Reportonactivitiesfor2019

May2020

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SummaryThere is palpable progress in GAFFI’s mission to reduce illness and death associated with fungaldiseases worldwide and support greater awareness. Its achievements in 2019, its sixth year ofoperation,include:

• GAFFIorganizedand leadtheworld’s firstconferenceonfungaldiseasesandhealth systems inLima, Peru in September 2019with PAHO and CDC. Thismeeting, in Spanish,was attended by 18LatinAmericanandCaribbeancountriesanddevelopeda7-pointplantoadoptthelatestdiagnosticsforfungaldiseasesandintegratethesewithinHIV/AIDS,TBandhospitalprograms.Themeetingalsoaddressed antifungal drug resistance (AMR) and the new GLASS program on collecting data onresistanceinCandidaspp.

• BurdenofSeriousFungalDiseases:Theprogramofmappinghowmanyfungaldiseasestherearein each country has now reached 98 countries. Newmaps of histoplasmosis hot spots for SE Asiawere published. The first estimation of the burden of fungal keratitis was presented – an annualincidenceof1.05-1.40millioneyesaffected.

• ApplicationtotheWHOtoincludeHistoplasmaantigenasEssentialontheModelListofinvitroDiagnostics:GAFFI’sapplicationforHistoplasmaantigentobeincludedtheWHOEssentialDiagnosticlist was accepted and further applications for Aspergillus antigen, Aspergillus antibody andPneumocystisPCRsubmitted.

• Diagnostic Laboratory Hub in Guatemala: In 2017-18, there was a 22% incidence of life-threatening infection among 4,666 people with HIV, rising to 33.1% in those with low (< 200CD4/mm3)counts.AdvancedHIVdiseaseisthenorm(52%)innewlypresentingpeoplewithHIVandin these,histoplasmosis is found in7.9% followedby tuberculosis (7.1%).Patientsarescreened fordisseminated histoplasmosis, cryptococcal meningitis, tuberculosis and non-tuberculosismycobacteria. Additional testing is done for clinical suspicion, including PCR for Pneumocystispneumonia.

• StateDiagnosticMycologyLaboratories in India:TheIndianCouncilofMedicalResearch(ICMR)hasinitiatedmycologyreferencelaboratoriesat40differentlocationsofthecountryoverthenext5years,with4establishedinBhopal,NewDelhi,JodhpurandPuducherry.

• FungalNTDs:GAFFImadethecaseofparacoccidioidomycosisinS.AmericaandsporotrichosistobeacceptedasNTDsandthishasbeentakenupbyPAHO.GAFFIinitiatedasurveyofexpertsontheoptimaldiagnosticapproachto theskinNTDs,mycetoma,chromoblastomycosisandsporotrichosis,which is nowpublished. The case for fungal keratitis to be adopted as aNeglected TropicDisease(NTD) byWHOwasmade again, and the first estimate of annual incidence (over 1,000,000 eyes)presentedatECCMIDinApril.

• GAFFI’s Ambassadors’ activities: Multiple educational programs and awareness have beendeliveredinMexico,Indonesia,India,Serbia,Hungary,France,Norway,Portugal,Nigeria,Cameroon,GhanaandSouthAfrica.

• Health professional education: GAFFI’s educational partner LIFE-Worldwide has expanded itsofferings of multiple online videos and podcasts on key fungal disease topics. Many diagnosticproceduresarenowdemonstratedbyvideoforthefirsttime.

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GAFFI’sGoalsGAFFIhas4primarylong-termgoals,supportedbyadvocacy: Goal1-Increaseawarenessoftheimpactoffungaldisease Goal2-Improveaccesstodiagnosticsforfungaldisease Goal3-Improveaccesstoappropriateandaffordableantifungaltherapeuticswitha focusongenericagents Goal4-Improveeducationofhealthprofessionalsaboutfungaldisease.GAFFI10-yearRoadmap‘95-95by2025’focusedandfleshedouttheseobjectivesasfollows:

•Ensurethat95%ofpeoplewithseriousfungaldiseasearediagnosedand95%treatedby2025(95-95)

•SupportthegoalofreducingAIDSdeathstofewerthan500,000by2020,withadeterminedfocusonthecommonestlethalfungalinfections.

Toaccomplishthesegoals,itisnecessaryineachcountryto:•Ensurethataffordablediagnostictestsforallcommonanduncommonfungalinfectionsaremade

available, focused on rapid, non-culture testing. The WHO endorsed Essential Diagnostic tests(2019)forfungaldiseases

•Integratefungaldiseasesdiagnosticsintothehealthsystemofeachcountryincludingatleastonelaboratory ledbyanexpert in fungaldiseaseanda criticalmassofhealthcareprofessionalspercountry

• Develop a network of expert clinicians and ‘train the trainer’ programs, supported by clinicalguidelines

•EnsuredistributionofantifungalagentsontheWHOEssentialMedicineListtoreachallthosewhoneedthem.

•Establishongoingsurveillanceoffungalinfectionsofhighburdentoinformclinicalpractice,trainingandresearchneeds

•Developlocalexpertsinpublichealthmycology

GAFFI’sorganisationGAFFI’sBoardischairedbyProfessorNigelLightfoot(UK)andsupportedbyVictorRydgren(Vice-Chair)(Norway),YasuMori(japan),ProfessorMichelGlauser(Switzerland),ProfessorPatrickFrancioli(Switzerland)andOddiAasheim(UK).ProfessorDavidDenningisChiefExecutive,MsEmmaOrefuwaChiefExecutiveKenyaandTimothyMossHeadofAdministration.GAFFIandGAFFIUKhaveidenticalBoardmembershiptofacilitateachievingGAFFI’saims.

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Goal1-IncreaseawarenessoftheimpactoffungaldiseaseAmajorGAFFIgoal is increaseawarenessof fungaldiseaseglobally,especiallyamongglobalhealthagenciesandcountrymedicalopinionleadersanddecision-makers.GAFFIhasapproachedthisinpartby estimating the burden of fungal diseases country-by-country, identifying and highlightingdiagnostic and therapeutic gaps and supporting epidemiological studies to better define fungaldiseaselocally.1.1BurdenoffungaldiseaseIn 2019, burden papers were published for a further 8 countries including Ghana, South Africa,Namibia, Ethiopia, Kyrgyzstan, Tajikistan, Taiwan and Sweden. Fungal disease estimates are nowpublishedfor65countriesasshownhere:Abstracts and posters of country serious fungaldisease burdens were presented in 2019 atseveral ECCMID and TIMM congresses forParaguay, Sudan, Morocco, Cote d’Ivoire andAzerbaijan.TheHealthSystemsmeeting in Lima(Section5)generated the firstburdenestimatesforBolivia,Panama,Nicaragua,Honduras,CostaRicaandCuba,here.1.2DALYsestimatedforinvasiveaspergillosisInIran,wherethereisgreatinterestandfocusonfungaldisease,thesocietalimpactofinvasiveaspergillosiswasassessedusingdisability-adjustedlifeyears(DALYs)(Tavakoli,2019).TheDALYsofinvasiveaspergillosiswasestimatedat164.13per100,000population,ofwhichyearsoflifelost(YLLs)constitutethemajorityofIAburden.Theagegroupsmostaffectedwere30-49years.AnincreasingburdenofIAinIran,despitetheextensiveuseofprophylaxis,ischallengingthepublichealth.ThisisthefirstDALYestimateforthisdisease,andoneofveryfewforfungaldiseasesgenerally.

1.3GlobalburdenoffungalkeratitisAposteratECCMIDinAmsterdam,April2019,reportedasystematicreviewoftheliterature.Aminimumglobalannualincidenceestimateof1,052,794cases(range736,970-1,368,660)wasfound,withthehighestratesinAsiaandAfrica.Theoutcomesweregenerallypoor,with8-11%ofpatientshavingtohavetheeyeremoved,anannuallossofanestimated94,753to115,810eyes.

Goal2-ImproveaccesstodiagnosticsforfungaldiseaseIn the last 10 years, there has been a true revolution in fungal diagnostics shifting from ‘classical’culture andmicroscopy to PCR, antigen and antibody detection. Improved access to sensitive andrapiddiagnostics isacritically importantGAFFIgoal,especially inlow-andmiddle-incomecountriesandasfungaldiseasesareoftenclinicallysilentintheirearlystagesandcanmimicotherinfections,specific diagnostic tests are required for diagnosis.Many hospitals and countries have little or nodiagnosticcapability.Complextestformats,expense,inadequatelaboratoryinfrastructureandalackoftrainingareallbarrierstodiagnostictesting.

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2.1IntegrationoffungaldiseasesintohealthsystemsinLatinAmericaInLima,PeruinSeptember2019,theGlobalActionFundforFungalInfections(GAFFI)convened60delegatesfrom18LatinAmericanandCaribbeancountriestodiscusshowfungaldiseasediagnosisandantifungaltherapycouldbebetterintegratedintohealthcaresystemsacrossthecontinent(GFIF4,2019).Thegrowingproblemofantifungalresistancewasoneofthemeeting’sfocalpoints,emphasisedbytheglobalemergenceofCandidaauris.Seesection5.1.2.2EssentialDiagnosticsforfungaldiseasesandadvancedHIVinfectionGAFFI’sapplicationforHistoplasmaantigentobeincludedontheWHOModelListforinvitroDiagnosticswasapproved.Therearecurrently2testscommerciallyavailable,bothinELISAformat.Onehasasensitivityof81%andaspecificityof99%andadiagnosticaccuracypf96%(Link:Immy).Theotherhasasensitivityof95%(100%againstculturepositives)andaspecificityof70%withadiagnosticaccuracyof86%.(Link:http://optimumidx.com/).Inlate2019,thelateralflowassayforHistoplasmaantigenwaslaunchedwithexcellentperformanceonstoredandcultureprovencases(sensitivityof96%andspecificity90%,whentheLFAwasreadmanually).ThisapplicationfollowedGAFFI’ssuccessfulmeetingonEssentialDiagnosticsinKampalainApril2018andpublicationofasummaryofthatmeetingin2019.

In2019,GAFFIhasappliedforAspergillusantigen,AspergillusIgGantibodyandPneumocystisPCRtobeadoptedontotheEssentialDiagnosticlist.Theoutcomewillbeknowninmid2020.DiscussionswiththeEDLteaminGenevaabouttherapeuticdrugmonitoringoftheessentialmedicinesitraconazoleandvoriconazoleleadtoaconclusionthatthesewouldnotbesupportedcurrentlyas‘diagnostics’.

Thereisaneedtostandardise(possiblyviacommercialization)oftheantibodytestsforparacoccidioidomycosis,chronicandsubacutehistoplasmosisandsporotrichosis.2.3DemonstrationprojectinGuatemala(ContributionofProfessorJuanLuisRodriguezTudela)ThethirdyearofGAFFI’sdemonstrationprojectinGuatemalaiscomplete:‘MinimisingHIVdeathsthroughrapidfungaldiagnosisandbettercareinGuatemala.”ThisprojectincollaborationwiththeAsociacióndeSaludIntegral(ASI)(MedicalDirectorDrEduardoArathoon,andDrBlancaSamayoaGAFFIAmbassadorsforGuatemala)withexternalinputfromGAFFISeniorAdvisorProfJuanLuisRodriguezTudelaandGAFFIAmbassadorforSpainDrAnaAlastruey-Izquierdo.GAFFIisindebtedtotheJYLAGFoundationforfinancialsupport.

ThefirstcaseofchronicpulmonaryaspergillosisdiagnosedwithAspergillusantibodyLFAinKagando,Uganda

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Thefirstpublicationofthisprojectisalreadyavailable:SamayoaBetal.TheDiagnosticLaboratoryHub:ANewHealthCareSystemRevealstheIncidenceandMortalityofTuberculosis,Histoplasmosis,andCryptococcosisofPWHinGuatemala(seepublicationlist).2.3.5Nextsteps• Documentthesuccessesandchallengesoftheprojectinpublications.Afellowshipawardedtothe

GuatemalateamisbeingtrainedattheMedicalMycologyReferenceLaboratoryinSpainandherPhDthesisincludesthecomplexdataanalysisoftheproject.

• Analysein2020,bymeansofasurvey,theperformanceoftheprojectinordertodesignwhichinterventionsareneededtoimplementaprogramtodecreasethemortalityofpatientslivingwithHIVandOIs

• Facilitatecountryandgovernmentownershipoftheproject• Workwiththegovernmenttoensureantifungaldrugaccessandnocosttopatientsoraffordable

prices,includingflucytosineandliposomalamphotericinB• Assessthevalueofadditionaltestsinthediagnosticportfolio,includingAspergillusIgG,and

probablyToxoplasmaserologyandTBantigen(LAM)testing.2.4GuidelinesfordisseminatedhistoplasmosisinHIV/AIDS–theManausdeclarationInLatinAmerica,probablymorepeopledieofhistoplasmosiscomplicatingAIDSthantuberculosis.InMarch2019,inManaus,Brazil,the2ndmeetingonHistoplasmosisintheAmericasandCaribbeanwasheldwithrepresentationfrommostLatinAmericancountriesaswellasJamaica,Cuba,DominicanRepublicandTrinidadandTobago.Thefocusofthemeetingwasadiscussiononhowbesttoutilizethenewknowledgeaboutthevalueofnewrapidtestingforhistoplasmosis.AManausDeclarationwasissuedforalladvancedHIVpatientsintheAmericasandCaribbean:1.TimelyaccesstoantigenorPCRdiagnostictests(iewith48hoursinaworkingweek).2.AccesstoamphotericinB,liposomalamphotericinBanditraconazoleinthepublicsectorby2025.

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2.5DiagnosisoffungalNTDsFollowingmeetingof>50delegatestoISHAMcongressinAmsterdam,2018(seeGAFFI2018AnnualReport),23experiencedmycologistsandcliniciansparticipatedinasurveytodescribecurrentpracticeinthediagnosisofmycetoma,chromoblastomycosisandsporotrichosis(Hayetal,2019).Questionswereinthreecategories:1)forwell-equippeddiagnosticorclinicalsettingsineachrespondent’scountry,2)confirmatoryteststhatcouldbeusedinperipheralclinicsorlaboratorieswithlittleexpertiseinmycologicaltechniquesand3)thebestmethodsofobtainingdiagnosticspecimens.Theresponsesaresummarizedhere:

and

Thesurveyidentifiedthatthediagnosisofsporotrichosisisthemostproblematicwithmosttestshavingpoorsensitivityexceptfungalculture.Aclearneedtoimprovemycologicaldiagnosticcapacityisrequired,includingmorerobustevaluationsofantibodydetectionandskintesting,aswellasdevelopinginnovativediagnosticsolutions.2.6MycologyDiagnosticReferencecentresinIndiaTheIndianCouncilofMedicalResearch(ICMR),NewDelhihastakenupamajorinitiativetosetupmycologyreferencelaboratoriesat40differentlocationsofthecountryoverfiveyearsperiod;onelaboratoryeachinsmallprovinces,andmorethanoneinlargeprovinces.Thereferencelaboratorieswillprovideadvanceddiagnosticsineachcatchmentareaandestablishastrongplatformfortrainingandresearchonfungalinfections.ThisinitiativewasactivelypromotedbyGAFFI’sSeniorAdvisorDrSwarupSarkarandProf.ArunalokeChakrabarti(GAFFISeniorAdvisorandHeadoftheNationalMycologyReferenceLaborarory)ismentortotheprogram.

Thereferencelaboratorieswillalsoformamycologynetworkforsurveillanceofmappingoffungaldiseaseofthecountry,organizeCMEstocreateawarenessandtrainingofdoctorsandlaboratory.Inthisyear,fourcentreshavebeenidentifiedatAllIndiaInstituteofMedicalScience,Jodhpur;JawaharlalInstituteofPostgraduateMedicalEducationandResearch,Puducherry;AllIndiaInstituteofMedicalScience,Bhopal;andLadyHardingeMedicalCollege,NewDelhi,complementingtheNationalMycologyReferenceLaboraroryandWHOCollaboratingCentreatPGIMR,Chandigarh.

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Fundshavebeensanctionedforthepurchaseofequipment,consumablesandrecruitmentofdedicatedstaffinmycology.Ithasbeendecidedtoincorporatenon-culturebaseddiagnosticsinthisyearatthosecentres.ManpowerwillbetrainedinChandigarh.TheywillalsoparticipateintheexternalqualityassuranceprogramrunbytheNationalReferenceLaboratory

2.7Kenya–theFIP-KenyaprogramGAFFIhasbeenworking inpartnershipwith thegovernmentsofKenyaand Japan toprovidemuchgreater capacity for fungal disease diagnosis in Kenya. The Fungal Infections Program (FIP-Kenya)development program aims to provide the major urban centers with excellent radiology,histopathologyandfungaldiseasediagnosticsandsupportleadingclinicalpersonnelthroughtraining,in combination with networking, quality assurance and surveillance programs. Emma Orefuwa(GAFFI)isinclosecollaborationwiththeMinistryofHealthtoenabletheprogramtostart,probablyin2021(delayedbecauseofCOVID-19).Goal3-Improveaccesstoappropriateandaffordableantifungaltherapeutics

withafocusongenericagents

AccesstoaffordableantifungalagentsremainsacriticalgoalforGAFFI,withsomeprogressmadein2018.3.1GlobalmappingofcurrentavailabilityandpriceofantifungaldrugsGAFFIhassubstantiallyupdateditsantifungalmaps,notablywithvoriconazoleandnumerousothercountry data. This is ongoing. Enormous gaps in coverage still exist, notably with liposomalamphotericinB,flucytosine,voriconazoleinAfricaandtopicalnatamycin.3.2Echinocandinantifungals(caspofungin,micafunginandanidulafungin)

TherecurrentoutbreaksandendemicfociofCandidaaurishavepromptedGAFFItoreconsiderapplyingtotheWHOfortheintravenousechinocandinsas‘EssentialMedicines’.Countrieswithknownongoingproblems(i.e.endemicity)withCandidaaurishaveincludedKuwait,India,KenyaandSouthAfrica.TheWHOapplicationwillbesubmittedin2020andaccompaniedbyglobalmapsofavailability.

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3.1.2ImprovedpricingofliposomalamphotericinBforcryptococcalmeningitisIn2017,GileadagreedtosupplyliposomalamphotericinB(Ambisome)atUSD$16.25per50mgvial,asignificant price reduction. The liposomal formulation of amphotericin B is less toxic thanconventional amphotericin B and penetrates into the brain better. Logistical and access issuescontinue(seeantifungalavailabilitymaps),andthereisonlylimitedsuccessofthisprogramsofar.

Goal4-ImproveeducationofhealthprofessionalsaboutfungaldiseaseHealth professionals need to have fungal disease at the front of their mind when dealing withpatients with complex health problems. Laboratory training is critical for building diagnosticcapability. Antifungal prescribing can be complex, and pharmacists need to be aware of druginteractionsanddoseadjustments.GAFFI, in concertwithmanyothers, is committed to improvinghealthprofessionalcompetencerelatedtofungaldiseases.Inadditiontoits‘Factsheets’:GAFFIalsohasatwitteraccountwith>1,600followers.4.1GAFFIAmbassadorsGAFFI’sAmbassadorsnetworkexpandedin2019toincludeWadhaAmAlfouzan(Kuwait),GloriaAguilarBarreto(Paraguay),BrightOcansey(Ghana),ChristopheHennequin(France),TafeseTufa(Ethiopia),CaraMiaDunaiski(Namibia),LuisOstrovsky-Zeichner(USA),AiahKhateb(SaudiArabia).GAFFI’sAmbassadorgroupfromLatinAmericaplayedanimportantpartintheLimaHealthSystemsmeetingandfollowup.AllGAFFI’sAmbassadorsarelistedhere:Theircountryreportsfor2019arefoundinthelastsectionofthisreport.GAFFIisextremelygratefultoitsAmbassadorsfortheircontinuingeffortsrelatedtoraisingtheawarenessoffungaldiseases,directadvocacy,educationalinitiativesandprovidinginformationabouttheircountry.

HereDrSamuelFayemiwo(GAFFIAmbassador,Nigeria,secondfromright)hostsadinnerinManchesterwith(fromleft)DrHarunaMuda(ManchesterMetropolitanUniversity),EmmaOrefuwa(GAFFI),ProfIsaacAdewole(MinisterforHealth,Nigeria),DrKelechiNjoku(UniversityofManchester),andDrAkanInyeneOtu(Manchester).4.2OnlinelecturesonfungaldiseasesGAFFI’seducationalpartnerLIFE-Worldwidehasproducedmultipleonlinevideosandpodcastsonkeyfungaldisease topics.These includemanydiagnosticproceduresbutprincipallyvideo lectureswithaccompany PowerPoint presentations on over 35 fungal diseases topics, including antifungalchemotherapy.Moreintendtobeaddedoverthecomingmonths.

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4.3OnlinecourseonfungalmicroscopyandhistologyLaunchedin2016,theonlinefreecoursewww.microfungi.netistranslatedinto4languages(Spanish,French and Portuguese aswell as English) and accredited by theUK Royal College of pathologists.Laboratorytechniciansanddoctorscanearncontinuingprofessionaleducationpoints(CPDandCME)whilelearningacriticalskill.Over800studentshaveenrolledfromacrosstheworldandcompletionratesarelikelytoriseascertificationhasbeengrantedbytheRoyalCollegeofPathologistsintheUK.

Advocacysupportingtheabove4goals

AdvocacyisakeycontinuingmissionforGAFFI.AdvocacyhasandremainsfocusedontheWHOanditsregionalofficesbutisbroadeningtoincludecountryministriesofhealthandrelatedinstitutions.5.1HealthSystemsandFungalDiseases–LatinAmericaInLima,PeruinSeptember2019,GAFFIconvened60delegatesfrom18LatinAmericanandCaribbeancountriestodiscusshowfungaldiseasediagnosisandantifungaltherapycouldbebetterintegratedintohealthcaresystemsacrossthecontinent.ThestimulusfortheGFIF4meetingwasapaperpublishedinLancetInfectiousDiseasesbyColeetal(2017)“Improvementoffungaldiseaseidentificationandmanagement:combinedhealthsystemsandpublichealthapproaches.”Thispapernotedthata)“Fungaldiseasediagnosisrequiresahighlevelofclinicalsuspicionandspecialisedlaboratorytesting,inadditiontoculture,histopathology,andimagingexpertise”andb)“Healthsystemslinkingdiagnosticfacilitieswiththerapeuticexpertisearetypicallyfragmented,withmajorelementsmissinginthousandsofsecondarycareandhospitalsettings.”TherewasalsoasignificantfocusoncapturingsusceptibilitydataofCandidaspp.fromthecontinent,viatheWHOGLASSprogram.ThemeetingwasheldinSpanishwithsimultaneoustranslationintoEnglish.TheprogramandestimateoftheburdenoffungaldiseaseinLatinAmericaishere.ThefullreportisduetobeissuedinJune2020.5.1.1Healthcaresystems,workforceandburdenoffungaldiseasesThemeetingheardabouttheburdenoffungaldiseases,thecomplexityofmanyofthepatients’healthproblems,challengesininterpretationofradiologyandthecurrentstatusofhealthcaresystemsinmanycountries.Inparticular,healthexpenditure,healthcareaccessandqualityofcarewereshowntobehighlyvariableacrossthecontinent.Amajorthreattohealthcarewastheshortageofhealthcareworkers:30%ofcountriesdidnothaveenoughhealthcareworkerstocoverbasichealthneeds.Healthworkforceper10,000population(2017-2018)foralltheAmericaswas89.3,distributedasNorthAmerica170.8andLatinAmericaandtheCaribbean42.6.5.1.2FungaldiseasediagnosticsThemeetingalsoaddresseddiagnosticsforfungaldiseases.Manynon-culturetestsareunavailableacrosstheregion.TheRegionisparticipatingintheearlyimplementationoftheGlobalWHOinitiativetostrengthenlaboratorymycologycapacity,datamanagement,andAMRCandidasurveillance.TheNationalReferenceLaboratoryinClinicalMycologyattheInstitutoCarlosG.Malbrán,BuenosAires,Argentinaisanexampleofawell-establishedlaboratoryintheregion,andtheDiagnosticLaboratoryHubatthe

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ASIinGuatemalaanotherinnovativeexampleofaprogressiveapproachtodiagnostics.Themeetingmademultiplerecommendationswithrespecttoadoptionofrapidnon-culturediagnosticsanddefined3prioritiesregardingdiagnostics:Keypriority1:AllWHOrecommendedEssentialDiagnosticsforfungaldiseasesshouldbeimplementedforroutineuseinpublichospitals(provincial-stateequivalentandabove)andAIDSfocusedclinics.ThiswillstrengthendiagnosticcapabilitythroughouttheRegion.Keypriority2:Thesedevelopmentsshouldbeaccompaniedbyengagementwithexternalproficiencyqualityassuranceprograms.DevelopmentofNationalDiagnosticMycologylaboratoriesandnetworkswouldsupportcriticalmassinthisdiscipline.Keypriority3:ApplicationsshouldbemadetotheWHOtoincludePneumocystisPCRasanEssentialDiagnostic.5.1.3EssentialantifungalmedicinesBothconventionalamphotericinB(approved1957)andfluconazole(approved1990)areavailableinallcountriesbutliposomalamphotericinB(approved1995)isnotapprovedoravailableinseveralcountries.Itraconazole(approved1991)ismostlyavailableacrosstheregionbutvoriconazole(approved2002)isnotavailableinseveralcountries.Flucytosine(approved1974),isonlyavailableinColombia,CubaandSurinam.TopicalnatamycinisonlyavailableinArgentina,Colombia,CubaandMexico.TheproblemofCandidaaurisandageneralincreaseinazoleresistancepromptedmanydiscussionsonhowbesttoaddressresistancewithcurrentantifungals.ThemeetingwasintroducedtothePAHOStrategicfundwhichisableto1)negotiatecompetitiveprices,whichisparticularlyhelpfultosmallercountries,2)providetechnicalsupportforplanning,procurementanddistribution,and3)providealineofcreditalineofcreditforgovernments.AlltheEssentialsystemicantifungalsareavailablethroughtheFundapartfromtopicalnatamycin.Withrespecttoantifungaltherapy,themeetingagreedthat:Keypriority4:ApplicationsshouldbemadetotheWHOtoincludeechinocandinsasEssentialMedicines.5.1.4Addressingpublichealth,antifungalresistanceandstewardshipSeveralpresentationsaddressedtheroleofdiagnosticsforantifungal(andanti-bacterial)stewardshipandlaboratorycapabilityindetectingantifungalresistance.InLatinAmerica,limitedresourceshavebeenallocatedforaddressingantifungaldrugresistance,andfewcountriesperformanysurveillance.LittleinformationexistsaboutthepopulationprevalenceorclinicalincidenceofantifungalresistanceinmanypartsofLatinAmerica.Themeetingmademultiplerecommendationsforlaboratoriesandwellasdefining2priorities:Keypriority5:Strengtheningofpublichealthforfungaldiseasesincludinga)developmentofspecificsurveillanceprogramstotrackfungalinfectionsofpublichealthimportance,includingCandidaauris,theNTDsporotrichosisandseriousendemicfungalinfectionsandb)activeepidemiologyresearchprograms,usingpointofcareandnon-culturediagnostics.

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Keypriority6:Nationalantifungalresistancesurveillanceprogramsshouldbedevelopedinpublichospitals(provincial/stateequivalentandabove),withnationalreporting.5.1.5EducationOngoingtrainingisessentialtoprovidequalitycaretopatientswithfungaldiseases.Fungaldiseasespresenttonumerousdifferentmedicalspecialtiesincludingprimarycare,dermatology,respiratorymedicine,HIV/AIDSandinfectiousdiseases,intensivecare,gynaecology,haematology,ophthalmology,otolaryngology,paediatricsandpharmacy.TherearecoursesforfungaldiseasesinseveralcountriesofLatinAmericaincludingArgentina,Brazil,Chile,Colombia,CostaRica,Ecuador,Peru,UruguayandVenezuela(listedinthereport).Themeetingendorsedacommonmedicalcurriculumforfungaldiseasesaswellasidentifying2priorities:Keypriority7:Substantialeducationaleffortsofhealthcareprofessionals,notablyintheuseofnon-culturediagnostics,antifungalusageandstewardshipprograms,WHOGuidelinesforAdvancedHIVdisease,cryptococcalmeningitisandotherinternationalclinicalandlaboratorypracticeguidelines.Keypriority8:Assessmentandthenimplementationofartificialintelligencesystemstocounteracttheshortfallinhealthcareprofessionals,notablyinradiology,histopathology,dermatologyandophthalmology.5.1.6Fungaldiseases,healthsystemsandSustainableDevelopmentGoalsThemeetingfulfilleditsdirectobjectiveofaddressinghowtoreduceprematuredeathandimprovethehealthofpeopleinLatinAmerica,whichis(SDG3).Inaddition,severalotherSDGsareaddressablebyimplementingimprovementsforfungaldiseasediagnosisandcare.TheseincludeSDGs1,4,8,9,12,16and17.5.3FungalkeratitismaybeincludedasaprioritydiseasebytheWHOGAFFI applied to theWHO for Fungal Keratitis to be accepted as an NTD, but this has not beenacceptedbecauseofthenumberofunfulfilledtasksformanyotherNTDs.GAFFI’sfocuswillthereforeshifttotheBlindnesspreventionprogramatWHO.InOctober2019,launcheditsfirstWorldReportonvision.

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5.4FungalDiseaseAwarenessWeekTheNationalInstituteforCommunicableDiseasesinJohannesburg,SouthAfricahostedseveralactivitiesforFungalDiseaseAwarenessWeekin2019.ThisincludedaneducationalfungalfactwalkacrosstheNICDcampuswithinteractivegames(PCPgamepicturedbelow).

5.5GAFFIWestandNorthAfricanmeetingatTIMMAttheTIMMmeetinginNice,JeanPierreGangneuxandChristopheHennequinhostedadinnerofGAFFIAmbassadorsandfungalexpertsfromNorthandWestAfrica.

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5.6GAFFIpresentstotheGlobalHealthcommitteeattheBundestag,GermanyAspartoftheOneHealthconcept,GAFFI’sChiefExecutiveProfessorDavidDenningandSeniorMedicalAdviserProfessorJuanLuisRodriguezTudelaspokeatthehourlongmeetingintheBundestagpresentingthecaseformoreinvestmentintofungaldiseasesbyGermanyandEU.SeparatemeetingswithFederalMinistryofHealthandFederalMinistryofEducationandResearchofficialsresponsibleforGlobalHealthtoexchangeideasabouthowGermanycouldbestcontributetoimprovinghealthinAfricaandEasternEuroperelatedtofungaldiseases.2020plansandaspirations

The Diagnostic Laboratory Hub in Guatemala is preparing several publications, including thediagnosticoutcomesover2017and2018andanytrends.Aneconomicevaluationoftheprogramisalsounderway.

GAFFIhasappliedtotheWHOforAspergillusantigen,AspergillusantibodyandPneumocystisPCRtobeEssentialDiagnostics.

AsecondnationaldemonstrationprojectwastobelaunchedinKenyain2020,butisdelayedbecauseof the COVID-19 crisis. FIP-Kenya is a unique initiative that will improve clinical outcomes bystrengthening public health capabilities and promoting research on the understanding, prevention,diagnosisandtreatmentoffungal infections.MsEmmaOrefuwaasChiefExecutiveKenyawilldrivethistransformationalprojectforward.

Furtheradvocacyandactionarenecessarytoensurethatantifungals (especially flucytosine,topicalnatamycin and voriconazole) are available to everyone is necessary and will be addressed, withpartners.Theantifungalscountrydatabasewillbecontinuallyupdatedin2020.

Glossaryofterms,organisationsandabbreviations:AMR–AntimicrobialResistanceCDC–USCentersforDiseaseControlandPreventionEDL–EssentialDiagnosticsListFIP-Kenya–FungalInfectionsProgramKenyaJICA–JapanInternationalCo-operationAgencyLIFE–LeadingInternationalFungalEducationMALDI-TOF–Matrix-assistedlaserdesorption/ionizationtime-of-flightmassspectroscopyMSF–MedicinesSansFrontièresPAHO–Pan-AmericanHealthOrganizationPCR–PolymerasechainreactionSDG–SustainableDevelopmentGoalsUNITAID–AgencyhostedbyWHOinGeneva.WHO–WorldHealthOrganisation

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PublicationsBurdenofdiseasepapers:1. HedayatiMT,ArmakiMT,Jamshid,CharatiY,HedayatiN,SeyedmousaviS,DenningDW.Burdenof

fungalinfectionsinIran.JInfectDisDevCtries2018;12:910-18.

2. Hilmioğlu-PolatS,SeyedmousaviS,IlkitM,HedayatiMT,InciR,TumbayE,DenningDW.EstimatedburdenofserioushumanfungaldiseasesinTurkey.Mycoses2019;62:22-31.

3. OcanseyBK,PesewuGA,CodjoeFS,Osei-DjarbengS,FegloPK,DenningDW.EstimatedburdenofseriousfungalinfectionsinGhana.JFungi2019;5:38.

4. TurdumambetovaGN,OsmanovA,DenningDW.TheburdenofseriousfungalinfectionsinKyrgyzstan.JFungi(Basel)2019;5:66.

5. BobokhojaevOI,OsmanovA,AlievSP,RadjabzodaAS,AvgonovZT,ManonovST,DenningDW.TheburdenofseriousfungalinfectionsinTajikistan.JFungi(Basel)2019;5:68.

6. DunaiskiCM,DenningDW.EstimatedburdenoffungalinfectionsinNamibia.JFungi(Basel)2019;5:75.

7. HuangYS,DenningDW,ShihS-M,HsiungCA,WuU-I,SunH-S,ChenP-Y,ChenY-C,ChangSC.FungaldiseasesinTaiwan–NationalInsuranceDataandEstimation.JFungi(Basel)2019:5:78.

8. ÖzenciV,KlingsporL,UllbergM,ChryssanthouE,DenningDW,KondoriN.EstimatedburdenoffungalinfectionsinSweden.Mycoses2019;62:1043-1048.

9. TufaTB,DenningDW.BurdenoffungalinfectionsinEthiopia.JFungi(Basel)2019;5(4):109.

10. SchwartzIS,BoylesTH,KenyonCR,HovingJC,BrownGD,DenningDW.TheestimatedburdenoffungaldiseaseinSouthAfrica.SAMJ2019;109:885-892.

11. SamayoaB,AguirreL,BonillaO,MedinaN,Lau-BonillaD,MercadoD,MollerA,PerezJC,Alastruey-IzquierdoA,ArathoonE,DenningDW,Rodríguez-TudelaJL.TheDiagnosticLaboratoryHub,anewHealthcaresystemrevealstheincidenceandMortalityofTuberculosis,HistoplasmosisandCryptococcosisofPLHIVinGuatemala.OpenForumInfectDis2019;7(1):ofz534.

12. vanSchalkwykE,MpembeRS,ThomasJ,ShupingL,IsmailH,LowmanW,KarstaedtAS,ChibabhaiV,WadulaJ,AvenantT,MessinaA,GovindCN,MoodleyK,DawoodH,RamjathanP,GovenderNP;GERMS-SA.EpidemiologicShiftinCandidemiaDrivenbyCandidaauris,SouthAfrica,2016-2017.EmergInfectDis2019;25(9):1698-1707.

13. TavakoliM,YazdaniCharatiJ,HedayatiMT,MoosazadehM,BadieeP,SeyedmousaviS,DenningDW.Nationaltrendsinincidence,prevalenceanddisability-adjustedlifeyearsofinvasiveaspergillosisinIran:asystematicreviewandmeta-analysis.ExpertRevRespirMed2019;13:1121-1134.

Key papers, reviews and position papers 1. LoyseA,BurryJ,CohnJ,FordN,ChillerT,RibeiroI,Koulla-ShiroS,MghambaJ,RamadhaniA,

NyirendaR,AliyuSH,WilsonD,LeT,OladeleR,LesikariS,MuzooraC,KalataN,TemfackE,MapoureY,SiniV,ChandaD,ShimwelaM,LakhiS,NgomaJ,Gondwe-ChundaL,PerfectC,ShroufiA,Andrieux-MeyerI,ChanA,SchutzC,HosseinipourM,VanderHorstC,KlausnerJD,BoulwareDR,HeydermanR,LallooD,DayJ,JarvisJN,RodriguesM,JaffarS,DenningD,MigoneC,DohertyM,LortholaryO,DromerF,StackM,MolloySF,BicanicT,vanOosterhoutJ,MwabaP,KanyamaC,KouanfackC,MfinangaS,GovenderN,HarrisonTS.Leavenoonebehind:responsetonewevidenceandguidelinesforthemanagementofcryptococcalmeningitisinlow-incomeandmiddle-incomecountries.LancetInfectDis2019;19:e143-7.

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2. OladeleRO,OsaigbovoII,AyanlowoOO,OtuAO,HoeniglM,CornelyOA,ChakrabartiA,DenningDW.Theroleofmedicalmycologysocietiesincombatinginvasivefungalinfectionsinlowandmiddleincomecountries:aNigerianmodel.Mycoses2018;62:16-21.

3. PageID,ByanyimaR,HosmaneS,OnyachiN,OpiraC,OpwonyaJ,RichardsonMD,SawyerR,SharmanA,DenningDW.Chronicpulmonaryaspergillosiscommonlycomplicatestreatedpulmonarytuberculosiswithresidualcavitation.EurRespJ2019;53:1801184.

4. Rozaliyani A, Sedono R, Jusuf A, Rumende CM, Aniwidyaningsih W, Burhan E, Prasenohadi P,HandayaniD,YunihastutiE, SiagianFE, JayusmanAM,RusliA,SungkarS,Prihartono J,HagenF,Meis JF, Wahyuningsih R. A novel diagnosis scoring model to predict invasive pulmonaryaspergillosisintheintensivecareunit.SaudiMedJ.2019Feb;40(2):140-146.

5. Griffiths J, Colombo AL, Denning DW. The case for paracoccidioidomycosis to be accepted as aNeglectedTropical[Fungal]Disease.PLoSNeglTropDis2019;13:e0007195.

6. KwizeraR,MusaaziJ,MeyaDB,WorodriaW,BwangaF,KajumbulaH,FowlerSJ,KirengaBJ,GoreR,DenningDW.Burdenof fungalasthma inAfrica:Asystematic reviewandmeta-analysis.PLoSOne2019;14:e0216568.

7. BakerJ,SetianingrumF,WahyuningsihR,DenningDW.MappinghistoplasmosisinSouthEastAsia–implicationsfordiagnosisinAIDS.EmergMicrobInfect2019;8:1139-45.

8. BongominF,GovenderNP,ChakrabartiA,Robert-GangneuxF,BoulwareDR,ZafarA,OladeleRO,RichardsonMD,GangneuxJ-P,Alastruey-IzquierdoA,BaziraJ,BoylesTH,SarcarlalJ,NacherM,ObayashiT,WorodriaW,PasqualottoAC,MeyaDC,ChengB,SriruttanC,MuzooraC,KambuguA,RodriguezTudelaJL,JordanA,ChillerTM,DenningDW.EssentialinvitrodiagnosticsforadvancedHIVandseriousfungalinfections:Internationalexpert’sconsensusrecommendations.EurJClinMicrobiolInfectDis2019;38:1581-84.

9. StuckyHunterES,RichardsonMD,DenningMD.EvaluationofLDBioAspergillusICTlateralflowassayforIgGandIgMantibodydetectioninchronicpulmonaryaspergillosis.JClinMicrobiol2019;57:e00538-19.

10. Hay R, Denning DW, Bonifaz A, Queiroz-Telles F, Beer K, Bustamante B, Chakrabarti A, Chavez-LopezMG,ChillerT,CornetM,EstradaR,Estrada-ChavezG,FahalA,GomezBL,LiR,MahabeerY,MosamA,SoavinaRamarozatovoL,RakotoAndrianariveloM,RapelanoroRabenjaF,vandeSandeW,ZijlstraEE.TheDiagnosisofFungalNeglectedTropicalDiseases(FungalNTDs)andtheRoleofInvestigationandLaboratoryTests:AnExpertConsensusReport.TropMedInfectDis2019;4(4).

11. Bongomin F, Kwizera R, Denning DW. Getting Histoplasmosis on the Map of InternationalRecommendationsforPatientswithAdvancedHIVDisease.JFungi(Basel)2019;5(3):E80.

12. CaceresDHAdenisA,deSouza JVB,GomezBL,CruzKS,PasqualottoAC,RavasiG,PerezF,TomChiller,deLacerdaMVG,NacherM,TheInternationalHistoplasmosisAdvocacyGroup(iHAG).TheManausDeclaration:CurrentSituationofHistoplasmosisintheAmericas,ReportoftheIIRegionalMeetingoftheInternationalHistoplasmosisAdvocacyGroup.CurrFungInfectRep2019;13:244–249.

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PressreleasesandGAFFInewsitemsin2019:Fromhttps://www.gaffi.org/media/news/February1stNewcropfungicidescouldincreaseantifungalresistanceWHOrequestedtoactFebruary11thGHANA’SCPAAWARENESSSEMINARONWORLDASPERGILLOSISDAYMarch19th1in15TBsufferersgoontodevelopchronicpulmonaryaspergillosis,treatmentcouldsave1000soflivesMarch26thTheManausDeclarationonHistoplasmosisintheAmericasandCaribbean100by2025April9thGAFFIissuesits5thannualreporthighlightingitsextensiveadvocacyworkApril16thECCMID2019presentations:burdenoffungaldiseaseestimatesforNamibia,ParaguayandKyrgyzstan;andfungalkeratitisleadstoover600,000blindeyesannuallyMay20thParacoccidioidomycosisinSouthAmericashouldbeaNeglectedFungalTropicalDiseaseJune5thDrSwarupSarkarjoinsGAFFIasaSeniorAdvisorJuly5thLDBio rapid Aspergillus IgG test is sensitive and specific for chronic pulmonary aspergillosis July11thFollowingGAFFIsubmissionWHOendorsesHistoplasmaantigenasanEssentialDiagnosticAugust6thHyper-endemicareasforhistoplasmosisrevealedinnewSEAsianmapsSeptember6thGAFFIcalls togetherexperts inLimato formulatenewthinkingonfungaldiseasemanagement inLatinAmericaSeptember20thTHEGLOBALACTIONFUNDFORFUNGAL INFECTIONS(GAFFI)WILL#FIGHTFUNGUSWITHGLOBALAWARENESSCAMPAIGNOctober1stMedicalexpertsstresstheneedfornewwaysofdiagnosingneglectedtropicalfungalskindiseaseOctober14thFungal infectionburden inMorocco, Sudan,Coted’Ivoire, TajikistanandAzerbaijanpresentedatTIMMDecember12thGAFFIpresentsthecaseforinvestmentintofungaldiseasestoBundestag,Berlin.

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GAFFI’sAmbassadorsawarenessandeducationalinitiatives:LatinAmerica

TheGAFFIAmbassadorsfromLatinAmericamademajorcontributionstotheLimaHealthSystemsmeeting,describedabove(Section5.1).Argentina(DrFernandoRiviera),Brazil(DrFlavioQuierosTelles),Chile(DrEduardoAlvarez-Duarte),Colombia(DrJorgeProfessorJorgeAlbertoCortésandProfessorCarlosArturoAlvarez-Moreno),Ecuador(DrJeanneteZurita),Guatemala(DrEduardoArathoonandDrBlancaSamayoa),Mexico(DrDoraCorzo-LeonandProfessorAlexandroBonifaz),Paraguay(DrGloriaCelesteAguilarBarreto),Peru(DrBeatrizBustamante),Uruguay(DrMarinaMacedo).

Mexico(DrDoraCorzo-LeonandProfessorAlexandroBonifaz)

AnonlinecoursewasdevelopedbytwoMexicaninfectiousdiseasesspecialists(DoraCorzo-LeonandNormaRivera).ThecourseaimedtoimprovediagnosisofSFIsandwasdeliveredfromApril-June2019.Thecoursewascarriedout100%inSpanishandconsistedof9onlineinteractivesessionseveryweek.Thetopicswere:biosecurity,stainingtechniques,cytology,histology,fungalculturetechniquesanddiagnosticswithoutculture.Severalonlineresourceswereused,includinghttp://www.life-worldwide.organdhttp://www.microfungi.net.Atotalof137peopleregisteredforthecourse.Registrantswerefromfourdifferentcountries,Mexico(126,92%),Ecuador(9,6.6%),Australia(1,0.7%)andBolivia(1,0.7%).Mexicanparticipantsconnectedfrom15ofthe32regions(47%)inMexico.Mostparticipantswerephysicians(76%),54wereIDspecialistsand19wereIDresidents.Sixtyparticipants(60/137,44%)completedthecourse.PreliminaryresultsofthiscoursewerepresentedatFIS2019(abstractpublishedataccessmicrobiologyhttps://doi.org/10.1099/acmi.fis2019.po0195)atEdinburghandfinalresultswillbepresentedinMycology2020atLondon.

India(ProfessorArunalokeChakrabarti_

Trainingindiagnosticmycology

TheNationalMycologyReferenceCenterconductedregulartrainingoffaculty/scientistsandtechnicalstafftwiceannuallyforthelast12years.Thetopicscoveredinthecourseinclude;processingofclinicalspecimenforcultureanddirectmicroscopy,phenotypicidentificationofyeastandmoulds,serologicaltechniquesforthediagnosisoffungalinfections,therapeuticdrugmonitoring(TDM)ofantifungals,DNAandMALDI-TOFbasedmoleculartechniquesforthediagnosisoffungalinfections,identificationoffungalagentsandtypingoffungi,antifungalsusceptibilitytesting;preservationoffungi,tissuereactions&histopathologyoffungalinfections.Nearly350participantshavebeentrainedfromthiscenterovertheseyears.

OtherthanNationalReferenceCentreatChandigarh,VallabhaiPatelChestInstituteatDelhi,StJohnsMedicalCollegeandResearchInstituteatBengaluruandRamChandraMedicalCollegeatChennaihaveconductedtrainingprogramsforparticipantsofIndia.

Trainingonclinicalmycology

Withtheaimofcreatingawarenessontheclinicalmycology,‘FungalInfectionsStudyForum’(FISF)inIndiaconductseducationalandtrainingactivitiesforclinicians.Sixtrainingcoursesoverthelast2yearshavebeenrunatdifferentcitiesinIndia.ThiscourseissupportedbyaneducationalfundfromGilead.Thetrainingobjectivesofthecourseare:ToenumeratecommoninvasivefungaldiseasesinIndiaanddescribetheirepidemiology;Toprovidetriggersforsuspicionofinvasivefungalinfectionusingclinicalparametersandradiologicalfindings;Ensureappropriatelaboratorytestsareorderedandinterpretlaboratoryreports;Optimisethemanagementofinvasivefungalinfectionsand;Toclarifywhenandwhennottouseantifungals.Eachcourseisattendedby60-80clinicians.In2020,theplanistoconduct10morecoursesatdifferentcitiesinIndia.FISFhasalsodevelopede-trainingcoursewith16modulescoveringthetaxonomyoffungi,epidemiology,diagnosis,managementof

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invasiveandallergicfungaldiseases.Thise-coursehasbeenrunningsuccessfullyforthelastthreeyearswiththeeducationgrantfromPfizer,India.

ClinicaltrainingcourseatPune,India

Inaddition,ashort-termtrainingprogramfor1-3monthsisalsoavailableforthepeopleofsoutheastmembercountriesunderSEARO.ThecenteralsoconductedtraininginMyanmar,ThailandandNepalinlasttwoyears.

TrainingcourseatYangon,Myanmar

Indonesia(ProfessorRetnoWahyuningsih)

Throughout2019variousactivitiesinvolvingthedisseminationofknowledgeaboutfungaldiseaseshavebeencarriedout.Theseactivitiesincludepresentations;workshopsandresearchonfungaldiseasesinIndonesia.TheactivitiesofRetnoWahyuningsih(RW)asIndonesiaGAFFIambassadorareasfollows

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1.InJune2019akickoffmeetingandworkshoptoinitiateastudyonhitoplasmosisepidemiologyinIndonesiawasheld.ThestudyisacollaborationwithProf.D.DenningfromManchesterUniversity,UKandProf.ConchitaToriellofromUniversidadNacionalAutónomadeMéxico,MexicoCity(UNAM).Weareimplementinghistoplasminskintestingamongpatientswithchroniclungdiseases.ThestudywasconductedinhospitalsinJakarta,Sukabumi,Bandung,Semarang,Malang,Surabaya,Bali,Manado,andMedan,ThestudywillbecontinueduntilSeptember2020.

2.AttheAsiaPacificSocietyofMedicalMycologyconference,RWgavealectureentitledMucormycosis:diagnosisandmanagement.TheconferencewasheldinGuangzhou,ChinainNovember22-24,2019.

3.AsanAsiaFungalWorkingGroup(AFWG)member,anISHAMtaskforce,shehasparticipatedinseveralworkshopsandsymposiaheldbyAFWGin2019.ThescientificactivitywascalledMedicalMycologyTrainingNetwork(MMTN).ThetrainingsessionswereheldJuly20-21inPenang,MalaysiaandinDecember6-82018inHanoi,Vietnam.Herpresentationswere:

a.Chronicpulmonaryaspergillosis(CPA)–Penang

b.IdentificationofMucoromycotina(Zygomycetes)-Penang

c. Directexaminationforthediagnosisoffungalinfection-Hanoi

d.Slidecultureformoldidentification-Hanoi

e.IdentificationofZygomycetes-Hanoi

4.Alectureentitled“DiagnosisDrivenApproachesofInvasiveFungalInfection(IfIs):WhatTestShouldWeDo”waspresentedbeforedoctorsininternalMedicineat16November2019inJakarta.

5.ParticipatedinthenationalformularycommitteeorganizedbytheMinistryofHealthoftheRepublicofIndonesiatodeterminetheavailabilityofantifungaldrugsinIndonesia.

6.OurstudyontheCandidakruseiinJakarta,Indonesiafoundoutsomethingdifferent.Somestrainsweresusceptibletofluconazoleinvitroandinvivo.C.kruseihasbeenknownasaspeciesthatisresistanttofluconazole.

Iran(ProfessorMohammadHedayati)

Mohammadleadtheworld’sfirstestimateoftheimpactofinvasiveaspergillosisonyearsoflifelost(YLLs)anddisabilityadjustedlifeyears(DALYs)(Tavakoli,2019).

France(ProfJean-PierreGangneuxandChristopheHennequin)

AttheTIMMmeetinginNice,JeanPierreandChristophehostedadinnerofGAFFIambassadorsandotherexpertsfromBurkinaFaso

Portugal(DrRaquelSabino)

During2019,8physicians(pathologistsandinfectiousdiseasesclinicians)performedtheirtrainingintheReferenceMycologylaboratoryattheNationalhealthInstituteDr.RicardoJorge.Thesetrainingperiods included raising the awareness to the majority of fungal infections, etiological agents,epidemiologyofthoseinfectionsandavailablediagnosticmethods.GAFFI leafletsweredeliveredtoall.

A radio interview to Raquel Sabino was given to a national channel, focusing fungal infections:https://www.rtp.pt/play/p2063/e432194/ponto-de-partida

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Serbia(ProfessorValentinaArsicArsenijevic)andRomania(ProfessorMihaiMares)

RegionalcooperationhasbeensteppedupinseveralwaysincludingtheBalkanFungusmeetingsaswellascollaborativetrainingandstudiesinthefield.

https://balkanfungus2020.com/

Hungary(DrJanosSinko)

InHungary,extensivetrainingandawarenessactivitieswereundertaken:1. CoursesandcasediscussionsformedicalstudentsandresidentsatSzegedUniversityandatSemmelweisUniversityBudapestFacultyofMedicine.(InHungarianandinEnglish)2. PostgraduatecourseoninvasivefungalinfectionsforintensivecarespecialistsatSemmelweisUniversityBudapest.3. PresentationanddiscussiononthemanagementofnosocomialcandidainfectionsatJahnFerencHospital,Budapest.4. RoundtablediscussiononmouldinfectionsinoncohematologyattheUniversityofPecs,Hungary.5. Updateonantifungalmanagementatthe47thCongressoftheHungarianSocietyofInfectologyandClinicalMicrobiology,2019.6. Choiceofantifungalcompoundsininvasivemoulddiseases,specialfocusonisavuconazoleatthe47thCongressoftheHungarianSocietyofInfectologyandClinicalMicrobiology,2019.7. PresentationanddiscussiononinvasivemouldinfectionsintheICUatPfizerInfectologyDaystandalonemeeting,withanonlineversionrecorded.

Egypt(DrSherifZaki)

TheEgyptianAssociationofMedicalMycologists(EAMM)wasdecreedat10thofApril2019bySherifZakitounifyalltheeffortsforverifying(GAFFI)GoalsinEgypt.Untilnow40medicalmycologistsregisteredformembershipfromEgypt,Libya,andIraq.

TheoccasionoftheEgyptianScientificSocietyofBronchology(ESSB)annualmeetinginCairoinDecember2019,providedanopportunityforSherifandDavidDenning(GAFFI)tomeetupwiththeleadershipoftheWHORegionalOffice(EMRO)andwiththearepresentativeoftheMinistryofhealth,responsibleforchestdiseasesandTB.DiscussionscenteredaroundimproveddiagnosticaccessforAspergillusintheregionandinEgyptaswellassettingupanationalnetworkofmycologylabs.

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Cameroon(DrChristineMandengue)

Aone-daySensitisationMeetingonHistoplasmosisinHIVandMycetomawasheldinattheUniversitédesMontagnesinBangangté,aruralsavannazoneinthewestregionofCameroononOctober1st2019.

There are 2 hospitals in Bangangté and theUniversité des Montagne’s teaching hospital is beingconstructed as well as 6 rural health centers. There are 2 AIDS-care units in Bangangté with arecruitmentof~50newHIV-infectedcasesmonthly;buthistoplasmosisisunknownintheseunits.

Despite farmingbeing the predominant activity in this rural savanna area, no clinical cases ofmycetomaareknown.CasesdiagnosedasmelanomaandKaposi’ssarcomaofthefootcouldbemisdiagnosisofmycetoma.

110participantsattendedcomprising74medicineandbiologystudents,16health-careprofessionals(practitionners,dentist,nurses, laboratory technicians),and19other lecturersandnon-healthcareprofessionals.Thekeyspeakerswereadermatologist,histopathologist,molecularbiologist,andalabtechnicianmastersstudent fromtheUniversitédesMontagnesandaguestmedicalmycologyfromtheUniversityofDouala.Stickyautopostersonhistoplasmosisandmycetoma,algorithmofsuspicionofthediseasesandcertificateofparticipationweregiventoallattheendoftheevent.

Theaspirationsafterthemeetingaretoidentifypotentialpatientsfordiagnosis(urine;surgicalbiopsies)(histoplasmaantigenkitsareawaited).Concerningmycetoma,ProfFahalfromtheMycetomaResearchCentreinKhartoumhasofferedtoprocessfordiagnosisallspecimenssent.Finallywithourresults,wewillmakethecaseforitraconazoletobeavailableviaengagementoftheMinistryofHealth,andworkwiththeWHOofficeinCameroononmycetoma.

SouthAfrica(DrNeleshGovender)

Severalpaperswerepublishedin2019documentingtheburdenoffungaldiseasesinSouthAfrica.

TheFederationforInfectiousDiseasesSocietiesofSouthernAfrica(FIDSSA)(www.fidssa.co.za)launchedaMycosesInterestGroupatitsnationalbiennialconferenceinJohannesburg,7-9November2019.Approximately40FIDSSAmembershavesigneduptothissmallworkinggroup.

AsituationupdateonCandidaaurisinSouthAfricawasdiscussedattheMinisterialAdvisoryCommitteeforAntimicrobialResistanceandconcreteactionsproposedfor2020.SAwillparticipateinWHOGLASSforCandidabloodstreaminfections.

TheSANationalDepartmentofHealthconstitutedataskteamforadvancedHIVdiseasewhichwilladdressaccesstoessentialmedicines,healthcareworkertrainingandpatienteducationforimportantmycosesinthispopulation.

SAcontinueditsflucytosineaccessprogrammeforcryptococcalmeningitisatpilothospitalsacrossthecountryin2019–atthesesites,eligiblepatientsaretreatedwithamphotericinBand

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flucytosinefor1week.Atnon-accesssites,combinationamphotericinBandfluconazolecontinuestobeofferedasthestandardofcareforinductionphasetreatment.

TheSouthernAfricanHIVCliniciansSocietyupdateditsinfluentialguidancedocumentondiagnosis,preventionandmanagementofcryptococcaldiseaseamongpeoplelivingwithHIV.ThisguidelinewaspublishedinDecember2019.Theguidelinewritingcommitteeispicturedhere.

RepublicofCongo(AmonaModesteFructueux)

Following the preliminary estimate of serious fungal infection report in 2016, a re-estimate issubmittedforpublication.

Nigeria(DrRitaOladeleandDrSamuelFayemiwo)

TheMedicalMycologySocietyofNigeriaorganisedthe2ndNationalConferenceofMedicalMycologyinLagos,10-12th,April2019.Thethemeoftheconferencewas“Managingseriousmycoses:circumventingchallengesinaresourcelimitedcountry”.Itwasattendedbyover80peopleincludingGAFFIAmbassadorsfromFrance(JeanPierreGangneux),Cameroon(ChristineMandengue)(whopresentedonhistoplasmosis)andGhana(BrightOcansey).TheIndependentnewspaperinNigeriafeaturedlongarticle:“ScientistsurgeFGtoestablishMycologyLaboratories.”https://nnn.com.ng/society-urges-fg-to-provide-reference-laboratory-to-tackle-fungi-infections/

IncollaborationwiththeCDCandGAFFI,theMedicalMycologySocietyofNigeria(MMSN)organisedtheFungalDiseaseAwarenessweekbetweenSeptember21-25,2019acrossNigeriatohighlightthecriticalneedforincreasedrecognitionandawarenessoffungaldiseases.TheFungalDiseaseAwarenessWeek2019tagged:“ThinkFungus.”wasfocusedonthe“Increasedawarenessaboutfungaldiseasesasoneofthemostimportantwaystoimproveearlyrecognitionandreducedelaysindiagnosisandtreatment.ThepressconferenceswereattendedbyprominentPhysiciansindifferentcenterslikeLagos,Ibadan,Awka,Benin,Calabar,andothersacrossthecountry."

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Ghana(BrightOcansey)

AnNGO,FungalInfectionsKareInitiative(FIKI)GhanawassetuptomirrorGAFFIactivitiesinGhanabasedonthefourgoalsmentionedabove.

The1stFungalDiseaseAwarenessSeminarwasheldonthe1stFebruary,2019attheKorle-BuTeachingHospital(KBTH),Accra,GreaterAccraregionincommemorationoftheWorldAspergillosisDay.ItwasorganizedbyFIKIGhanaincollaborationwithChestDiseasesClinic,KBTHandMedicalJournalistsAssociationofGhana.Thethemeoftheseminarwas“ConsideringCPAforimprovedTBmanagement”.SpeakerswereDrRitaOladele(NigeriaGAFFIambassador)presentedon“CPA:AcauseofsmearnegativeTBand/orTBtreatmentfailure”andProfDavidDenning(GAFFIChiefExecutive)viaapre-recordedvideopresentedon“CPA:Clinicalspectrum,DiagnosisandTreatment”.TheseminarwaschairedbyDrJaneAfriyie-Mensah(Head,ChestDiseasesClinic)

Therewere82attendeesfromfourregions.Attendeescomprisedofclinicians,microbiologists,medicallaboratoryscientists,nurses,lecturers,pharmacists,alliedhealthcarepractitioners,healthsciencesstudentsandnon-healthcareprofessionals.EducationmaterialsfromLIFEandFIT,UKweredistributedtoattendees.

ThroughouttheyeareducationalmaterialsweredistributedtohealthcareprofessionalsinvariousmedicalfacilitiesinGhana.

FinancialsupportwasobtainedfromFIT,UKtoundertakegapanalysissurveysinGhana,whichisongoing.

DuringtheCDC’sFDAW2019,flyerswerecreatedandsharedonsocialmediaplatforms.However,aplannedpresentationon25thSeptonthe“BurdenonSFIinGhana”attheKetuSouthMunicipalHospital,Aflao,Voltaregionwascalledoffbuteducationalmaterialsweredistributedtohealthcareprofessionals.

Kenya(JohnGuto)

TheUKEastAfricanHealthAlliancehaditsannualmetinginLondon inApril2019andhasagreedtosetupaUKKenyaHealthAlliance,tomirrortheUKUgandaHealthAlliance.

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Uganda(DrFelixBongominandDrDavidMeya)

Inadditionto2publicationssupportingGAFFI’smission(EssentialDiagnositis–reportoftheKampalameetingandhistoplasmosisreview,FelixBongominhassupportedthetestingofpossiblecasesofchronicpulmonaryaspergillosiswiththelateralflowassayforAspergillusantibody.HerehemetwithDrOliverPenneywhoisvolunteeringinKagandoandprovidedsometestsforhim.

DrDavidMeyaandcolleaguespublishedthefirstreviewonfungalasthmainAfrica.Aprospectivemulti-countryassessmentoffungalsensitisationandasthmaseveritywaspresentedinNairobiatthe5thKenyaInternationalLungHealthConference