Can improved surveillance and treatment access reduce the burden of cryptococcal disease in South Africa?

Cryptococcal disease is a serious fungal infection caused by Cryptococcus species, most commonly affecting people with weakened immune systems. In individuals living with HIV, particularly those with advanced disease, the infection can spread to the brain and cause cryptococcal meningitis, a life-threatening condition if not diagnosed and treated early.

In South Africa, cryptococcal disease remains a major public health concern despite expanded access to antiretroviral therapy (ART). Late HIV diagnosis, interruptions in treatment, and challenges in linking patients to care continue to result in many individuals presenting with advanced immunosuppression, where the risk of severe opportunistic infections is highest.

While routine surveillance provides national estimates of disease burden, it often does not capture detailed information on how patients present, the treatments they receive, and their outcomes. Laboratory-based surveillance, such as the GERMS-SA surveillance programme, addresses this gap by linking confirmed cases to clinical and treatment data, offering a clearer picture of disease patterns and care across provinces.

The objective of this study was to describe the epidemiology, including clinical characteristics, antifungal treatment, and outcomes, of laboratory-confirmed cryptococcal disease reported through the GERMS-SA surveillance programme in the Eastern, Northern, and Western Cape provinces of South Africa between 01 January 2022 and 31 December 2024.

Materials and Methods

This was a descriptive study using data from the GERMS-SA national laboratory-based surveillance programme, which monitors laboratory-confirmed cases of cryptococcosis reported by both public and private clinical microbiology laboratories across South Africa.

The study population comprised all individuals with confirmed cryptococcal disease diagnosed in the three provinces during the study period. Inclusion criteria for an incident case of cryptococcosis were defined by a positive cerebrospinal fluid (CSF) India ink test, a positive CSF CrAg test or culture of Cryptococcus species from any specimen. Duplicate episodes, defined as any positive laboratory sample within 30 days, were excluded. Cases of isolated cryptococcal antigenaemia (the presence of CrAg in the blood) were not included.

Results

Between 01 January 2022 and 31 December 2024, GERMS-SA detected 3 656 laboratory-confirmed cases of cryptococcal disease across the EC, NC, and WC provinces. Of these, 664 (18%) cases were identified at ESS, where clinical information is routinely collected, while the remaining 2 992 (82%) cases were reported from non-ESS facilities where no clinical data is available.

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