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The Medical Mycological Iceberg

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The Medical Mycological Iceberg A STUDY OF INCIDENCE AND PREVALENCE The Medical Mycological Iceberg LIBERO AJELLO, Ph.D. Cryptococcus neoformans in India ink preparation. 1175X ANY attempt to quantitate the impact of the coses are not compiled regularly by any nation or mycoses Ion public health is doomed to fail- organization. Information on the occurrence of ure. Since they are not classified among the notifi- mycoses is further obscured by commercial se- able diseases, hard data on their incidence and crecy, which makes it difficult to obtain or to prevalence, as well as information on the morbid- publish figures on the dollar and cents value of the ity and mortality they cause, are either fragmen- antifungal pharmaceutical preparations marketed. tary or simply not available. Consequently, the public is apathetic, and public The situation that confronts us can well be lik- health organizations have not given any truly sig- ened to an iceberg. The only visible portions of nificant or sustained support to programs to con- the vast bulk of the mycoses problem are a few trol these diseases. peaks and crags. Even these are only dimly re- This report of the incidence and prevalence of vealed at best by the scattered reports that are mycoses was compiled from numerous case re- available on the incidence and prevalence of fun- ports, reviews, and surveys published by investiga- gus infections. tors throughout the world. Data on the number of persons affected by my- Cutaneous Mycoses Dr. Ajello is chief, Mycology Section, Laboratory It should be obvious to all that the cutaneous Division, Center for Disease Control. This article mycoses do, indeed, constitute a serious public is based on a paper presented at the International health problem. Their toll in terms of suffering, Symposium on Mycoses, Washington, D.C., Feb- disability, man-hour losses, psychological trauma, ruary 24-26, 1970. It is also published in the pro- and monetary expenditure is much greater than is ceedings of the meeting by the Pan A merican generally realized. Among this group of diseases are Health Organization (Scientific Publication No. some that approach dental caries and the common 205). Tearsheet requests to Dr. Libero Ajello, cold in both incidence and prevalence. Untold Center for Disease Control, Atlanta, Ga. 30333. numbers of people throughout the world are af- May 1971, Vol. 86, No. 5 437 flicted by the specialized fungi that invade and than 90 percent of those with dysidrotic lesions on destroy skin, hair, and nails. the soles. Tinea versicolor. In tropical regions of the Blank and co-workers (9) reported that skin world, tinea versicolor is widespread. Millions of diseases among the American troops in Vietnam persons are infected in Africa, Asia, and Latin are the commonest cause of disability. In the America. For ex-ample, in the Democratic Repub- Mekong Delta, for example, 77 percent of 209 lic of the Congo, Vanbreuseghem (1) noted that men required hospitalization for foot infections. this disease was the most prevalent of all the my- The most frequent etiologic agent of the derma- coses. The disease is rife among the inhabitants of tomycoses was Trichophyton mentagrophytes. the coastal areas of Mexico, the so-called tierras Tinea capitis. Despite such optimistic state- calientes, and Gonzalez-Ochoa (2) has observed ments as "Ringworm of the scalp, a scourge of a 50 percent rate of infection in the general popu- childhood for more than 2,000 years, has finally lation. yielded to treatment with griseofulvin" (10), this An equally high prevalence of this disease was disease still flourishes in many parts of the world encountered by Marples (3) in Western Samoa. (11-13). It is especially prevalent in the underde- A similar situation must exist throughout Melane- veloped areas of Africa, Asia, and Latin America, sia and Polynesia. Indifference to tinea versicolor where funds for specific medication with griseoful- is universal; many victims are either unaware of vin are not readily available. The prevalence of their infection or are resigned to live with it be- tinea capitis is directly related to the economic cause of limited financial resources and lack of status of the families and of the country in which medical facilities. they live. For example, a survey by Vanbreu- Although tinea versicolor is especially prevalent seghem (14) in Somalia showed a 36 percent in the tropics, it occurs elsewhere as well. Stein's prevaclence among boys 5-10 years of age. In the data (4) show that it is responsible for approxi- Sudan, Mahgoub (15) noted that 17 percent of mately 5 percent of the fungus infections in tem- the students in a boys' boarding school were in- perate regions. Certainly this disease is not un- fected. common in the United States. Dermatologists are The incidence of scalp infections is also high in well acquainted with it and treat many patients. the Middle East and parts of Asia. Rates reached Tinea pedis. Tinea pedis is another cosmopol- itan disease; myriads of cases occur in all coun- tries of the world. In contrast to tinea versicolor, this disease is more widespread in temperate than in tropical areas. As it happens, athlete's foot is virtually unknown in those regions where large numbers of inhabitants go without shoes because of the combined factors of warm climate and low income. In other areas, however, it may affect from 50 to 90 percent of the people in the course of their lives (5). English (6) estimated that up to 70 percent of the general population may have clinical signs of tinea pedis, although only a small percentage of such persons can be proved to have a mycotic infection. In certain population groups, however, the rate of confirmed cases may be high. Hulsey and Jor- dan (7) observed fungus infections in 63 percent of the university students they examined. During World War II, Hopkins and co-workers (8) found lesions in the feet of more than 80 percent of the men on an infantry post. Microscopic studies of the skin revealed fungus elements in 70 percent of Appearance of Malassezia (Pityrosporum?) furtur in skin scraping those who had intertrigo of the toes and in more from a case of tinea versicolor. 1200X 438 HSMHA Health Reports Athlete's foot caused by Trichophyton rubrum (left). Loss of ha.r in circular patches caused by Microsporum audoulnil (right). 23 percent in a home for boys in Poona, India, In a carefully conducted epidemiologic study in (16) and 10 percent in a school in Kashmir (17). New Guinea (23), the social consequences stem- In general, scalp infections in Europe and the ming from tinea imbricata were discovered to be United States are relatively infrequent. As in other profound. The shunning of infected men as pro- parts of the world, however, their prevalence is spective husbands contributes to bachelorhood. greatest among the socially deprived groups. Be- Infected women are married at a later age than ginning in 1960, one of the most extensive surveys uninfected ones, and then most often they become of tinea capitis in history was conducted in Yugo- the second wife of a polygamous husband. In ad- slavia under the direction of Grin (18). A total of dition, infected children and adults are discrimi- 1,782,000 people were screened. Among them, nated against educationally and in employment. 94,296 cases of tinea capitis were diagnosed, cor- Lack of funds for mass treatment and control responding to an infection rate of 5.3 percent. In programs prevents reduction or elimination of the some villages, morbidity was as high as 8.6 per- disease and its attendant social problems. cent. In Greece, a survey (19) revealed a 1.4 Tinea corporis. Tinea corporis and nail infec- percent level of infection among 4,701 children tions are quite prevalent throughout the world. examined. In one village, however, the incidence Data on their freauency are not available, but the was 17 percent. A Washington, D.C., survey in general opinion is that these conditions are not 1959 (20) showed that 0.8 percent of the elemen- uncommon and some, such as nail infections, are tary school children were infected, and in an At- increasing in prevalence (10). lanta, Ga., study, 2.6 percent of 1,753 school chil- An indirect estimate of the size of the cuta- dren had tinea capitis (21 ). neous mycoses infections can be obtained through Although the tineas are not usually disabling, data on expenditures for antifungal preparations. they do constitute an important public health Information obtained in 1960 (24) revealed that problem. In many countries, children with ring- $25 million had been spent for ringworm medica- worm of the scalp are barred from school until tions during the previous year. More recently, the they are cured. Thus, at a critical age in their Wall Street Journal of March 6, 1968, quoted the lives, they are deprived of their educational rights. 1966 sales of griseofulvin at $6,700,000. If we In addition, they may be subjected to psychologi- assume, conservatively, that $25 million has been cal traumas by being forced to wear distinctive spent in the United States for ringworm medica- headwear and by being shunned by their peers tions every year since 1959, their dollar value to and by neighborhood families. date in this country alone comes to $275 million Tinea imbricata. The social consequences of for the past 11 years. Trichophyton concentricum infections in Melane- Subcutaneous Mycoses sia and Polynesia merit special attention. Tinea im- Under the heading of subcutaneous mycoses the bricata is well established in many islands in the following three diseases are discussed: chromo- southern part of the Pacific Ocean. Infection rates blastomycosis, mycetomas, and sporotrichosis.
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