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Antifungal resistance: more research needed We welcome the efforts of the Antimicrobial Resistance Funders’ Forum, led by the UK Medical Research Council, to coordinate approaches for research on antimicrobial resistance, as reported by Geoff Watts (Aug 2, p 391).1 However, we wish to voice our concerns at the apparent restriction of these efforts to antibacterial resistance. Although undoubtedly an area of major global concern, bacteria are not the only microbes for which resistance is a growing threat to human health and wellbeing. In particular, drug resistance in fungal pathogens needs urgent research attention.2

Invasive fungal disease aff ects more than 2 million people worldwide and now accounts for more deaths annually than either tuberculosis or malaria.3 Mortality rates for invasive fungal disease are generally higher than for bacterial disease, and despite new antifungals, can approach 75% in specifi c clinical settings.4 Although treatment options are available, the incidence of clinically relevant resistance is increasing; the triazole class of drugs are the only effective oral treatment for invasive aspergillosis and pan-azole resistance is increasingly detected.5 Alarmingly, triazole resistance in Aspergillus species recovered from rural locations has recently been reported in the environment in the UK.6 Despite this fi nding, fungal disease and biology receives less than 2% of the UK’s annual public and philanthropic infection biology research budget, and less than £1·5 million from these sources is spent specifically on antifungal resistance research every year.7 The UK has a strong research base in fungal biology, recently strengthened by a Wellcome Trust

Strategic Award, and unique strengths in the clinical aspects of mycology (eg, British Society for Medical Mycology, UK Clinical Mycology Network, and the National Aspergillosis Centre). We urge the Antimicrobial Resistance Funders’ Forum to take advantage of this expertise and advocate strongly for the inclusion of antifungal resistance in the forthcoming funding rounds.DWD holds founder shares in F2G (biotechnology company specialising in antifungal research and development), and has been paid for talks on behalf of Astellas, Merck, Gilead, and Pfi zer. All other authors declare no competing interests.

Rosemary A Barnes, Neil A R Gow, David W Denning, Robin C May, *Ken Haynes, on behalf of the British Society of Medical Mycologyk.haynes@exeter.ac.uk

University of Cardiff , Cardiff , UK (RAB); University of Aberdeen, Aberdeen, UK (NARG); University of Manchester, Manchester, UK (DWD); University of Birmingham, Birmingham, UK (RCM); and University of Exeter, Exeter EX4 4QD, UK (KH)

1 Watts G. UK declares war on antimicrobial resistance. Lancet 2014; 38: 391.

2 Vermeulen E, Lagrou K, Verweij PE. Azole resistance in Aspergillus fumigatus: a growing public health concern. Curr Opin Infect Dis 2013; 2: 493–500.

3 Brown GD, Denning DW, Gow NA, Levitz SM, Netea M, White TC. Hidden killers: human fungal infections. Sci Transl Med 2012; 4: 165rv13.

4 Falagas ME, Apostolou KE, Pappas VD. Attributable mortality of candidemia: a systematic review of matched cohort and case-control studies. Eur J Clin Microbiol Infect Dis 2006; 2: 419–25.

5 Bueid A, Howard SJ, Moore CB, et al. Azole antifungal resistance in Aspergillus fumigatus: 2008 and 2009. J Antimicrob Chemother 2010; 6: 2116–18.

6 Bromley MJ, Muijlwujk G, Fraczek MG, et al. Occurrence of azole resistant species of Aspergillus in the UK environment. J Glob Antimicrob Resist 2014; published online June 21. http://dx.doi.org/ 10.1016/j.jgar.2014.05.004.

7 Head MG, Fitchett JR, Atun R, May RC. Systematic analysis of funding awarded for mycology research to institutions in the UK, 1997–2010. BMJ Open 2014; 4: e004129.

risk areas (PrEP was not provided to men in this analysis either). This result corresponds with earlier work.2 If a greater budget was available, then it might become aff ordable to provide more interventions to more of the population, but our focus was on finding a constructive way to think about the real dilemmas and opportunities currently facing HIV prevention programmes.

Since HIV is spread between men and women, it is not the case that only the immediate recipients of an intervention will benefit. In the focused scenario presented, 40% of infections in women who are not sex workers were averted. The analysis was constructed under the assumption that the aim of the programme was to reduce HIV incidence. A political recommendation might well include many other factors and objectives and results might be modified if such additional constraints were included. Indeed, the Kenya HIV Prevention Roadmap launched in June deliberately makes recommendations for investments in HIV prevention in women.3

TBH received grants and personal fees from the Bill & Melinda Gates Foundation during the conduct of the study; grants and personal fees from World Bank; grants from UNAIDS, and The Rush Foundation; personal fees from the University of Washington, New York University, Children’s Investment Fund Foundation, and Global Fund outside of the submitted work. All other authors declare no competing interests.

*Sarah-Jane Anderson, Malayah Harper, Nduku Kilonzo, Timothy B Halletsarah-jane.anderson@imperial.ac.uk

Department of Infectious Disease Epidemiology, Imperial College London, London W2 1PG, UK (S-JA, TBH); UNAIDS Secretariat, Geneva, Switzerland (MH); National Aids Control Council, Nairobi, Kenya (NK)

1 Anderson S-J, Cherutich P, Kilonzo N, et al. Maximising the eff ect of combination HIV prevention through prioritisation of the people and places in greatest need: a modelling study. Lancet 2014; 384: 249–56.

2 Gomez GB, Borquez A, Case KK, Wheelock A, Vassall A, Hankins C. The cost and impact of scaling up pre-exposure prophylaxis for HIV prevention: a systematic review of cost-eff ectiveness modelling studies. PLoS Med 2013; 10: e1001401.

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Syrian refugees in Turkey: eff ects on intensive care

Since the civilian war in Syria began, millions of Syrian refugees have migrated to neighbouring countries.

3 Ministry of Health, National AIDS Control Council, National STI and AIDS Control Programme. Kenya HIV Prevention Revolution Road Map. 2014. http://www.nacc.or.ke/attachments/article/418/Kenya_HIV_Prevention_Revolution_Road_Map.pdf (accessed Sept 25, 2014).

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1428 www.thelancet.com Vol 384 October 18, 2014

italisation costs recently, although the price of medicine is established by the government rather than the market itself, and the process of price development has been non-transparent until now. The price of drugs and supplies is high, which can be a source of corrupt income, as recently exemplified by the China branch of British drug maker GlaxoSmithKline, which was convicted of bribing officials, medical associations, hospitals, and doctors, and will have to pay the Chinese Government ¥3 billion (US$489 million).2 The price of medical services themselves is too low, meaning that the public forget that it is the medical personnel who provide them with a professional medical service. If people think that health-care workers are selling drugs and equipment, they can think that they are corrupt. Because hospitals do not provide enough protection for doctors, violence against doctors has become a way for people to relieve their dissatisfaction.

The deteriorating doctor–patient relationship has a substantial negative effect on both health-care workers and patients. The price of Chinese medicine should be transparent. An increase in the medical service price and a reduction of the price of medical non-service could help to improve the doctor–patient relationship in China.We declare no competing interests.

Mian Xie, *Xuemei Zhangswinters@sina.com

Department of Anesthesiology, West China Hospital, Sichuan University, Sichuan Province, China (MX); and Department of Ultrasound, Chongqing Health Center for Women and Children, Chongqing, Chongqing City, China 400010 (XZ)

1 Violence against doctors: why China? Why now? What next? Lancet 2014; 383: 1013.

2 Yan S. China fi nes GlaxoSmithKline nearly $500 million for bribery. Sept 19, 2014. http://money.cnn.com/2014/09/19/news/china-gsk-bribery (accessed Sept 19, 2014).

Health-care pricing in ChinaIn China, violence against medical staff has drawn worldwide attention, and occurs for many reas ons, as discussed previously.1 As first-line health-care workers in China, we think the absence of transparency and marketisation of Chinese hospitalisation costs are important reasons for the violence.

The Chinese Government has been trying to achieve more transparency and marketisation of Chinese hosp-

Asso

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s Pre

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According to the Disaster and Emer-gency Management Agency of the Turkish Government, by July 18, 2014, 1 000 103 Syrian refugees were regist ered in and outside of the 22 camps in 11 provinces in Turkey.1 By April 19, 2014, 43 197 surgical operations, excluding caesarean sections and spontaneous deliveries, were done in the Syrian refugee population.2 Thou sands of seriously injured trauma patients from Syria were brought to Turkey for emergency operations and postoperative intensive care.

Adana Numune Training and Research Hospital provides tertiary care to a large population, and is located very close to the Syria–Turkey border. Between June 1, 2012, and July 15, 2014, 234 233 Syrian patients were admitted to the hospital, with 2842 of them staying in hospital and 1812 surgical procedures being done. The wards have been overstretched as surgical care demand has increased—mostly orthopaedic procedures.3

During the same period, 280 Syrian patients were treated in intensive care units. Among them, 80 trauma patients were admitted to surgical intensive care units. The most common injury was gunshot wounds (63·8%). The mean APACHE II score on admission was 15·7. 61·3% of patients were operated on after admission. The rest of the patients had non-operative intensive care. The mean length of stay in intensive care units was 12 days. Various complications developed in 75% of patients, and the mortality rate was 55% (n=44). The mean cost per admitted patient has been estimated to be 3723 Turkish liras.3 As the number of seriously injured patients who need intensive care increases, the cost of care will inevitably increase. Besides the fi nancial cost, health-care providers currently have a large number of patients who they have diffi culty communicating with bec ause of a language barrier, who

have no medical records, and who are socially and psychologically aff ected.4

The Turkish people and Government are committed to providing social and medical care for Syrian refugees. However, this additional burden and the excessive demands on the health-care system have the potential to negatively aff ect Turkey’s health-care resources. The inter-national community has to be aware of this and assist Turkey’s efforts to provide adequate health care to Syrian refugees. We declare no competing interests.

Hatice K Ozdogan, Faruk Karateke, *Mehmet Ozdogan, Salim Satarmehmetozdogan01@gmail.com

Department of Anesthesiology and Reanimation (HKO), Department of General Surgery (FK), and Department of Emergency Medicine (SS), Adana Numune Training and Research Hospital, Adana, Turkey; and Bahcesehir University, Gaziantep Medicalpark Hospital, General Surgery, Sehitkamil Mah, Gaziantep, 27060 Turkey (MO)

1 Disaster and Emergency Management Agency of the Turkish Government. https://www.afad.gov.tr/TR/IcerikDetay1.aspx?IcerikID=747&ID=16 (accessed Aug 27, 2014).

2 Disaster and Emergency Management Agency of the Turkish Government. Report on population movements from Syria to Turkey. Ankara: Disaster and Emergency Management Agency of the Turkish Government, 2014.

3 Karakuş A, Yengil E, Akkücük S, Cevik C, Zeren C, Uruc V. The refl ection of the Syrian civil war on the emergency department and assessment of hospital costs. Ulus Travma Acil Cerrahi Derg 2013; 19: 429–33.

4 Döner P, Ozkara A, Kahveci R. Syrian refugees in Turkey: numbers and emotions. Lancet 2013; 382: 764.