Global Fungal Infection Forum 2 in Liverpool

GAFFI convened the second Global Fungal Infection Forum in Liverpool on October 26th 2016 to address the following objectives for chronic pulmonary aspergillosis:

Primary: To develop an operational definition of CPA for epidemiological research and clinical care in LMICs and a strategy for disseminating the operational definition.

Secondary:1.To share and discuss the latest data on chronic pulmonary aspergillosis following TB.
2.To update therapies for CPA, availability and gaps.

This meeting overviewed the global burden of fungal diseases and focus on chronic pulmonary aspergillosis (CPA) and subacute invasive aspergillosis (SAIA) after TB, and in particular the 2.7 million people with smear negative people each year and post-TB sequelae. Many of these people will have CPA, SAIA, histoplasmosis, coccidioidomycosis and ABPA. In particular we wished to develop an operational case definition for CPA that is useful for public health. We will develop the program and definitions in collaboration with the WHO TB department.  We concluded with a keynote talk on the mycome of the lung, which has implications for diagnosis and antifungal therapy, and resistance in particular.

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To achieve these objectives, thirty-three experts from institutions with some CPA diagnostic capacity, or in the process of developing it, as well as some senior doctors from several Sub-Saharan African lower income countries with TB and respiratory disease experience joined forces for discussions in Liverpool.
After a day of debate and follow up discussions by email, a draft manuscript was in preparation for submission in 2017 entitled “Operational definitions of chronic pulmonary aspergillosis in low resource settings”. The proposed definition includes symptoms of persistent cough, weight loss, and haemoptysis combined with progressive cavitary infiltration on imaging, with or without a fungal ball, and-or pleural thickening, all present for at least 3 months, together with a positive Aspergillus IgG antibody test.

Final consensus definition

Consensus was built around the following definition of CPA in resource limited settings was agreed through participant consensus:

1 – Symptoms for 3 months or longer (haemoptysis and/or persistent cough, and/or weight loss) (other symptoms are common, but not required, notably fatigue, chest pain and sputum production)
2 – Radiological features (progressive cavitation on chest imaging AND/OR intracavitary fungal ball AND/OR pleural thickening or pericavitary fibrosis or infiltrates all adjacent to cavities)
3 – Microbiological evidence of Aspergillus infection (positive Aspergillus-specific IgG and/or sputum microscopy showing hyphae consistent with Aspergillus and/or Aspergillus growth on 2 or more sputum or other respiratory samples)
4 – Mycobacterial infection should be ruled out with smear, GeneXpert and/or mycobacterial culture. It is possible for mycobacterial infection and CPA to be present concurrently, but this diagnosis requires characteristic radiological findings on CT scan that are not present with PTB including pleural thickening, a fungal ball or other intra-cavitary material, or marked peri-cavitary infiltrates in addition to a positiveAspergillusIgG antibody test.

The Global Forum was supported by the following companies to whom GAFFI is most grateful: IMMY, LD Bio, DYNAMIKER, OMEGA, TIONJIN ERA BIOLOGY, BIOGX, CIDARA, GILEAD, PFIZER, ECMM, MIRAVISTA, BECKMAN COULTER, BIOMERIEUX, and PULMOCIDE.