Mortality Trends in Risk Conditions and Invasive Mycotic Disease in the United States, 1999-2018

Abstract

Background: Invasive fungal infections in the United States are chronically underdiagnosed and a lack of coordinated surveillance makes the true burden of disease difficult to determine. The purpose of this analysis was to capture mortality-associated burden of risk conditions and fungal infections.

Methods: We analyzed data from the National Vital Statistics System from 1999 through 2018 to estimate the mortality attributed to risk conditions and related fungal disease.

Results: The number of risk conditions associated with fungal disease is steadily rising in the United States, with 1 047 422 diagnoses at time of death in 2018. While fungal disease decreased substantially from 1999 to 2010, primarily due to the control of human immunodeficiency virus (HIV) infection, the number of deaths with fungal diagnosis has increased in the non-HIV cohort, with significant increases in patients with diabetes, cancer, immunosuppressive disorders, or sepsis.

Conclusions: The landscape of individuals at risk for serious fungal diseases is changing, with a continued decline in HIV-associated incidence but increased diagnoses in patients with cancer, sepsis, immunosuppressive disorders, and influenza. Additionally, there is an overall increase in the number of fungal infections in recent years, indicating a failure to control fungal disease mortality in these new immunocompromised cohorts. Improvement in the prevention and management of fungal diseases is needed to control morbidity and mortality in the rising number of immunocompromised and at-risk patients in the United States.

Keywords: United States; fungal disease; mortality analysis; mycoses.

Figure 1.

Burden of immunosuppressive diseases and conditions. Total number of diagnoses of associated risk conditions and diseases at time of death over time. Abbreviation: HIV, human immunodeficiency virus.

Figure 2.

Burden of fungal disease. Total number of diagnosed fungal infections by type in (A) all recorded deaths and (B) in persons without an HIV diagnosis, over time. Abbreviation: HIV, human immunodeficiency virus.

Figure 3.

Fungal disease diagnosis by underlying condition. A) Age adjusted rate and B) total number of diagnosed fungal infections by underlying at-risk condition at time of death. Abbreviation: HIV, human immunodeficiency virus.

Figure 4.

Trends in fungal disease diagnosis by underlying condition. Linear regression of the total number of fungal disease diagnoses reported from 2009 to 2018 in patients with (A) cancer, (B) diabetes, (C) HIV, (D) influenza, (E) immunosuppressive disorders, and (F) sepsis. Abbreviation: HIV, human immunodeficiency virus.

Figure 5.

Burden of fungal infections in diverse risk condition types, 2018. Rate of fungal infections in patients with (A) cancer, (B) HIV, (C) transplant complications, or (D) autoimmune disease, by type. Abbreviation: HIV, human immunodeficiency virus.

Figure 6.

Fungal disease type by associated condition. Rate of fungal diagnoses by type in patients with (A) cancer, (B) diabetes mellitus, (C) HIV, (D) sepsis, or (E) transplant complications. Abbreviation: HIV, human immunodeficiency virus.