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Meta-Analysis
. 2019 May 16;14(5):e0216568.
doi: 10.1371/journal.pone.0216568. eCollection 2019.

Burden of fungal asthma in Africa: A systematic review and meta-analysis

Richard Kwizera  1   2 , Joseph Musaazi  1 , David B Meya  1   3 , William Worodria  3   4 , Freddie Bwanga  5 , Henry Kajumbula  5 , Stephen J Fowler  6 , Bruce J Kirenga  2   3   4 , Robin Gore  7 , David W Denning  8
Affiliations
Meta-Analysis

Burden of fungal asthma in Africa: A systematic review and meta-analysis

Richard Kwizera et al. PLoS One. .

Abstract

Background: Asthma is one of the neglected diseases in Africa with a high prevalence. Allergic fungal diseases have been reported to complicate asthma progression and treatment outcomes. However, data about fungal asthma and its associated complications are limited in Africa. We aimed to estimate the burden of fungal asthma among adults and children in Africa using a systematic review.

Methods: We first engaged the Institute for Health Metrics and Evaluation (IHME) to highlight the trend in morbidity and mortality attributed to asthma in Africa. We then searched PubMed, HINARI and Google Scholar for all studies of any design focusing on fungal asthma in any African country. Languages were restricted to English and French, but not year of publication. We estimated the weighted prevalence of allergic fungal infections among asthmatics with a 95% CI and pooled the results using a random effects model. This study is registered with PROSPERO, number CRD42019117319.

Results: The IHME data showed that there has been a gradual increase in morbidity and mortality due to asthma in African adults with a prevalence of 4%. Our search retrieved 5233 citations. We retained 20 studies that met our selection criteria. These were from 13 African countries published between 1967 and 2018. There were eight cross-sectional studies and twelve review articles. The average asthma prevalence in Africa was 6% from these studies. The prevalence of fungal sensitisation was relatively high (3-52%) in the asthmatic population with an average of 28% and a pooled estimate of 23.3%, mostly due to Aspergillus species. Prevalence of Allergic bronchopulmonary apsergillosis was estimated at 1.6-21.2%. Diagnosis of fungal allergy was mostly made by skin prick tests. There was no data on the use of medication to manage fungal asthma. None of the studies evaluated the association between fungal allergy and asthma severity. Data were lacking in children.

Conclusion: There is a high prevalence of fungal sensitization among Africans with asthma. Fungal asthma is a significant problem in Africa but there remains a paucity of data on the epidemiology and associated complications. There is urgent need for national epidemiological studies to estimate the actual burden of fungal asthma in Africa.

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Conflict of interest statement

RK, JM, FB, WW, DBM, SJF, HK and BJK declare no conflict of interest. Dr Gore has received financial support in the last 3 years for career development seminars from Novartis UK. Dr Denning and family hold Founder shares in F2G Ltd, a University of Manchester spin-out antifungal discovery company. He acts or has recently acted as a consultant to Scynexis, Cidara, Quintiles, Pulmatrix, Pulmocide, Zambon, iCo Therapeutics, Roivant and Fujifilm. In the last 3 years, he has been paid for talks on behalf of Astellas, Dynamiker, Gilead, Merck, Mylan and Pfizer. He is a longstanding member of the Infectious Disease Society of America Aspergillosis Guidelines group, the European Society for Clinical Microbiology and Infectious Diseases Aspergillosis Guidelines group and the British Society for Medical Mycology Standards of Care committee. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Figures

Fig 1
Fig 1. Trends in morbidity and mortality due to asthma in Africa.
There has been a gradual increase in the prevalence, deaths and disability-adjusted life years attributed to asthma among adults in Africa over the years (source: IHME; Seattle, WA) [42]. Each line is a separate age category (years).
Fig 2
Fig 2. Citation selection process for the systematic review.
Twenty studies were found describing the burden of fungal asthma in Africa. Eight were epidemiological studies and the twelve were review articles.
Fig 3
Fig 3. Distribution of studies describing burden of fungal asthma in Africa.
Twenty studies were found from thirteen (out of 54) African countries. The shaded areas represent countries with data from epidemiological study and/or review article. Map was created and reprinted from [https://mapchart.net/africa.html#] under a CC BY license.
Fig 4
Fig 4. Forest plot showing meta-analysis on prevalence of fungal sensitisation.
There was a lot of variation in the prevalence of fungal sensitisation across the eight studies included in the meta-analysis (p-value <0.01). Broken vertical line indicates the combined (overall) estimates. ES (95% CI) denotes weighted estimates of prevalence and their 95% confidence intervals based on the variance in each individual study.
See this image and copyright information in PMC

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