Context:

India is quietly entering a phase where fungal infections which were once considered rare, opportunistic, or limited to specific geographies, are becoming a widespread public health concern. A combination of environmental change, weakened immunity in the population, overuse of antibiotics, and inadequate diagnostic facilities has contributed to the rise of fungal diseases. At the same time, an organisational shift within the Indian Council of Medical Research (ICMR), which is integrating specialised mycology laboratories with a broader infectious diseases network, has triggered debate about whether the country may lose focused attention on fungal research at a critical moment.

ICMR’s Lab Integration:

ICMR has begun integrating its specialised fungal labs under the broader Infectious Diseases Research and Diagnostic Laboratory (IDRL) network. While the council has emphasised that fungal research remains a priority and that these labs have actually been upgraded, researchers worry that dilution of focus and resource competition could undermine progress.

For nearly five years, ICMR’s Mycology Network (MycoNet), comprising eight Advanced Mycology Diagnostic and Research Centres (AMDRCs), has made important contributions. These centres:

• • mapped fungal infections,
  • generated early national-level data,
  • built technical capacity,
  • and ensured faster diagnosis in major institutions.

Some centres have documented first-in-India reports of resistant or rare fungi, such as:

• • azole-resistant Madurella fahalii,
  • Arthrinium rasika ravindrae causing keratitis,
  • Fonsecaea nubica causing chromoblastomycosis.

Researchers fear that merging niche labs into a larger network may reduce dedicated funding streams and shift focus to broader pathogens.

The Rising Burden of Fungal Diseases in India:

• • A 2022 study in Open Forum Infectious Diseases estimated that over 57 million Indians, about 4.1% of the population, suffer from serious fungal diseases, giving the country the highest fungal disease burden per capita in the world.
  • More strikingly, the estimated annual burden of serious fungal infections was found to be ten times higher than tuberculosis, one of India’s most pervasive infectious diseases.
  • The numbers are startling because fungal infections are often underestimated, misdiagnosed, or diagnosed late. Limited surveillance and patchy diagnostic capabilities mean the true burden could be even higher. Researchers involved in these estimates have stressed that the goal is not just to capture prevalence but to push for better diagnostic tools, surveillance systems, and expert training.

Types of Fungal Infections:

Superficial and Cutaneous Infections

• • • Ringworm, athlete’s foot, and onychomycosis affect the skin, feet, and nails.
    • Candidiasis commonly affects the mouth, skin folds, and genitals.

These infections are widespread and often overlooked because they are common and treatable, although recurrent cases signal deeper public health gaps.

Invasive and Deep Fungal Infections

These are far more dangerous and often fatal without quick diagnosis:

• • • Histoplasmosis: a lung infection caused by Histoplasma, usually from soil exposure.
    • Aspergillosis: inhalation of Aspergillus spores, especially dangerous for people with lung disease.
    • Candidemia: bloodstream infection that is life-threatening and common in ICU patients.
    • Mucormycosis: a fast-spreading fungal infection known for its devastating outbreaks, particularly after Covid-19.

Invasive infections demand technical expertise and advanced laboratory capabilities—resources that are unevenly distributed across India.

What Is Driving the Increase?

• • Climate Change: Rising temperatures and humidity create ideal conditions for fungal growth. Warmer environments favour tougher, more resistant fungi, which can survive in soil, air, and built spaces. This allows their spores to spread more easily and persist longer.
  •  Urbanisation and Pollution: Dust from construction, poor indoor ventilation, and high levels of air pollution allow fungal spores to circulate freely in crowded cities. Inhalation risks increase, especially for people with respiratory illnesses.
  •  Antibiotic Misuse: Overuse of antibiotics disrupts the body’s natural bacterial ecosystem, allowing fungi, particularly Candida species, to multiply unchecked. The post-Covid period, with high antibiotic consumption and weakened immunity, has intensified this challenge.
  •  Immunity Decline: People recovering from Covid-19, individuals with diabetes, cancer patients, and others with weakened immune systems are more susceptible to invasive fungal infections such as mucormycosis, candidemia, and aspergillosis.

Why Dedicated Fungal Research Still Matters:

Fungal diagnostics require specialised skill sets that are not interchangeable with routine bacterial or viral testing.

1. Complex Diagnostics: Unlike many bacterial or viral tests, fungal diagnosis depends heavily on:

• • • specialised culture media,
    • molecular tools such as PCR,
    • antigen tests like cryptococcal assays,
    • and expertise in identifying rare species.

A recent review of microbiology labs in Odisha showed worrying gaps:

• • • Fewer than half had antifungal susceptibility testing.
    • Less than 15% conducted cryptococcal antigen tests—despite its essential WHO classification.

This under-recognition leads to under-reporting, which in turn results in chronic underinvestment.

2. Rising Antifungal Resistance: Misuse of antifungal medicines in agriculture and human health has accelerated resistance. Azole resistance in Aspergillus and Candida species is becoming a global concern, reducing treatment options.

3. Shortage of Trained Mycologists: India has very few formally trained medical mycologists. Without a clear institutional strategy, this expertise gap may widen.

4. Importance of Early Detection: Late diagnosis significantly increases mortality in invasive fungal infections. Dedicated centres improve turnaround time and accuracy, especially in tertiary hospitals.

Building a Strong National Fungal Surveillance System:

India needs a surveillance strategy that goes beyond clinical reporting. Fungal pathogens evolve in the environment long before they infect humans. Therefore, surveillance must be ecological, predictive, and continuous.

Proposed Multi-Tiered Diagnostic Model: Public health experts suggest a pyramid structure:

1. District Hospitals

• • • KOH microscopy
    • Basic fungal cultures
    • Affordable rapid antigen tests

2. State-Level Laboratories

• • • PCR-based fungal panels
    • Drug resistance testing

3. Regional Centres of Excellence

• • • Genome sequencing
    • Molecular epidemiology
    • AI-assisted microscopy
    • Research collaborations

ICMR’s Position: Strengthening Through Integration:

ICMR maintains that lab integration is part of a broader effort to strengthen capacity for viruses, bacteria, fungi, and parasites under a unified system following the One Health approach. According to the council:

• • • fungal labs are not being downgraded,
    • their scope has been expanded,
    • and new IRDLs are being established across states.

Each IRDL requires ₹10–16 crore over five years, covering equipment, staff, and consumables. ICMR argues that integrated funding will ensure sustainability rather than fragmentation.

Additionally, the mycology verticals within IRDLs remain connected to:

• • • MycoNet,
    • the Antimicrobial Resistance Surveillance Network (AMRSN),
    • and NARS-Net for respiratory pathogens.

What India Must Prioritise:

• • Strengthen Laboratory Infrastructure: Advanced mycology labs should serve as hubs to train district and state hospitals, run proficiency testing, and maintain isolate repositories.
  • Scale Up Antifungal Stewardship: Hospitals must monitor prescriptions, restrict irrational use, and implement audits similar to antimicrobial stewardship programmes.
  • Improve Public Awareness: People must understand risk factors—damp spaces, construction dust, cyclone-hit areas—and recognise early symptoms.
  • Expand Training: Medical colleges should integrate more structured mycology training to counter the severe shortage of specialists.
  • Invest in Research: Genomic studies, drug-resistance tracking, and ecological mapping of fungi must be scaled up before outbreaks hit.

Conclusion:

India’s fungal disease burden is no longer an invisible issue. As climate change, pollution, antibiotic misuse, and weakened immunity converge, fungal infections are emerging as a long-term public health challenge. While ICMR’s integrated lab model aims to create a stronger, unified diagnostic ecosystem, the country must ensure that dedicated fungal research and expertise remain protected and well-funded. Timely diagnosis, strong surveillance, trained specialists, and sustained investment will determine whether India can stay ahead of this evolving threat or face escalating morbidity and mortality in the years to come.