Invasive fungal infections (IFIs) and medical mycology receive little attention in Ghana. However, the present evolution of biomarker assays for IFIs, offers an opportunity for an increased access to fungal laboratory testing in resource-limited settings, and probably make a case for availability of essential antifungal agents. Using surveys and personal communications, the state of medical mycology and IFI in Ghana were highlighted. Inadequate awareness and insufficient access to fungal diagnostics and therapeutics were identified as the key challenges, the establishment of the Ghana Medical Mycology Society was discussed, and recommendations were made to improve the status quo

Afriyie-Mensah, Jane S

Agyei, Martin

Asamoah, Isabella

Chakrabarti, Arunaloke

Dadzie, Edmund A

Denning, David W

Eduful, Stephen K

Essien-Baidoo, Samuel

Hoenigl, Martin

Ocansey, Bright K

Oladele, Rita O

Opintan, Japheth A

Osaigbovo, Iriagbonse I

Osei, Mary-Magdalene

Puplampu, Peter

Richardson, Malcolm D

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UC San DiegoUC San Diego Previously Published WorksTitleImproving awareness, diagnosis and management of invasive fungal infections in Ghana: establishment of the Ghana Medical Mycology SocietyPermalinkhttps://escholarship.org/uc/item/7g70b69sJournalMedical Mycology, 60(9)ISSN1369-3786AuthorsOcansey, Bright KDadzie, Edmund AEduful, Stephen Ket al.Publication Date2022-09-30DOI10.1093/mmy/myac069 Peer reviewedeScholarship.org Powered by the California Digital LibraryUniversity of CaliforniaMedical Mycology , 2022, 60 , myac069 https://doi.org/10.1093/mmy/myac069 Brief Report Advance access publication date: 8 September 2022 Improving awareness, diagnosis and management of invasive fungal infections in Ghana: establishment of the Ghana Medical Mycology Society Bright K. Ocansey 1 ,∗, Edmund A. Dadzie 2 , Stephen K. Eduful 3 , Martin Agyei 4 , Mary-Magdalene Osei 5 , Peter Puplampu 6 ,7 , Isabella Asamoah 7 , Rita O. Oladele 8 , Iriagbonse I. Osaigbovo 9 , Jane S. Afriyie-Mensah 6 ,7 , Japheth A. Opintan 5 , Samuel Essien-Baidoo 10 , Arunaloke Chakrabarti 11 , Martin Hoenigl 12 ,13 , David W. Denning 1 and Malcolm D. Richardson 1 ,14 1 Division of Evolution, Infection and Genomics, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9NT, UK 2 Department of Health and Allied Sciences, Baldwin University College, Accra GA-082, Ghana 3 Department of Medical Laboratory Sciences, School of Biomedical and Allied Health Sciences, University of Ghana, Accra GA-337, Ghana 4 Department of Medicine, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi AK-448, Ghana 5 Department of Medical Microbiology, University of Ghana Medical School, Accra GA-270, Ghana 6 Department of Medicine and Therapeutics, University of Ghana Medical School, Accra GA-221, Ghana 7 Department of Medicine and Therapeutics, Korle-Bu Teaching Hospital, Accra GA-221, Ghana 8 Department of Medical Microbiology, College of Medicine, University of Lagos, Lagos 101017, Nigeria 9 Department of Medical Microbiology, College of Medical Sciences, University of Benin, Benin City 300213, Nigeria 10 Department of Medical Laboratory Sciences, School of Allied Health Sciences, University of Cape Coast, Cape Coast CC-071, Ghana 11 Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India 12 Section of Infectious Diseases and Tropical Medicine, Division of Pulmonology, Medical University of Graz, Graz 8036, Austria 13 Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, CA 92093-0021, USA 14 Mycology Reference Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester M23 9LT, UK ∗To whom correspondence should be addressed. Bright K. Ocansey, BSc, Division of Evolution, Infection and Genomics, Faculty of Biology, Medicine and Health, University of Manchester, Core Technology Facility, Grafton Street, Manchester M13 9NT. Tel: + 44 7539311942; E-mail: obkatey91@gmail.com or bright.ocansey@postgrad.manchester.ac.uk Abstract Invasive fungal infections ( IFIs ) and medical mycology receive little attention in Ghana. However, the present evolution of biomarker assays for IFIs, offers an opportunity for an increased access to fungal laboratory testing in resource-limited settings, and probably make a case for availability of essential antifungal agents. Using surveys and personal communications, the state of medical mycology and IFI in Ghana were highlighted. Inadequate awareness and insufficient access to fungal diagnostics and therapeutics were identified as the key challenges, the establishment of the Ghana Medical Mycology Society was discussed, and recommendations were made to improve the status quo. Lay Summary Invasive fungal infections ( IFIs ) receive little attention in Ghana, despite its growing relevance globally. Using surveys and personal communica- tions, the main challenges were identified, and the formation of the Ghana Medical Mycology Society was discussed as a tool to improve the status quo. Keywords: Ghana, invasive fungal infections, diagnostics, antifungal agents, research          International Fungal Education ( LIFE ) and Global Action for Fungal Infections ( GAFFI ) burden-estimate projects have stimulated interest in medical mycology in many African countries including Ghana. The evolution of rapid and simple fungal biomarker assays and access programs for essential antifungal agents offers a unique opportunity for low- and middle-income countries ( LMICs ) to improve diagnosis and management of patients suffering from IFIs. In this report, we highlight the current state of IFIs and medical mycology in Ghana, by identifying the key challenges and discuss the formation of the Ghana Medical Mycology Society ( GMMS ) , Introduction Globally, the burden of invasive fungal infections ( IFIs )continue to increase due to the expansion of the populationat risk and emerging risk groups including the coronavirusdisease 2019 ( COVID-19 ) .1 , 2 Recent concerns are, increasingantifungal resistance, multi-drug-resistant Candida auris andemergence of rare infections.3 –5 Notwithstanding, IFIs receivelittle attention in many parts of the world, particularly Africathat is disproportionately affected by IFIs due to the HIV andtuberculosis epidemic and the tropical climate.6 The LeadingReceived: August 12, 2022. Revised: August 28, 2022. Accepted: September 6, 2022 © The Author ( s ) 2022. Published by Oxford University Press on behalf of The International Society for Human and Animal Mycology. This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( https://creativecommons.org/licenses/by/4.0/) , which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.2 Ocansey et al. f  rMI  o  y  s  t  c  pRI  t  3  t  t  r  l  a  m  o  a  c  f  a  l  m  d  l  tG  m  i  l g  r  c  g  i  e  C  c  s  n  a  i  t t  T  t  M  a  p  h F  i  s  G  s  t  c  a  (  C  h  i  o  o  M  o c  w  i  b  TTDHFIMAAFIAFVNEclormerly Ghana Medical Mycology Group ( GMMG ) andecommendations to improve the status quo. ethods nformation was gathered from a previously published studyn IFIs in Ghana,7 findings from three unpublished gap anal-sis surveys to evaluate IFI awareness among health sciencestudents, availability and accessibility to fungal laboratoryests and essential antifungal agents in Ghana, and personalommunications with relevant stakeholders were used torepare this report. esults and discussion n 2019, about 4% of the Ghanaian population was estimatedo suffer from serious fungal infections yearly, including over5 000 affected by IFIs.7 This estimate may not represent arue reflection of a burden of IFIs in Ghana, because some ofhe prevalence or incidence rates used were borrowed fromegional and global studies due to absence of local epidemio-ogical data. The study also reported that, data on IFIs gener-lly consist of few sporadic case reports where diagnoses wereostly made post-mortem, probably indicating a low indexf suspicion.7 Furthermore, in some of the case reports, theuthors bemoaned the insufficient clinical suspicion and inac-essibility to critical fungal laboratory tests and essential anti-ungal agents. Real life epidemiological studies are needed for true burden to be appreciated. For example, a recently pub-ished study revealed that disseminated histoplasmosis may beore common than cryptococcal meningitis in Ghana contra-icting the findings from the model study.8 The few epidemio-ogical studies are often spearheaded by foreign clinicians andhe upskilled diagnostic capacity declines after the study.9 , 10 oing forward, study investigators must engage policyakers and clinical leads towards drawing a framework formplementation and ensuring the integration of the researchaboratory testing into clinical practice. There are currently no surveillance or case notification pro-rams for any IFI in Ghana. Meanwhile, the steady prevalenceate ( ∼2.0% ) of HIV, TB burden ( 286/100 000 ) , increase inable 1. Availability of fungal diagnostics and essential antifungal agents in Ghaest Availability On Ghanairect microscopy ( KOH ) Often N/A istopathology ( fungal stains ) Occasionally N/A ungal culture Rarely N/A mmunoassay Rarely N/A olecular Rarely N/A ntifungal susceptibility Rarely N/A ntifungal agent Availability On Ghana Eluconazole Often Yes traconazole Occasionally Yes mphotericin B Rarely No lucytosine Rarely No oriconazole Rarely No atamycin Rarely No DL-essential diagnostics list, N/A-not applicable ( because Ghana has no EDL curroccal antigen, GM- Galactomannan, PCR-polymerase chain reaction, GLASS-Gloist. ancer rates ( 2000–5000 increase per year in the last decade ) ,radual introduction of kidney ( over 20 live donor transplantsn the last decade ) and stem cell transplant procedures andxpanding ICU beds ( 149 beds, over 100% increase since theOVID-19 pandemic ) also makes way for the significant oc-urrence of IFIs.11 –15 Unpublished data from three gap analy-is surveys in Ghana, suggest that awareness on IFIs among fi-al year health sciences students was inadequate and the avail-bility of fungal diagnostics and antifungal drugs ( Table 1 )s poor, particularly in relation to the WHO recommenda-ions.16–19 In Ghana, medical mycology is underdeveloped and at-racts little interest in academia and professional practice.eaching hours allocated for mycology are limited and op-ions for specialization in mycology are almost non-existent.oreover, numbers of educators, researchers, and trainers arelso woefully inadequate. Unlike, plant mycology, there areresently no established medical mycology units/divisions inealth/medical institutions in Ghana. To increase awareness, a non-governmental organization,ungal Infections Kare Initiative ( FIKI ) Ghana was foundedn 2019 led by BKO and EAD. FIKI Ghana organized twoensitization seminars with the second inaugurating theMMG. The foundation also facilitated the three gap analy-is surveys mentioned previously with financial support fromhe Fungal Infection Trust ( FIT ) . FIKI Ghana also establishedollaborative links with the International Society for Humannd Animal Mycology ( ISHAM ) , Centre for Disease Control CDC ) Mycotic Disease Branch, UK National Aspergillosisentre, and Mycology Reference Centre, Manchester thatave been extended to GMMS and continue to strengthent. The role of professional networks in the advancementf unpopular fields such as medical mycology cannot beveremphasized and strongly demonstrated by the Medicalycology Society of Nigeria ( MMSN ) that charted a modeln how societies can contribute to combating IFIs in LMICs.20 GMMS, is a network of multidisciplinary cadre of health-are professionals ( HCP ) mainly clinicians and scientists asell as health science researchers and academics with interestn medical mycology or fungal infections. The current mem-ership includes infectious disease specialists/consultants,na.  EDL On WHO EDL 16 , 17 Yes Yes Yes Yes ( Aspergillus Ag and Ab, CrAg, Histoplasma GM ) Pneumocystis jirovecii PCR Yes and WHO GLASS programme ( Candida spp. ) ML 18 On WHO EML 19 Yes Yes Yes Yes Yes Yes ently ) , KOH-Potassium hydroxide, Ag-antigen, Ab-antibody, CrAg- Crypto- bal Antimicrobial Resistance Surveillance System, EML- essential medicines Medical Mycology, 2022, Vol. 60, No. 00 3 Table 2. GMMS activities. Activity Frequency Journal club Quarterly Case report forum Quarterly Serious mycoses symposium Annual ( during fungal diseases awareness week ) Aspergillosis lecture Annual ( on World Aspergillosis Day ) Training workshop Annual National scientific conference Biennial Fungal infection talk ( facility based ) Bi-annual Question of the week ( via WhatsApp ) Weekly                                               dermatologists, clinical microbiologists, medical laboratoryscientists, pulmonologists, and pharmacists. GMMS has a vision to reduce illness and death associatedwith fungal diseases in Ghana. The GMMS’ mission is toincrease awareness, build diagnostic and therapeutic capacity,campaign for access to critical diagnostics and antifungalagents, drive research, and influence the gradual integrationof the discipline into health systems in Ghana, mainly throughan eight-itemized activity schedule ( Table 2 ) . The society alsocirculates advocacy leaflets and disseminates links of freetraining, educational, and clinical resources. Since its incep-tion in February 2020, GMMS has successfully organizedseveral meetings and activities in three consecutive years. Thesociety has also occasionally served as a platform to provideguidance on diagnosis and treatment of IFIs to Ghanaianclinicians and scientists with support from our internationalaffiliations. GMMS continuously shares participation detailsof meetings in the field of medical mycology to members andurges to disseminate to colleagues. Members are constantlyencouraged to register with ISHAM, to take advantage ofassociated benefits and currently have 20% of our membersregistered with ISHAM. The recommended framework for a short term, is for thegovernment to adopt and upgrade the WHO Essential Di-agnostic and Medicine lists respectively, particularly in thetertiary hospitals. Also, training of technical laboratory staffand clinicians in these institutions will lay a solid foundationfor the integration of clinical mycology in the healthcare sys-tem broadly. From a practical perspective, the easiest tests toadopt are the lateral flow assays, especially cryptococcal andHistoplasma antigen and Aspergillus antibody in HIV and TBcontrol programmes, respectively. From this start, direct mi-croscopy and fungal culture could be the next step. From apublic health and clinical perspective, undertaking a surveil-lance of key fungal diseases through a hospital and labora-tory reporting network, would be valuable in improving localepidemiology and encouraging and attracting clinical researchwith international funding. Conclusion Ghana is challenged with the underrecognition of IFIs and un-derdevelopment of medical mycology. In face of the numerouschallenges, the GMMS remains resolute and optimistic to actas a major driver to increase awareness, advance the diagnos-tic and therapeutic skills of clinicians and scientists, improveaccess to fungal diagnostics and antifungal drugs, and cham-pion the integration medical mycology into health systems inGhana. Funding None Declaration of interest The authors declare no potential conflict of interest. References 1. Fausto A, Rodrigues ML, Coelho C. The still underestimated prob- lem of fungal diseases worldwide. Front Microbiol . 2019; 10: 1–5.2. Song G, Liang G, Liu W. Fungal co-infections associated with global COVID-19 pandemic: a clinical and diagnostic perspective from China. Mycopathologia . 2020; 185: 599–606.3. Fisher MC, Alastruey-Izquierdo A, Berman J et al. Tackling the emerging threat of antifungal resistance to human health. Nat Rev Microbiol. 2022: 1–5.4. Hoenigl M, Salmanton-García J, Walsh TJ et al. Global guideline for the diagnosis and management of rare mould infections: an initiative of the European Confederation of medical mycology in cooperation with the International Society for Human and Ani- mal Mycology and the American Society of Microbiology. Lancet Infect Dis. 2021; 21: e246–e257.5. Chen SC, Perfect J, Colombo AL et al. Global guideline for thediagnosis and management of rare yeast infections: an initiative of the ECMM in cooperation with ISHAM and ASM. Lancet Infect Dis . 2021; 21: e375–e386.6. Oladele RO, Akase IE, Fahal AH et al. Bridging the knowledge gapon mycoses in Africa: setting up a pan-African mycology working group. Mycoses . 2020; 63: 244–249.7. Ocansey BK, Pesewu GA, Codjoe FS et al. Estimated burden of serious fungal infections in Ghana. J Fungi . 2019; 5: 1–15.8. Ocansey BK, Otoo B, Asamoah I et al. Cryptococcal and histo- plasma antigen screening among people with human immunodefi- ciency virus in Ghana and comparative analysis of OIDx histo- plasma lateral flow assay and IMMY histoplasma enzyme im- munoassay. Open Forum Infect Dis . 2022; 9: ofac277. Oxford University Press.9. Mamoojee Y, Shakoor S, Gorton RL et al. Low seroprevalence of cryptococcal antigenaemia in patients with advanced HIV infection enrolling in an antiretroviral programme in Ghana. Trop Med Int Health . 2011; 16: 53–56.10. Leck AK, Thomas PA, Hagan M et al. Aetiology of suppurative corneal ulcers in Ghana and South India, and epidemiology of fun- gal keratitis. Br J Ophthalmol. 2002; 86: 1211–1215.11. Ali H, Amoyaw F, Baden D et al. Ghana’s HIV epidemic and PEP-FAR’s contribution towards epidemic control. Ghana Med J . 2019; 53: 59–62.12. Challenge Facility for Civil Society Ghana National TB Voice Network TB in Ghana . Accessed December 21, 2021. www. tbvoicenetwork.net .13. Statista. Number of cancer cases in Ghana from 2010 to 2019 .Accessed August 26, 2022. https://www.statista.com/statistics/ 1283497/cancer- cases- in- ghana/.4 Ocansey et al. 1   1  1  1   1    1   2    4. Boima V, Amissah-Arthur MB, Yorke E et al. Determinants of will-ingness to accept kidney transplantation among chronic kidney dis-ease patients in Ghana. BMC nephrol. 2021; 22: 1–2.5. Siaw-Frimpong M, Touray S, Sefa N. Capacity of intensive careunits in Ghana. J Crit Care . 2021; 61: 76–81.6. World Health Organization. The Selection and Use of Essen-tial in Vitro Diagnostics ; 2021; 1031. https://apps.who.int/ iris/bitstream/handle/10665/339064/9789240019102-eng.pdf? sequence=1&isAllowed=y .7. Global Antimicrobial Resistance Surveillance System ( GLASS )Early Implementation Protocol for Inclusion of Candida Spp.;2019.8. Ministry of Health Ghana National Drugs Programme ( GNDP )Essential Medicines List Ministry of Health Seventh Edition( 7th ) , 2017. Published 2017. Accessed January 19, 2021.https://www.moh.gov.gh/wp-content/uploads/2020/07/GHANA- EML-2017.pdf.9. WHO. World Health Organization. World health organizationmodel list of essential medicines. 2019; 21: 119-134. https://www.who.int/publications/i/item/WHOMVPEMPIAU2019.06 .0. Oladele RO, Osaigbovo II, Ayanlowo OO et al. The role of medicalmycology societies in combating invasive fungal infections in low-and middle-income countries: a Nigerian model. Mycoses . 2019;62: 16–21.

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Improving awareness, diagnosis and management of invasive fungal infections in Ghana: establishment of the Ghana Medical Mycology Society

Improving awareness, diagnosis and management of invasive fungal infections in Ghana: establishment of the Ghana Medical Mycology Society.

Improving awareness, diagnosis and management of invasive fungal infections in Ghana: establishment of the Ghana Medical Mycology Society.

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