The global annual burden of fungal diseases, ranging from minor skin and mucous membrane infections to serious life-threatening systemic diseases, has been estimated at billions, with millions estimated to have severe infections.¹ Ensuing mortalities from life-threatening fungal infections have also been reported to be over a million cases annually worldwide.¹ Though the mortality because of fungal diseases is comparable to those from other diseases targeted in the sustainable development goals (SDG), such as tuberculosis and malaria, fungal diseases, however, are relatively neglected by the general public and health authorities in many countries across the world.²

Very little attention is focused on the control and management of fungal infections, and people in many communities are oblivious of the disease burden, progression and ramifications. A recent report by the Centers for Disease Control and Prevention (CDC), aimed at guiding public health educational efforts on invasive fungal diseases (IFDs) in America, showed a low awareness across all fungal diseases. This low awareness varied by disease from 4.1% for blastomycosis to 24.6% for candidiasis. More than two-thirds (68.9%) of respondents had never heard of any of the diseases.³

Despite these alarming statistics, research funding and public health policies continue to overlook fungal diseases, diverting more resources toward bacterial and viral infections, and today there are still significant gaps in fungal disease diagnosis, surveillance and management, particularly in low- and middle-income countries (LMICs).² Many healthcare professionals are also unaware of the latest advancements in fungal diagnostics and treatment, further compounding the challenges in tackling these infections effectively.³

Accounting for over 16% of the global population, Africa is the second most populated continent in the world⁴ and has a significant proportion of underlying risk factors for serious fungal diseases such as human immunodeficiency virus (HIV), diabetes and tuberculosis (TB).^5,6,7,8,9 Human immunodeficiency virus prevalence in Africa has not only added to the burden of tuberculosis but has also influenced the burden of cryptococcal infections and Pneumocystis jirovecii pneumonia.^5,9,10 Immunosuppression caused by HIV weakens host defences, making this population highly vulnerable to opportunistic fungal infections.⁶ Sub-Saharan Africa currently has the highest global burden of cryptococcal meningitis.¹⁰ It had been reported by the CDC that across all ages, candidaemia rates were approximately twice as high among Black people compared with other races and ethnicities.¹¹

Developing countries such as Nigeria are likely to suffer a more intense negative impact concerning morbidity and mortality from severe fungal diseases because they have a high population of at-risk groups and are more resource limited.^3,9,12 Nigeria, as the seventh most populated country in the world and the most populated country in Africa,⁴ has been estimated to have one of the highest burdens (11.8%) of invasive fungal infections here in Africa.⁹ The country has the sixth highest burden of tuberculosis in the world⁵; this condition is the most significant risk factor for chronic pulmonary aspergillosis.¹³

Unfortunately, the burden of fungal diseases in LMICs like Nigeria is exacerbated by the lack of awareness and widespread surveillance systems, leading to underreporting from the populace and misdiagnosis from the healthcare front. In many healthcare facilities, fungal infections are often mistaken for bacterial infections, resulting in inappropriate antibiotic use and worsening antimicrobial resistance. Furthermore, inadequate access to antifungal medications because of high costs and limited supply chains further contributes to poor health outcomes in affected populations.⁹

Understanding the level of awareness and public perception regarding diseases of public health significance is essential for developing effective health communication and intervention strategies. Surveys that assess awareness and perception offer critical insights into prevailing knowledge gaps, misconceptions and community attitudes, thereby guiding the creation of targeted and culturally sensitive educational interventions. Evidence from successful public health campaigns – such as those addressing TB and HIV – demonstrates that well-informed, media-driven outreach can significantly elevate awareness, even in underserved or low-literacy populations.¹⁴ Building on this model, electronic and social media campaigns can be strategically deployed to raise the profile of IFDs, which have remained largely neglected despite their increasing burden. This survey was conducted by a fungal disease capacity-building and surveillance programme prior to any intervention, with the goal of determining the level of awareness and perception of IFDs among the general populace in Nigeria.

A total of 1241 members of the general populace in Lagos, Oyo and Cross River states, Nigeria, were involved in this study. The mean age of the participants was 37.1 ± 16.1 years. Just over half of the participants were female (627 [50.5%]). The highest frequency of participants was single (636 [51.2%]), had tertiary education as their highest educational level (538 [43.4%]) and had their household income within the lowest range of less than 30 000.00 naira ($40.00) a month (320 [25.8%]). Over two-thirds of the participants (72.0%) had no chronic diseases, and over three-quarters of the participants (75.3%) were not on any long-term medication. Over half of the participants (644 [51.9%]) had never visited a medical doctor in the past 12 months (Table 1).

Fewer than one-fifth of the participants (240 [19.3%]) were aware of IFDs (Table 1). Awareness of the various diseases was poor, with the least recognised being mucormycosis (58 [4.7%]), followed by histoplasmosis (69 [5.6%]), cryptococcosis (77 [6.2%]), aspergillosis (98 [7.9%]) and invasive candidiasis (121 [9.8%]) (Table 1). The highest frequency of participants was unsure if they knew someone who had a history of fungal disease (462 [37.2%]), if fungal diseases were not serious (552 [44.5%]), could cause disfigurement (677 [54.6%]) or could cause blindness (66.3%). They were also unsure if fungal diseases could be fatal (625 [50.4%]), could be treated with antibiotics (653 [52.6%]), were difficult to treat (677 [54.6%]), could complicate HIV or diabetes (60.7%) or could be mistaken for tuberculosis (798 [64.3%]). The highest frequency of respondents (509 [41.2%]) reported that they never had a history of fungal disease. Almost two-thirds of participants (820 [66.1%]) had poor perception of IFDs (Table 2).

Higher educational level was associated with greater awareness in the multivariable models for all fungal diseases, as participants with a tertiary education level were much more likely to have awareness of IFDs (adjusted odds ratio [aOR] = 17.082, confidence interval [CI]: 9.269–31.479, p < 0.001), aspergillosis (aOR = 19.401, CI: 6.019–62.533, p < 0.001), invasive candidiasis (aOR = 41.988, CI: 10.251–171.990, p < 0.001), cryptococcosis (aOR = 8.967, CI: 3.488–23.054, p < 0.001), mucormycosis (aOR = 34.697, CI: 4.723–254.907, p < 0.001) and histoplasmosis (aOR = 16.668, CI: 3.974–69.914, p < 0.001) than those with lower levels of education. Female participants were more likely to be aware of invasive candidiasis than male participants (aOR = 1.539, CI: 1.030–2.300, p = 0.036), and participants with chronic diseases were twice as likely to have awareness of invasive candidiasis than those with no history of chronic disease (aOR = 2.048, CI: 1.366–3.069, p = 0.001). Participants who earned higher within the range of 101 000.00 naira to 300 000.00 naira monthly were over twice more likely to have awareness of histoplasmosis than those earning within the lowest range of less than 30 000.00 naira monthly (aOR = 2.241, CI: 1.037–4.843, p = 0.040) (Table 3).

Participants with chronic diseases were twice as likely to have awareness of histoplasmosis than those with no history of chronic disease (aOR = 2.228, CI: 1.249–3.976, p = 0.007). There was a convex relationship between the participants’ history of long-term medications being used and their awareness of histoplasmosis, as those who were not on any long-term medications (aOR = 4.096, CI: 1.198–14.001, p = 0.025), those who were on three to five medications (aOR = 8.178, CI: 2.042–32.749, p = 0.003) and those on six or more medications (aOR = 8.170, CI: 1.130–59.074, p = 0.037) were more likely to be aware of histoplasmosis compared with those who were on one to two medications (Table 3).

Higher educational level was also associated with better perception of fungal diseases, as participants with secondary (aOR = 2.116, CI: 1.005–4.454, p = 0.049), tertiary (aOR = 5.420, CI: 2.615–11.234, p < 0.001) and postgraduate education (aOR = 5.372, CI: 2.485–11.616, p < 0.001) as their highest educational level were more likely to have good perception compared with those with no formal education. Participants who were single (aOR = 6.772, CI: 1.891–24.252, p = 0.003), married (aOR = 4.947, CI: 1.435–17.052, p = 0.011) and widowed (aOR = 4.384, CI: 1.032–18.627, p = 0.045) were more likely to have good perception compared with those who were divorced. Participants who had visited the doctor three to five times in the past 12 months were about one and a half times more likely to have a good perception of fungal diseases (aOR = 1.485, CI: 1.009–2.185, p = 0.045) compared with those who never visited a doctor in the past 12 months (Table 4).

Serious fungal infections are associated with high morbidity, mortality and cost of care.² Community awareness of invasive fungal infections was low, with only less than a fifth of the participants in this study having awareness of any one or more of the IFDs. This is despite the high burden of infection in this population, where it has been estimated that up to 12% of the population suffer from a serious fungal infection annually.⁹ Our finding in the general populace is likely a reflection of the general low level of awareness of fungal infections in our setting. An earlier study by Oladele et al. had demonstrated such low levels even among medical personnel in the same country.¹⁶

Invasive candidiasis, which was the IFD with the highest level of awareness (9.8%), still had less than a tenth of the participants reporting their awareness of it. This pattern of awareness is similar to a recent study on awareness of fungal diseases in America, where public awareness was seen to be low. In that study, the IFD with the highest level of public awareness was similarly candidiasis (24.6%).³ It was purported that the relatively higher awareness of candidiasis compared with other fungal infections was a result of its frequent involvement in vulvovaginal infections, which is a common infection causing millions of outpatient visits nationwide.^1,3 In our study, perception of fungal disease was also low, with about two-thirds (820 (66.1%)) having poor perception. This poor awareness and perception of serious fungal infections may have a negative effect on the health-seeking behaviour of infected individuals in the country. Those unaware of these conditions may not access medical care early enough, allowing such diseases to thrive, thus increasing the burden of serious fungal infections in the populace. Our study revealed that higher educational level was associated with greater awareness for all fungal diseases and associated with good perception of fungal diseases. Furthermore, those with frequent doctor visits demonstrated higher awareness levels. Participants who had visited a doctor six or more times in the past year had the highest awareness of IFDs (27.8%) compared to those who had not visited a doctor (18.2%). This suggests that healthcare encounters play a crucial role in increasing awareness of fungal diseases, emphasising the importance of patient education in clinical settings.

Factors such as occupation and endemicity have been suggested to influence awareness of serious fungal infections³ and education somewhat influences occupational class and knowledge of endemic diseases. These might explain the observed higher awareness and perception in the educated population. However, this associative explanation is limited because other factors such as experience of any of the disease(s), knowledge of an infected person(s) or health literacy, which are difficult to measure, may be responsible for our findings.

Despite the widespread dearth of awareness and the critical need to improve awareness, there is a scarcity of literature assessing the awareness and perception of fungal infections in various populations. Such data are important for needs assessment and planning of intervention to ensure that there is adequate awareness and early diagnosis and treatment. There need to be concerted efforts to improve public awareness and knowledge in order to prevent and control IFDs. This brings to the fore the role of international days set aside for awareness creation. One such initiative is the Fungal Disease Awareness Week, which emphasises early detection and life-saving treatment of serious fungal infections.¹⁷ Another is the World Aspergillosis Day, which raises awareness of aspergillosis, a fungal infection with varying manifestations.¹⁸ It is quite commendable that the most recent World Aspergillosis Day was dedicated to raising the awareness and knowledge and highlighting the experiences of the general population living with this infection.¹⁹

In recent years, various initiatives have emerged globally to promote awareness of fungal diseases. Notably, African Fungus Day has helped to highlight the significance of fungal infections across the continent through regional collaboration and public outreach campaigns.²⁰ Additionally, the Global Action for Fungal Infections (GAFFI) initiative, Fight Fungal Infections, continues to support awareness and advocacy efforts worldwide.²¹ Educational programmes like ‘Fungi Connect’, targeted at children and young people, have also played a role in fostering early understanding and interest in fungal diseases through engaging learning tools and activities.²²

Awareness creation in LMICs such as Nigeria still has a long way to go in spite of these laudable measures. A major obstacle to raising awareness and reducing the burden of fungal infections is lack of funding. Fungal infections are grossly neglected and ranked low on the priority for funding by most governments and prospective donors even though there is a growing population of susceptible individuals and a threat to public health posed by these diseases.²³ It is expected that advocacy efforts such as those of medical mycology societies will result in improvement in funding opportunities for fungal infection awareness, diagnosis and management.²⁴

The role of mass media, particularly digital platforms, in shaping health perceptions cannot be overstated. In recent years, social media has proven to be a powerful tool in promoting awareness about various infectious diseases, from Ebola to coronavirus disease 2019 (COVID-19).¹⁴ Leveraging these platforms to educate the public on fungal infections could bridge the awareness gap, foster early recognition of symptoms and encourage timely medical intervention. Community outreach programmes, integration of fungal disease education into primary healthcare systems and multilingual health promotion campaigns can also play a significant role in reaching diverse populations.¹⁶

Collaboration with community leaders, healthcare providers and local media outlets could enhance outreach efforts and ensure that accurate, accessible information reaches a broad audience. Furthermore, integrating IFD awareness programmes into school curricula, particularly in secondary and tertiary institutions, may foster greater understanding and encourage preventive practices from younger ages. The findings from this survey will also serve as a baseline for comparison with future surveys.

Awareness and perception of IFDs in Nigeria are low. The low level of awareness and perception of fungal infections requires determined efforts through education, advocacy and funding to ensure fungal infections are identified early and adequately controlled. This study highlights the critical need for increased public health awareness and education on IFDs in Nigeria. Recognising this crucial gap in awareness and perception of IFDs, the Fungal Diseases Surveillance Program Committee has initiated a targeted social media campaign (#ThinkFungal). This campaign is strategically designed to first engage clinicians – who play a pivotal role in early detection and management – and subsequently reach the general public, focusing on the promotion of early hospital presentation at the onset of symptoms to improve overall outcomes. By leveraging the wide reach of digital platforms, the campaign aims to improve awareness, promote timely diagnosis and ultimately reduce the morbidity and mortality associated with these often-overlooked infections.