London School of Hygiene & Tropical Medicine

This week has seen two important stories reach the internet – and I am not talking about Yanny/Laurel debate either. This was the highlighting of the problem of AMR in mycology and the release of the WHO list of essential diagnostic test.

Rising anti-fungal resistance

The recent paper in Science reviewed the problem of antifungal resistance, something I have been concerned about for a while (think of the frogs!) and we have discussed within our seminar series. According to the review, fungi account for approximately 30% crop yield loss worldwide and a global mortality rate that exceeds malaria and on par with TB and HIV. The problems facing both agriculture and clinicians mirrors that of antibacterial resistance in both biology and social factors.

Drug resistance arises after introduction of an anti-fungal due to their highly plastic genomes exacerbated by the withdrawal of some chemical classes due to regulatory changes and the drawn out approval process for new anti-fungals. Crops are bred for maximum productivity under a fug of pesticides, often at a cost of lost inherent resistance. The use of monotherapy has led to resistance developing but there are encouraging signs with the development of combination therapy (some formulations are only available mixed) and a possible vaccination C. albicans in clinical trials. Fungal resistance and fungal disease don’t make the news so often, possibly as this is perceived as an agricultural/immunocompromised problem but increasing infections are a concern and more needs to be done to tackle the problem.

WHO lists essential diagnostic tests

The WHO SAGE-IVD group (including Prof Rosanna Peeling from LSHTM) has released a list of essential diagnostic (EDL) tests to improve diagnosis and treatment outcomes, which complements the WHO Model List of Essential Medicines (EML). The EDL aims to provide guidance and reference to develop and/or update lists of national essential in vitro diagnostics (IVDs) and/or medical devices. The EDL comprises a group of general laboratory tests that can be used for routine patient care as well as for the detection and diagnosis of a wide array of disease conditions–communicable and NCDs. The WHO plans future editions of the EDL to include antimicrobial resistance, neglected tropical diseases, NCDs, outbreaks/emergencies and sepsis. The list will be expanded and updated annually, with the intention to ultimately cover a broad, comprehensive spectrum of disease.

While a list of essential tests works well in countries with a significant healthcare budget and infrastructure there is a slight danger of highlighting what is absent from LICs or prioritising testing for less urgent medical conditions. To counter this, the WHO states that the EDL must not” be used in isolation, but “in the context of the scope of testing services that meet the clinical needs and expectations in each country through their own particular laboratory networks”. Additionally the EDL is presented in two tiers: I) one for Primary health care consisting of healthcare professionals but no trained lab personnel or self-testing and II-IV) for Healthcare facilities with clinical laboratories (ranging from district hospitals to national reference laboratories). The EDL has a focus on several viral pathogens (inc HIV) as well as TB, syphilis and malaria through prequalified products.

How useful the list will be remains to be seen, but unlike EML this is about access for all and, for now, encouragement to have a microbiology laboratory running AMR phenotype tests.