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Review Article
Indian J Med Res 153, March 2021, pp 311-319
DOI: 10.4103/ijmr.IJMR_768_21
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One Health aspects & priority roadmap for fungal diseases : A

mini-review
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Sayantan Banerjee1, David W. Denning4,5 & Arunaloke Chakrabarti2,3

1
Department of Infectious Diseases, Beleghata Infectious Diseases & BG Hospitals, Beleghata, Kolkata,
West Bengal, 2Department of Medical Microbiology, 3Center of Advanced Research in Medical Mycology,
Postgraduate Institute of Medical Education & Research, Chandigarh, India, 4Manchester Fungal
Infection Group, Faculty of Biology, Medicine and Health, The University of Manchester, United Kingdom
& 5Global Action Fund for Fungal Infections, Geneva, Switzerland

Received March 13, 2021

Fungal diseases have not been taken seriously in public health agendas as well as research priorities,
despite of globally causing an estimated two million deaths every year, and the emergence of many
troublesome fungal pathogens like Candida auris, azole resistant Aspergillus fumigatus, terbinafine and
azole resistant dermatophytes, and zoonotic sporotrichosis in humans. Fungi are also responsible for
huge losses of agricultural products and stored crops as well as recent massive and unexpected mortality
in animals caused by white-nose syndrome in the bats and Chytridiomycosis in amphibians. This
review aims to underscore the need for collaborative, multisectoral, and trans-disciplinary approach
to include the One Health approach as an essential component of surveillance, prevention, and control
of globally emerging fungal diseases. Rigorous evidence based surveillance of the environment as well
as strengthening rapid and quality diagnosis of fungal diseases can save millions of lives and reduce
significant morbidity.

Key words Fungal diseases - fungus - One Health - zoonotic

Introduction Acute Respiratory Syndrome (SARS), Middle East

The past few decades witnessed the emergence Respiratory Syndrome (MERS) and SARS-CoV-2
of several novel infectious diseases that had their coronaviruses, human influenza virus from avian and
origin primarily in animals and created havoc in the swine sources, and many life-threatening zoonotic viral
human society. Continued global warming secondary infections1. Public health systems are geared mainly
to injudicious human activities like intensification to tackle viral infections especially during the present
of agriculture, rapid and unplanned urbanization, coronavirus pandemic, forgetting other equally life-
alteration and destruction of ecosystems, and massive threatening bacterial and fungal infections2. However,
global movement and trade has led to the emergence this neglect may have profound long-term impact,
of a series of novel respiratory viruses like Severe which is underestimated.

© 2021 Indian Journal of Medical Research, published by Wolters Kluwer - Medknow for Director-General, Indian Council of Medical Research
311
 312 INDIAN J MED RES, MARCH 2021

The term ‘One Health’ by inclusion of human, of the newly described drug-resistant invasive fungal
animal and plant health together though first coined species - Candida auris, across many critical care
during the concerted efforts to combat the emergence of units in different continents over the last decade is an
SARS coronavirus and H5N1 influenza in 2003-20043, example of such a resilient and transmissible human
pathogen19.
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the concept gained popularity with the recognition of

the evolution of antimicrobial resistance (AMR) in Plant pathogenic fungi are responsible for major
humans, related to the environment, plant and animal destruction of staple food crops like wheat, rice and
health4. corn, jeopardizing global food security20,21. Fungal
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Along with the emerging viral and toxins that contaminate stored food grains can cause
multidrug-resistant bacterial pathogens, in the past few acute toxicities or chronic effects like carcinogenesis.
decades newly emerging fungal illnesses pertaining These toxins are also lethally deployable as biological
to plants and animals, crossing over to humans have weapons against humans and food supplies22. Water
obtained great importance5. The previously unknown damaged buildings provide niches for fungal groups,
human outbreaks of Sporothrix brasiliensis related to to proliferate with damaging fungal generated volatiles
close exposure to cats in South America6, increasing and allergens contributing to ill health.
load of fungal keratitis related to agricultural The American Academy of Microbiology
activities without eye protection7, continued burden Colloquium on One Health aspects of fungal diseases
of sporotrichosis related to unprotected horticultural strongly support development of new approaches to
activities8, emergence of histoplasmosis and protect frogs, salamanders, bats, and other animals
chromoblastomycosis in newly described geographical from pathogenic fungi12 and develop new methods of
areas, the menace of drug-resistant dermatophytosis9 preventing fungal infections in crop plants by reducing
and aspergillosis10 to name a few, are the new-age One azole dependence in the face of rising azole resistance
Health related fungal hazards. among Aspergillus species23 by promoting the use of
Thriving at 33-37° C is necessary for a fungal gene silencing methods and genetically modified crop
species to become a human commensal or pathogen. production12.
There are close to 6 million estimated fungal species Fungal diseases are silent killers - out of public
on earth11, out of which, nearly 600 fungal species health priority
can cause human disease12. The number of pathogenic
fungal species is growing rapidly due to temperature Fungi are silent killers, causing the death of
adaptation. Through advancement of molecular over two million people every year24 - this makes
biology and sequencing techniques, it is evidenced fungal diseases one of the top global causes of death
that the number of fungal species as a part of the ahead of tuberculosis and malaria, yet concealed
human microbiome – either as a commensal or a by only listing the primarily underlying diseases
pathogen may be grossly underestimated due to the (i.e. leukaemia or COPD). With the advancement
inability to culture many of those, leaving room for of cancer chemotherapy, solid organ and stem cell
new surprises as emerging fungal infections13. Other transplants, increased survival of acute respiratory
than human, bats and poikilothermic animals like fish distress syndrome and other critically ill patients in
and amphibians are prone to serious fungal infections. the intensive care, and the extensive use of indwelling
Recent investigations have suggested high incidence of medical devices, the gross number and proportion
of patients susceptible to serious invasive systemic
severe fungal diseases causing extinction of many wild
fungal illnesses have increased significantly in the
amphibians and bat species14,15. It has been proposed
past few decades25. Worldwide annual occurrence
that the extinction of the dinosaurs 65 million years
of over 300,000 cases of invasive aspergillosis and
ago was driven in part by fungal diseases16.
700,000 invasive candidiasis cases are reported26,
Fungi are remarkably resilient and transmissible vulnerable people are disproportionately affected and
breaking geographical, environmental and species those afflicted with long term fungal disease and its
barriers. Broad groups of fungi were found to survive sequelae live in misery due to morbidity, the inability
in areas of high radiation around the Chernobyl nuclear to work and stigma. Global estimates of fungal
disaster site17 as well as in the Japanese module of the illnesses24,26 suggest a global annual occurrence of
international space station18. The rapid transmission more than three million cases of chronic pulmonary
 BANERJEE et al: FUNGAL DISEASES & ONE HEALTH 313

aspergillosis, and 10 million cases of fungal asthma, a and is more common in patients hospitalized with
large part of which is undiagnosed in resource limited COPD31, lung cancer32 and occasionally other solid
settings27. Despite of advancement of HIV treatment, tumours, corticosteroid therapy, liver failure, transplant
there are global reports of more than 200,000 cases recipients, notably allogeneic stem cell and lung, but
also renal and heart recipients, complicating severe
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of cryptococcal meningitis, and 500,000 cases of

Pneumocystis jirovecii pneumonia, which are otherwise influenza (19%)33 and severe COVID-1934,35.
largely preventable and treatable28. It is estimated that The environmental route of resistance occurs
nearly a million eyes lose vision due to fungal keratitis, as a result of exposure to azole fungicides or sterol
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mostly related to agricultural activities, out of which, 14α-demethylation inhibitor (DMI) fungicides in the
a significant proportion is from the developing world environment. The development of azole resistance is
and the global south24,26,29. Fungi causing skin and mostly a bystander effect on Aspergillus fumigatus,
subcutaneous diseases, endemic fungal infections, as the agricultural targets for DMI fungicides are
fungal rhinosinusitis and fungal keratitis mostly usually other fungi36. In areas where the azole
affect people without any pre-existing conditions, resistance rates in Aspergillus exceeds 10%, current
living and working closely in certain environmental guidelines recommend voriconazole or isavuconazole
niches. Fungal asthma, caused by airborne fungi such in combination with an echinocandin or liposomal
as Aspergillus spp., exacerbates asthma in millions amphotericin B instead of azole monotherapy alone30.
of adults and children. Limited diagnosis and poor Hence the knowledge of the antifungal resistance status
measurement of disease morbidity means that the true of the surrounding environmental Aspergillus spp. can
scale of the problem is only partially known28. be vital to the survival of IA patients.
Most important fungal pathogens affect humans IA primarily occurs through environmental spore
from the environment, underscoring the need for contamination of hospitals and intensive care units. It
coordinated One Health monitoring and vigilance has been shown that construction works in and around
Most of the invasive and endemic fungal human hospital premises accounts for about half (49%) of the
pathogens are transmissible from the environment causes of nosocomial aspergillosis outbreaks37. The
rather than from fellow human beings. Among all authorities of the hospitals serving the high-risk groups
the environmentally transmitted fungal pathogens, for IA must conduct active surveillance for airborne
Aspergillus spp., the fungi causing mucormycosis, fungal spores and the wards for such patients should
Cryptococcus spp., Histoplasma spp., Sporothrix spp., be equipped with appropriate ventilation systems38,39.
and agents causing mycetoma, deserve special mention Several environmental studies on
in the Indian context due to the sheer volume of patients azole-resistant Aspergillus show that resistance
affected by them in the subcontinent. was acquired during stockpiling of inappropriately
Aspergillosis: Aspergillus spp. is a pathogen processed plant waste material, producing potential
which cause the broadest array of illnesses in hot spots for the evolution and selection of azole
human beings- ranging from superficial infection resistant Aspergillus40. The environmental route of
(otomycosis, onychomycosis and keratitis), resistance selection is thus a One Health challenge
chronic pulmonary aspergillosis (CPA), allergic that must involve cross-cutting discussions and actions
bronchopulmonary aspergillosis (ABPA), saprophytic among different stakeholders, for example, clinicians,
pulmonary or sinusoidal aspergillomas, a rapidly mycologists, agricultural researchers, pesticide and
evolving invasive form – which is almost always fungicide industrial houses, farmers and horticulturists,
fatal unless diagnosed and treated promptly30. In the legislators and policy makers, regulatory and municipal
last decade, the issue of azole resistance has become bodies10.
a significant menace in the treatment for all the forms Mucormycosis: Fungi causing mucormycosis are
of aspergillosis. It is postulated that in cases of CPA ubiquitous and can be found in decaying organic matter
and ABPA, the azole-resistance may develop during and in the soil. Depending upon the clinical syndromes
antifungal treatment, but, in case of acute invasive various modes of transmission have been described.
aspergillosis (IA), it is always primarily a resistant strain Inhalation of the spores from environmental sources is
acquired from the environment10. IA has also become considered as the most common mode of transmission41.
increasingly recognised in patients without neutropenia, Percutaneous implantation of spores during trauma,
 314 INDIAN J MED RES, MARCH 2021

burns and illicit injections are other important modes in association with rotting vegetation51. Most of the
of transmission. Gastrointestinal mucormycosis is case reports and studies from the WHO SEAR suggest
transmitted by ingestion of the spores contaminating that the diagnosis is made in the local and community
various foods and beverages. Renal mucormycosis, hospitals only on direct microscopy, and not the more
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which is rarely described outside of India, is likely sensitive antigen test. Early asymptomatic cryptococcal
to be caused by the inhalation of spores which antigenaemia precedes meningitis by a mean of three
disseminate hematogenously to the kidneys or through weeks, (~40% of cases) and is therefore missed and
invasive procedures of the urinary tract41,42. In a recent initiation of treatment is delayed52.
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multi-centre study of mucormycosis from India 56.8 per

Despite the cryptococcal antigen detection test
cent of the total 303 patients with mucormycosis had
having a sensitivity and specificity more than 99
underlying diabetes mellitus and 31 per cent had diabetic
per cent53, the test is not available in majority of the
ketoacidosis. In patients with rhino-orbito-cerebral
laboratories of the SEAR54. This test should be made
mucormycosis 65.7 per cent had underlying diabetes
routinely available for HIV patients with low CD4
mellitus43. Other common risk factors include
counts or in the presence of other AIDS defining
glucocorticoid use, haematological malignancies,
symptoms, as well as solid organ and stem cell
haematopoetic stem cell transplantation, solid organ
transplant recipients. New patients with HIV infection
transplantation, iron overload conditions, treatment
admitted to hospital or symptomatic should be screened
with desferrioxamine and AIDS41. Post-pulmonary
routinely for Cryptococcal antigen.
tuberculosis has been recently recognized as a risk
factor for pulmonary mucormycosis43. Probably the Histoplasma: Histoplasma capsulatum is a dimorphic
burden of mucormycosis is grossly under reported, fungus, which can thrive at both temperate as well as
because cultures are so often negative and only recently tropical countries, and is found in various parts of the
has the first PCR assay been commercialised. Incidence world, including all countries of the SEAR55,56. But the
and prevalence of this disease is difficult to estimate best environmental conditions for its growth are mean
because of various factors including lack of awareness temperature of 22 to 29°C, an annual precipitation of
of the disease even among trained physicians and lack 35 to 50 inches, and a relative humidity of 67 to 87 per
of standardized diagnostic strategies. Lack of proper cent57. It has been found to be present within 20 cm
denominators to express the disease burden is another of the surface of acidic soil, high in nitrogen content.
important obstacle44. A computational model based There is a strong environmental association with
on Indian literature using Monte Carlo algorithms decaying bird and bat guano in cool, moist soil away
estimated an overall mucormycosis prevalence of 0.14 from the sunlight58,59. Various activities that lead to
cases per 1000 population in India, coming to a total disruption of soil surface, like excavation, spelunking
burden of 187,460 patients45,46. The overall mortality (cave exploration), construction, bird handling and
in mucormycosis when well treated ranges from recreational activities, that can lead to the release of
30 to 46.7 per cent43,47,48. Based on the aforementioned its infectious conidia, which are subsequently inhaled,
computational model45,46, considering an attributable causes the pulmonary or disseminated multisystem
death rate of 38 per cent per year, mucormycosis kills disease, known as the Darling’s disease60,59. In a recent
over 105,000 people in the WHO South East Asian review, the most commonly associated environmental
Region (SEAR) per year. and wilderness-related risk factors for histoplasmosis
were found to be bird and bat watching, cave and cave
Cryptococcus: Cryptococcus is an important fungus
entrance exploration, and bamboo removal and burning.
causing meningitis and sometimes pulmonary and
Whereas occupational risk factors for histoplasmosis
disseminated diseases with substantial mortality. It
were found to be road construction, roofing, bridge and
predominantly affects patients with late stage HIV
water tower work, demolition, and masonry61.
infection and other immunocompromised conditions
and sometimes can even involve immunocompetent Among a case series reporting 31 cases from a
persons49. C. neoformans var grubii and single centre in New Delhi, India, 17 patients had a
var neoformans have been found in soil samples history of occupational exposure to agriculture and
from around the world in areas frequented by birds, 10 had significant occupational or domestic exposure
especially pigeons and chickens50. This fungus has to birds. These two exposures combined together
also been isolated from roosting sites of pigeons and comprised of 87 per cent of the cases58. Among a total
 BANERJEE et al: FUNGAL DISEASES & ONE HEALTH 315

of 213 cases reviewed from the Indian subcontinent, their jobs and become a burden on families and the
56 per cent of affected people were found to be community65.
apparently immunocompetent and 31 per cent were
Sporotrichosis can present with cutaneous,
immunocompromised. A significant number of patients
lymphocutaneous and systemic manifestations.
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(55%) of disseminated histoplasmosis from India are Severity depends on infecting species and the host
reported to have adrenal gland involvement58,62. A immune status. Majority of the cases of sporotrichosis
peculiarity of the disseminated histoplasmosis is its occur when the fungal spores are introduced through
strong gender predisposition towards male gender; the a cut or puncture in the skin while gardening or
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male : female ratio is reported to be as high as 6:1 from handling vegetation or organic matter. Historically
India58 as well as worldwide63. Chronic pulmonary environmental transmission from vegetations was the
histoplasmosis is barely known in India, probably most common source, but recently zoonotic infections
because a lack of Histoplasma antibody diagnosis56. have emerged with Sporothrix brasiliensis in South
A programme for establishing the rates of America via the bite, scratch, and contact with the
histoplasmin skin sensitivity in India should be exudate of an infected cat6. In India, however, the
undertaken to understand the exposure rate of the sapronotic transmission seems to be the major route of
population wherever cases have been documented transmission, which can be well prevented by wearing
and prioritise local diagnostic testing, especially in gloves and wearing boots while gardening to prevent
the north of the country. This diagnostic intervention puncture wounds66.
can also be guided by One Health monitoring of the Emergence of human-to-human transmissible
environment and ecological niches of the natural fungal pathogens and concerning antifungal
Histoplasma habitat. Histoplasma antigen testing resistance
should be implemented in hyperendemic localities
of histoplasmin sensitivity, particularly for advanced Invasive candidiasis: Multiple studies have shown
HIV cases. In fact at least one to two laboratories per the annual incidence of bloodstream infections with
region of India should have the facility of Histoplasma Candida spp. to be 1.2–26 cases/100,000 population,
antigen and antibody tests on a referral basis. across the world. Only seven per cent are community-
acquired, the remainder are hospital-acquired24. A 2015
Mycetoma and Sporotrichosis – occupation prospective study from 27 ICUs in India showed a mean
associated subcutaneous mycoses incidence of 6.51 cases of ICU-acquired candidemia
Mycetoma is a chronic, progressive destructive per 1,000 ICU admissions and a death rate of 35 –75
infection of the distal limbs involving all tissues. It per cent67. An estimated 14.3 million patients are
is recognized as a neglected tropical disease (NTD) admitted to ICUs in India each year. Blood culture is
by the WHO64, but it is not a notifiable disease except only ≈40 per cent sensitive for invasive candidiasis
in Sudan. Numerous different organisms may be (and lower for intra-abdominal candidiasis). Further,
implicated, and the appropriate treatment depends on the antifungal agents including, fluconazole and
the causative organism. Mycetoma is an implantation echinocandins substantially reduces the yield from
disease. Any age can be affected. Minor breaks in blood culture. Therefore, it is probable that the actual
the skin from thorns or handling infected materials number of cases of invasive and intra-abdominal
result in a slowly progressive local lesion. The foot candidiasis in ICUs in India exceeds 200,000, resulting
is the most common site of infection. From the skin in ≈100,000 deaths. Bloodstream infection caused by
and subcutaneous tissue, the disease typically invades Candida spp. outside ICUs is twice as common as in
bone and produces hypertrophic, gross lesions. The ICUs, and so in India >600,000 persons each year are
agents of eumycetoma are almost always resistant estimated to have invasive candidiasis.
to amphotericin B and flucytosine. Some respond to Inappropriate use of antimicrobials as well as
voriconazole or itraconazole, but most are intrinsically several disruptive practices in farming, pisciculture,
resistant to all antifungals, especially Madurella deforestation and natural habitat destruction is said to
spp. Eumycetoma patients usually respond poorly have contributed to the emergence of C. auris. Almost
to medical therapy. Improvement is slow and hard all outbreak investigations carried on nosocomial
to evaluate, even after months of therapy. Many outbreaks of C. auris have concluded that the organism
patients eventually fail to complete education or lose was acquired from extraneous sources rather than from
 316 INDIAN J MED RES, MARCH 2021

the patients’ endogenous flora. This finding suggests market and food storage facility waste and industrial
that despite no environmental reservoir reported till organic wastes, rather than unprocessed dumping and
date, it is possible that C. auris might have its own landfilling have been shown to significantly reduce the
environmental niche19,68. Candida species are not burden of pathogenic fungi as well as its associated
drug resistance10. These should be actively encouraged
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exclusive human pathogens or commensals and have

been found in insects and different plants like mangrove as best practice and advocated to policy makers and
forests, rubber and cassava plantations68. Adequate legislators.
One Health monitoring of environmental niches are Hospitals catering to the needs of
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required to track the emergence of similar pathogens. immunocompromised patients as well as critically ill
Dermatophytes: In India, the most common species patients, should be positively incentivized for regularly
causing skin and nail infections is the dermatophyte running environmental monitoring protocols for the
Trichophyton rubrum - an exclusively human pathogen, hospital air surveillance of fungal spores and reporting
followed by Trichophyton mentagrophytes - erstwhile of resistances once detected. Similar environmental
considered a zoonotic pathogen usually transmitted monitoring should be made compulsory, whenever
from companion domestic animals and Microsporum such a healthcare facility has an ongoing demolition or
gypseum - a soil associated pathogen. T. mentagrophytes construction programme.
is recently found to be on the rise in India69. Terbinafine Rapid, non-culture based testing is now important
and azole resistant, stubborn and recalcitrant to diagnose life-threatening fungal infections, as
dermatophyte infection is nowadays considered recognised by the WHO in listing several diagnostics
as one of the most difficult to treat conditions in as essential. Cryptococcal antigen testing and
dermatology clinical practice. Cases are complicated histoplasma antigen testing should be made routinely
with the widespread use of topical corticosteroids in available at all the referral antiretroviral therapy centres
combination with antifungal agents. Potent molecules and hospitals seeing new HIV patients. Aspergillus
like clobetasol propionate are available over the counter antigen, Pneumocystis PCR and B-D-glucan should
and are grossly abused which include buying over the be available as rapid tests for cancer treatment and
counter with or without the prescription of general transplant centres. Aspergillus antibody testing should
practitioners and local application for weeks to years70. be routinely available for all respiratory services,
The steroid combinations cost much lesser than pure especially those managing TB. Precise diagnosis will
potent antifungal creams, which make these popular. contribute to reducing premature deaths, low morbidity,
These are used often only for symptom control without lower wasted healthcare expenditure and AMR control
any instructions or supervision and patients often stop are reducing incorrect empirical antibiotic usage
using them when the itching and redness are mitigated (Table).
and reapply when the symptoms reappear70,71.
Conclusion
Combating antifungal resistance and investing in
diagnosis of fungal illnesses: The Indian government’s Fungal infections are more prevalent than
effort to ban colistin in animal usage by creating a strong previously appreciated, partly because of missed
legislation is a laudable one considering the increasing diagnosis, partly because of new risk factors and
menace of transmissible plasmid mediated colistin partly because of the emergence of new and muti-
resistance gene mcr-172. Similar concerted effort with drug resistant pathogens. Fungal allergic disease and
exposure in water-damaged buildings is also relatively
agricultural universities, farmer’s unions, pesticide
common. The last decade delivered great progress on
manufacturers and API manufacturers are needed to
commercialized, simple and inexpensive diagnostic
reduce usage of traditional azoles in farming as well
tests which can transform lives blighted by chronic ill
as newer congeners of recently developed antifungals.
health. Routine use of these diagnostics will reduce
Promotion of composting under controlled aerobic unnecessary anti-bacterial therapy and contribute to
conditions where aeration can be done through natural AMR control. Restriction of use of azole fungicides
convection or forced aeration under ambient tropical in agriculture should minimise repetitive emergence
summer and monsoon temperature which can actively of resistant Aspergillus, which is important as azole
reduce the levels of azole-resistant Aspergillus. Large antifungals increasingly become established for
scale facilities for composting household biowaste, fungal asthma and prophylaxis. New antifungals with
 BANERJEE et al: FUNGAL DISEASES & ONE HEALTH 317

Table. Diagnostics recognized as essential by the World combatting sporothrix brasiliensis: review of an emerging
Health Organization, in addition to direct microscopy, zoonotic fungal pathogen in South America. J Fungi (Basel)
histopathology and fungal culture 2020; 6 : 247.

Test Major usage Recommended 7. Venkatesh Prajna N, Krishnan T, Mascarenhas J, Srinivasan M,

Oldenburg CE, Toutain-Kidd CM, et al. Predictors of outcome
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turnaround time
in fungal keratitis. Eye 2012; 26 : 1226-31.
Cryptococcal HIV/AIDS, 1 day or less
antigen53 transplant recipients 8. Chakrabarti A, Bonifaz A, Gutierrez-Galhardo MC,
Mochizuki T, Li S. Global epidemiology of sporotrichosis.
Aspergillus Critical care, 2 days or less Med Mycol 2015; 53 : 3-14.
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antigen30 bronchoscopy,
immunocompromised 9. Bishnoi A, Vinay K, Dogra S. Emergence of recalcitrant
dermatophytosis in India. Lancet Infect Dis 2018; 18 :
Histoplasma HIV/AIDS, 2 days or less
250-1.
antigen55 transplant recipients
10. Verweij PE, Lucas JA, Arendrup MC, Bowyer P,
Pneumocystis HIV/AIDS, 2 days or less
Brinkmann AJF, Denning DW, et al. The one health problem
PCR73 transplant recipients,
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Aspergillus Respiratory patients, 7 days or less
11. Taylor DL, Hollingsworth TN, McFarland JW, Lennon NJ,
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Nusbaum C, Ruess RW. A first comprehensive census of
GenXpert negative
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suspected TB patients
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For correspondence: Dr Sayantan Banerjee, Department of Infectious Diseases, Beleghata Infectious Diseases & BG Hospitals, Beleghata,
Kolkata 700 10, West Bengal, India.
e-mail: [email protected]