Development of serology diagnosis of chronic aspergillosis and histoplasmosis in Indonesia Chronic pulmonary aspergillosis mimics pulmonary tuberculosis, and can follow it. An estimated 1.2 million are affected worldwide, and ~85,000 in Indonesia. Histoplasmosis is endemic in Indonesia but no burden estimate is possible as the only tools for diagnosis are culture and histopathology, which are slow and insensitive. The burden of histoplasmosis is not known in the world or in Indonesia, partly because of poor diagnostic tools. Chronic pulmonary histoplasmosis complicates other lung disease, notably COPD, and mimics tuberculosis.  Both fungal infections are misdiagnosed as 'smear negative TB'. These patients are often investigated for MDR TB, and treated inappropriately with anti-tuberculous medication. The 5 year mortality of chronic pulmonary aspergillosis is 75-80%, but reduced to ~40% with antifungal therapy.   In this grant we will: 1. Develop and evaluate in the UK and Indonesia the world's first point of care Aspergillus antibody screening assay to enable the diagnosis of chronic pulmonary aspergillosis. 2. Develop and evaluate in Indonesia a new Histoplasma antibody assay to enable the diagnosis of acute and chronic pulmonary histoplasmosis. 3. Identify for the first time 'hot spots' for histoplasmosis in Indonesia, so as to develop a sera bank for evaluating the antibody test, to support subsequent commercialisation.  We have access to highly purified recombinant Aspergillus fumigatus proteins, that have been used in an ELISA format to detect Aspergillus IgG antibody with a 97% sensitivity and a 90% specificity. In Manchester at the Mycology Reference Centre laboratories and National Aspergillosis Centre, we will use these proteins to develop a lateral flow device utilising our huge sera bank from patients with chronic pulmonary aspergillosis and other respiratory disorders to optimize performance against a gold standard assay (ImmunCap). We will then utilize the assay in field trials in the UK as a prospective screen for Aspergillus antibody in the laboratory, and in Jakarta in a cross-sectional study (n=600 patients) and a longitudinal study (n= 200 patients) both in patients with PTB. In the UK, the gold standard assay will be the ImmunoCap and in Jakarta the Siemens assay. During the field trials we will open up commercialization discussions.   In Jakarta, we will identify additional immunodominant proteins in Histoplasma capsulatum yeast phase. We will standardize growth and purification conditions for supernatant production to optimize sensitivity and specificity of a new ELISA Histoplasma antibody test using sera from non-immunocompromised patients with histoplasmosisand controls. We will further validate this assay on additional sera (see Aim 3), to optimize performance. We will prepare the materials for subsequent production of recombinant proteins for a second generation antibody test.    In parallel with this laboratory activity, we will undertake several skin testing surveys with histoplasmin in Jakarta and its surrounding cities (Bogor, Depok, Tanggerang and Bekasi - Jabodetabek), Bandung, Semarang, Surabaya, Bali, and Manado. This will be done by setting up a new Histoplasmosis network in Indonesia. We need to identify more sera for test validation and cutoffs, and the simplest way to do this in Indonesia, is to pinpoint areas of high endemicity and then actively seek out patients in those areas with chronic pulmonary histoplasmosis, through existing TB clinics, focusing on those with 'smear negative' TB. So in areas of >10% local skin test positivity, we will ask the local participating clinicians to identify possible patients and submit fungal diagnostic samples. Fungal culture of sputum or bronchoscopy fluid will be the gold standard for diagnosis. The Newton Fund builds research and innovation partnerships with developing countries across the world to promote the economic development and social welfare of the partner countries.