The next pandemic in the making?, Health News, ET HealthWorld
By Rohan Kar and Anurag Wasnik
New Delhi: Fungi – a native of planet Earth
The World Health Organization (WHO) recently released the first-ever list of 19 fungal pathogens having the potential to threaten the public health system, On this eve, Dr Hanan Balkhy, WHO Assistant Director-General, Antimicrobial Resistance (AMR), remarked, “Emerging from the shadows of the bacterial antimicrobial resistance pandemic, fungal infections are growing, and are ever more resistant to treatments, becoming a public health concern worldwide.”
So, what is all the fuss about fungi? Evolutionary history suggests that fungi’s first appearance on earth was around 1300 million years ago. Compared to bacteria (3.7 billion years) and viruses (approximately 1.5 billion years), fungi appear relatively new to this planet. In terms of fungi’s disease-causing potential, it is equally likely, if not more, when compared to bacteria or a virus. At this stage, one may wish to recall the mucormycosis or ‘black fungus” endemic that struck India during the COVID-19 pandemic. According to GoI estimates, there were 45,374 cases of mucormycosis in both cohorts of patients with active or recovered COVID-19. Notably, there were around 4300 ‘black-fungus’ deaths, approximately 10% of the reported cases.
The high mortality percentage from a fungal infection should be a cause of genuine concern, especially in planning for a probable future “fungal pandemic.” However, like other microbes, it is hard to predict when the next ‘fungal pandemic’ will strike the earth. Emerging evidence suggests that mycoses’ incidence and geographic range are spreading worldwide due to factors such as global warming and increased international travel and trade.
So where lies the problem?
Antifungal therapy remains a preferred treatment of choice in cases of acute and chronic fungal infections. However, the emergence of “antimicrobial-resistant fungi” has now started complicating the clinical management of fungal diseases by severely limiting the effectiveness of the current repertoire of antifungal drugs. Several studies have now begun to report on the evolution of multidrug-resistant Candida species. The situation is even more alarming for patients with invasive fungal infections and those with existing co-morbidities.
The Indian pharmaceuticals market is replete with antifungal formulations, and the antifungal market is expected to touch USD 1.6 billion by 2027, growing at a CAGR of approximately 10-11%. A massive demand exists for antifungal creams such as those treating athlete’s foot, ringworm, candidiasis, and fungal nail infection. Recently, the GoI proposed introducing over-the-counter (OTC) drugs in India through an amendment in the Drugs and Cosmetics Rules and allowing their sale in the retail market without doctors’ prescriptions. A draft notification was issued by the Union health ministry proposing 16 drugs, including topical antifungal creams, in the OTC list.
Given the emerging research on “antimicrobial-resistant fungi,” the GoI seems to have missed out on taking a proactive stance by including antifungal cream in the list of OTC medicines. This is like walking the same path that led India to a situation where an anti-microbial resistance-related health emergency seems imminent. This can be attributed largely to the unrestricted usage of antibiotics, as no prescription is needed to purchase them OTC. In one of our earlier articlesIn this article, we highlight the enormous challenge in managing anti-microbial resistance; however, policy makers’ discourse around “antimicrobial-resistant fungi” appears to be limited, and relevant institutional support mechanisms are equally lacking.
Breaking the silence: the need for policy action on Fungal Infections
Fungal infections (FIs) in humans have become a silent pandemic, with over 150 million severe cases resulting in approximately 1.7 million deaths each year. Despite this, FIs have been largely ignored by healthcare authorities and underestimated in comparison to other diseases such as tuberculosis and malaria. Climate change, pesticide resistance, and other factors are making FIs increasingly deadly and the threat is growing. Drug-resistant fungi is a rapidly emerging challenge and our limited knowledge about it is contributing to the high clinical mortality and economic burden posed by invasive fungal infections (IFIs).
While health ministries and researchers have focused on bacterial antimicrobial resistance, fungal antimicrobial resistance research and data are lacking. FIs put critically ill populations, such as the elderly and immunocompromised, at risk. It remains to be seen whether current health insurances cover deadly FIs in these patients and whether the healthcare system gives priority to FIs over other diseases such as Dengue and Malaria. The level of awareness about FIs at both the social and governmental levels and among healthcare authorities needs to be raised.
Climate change has had a major impact on many nations and the fungi living within them. To tackle this issue, research can be conducted on how fungi are impacted and potentially supercharged by the changing climate. This research could result in the identification of new niches that facilitate the development of resistance, leading to the creation of more effective management strategies. To minimize the emergence of drug-resistant fungi, it is important to incorporate species identification, antifungal susceptibility testing, and therapeutic drug monitoring practices into clinical practices.
A deeper understanding of the evolutionary processes behind the development of resistance is crucial for recognizing the circumstances that facilitate the development of these resistance mechanisms. The creation of environmental ‘hotspots’ databases can help identify areas where resistance is likely to emerge, such as in areas where agricultural fungicides are used. The standardization of antifungal susceptibility testing is also necessary to address the discrepancies in results between laboratories and difficulties in data interpretation. By gaining a better understanding of these factors, it will be possible to effectively battle the growing populations of resistant fungi and mitigate the impact of climate change.
Rohan Kar, Doctoral Researcher, Marketing Area, IIM Ahmedabad, and Anurag Wasnik, Innovation Lead, Atal Innovation Mission, NITI Aayog
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