Monday, 31 January 2011

Aspergillus fumigatus Causing Breathlessness in Mumbai

Recent weather conditions and smog in Mumbai, India (the location for the recent hit film Slumdog Millionaire) have triggered a wave of reports of people suffering breathing problems. Authorities blame the prevailing weather conditions which have been cool but humid (ideal for fungal growth) combined with record levels of particulates (dust, soot, spores etc.) over the last 5 days.

Mumbai, India
Environmental monitoring  shows that there are 60 to 70 very hazy smoggy days between November and February most years in Mumbai, so this is a long term problem that has peaked this year. Smog is a cocktail of toxic substances that can render sensitive individuals more vulnerable to infections, including lung infections.

Most patients reporting breathing difficulties are suffering from asthma, emphysema or chronic bronchitis and respond to treatment, but a significant minority  do not respond to treatment and are then referred to testing for fungal infection. 15-20% of all patients are found to be positive for Aspergillus fumigatus which causes symptoms similar to asthma.

Evidence is accumulating that A. fumigatus can grow in the lungs of some people, causing allergies in some, worsening the symptoms of asthma patients (Severe Asthma with Fungal Sensitivity, SAFS) and it is known that it can trigger long term illness in others (Allergic Bronchopulmonary Aspergillosis, ABPA) or much worse in patients who have recently had an organ transplant (Invasive Aspergillosis, IA) or who have pre-existing conditions such as Tuberculosis (Aspergilloma, Chronic Pulmonary Aspergillosis, CPA).

This hazard may well have had its cause contributed to by the smog in Mumbai. The hazards of smog have been reported before in connection with an increase in asthma rates, but levels of contact with Aspergillus have not been investigated in connection with this problem. Here we find that Aspergillus can be a major contributor to breathing problems caused by smog.

Wednesday, 26 January 2011

Top Fungal Disease Experts Meet in Texas, USA

A fine-tuned immune response to fungal infection is critical, as either insufficient or exaggerated responses compromise each person’s ability to fight fungal infection and not develop fungal allergy.
Last week saw a gathering of the world’s top immunologists (experts in the immune system) in the fungal disease field in Galveston, Texas to share and challenge the latest data on how the immune system interacts with fungi, at the first Gordon Conference on the “Immunology of Fungal Infection”. The meeting was organised and chaired by Gordon Brown (Aberdeen) with co-chairs Luigina Romani (Perugia) and Stuart Levitz (Boston). 

The complexity of the immune system is daunting, but with sustained research efforts by many stellar groups, we are starting to really understand how the body fights infection, and what goes wrong, allowing infection or allergy. The last few years has seen significant advances in our understanding of the innate and adaptive components underlying the protective and non-protective mechanisms of immunity. These discoveries allow a better understanding of immunodeficiency and disease susceptibility, and provide a means to develop novel approaches for immunotherapy and vaccination. Similarly important is the contribution of fungi to the plasticity of the immune system, from tolerance to autoimmunity.

Sadly it isn't possible to write about the many in depth presentations and conversations that took place at this meeting as it is a condition of the Conference that everything that is said is private, which helps everyone to relax and talk openly and thus maximise the possibilities of progress.
Gordon Research Conferences (GRC) bring together the world's leading researchers to promote cross-disciplinary discussions and research collaborations. The first Gordon Conference was held in the late 1920's when the founder Dr. Neil E. Gordon, of the Johns Hopkins University realised the difficulties scientists had when trying to discuss state-of-the-art research with each other. Dr Gordon started a series of week long informal meetings designed to promote excellent, direct communication between leaders of the field in question, and between scientists from different research fields who could benefit from an interdisciplinary approach.

The original concept devised by Dr Gordon has now expanded to include many different locations across the world with between 50 and 80 conferences held every year - see a short history of Gordon Conferences here.
There will be as second GRC on the Immunology of Fungal Infection in January 2013, also in Galveston, Texas.

Tuesday, 25 January 2011

Clamping Down on Mycotoxin Levels in Chinese Medications

Authorities in Hong Kong have started a major offensive against the sale of unregistered traditional 'Chinese' medications. Registration of all such medications is a requirement of law in China since the 3rd of December 2011, the intention of which is at least partly to be able to improve standards of production of these medications.

Many of these medications are derived from plant or animal sources and little formal effort has been  apparent in the past to control the levels of pollutants such as heavy metals, toxic elements (e.g. aflatoxins) and pesticide residues in these medications. The new regulations make it compulsory that these toxins are tested for in every medication sold, as is the requirement for all such substances sold into the European marketplace.

Unfortunately these new regulations have been brought in with apparently little notice (approximately one week - Similar efforts in Europe were carried out over several years and only come into force in April 2011) and this has caused large numbers of unregistered medications to become illegal almost overnight. Around one third of all chinese medications are untested, unregistered and now illegal. Testing takes time and costs money, it is not known how many medications will fail the tests and be effectively useless.

Though these measures have inflicted economic pain, especially when enforced with so little notice they are an essential part of removing as many toxins as we can from the food chain. The health effects of these toxins are often slow to appear and easy to miss though nontheless serious with long term implications for those who take them.

Once we know these substances are safe to take there may well be an upswing in the potential markets for these substances in the developed world, compensating for the short term losses currently being experienced by producers in China.
However European regulation also brings in some control over the claims made about what these substances can do & how well they do them. This is likely to be much harder to provide evidence for - perhaps there are a few more headaches to be overcome by this industry before they can be too confident about their future.

Thursday, 20 January 2011

Keep wild bird feeders clean

Many people like to put our feeders for wild birds, particularly during the worse winter months when birds are more likely to come into gardens searching for food as it is scarce in the wild - when snow is lying on the ground or when most water is frozen.
Many people will repeatedly refill feeders as it is used up, often before the feeder is empty, leaving a portion of the food at the bottom of the feeder that is never eaten.
Many feeders are difficult for birds to completely empty and these tend to hold uneaten food for some time. Put that together with dampness caused by the ingress of rain (few feeders are waterproof) and you have the ideal conditions for the growth of fungi. Once fungi such as Aspergillus grow several things can happen

  1. they can start to produce highly toxic mycotoxins
  2. they can produce spores that can kill an unhealthy bird
  3. 1. can increase the chances of  2. happening!
For the most part when there is plenty of food around my impression is that wild birds will avoid old food, but it is still possible that birds will regularly visit the food, risking infection. When weather conditions are harsh they may be forced to eat old food.

This news article highlights many other consequences of leaving food out until it becomes old, there are many infections that they can contract from poorly maintained feeders.

It is not safe to assume that because these birds live off the ground in the wild that they can tolerate dirty feeders or old food that has become mouldy. Try to ensure no food is left out for long periods of time. If it is uneaten then discard it, thoroughly wash the feeder in 1/10 diluted bleach/water (it may have to be partially dismantled to do a thorough job), dry and refill it. The writers of the article also recommend raking out the area under the feeder to prevent ground feeder having to feed off soiled ground.

Once you have done all that you may well be surprised at the number of birds that come visiting!

Monday, 10 January 2011

6 out of 10 Severe Asthmatics have Aspergillus in their Lungs

Over the last 30 years evidence has been accumulating that many people who develop severe asthma also show evidence of a fungus in their lungs - specifically Aspergillus fumigatus.

Many readers of this blog will be familiar with Aspergillus fumigatus as the fungal species that can cause severe invasive infections amongst immunocompromised people, but in people with apparently perfectly healthy immune systems these fungi are removed by several active 'cleaning systems' present in our lungs.
There are some rare exceptions where apparently healthy people do get chronic infections caused by Aspergillus fumigatus (referred to as chronic pulmonary aspergillosis (CPA)) and these are partly explained away by them having severe scarring of their airways or lung tissue caused by infections such as Tuberculosis. Once scarred the airways tend to lose their 'cleaning system' for that area, allowing other infections to settle in.
Apart from these exceptions people with healthy immune systems are pretty safe from infection by Aspergillus - except for asthma and Allergic Bronchopulmonary Aspergillosis (ABPA).

ABPA is a well described condition effecting some immunocompetant people who develop a chronic non-invasive infection of their lungs. Patient groups vulnerable to this include asthma and cystic fibrosis. It is suggested that there are 150 000 asthmatics afflicted with ABPA in the UK alone.

Around 15-20% of asthmatics have severe asthma. Of these around 25-50%% have fungal sensitivity (SAFS), equating to around 1-3 million people in the UK+USA.

But what does fungal sensitivity mean? We all breathe in differing amounts of fungi most of the time as they are present in the air around us at all times. Are asthmatics more sensitive to these fungi or do they actually have fungi growing in their lungs - rather like we could imagine a mild form of ABPA perhaps?

Do people with fungal sensitivity have an Aspergillus infection? This question is not easy to answer but there is a quick & easy test for the presence of fungi in our airways - the sputum test. This test is a simple matter of getting the patient to expectorate sputum and then attempting to grow fungus from the sputum - a process that takes about 10-14 days. if fungi grow out of sputum then we have a fair indicator that there are fungi in the lungs of the patient, though this is not definitive.
Fairs et.el. have recently showed that there is a strong association (63% SAFS patients were positive, only 7% non-asthmatic control group were positive) between severe asthma and fungi in the sputum, so we now know that there is a very good chance that severe asthma is strongly linked with viable fungi present in the lungs of severe asthmatics.

Can we conclude that a growing fungus e.g. Aspergillus is one cause of severe asthma? It is a seductive theory with a fair body of evidence accumulating, albeit largely circumstantial. Some doctors are already treating SAFS with an antifungal medication with good success (See clinical trial here) - as you would expect if fungi are causing the severity and if evidence continues to accumulate then many more will start to do so too.

Wednesday, 5 January 2011

First Catastrophic Flooding, then Biblical 'Pestilence' (mould)

Severe flooding in Bundaberg, Australia
The recent horrific events in Queensland, Australia show how whole communities can be severely effected by flooding - in this case the area effected is larger than Britain & Germany combined! Many buildings have been swept away but many more have stood up to the force of water and will remain once the floodwater recedes.

The immediate problems are of course loss of roads leading to difficulties in  providing food and water to those affected. There are also a number of severe challenges ahead for people living in these areas. The climate is warm and humid and is thus susceptible to various tropical diseases where water is an important factor in transmission. Mosquito's and all the diseases they can carry may well become a danger as pools of water settle and stagnate (e.g. Dengue fever), 'dirty water' diseases will be a big risk e.g. diarrhoea. If that wasn't enough venomous snakes are also being carried down the rivers into people's houses.

Unfortunately almost as bad is what comes next. As the flood waters recede there will be a lot of very wet buildings full of soaked possessions & furniture. Many of the houses will be wooden. These conditions are perfect for moulds to grow and they will everywhere they can. These floods have already lasted days so the moulds will already be growing in massive numbers - there is a huge amount of restoration work that needs to be done. Anything absorbent will have to be discarded, building materials stripped back and replaced, cleanable surfaces sterilized. It will not be advisable for anyone to resume living in these homes until this is carried out.

Aspergillus Website has guidelines for damp buildings including extensive advice from several sources on how to clean up flooded houses (including advice given to residents of New Orleans after the major floods that occurred there in 2005 after Hurricane Katrina), facemasks to protect people from fungal spores and videos of talks by Prof Malcolm Richardson on how to treat mouldy houses ( Video 1 (Rome meeting), Video 2 (Patients meeting)).

Can any of this mould damage be avoided? Unfortunately the only way to cut down on mould growth is to dry out the material it is growing on. The mould spores are ever present in the air so there is no way of preventing them landing on moist food sources. Once established the moulds will produce more spores which will be released into the air and so on until everything has dried out.

What are the risks to human health? There are severe risks for people with asthma & allergies that their conditions will be aggravated - see this recent review. People with compromised immune systems are at risk from infections e.g. transplant patients, people on high dose steroid treatment and others.

Disastrous floods like this most recent event in Australia cause health problems for many years to come and provision needs to be made for this.

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