Valdes Roberto Bollela
- Divisions of Clinical Immunology, Emergency, Infectious Diseases and Intensive Care Unit, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | | | | | - Arnaldo Lopes Colombo
- Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
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Abstract
The burden of fungal infections has been on the rise globally and remains a significant public health concern in Kenya. We estimated the incidence and prevalence of fungal infections using all mycology publications in Kenya up to January 2023, and from neighbouring countries where data lacked. We used deterministic modelling using populations at risk to calculate the disease burden. The total burden of serious fungal infections is estimated to affect 6,328,294 persons which translates to 11.57% of the Kenyan population. Those suffering from chronic infections such as chronic pulmonary aspergillosis are estimated to be 100,570 people (0.2% of the population) and probably nearly 200,000 with fungal asthma, all treatable with oral antifungal therapy. Serious acute fungal infections secondary to HIV (cryptococcal meningitis, disseminated histoplasmosis, pneumocystis pneumonia, and mucosal candidiasis) affect 196,543 adults and children (0.4% of the total population), while cancer-related invasive fungal infection cases probably exceed 2,299 and those in intensive care about 1,230 incident cases, including Candida auris bloodstream infection. The burden of fungal infections in Kenya is high; however, limited diagnostic test availability, low clinician awareness and inadequate laboratory capacity constrain the country's health system in responding to the syndemic of fungal disease in Kenya.
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Affiliation(s)
- Stanley N. Ratemo
- Research Department, Kisii Teaching and Referral Hospital, Kisii, Kenya
- CONTACT Stanley N. Ratemo
| | - David W Denning
- Manchester Fungal Infection Group, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Global Action for Fungal Infections (GAFFI), Geneva, Switzerland
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Ocansey BK, Adjei A, Denning DW. Mycologically confirmed chronic pulmonary aspergillosis in a post-pulmonary tuberculosis patient in Ghana. Ghana Med J 2022; 56:336-339. [PMID: 37575628 PMCID: PMC10416292 DOI: 10.4314/gmj.v56i4.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2023] Open
Abstract
Pulmonary tuberculosis (PTB) remains a major public health challenge in low- and middle-income countries. PTB may leave residual cavitation following treatment in some patients, allowing saprophytic colonization by Aspergillus species, resulting in a slow, progressive lung condition known as chronic pulmonary aspergillosis (CPA). PTB is the commonest underlying condition in CPA, mainly post-treatment. CPA is likely to be misdiagnosed as PTB reactivation due to clinical and radiological similarities. Ghana has a significant PTB burden, but only one case of clinically and radiologically diagnosed CPA has been reported, and epidemiological studies are also lacking. The definitive diagnosis of CPA comprises symptomatology, imaging findings and mycological evidence. Mycological evidence is critical to rule out other differential diagnoses, including non-Aspergillus pulmonary fungal infections and has implications for treatment choice. Herein, we present a case of mycologically-confirmed CPA in a previously treated PTB patient. Funding Fungal laboratory testing was provided by a CARIGEST SA studentship and research award to BKO and DWD respectively.
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Affiliation(s)
- Bright K Ocansey
- Division of Evolution, Infection and Genomics, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Abraham Adjei
- Chest Clinic, Department of Medicine and Therapeutics, Korle-Bu Teaching Hospital, Accra, Ghana
| | - David W Denning
- Division of Evolution, Infection and Genomics, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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Mohamed A, Obanda BA, Njeri HK, Loroyokie SN, Mashedi OM, Ouko TT, Gatumwa EM, Korir RK, Yaguchi T, Bii CC. Serological evidence of chronic pulmonary Aspergillosis in tuberculosis patients in Kenya. BMC Infect Dis 2022; 22:798. [PMID: 36284285 PMCID: PMC9594872 DOI: 10.1186/s12879-022-07782-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 09/17/2022] [Accepted: 10/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pulmonary tuberculosis (PTB) is a significant risk factor for fungal infection. The cavitary lesions post PTB serves as a good reservoir for fungal colonization and subsequent infection. Furthermore, the severe immunosuppression associated with HIV and TB co-infection is another predisposition. The inadequate capacity to investigate and manage fungal infection in PTB patients increases their morbidity and mortality. The study aimed to provide serological evidence of chronic pulmonary aspergillosis (CPA) among PTB patients in Kenya. Towards this, we analysed 234 serum samples from patients presenting with persistent clinical features of PTB infections despite TB treatment in four referral hospitals. METHODS This was a cross sectional laboratory based study and patients were recruited following an informed consent. Serological detection of Aspergillus fumigatus IgG was done using enzyme-linked immunosorbent assay (Bordier Affinity Products SA). Sputum samples were subjected to microscopy and standard fungal culture. The isolated fungi were subjected to macro and micro morphological identifications and confirmed by sequence analysis of calmadulin, betatubilin and ITS genes. RESULTS Serological evidence of CPA or fungal sensitization was 46(19.7%) and equivocal or borderline was 14(6.0%). Mycological investigations of sputum resulted in 88(38%) positive for fungal culture. Aspergillus spp. accounted for 25(28%) of which A. fumigatus was 13(14.8%), A. niger 8(9.1%), A. terreus, A. flavus, A. candidus and A. clavatus 1 (1.1%) each. This was followed by Penicillium spp. 10 (11.4%), Scedosporium spp. 5 (5.7%) and Rhizopus spp. 3 (3.4%). Among the yeasts; Candida albicans accounted for 18(20.5%) followed by C. glabrata 5(5.7%). Cryptococcus spp. was isolated from 3(3.4%) of the samples while 13(14.8%) were other yeasts. CONCLUSION Chronic pulmonary aspergillosis is a significant co-morbidity in PTB patients in Kenya that could be misdiagnosed as relapse or treatment failures in the absence of reliable diagnostic and clinical management algorithm. It could be the cause of persistent clinical symptoms despite TB treatment often misdiagnosed as TB smear/GeneXpert MTB/RIF® negative or relapse. We recommend that all patients with persistent clinical symptoms despite TB treatment should be subjected to fungal investigations before retreatment.
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Affiliation(s)
- Abdi Mohamed
- grid.33058.3d0000 0001 0155 5938Kenya Medical Research Institute, Centre for Microbiology Research, Mycology and Opportunistic Infections Laboratory, P.O.Box 54840-00200, Nairobi, Kenya
| | - Benear A. Obanda
- grid.33058.3d0000 0001 0155 5938Kenya Medical Research Institute, Centre for Microbiology Research, Mycology and Opportunistic Infections Laboratory, P.O.Box 54840-00200, Nairobi, Kenya
| | - Hannah K. Njeri
- grid.33058.3d0000 0001 0155 5938Kenya Medical Research Institute, Centre for Microbiology Research, Mycology and Opportunistic Infections Laboratory, P.O.Box 54840-00200, Nairobi, Kenya
| | - Sally N. Loroyokie
- grid.33058.3d0000 0001 0155 5938Kenya Medical Research Institute, Centre for Microbiology Research, Mycology and Opportunistic Infections Laboratory, P.O.Box 54840-00200, Nairobi, Kenya
| | - Olga M. Mashedi
- grid.33058.3d0000 0001 0155 5938Kenya Medical Research Institute, Centre for Respiratory Diseases Research, Tuberculosis Laboratory, P.O.Box 54840-00200, Nairobi, Kenya
| | - Tom T. Ouko
- grid.33058.3d0000 0001 0155 5938Kenya Medical Research Institute, Centre for Microbiology Research, Mycology and Opportunistic Infections Laboratory, P.O.Box 54840-00200, Nairobi, Kenya
| | - Evangeline M. Gatumwa
- grid.33058.3d0000 0001 0155 5938Kenya Medical Research Institute, Centre for Respiratory Diseases Research, Tuberculosis Laboratory, P.O.Box 54840-00200, Nairobi, Kenya
| | - Richard K. Korir
- grid.33058.3d0000 0001 0155 5938Kenya Medical Research Institute, Centre for Microbiology Research, Mycology and Opportunistic Infections Laboratory, P.O.Box 54840-00200, Nairobi, Kenya
| | - Takashi Yaguchi
- grid.136304.30000 0004 0370 1101Medical Mycology Research Centre (MMRC), Division of BioResources, Chiba University, 1-8- 1 Inohana, Chuo-ku, 260-8673 Chiba, Japan
| | - Christine C. Bii
- grid.33058.3d0000 0001 0155 5938Kenya Medical Research Institute, Centre for Microbiology Research, Mycology and Opportunistic Infections Laboratory, P.O.Box 54840-00200, Nairobi, Kenya
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11
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Chronic cavitary pulmonary aspergillosis in an immunocompetent child. Med Mycol Case Rep 2022; 37:33-36. [PMID: 35865451 PMCID: PMC9294259 DOI: 10.1016/j.mmcr.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 06/28/2022] [Accepted: 07/05/2022] [Indexed: 11/23/2022] Open
Abstract
Chronic pulmonary aspergillosis (CPA) is a progressive and destructive disease of the lung parenchyma. We report a 9-year-old boy diagnosed with CPA with a positive Aspergillus IgG and chest imaging of cavitary lung lesions. He was treated with oral Itraconazole with significant improvement. This shows that an index of suspicion should be heightened in the paediatric population with cavitary lung lesions because not all cavitary lung lesions are caused by Mycobacterium tuberculosis.
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12
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Ocansey BK, Otoo B, Adjei A, Gbadamosi H, Kotey FCN, Kosmidis C, Afriyie-Mensah JS, Denning DW, Opintan JA. Chronic Pulmonary Aspergillosis is Common among Patients with Presumed Tuberculosis Relapse in Ghana. Med Mycol 2022; 60:6661426. [PMID: 35953428 PMCID: PMC9462665 DOI: 10.1093/mmy/myac063] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/31/2022] [Accepted: 08/09/2022] [Indexed: 11/13/2022] Open
Abstract
Chronic pulmonary aspergillosis (CPA) may mimic pulmonary tuberculosis (PTB). The two diseases are clinically indistinguishable and may result in CPA misdiagnosed as PTB or vice versa. Although PTB is largely recognised as a differential diagnosis of CPA and often ruled out prior to CPA diagnosis, the reverse is uncommon. The aim of this study was to determine the proportion of CPA cases among patients being assessed for PTB. A cross-sectional survey was conducted among consecutive patients referred for GeneXpert Mycobacterium tuberculosis test for the diagnosis of PTB at the Korle-Bu Teaching Hospital, Accra, Ghana. Patients’ demographics, clinical and socioeconomic details were obtained using a structured questionnaire. Blood was collected for Aspergillus and HIV serology, and sputum samples obtained for Aspergillus culture. Chest radiograph was obtained, and computed tomography scan was also done for patients with positive Aspergillus serology or cavitation. CPA was defined using an algorithm developed by the Global Action for Fungal Infections (GAFFI) international expert panel. A total of 154 patients were included in the analysis, of whom 134 (87%) did not have a prior PTB diagnosis. There were 41 (26.6%) GeneXpert positive cases. CPA prevalence was 9.7% overall, but 50% in patients with a prior history of PTB and 3.7% in those without previous PTB. Although CPA is rarely considered as a differential diagnosis of PTB in Ghana, our findings show that CPA may affect half of patients being assessed for PTB relapse. Efforts to diagnose CPA should be prioritised in this patient group.
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Affiliation(s)
- Bright K Ocansey
- Division of Evolution, Infection and Genomics, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | | | - Abraham Adjei
- Chest Diseases Unit, Department of Medicine and Therapeutics, Korle-Bu Teaching Hospital, Accra, Ghana
| | | | - Fleischer C N Kotey
- FleRhoLife Research Consult, Accra, Ghana.,Department of Medical Microbiology, University of Ghana Medical School, Accra, Ghana
| | - Chris Kosmidis
- Division of Evolution, Infection and Genomics, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,National Aspergillosis Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Jane S Afriyie-Mensah
- Chest Diseases Unit, Department of Medicine and Therapeutics, Korle-Bu Teaching Hospital, Accra, Ghana.,Department of Medicine and Therapeutics, University of Ghana Medical School, Accra, Ghana
| | - David W Denning
- Division of Evolution, Infection and Genomics, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Japheth A Opintan
- Department of Medical Microbiology, University of Ghana Medical School, Accra, Ghana
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13
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Namusobya M, Bongomin F, Mukisa J, Olwit WK, Batte C, Mukashyaka C, Mande E, Kwizera R, Denning DW, Rhein J, Prasad S, Sekaggya-Wiltshire C. Chronic pulmonary aspergillosis in patients with active pulmonary tuberculosis with persisting symptoms in Uganda. Mycoses 2022; 65:625-634. [PMID: 35419885 PMCID: PMC9156563 DOI: 10.1111/myc.13444] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 03/31/2022] [Accepted: 04/07/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND The occurrence of chronic pulmonary aspergillosis (CPA) among drug sensitive pulmonary tuberculosis (PTB) patients on optimal therapy with persistent symptoms was investigated. METHODS We consecutively enrolled participants with PTB with persistent pulmonary symptoms after 2 months of anti-TB treatment at Mulago Hospital, Kampala, Uganda between July 2020, and June 2021. CPA was defined as a positive Aspergillus-specific IgG/IgM immunochromatographic test (ICT), a cavity with or without a fungal ball on chest x-ray (CXR), and compatible symptoms >3 months. RESULTS We enrolled 162 participants (median age 30 years; IQR: 25 - 40), 97 (59.9%) were male, 48 (29.6%) were HIV-infected, and 15 (9.3%) had prior PTB. Thirty-eight (23.4%) sputum samples grew A. niger and 13 (8.0%) A. fumigatus species complexes. Six (3.7%) participants had intra-cavitary fungal balls, and 52 (32.1%) had cavities. Overall, 32 (19.8%) participants had CPA. CPA was associated with prior PTB (adjusted odds ratio (aOR): 6.61, 95% CI: 1.85 - 23.9, p=0.004), and far advanced CXR changes (aOR: 4.26, 95%CI: 1.72 - 10.52, p=0.002). The Aspergillus IgG/IgM ICT was positive in 10 (31.3%) participants with CPA. CONCLUSIONS CPA may cause persistent respiratory symptoms in up to one-fifth of patients after intensive treatment for PTB. The Aspergillus IgG/IgM ICT positivity rate was very low and may not be used alone for the diagnosis of CPA in Uganda.
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Affiliation(s)
- Martha Namusobya
- Makerere Lung Institute, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Felix Bongomin
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda
| | - John Mukisa
- Department of Immunology and Molecular Biology, School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - William Kane Olwit
- Department of Radiology, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Charles Batte
- Makerere Lung Institute, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Claudine Mukashyaka
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Emmanuel Mande
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Richard Kwizera
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - David W Denning
- Manchester Fungal Infection Group, University of Manchester, Manchester, United Kingdom
| | - Joshua Rhein
- Centre for Global Health and Social Responsibility, University of Minnesota, Minneapolis, Minnesota, USA
| | - Shailendra Prasad
- Centre for Global Health and Social Responsibility, University of Minnesota, Minneapolis, Minnesota, USA
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Shen C, Qiao G, Wang C, Jin F, Zhang Y. Outcomes of surgery for different types of chronic pulmonary aspergillosis: results from a single-center, retrospective cohort study. BMC Pulm Med 2022; 22:40. [PMID: 35045860 PMCID: PMC8772183 DOI: 10.1186/s12890-022-01836-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 01/06/2022] [Indexed: 11/10/2022] Open
Abstract
Background The reported experience of surgical treatment for chronic pulmonary aspergillosis (CPA) mainly focused on simple aspergilloma (SA), few about other types of CPA. The present study aims to evaluate the outcomes of surgical treatment for different types of CPA. Methods We performed a retrospective analysis of 85 patients with CPA who underwent surgery from 2014 to 2020 at Shandong Provincial Chest Hospital. The patients were divided into four types, including SA, chronic cavitary pulmonary aspergillosis (CCPA), chronic fibrosing pulmonary aspergillosis (CFPA), aspergillus nodule (AN). We collected and analyzed the preoperative, perioperative, and postoperative data to evaluate the outcomes of surgical treatment of different types of CPA. Results The four groups had similar age (p = 0.22), symptoms (p = 0.36), lesion location (p = 0.09), VATS rate (p = 0.08), recurrence rate (p = 0.95), and had significant difference in surgical procedures (p < 0.01), time of surgery (p < 0.01), intraoperative blood loss (p < 0.01), postoperative complication (p = 0.01). CFPA (P = 0.01), longer surgical time (P = 0.001), and more intraoperative blood loss (P = 0.004) were risk factors of postoperative complication, more intraoperative blood loss (> 400 ml) was the independent risk factor (OR 13.5, 95% CI 1.6–112.1, P = 0.02). 6 patients relapsed after surgery with a recurrence rate of 7.1%. The mean time to relapse was 14.8 months (2–30 months) after surgery. Relapse occurred in 2 SA patients, 3 CCPA, and 1 CFPA, respectively, while none of the AN patients relapsed. No risk factor for recurrence was found. Conclusions Surgical resection seems safe and effective in the treatment of SA, AN, CCPA with a low complication and recurrence rate, while surgery for CFPA should be limited to selected patients because of its higher complication rate. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-022-01836-z.
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Bongomin F, Kibone W, Okot J, Nsenga L, Olum R, Baluku JB. Fungal diseases in Africa: epidemiologic, diagnostic and therapeutic advances. Ther Adv Infect Dis 2022; 9:20499361221081441. [PMID: 35281765 PMCID: PMC8905202 DOI: 10.1177/20499361221081441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Affiliation(s)
- Felix Bongomin
- Department of Medical Microbiology & Immunology, Faculty of Medicine, Gulu University, P.O. Box 166, Gulu, Uganda
- Non-communicable and Infectious Diseases Research (NIDER) Platform, Kampala, Uganda
| | - Winnie Kibone
- School of Medicine, Makerere University, Kampala, Uganda
| | - Jerom Okot
- Department of Medical Microbiology & Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda
| | - Lauryn Nsenga
- School of Medicine, Kabale University, Kabale, Uganda
| | - Ronald Olum
- Non-communicable and Infectious Diseases Research (NIDER) Platform, Kampala, UgandaSchool of Medicine, Makerere University, Kampala, Uganda
| | - Joseph Baruch Baluku
- Non-communicable and Infectious Diseases Research (NIDER) Platform, Kampala, Uganda
- Division of Pulmonology, Kiruddu National Referral Hospital, Kampala, Uganda; Makerere University Lung Institute, Kampala, Uganda
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