Review article

Epidemiological trends in skin mycoses worldwide

1 2 1
Blanka Havlickova, Viktor A. Czaika and Markus Friedrich
1
Global Clinical Development, Intendis GmbH, Berlin, Germany and 2Dermatology Out-patient Department, Department of Internal Medicine, Helios
Clinic Bad Saarow, Bad Saarow, Germany

Summary Fungal infections of the skin and nails are a common global problem. The high
prevalence of superficial mycotic infections shows that 20–25% of the world s
population has skin mycoses, making these one of the most frequent forms of
infection. Pathogens responsible for skin mycoses are primarily anthropophilic and
zoophilic dermatophytes from the genera Trichophyton (T.), Microsporum (M.) and
Epidermophyton (E.). There appears to be considerable inter- and intra-continental
variability in the global incidence of these fungal infections. Trichophyton rubrum,
T. interdigitale (mentagrophytes var. interdigitale), M. canis, M. audouinii, T. tonsurans and
T. verrucosum are the most common, but the attack rates and incidence of specific
mycoses can vary widely. Local socio-economic conditions and cultural practices can
also influence the prevalence of a particular infection in a given area. For example,
tinea pedis (athlete s foot) is more prevalent in developed countries than in emerging
economies and is likely to be caused by the anthropophilic germ T. rubrum. In poorer
countries, scalp infections (tinea capitis) caused by T. soudanense or M. audouinii are
more prevalent. This review summarises current epidemiological trends for fungal
infections and focuses on dermatomycosis of glabrous skin on different continents.

Key words: Skin mycoses, epidemiology, tinea, Trichophyton, Candida.

Introduction superficial fungal infections are relatively common in

Fungal infections of the skin and nails form the most
numerous and widespread group of all mycoses. The
prevalence of superficial mycotic infections has risen to
such a level in the last decades that skin mycoses now
affect more than 20–25% of the world s population,
making them one of the most frequent forms of
1
infections. The distribution of the dermatomycoses, their
aetiological agents and the predominating ana-tomical
infection patterns vary with geographical loca-tion and a
1,2
wide range of environmental and cultural factors.
Dermatophytes thrive at surface temperatures of 25–28
LC and infection of human skin is supported by warm and
humid conditions. For these reasons,
tropical countries and are exacerbated by the wearing of
occlusive clothing. In addition, the frequency of derma-
tomycoses is greater in communities with low socioeco-
nomic status: crowded living conditions provide multiple
opportunities for skin-to-skin contact and close proximity
to animals, while hygiene may be suboptimal. Moreover,
superficial skin infections show a low ten-dency to self
limitation, and absence of, or poor medical care further
increases the epidemic spread of skin mycoses.
Despite regional characteristics and predispositions for
dermatophyte infections, the spectrum of dermato-phytes
is not static. Booming mass tourism, interna-tional sports
activities and increasing migration mean that less common
or forgotten species are being imported and disseminated.

Correspondence: Blanka Havlickova, Intendis GmbH, Max-Dohrn Straße 10,

Berlin, Germany.
This review attempts to summarise current epide-
E-mail: blanka.havlickova@intendis.com miological trends for fungal infections. Its main focus is
on dermatomycosis of glabrous skin in different
Accepted for publication 8 July 2008 continents.

2008 The Authors

2 Journal compilation 2008 Blackwell Publishing Ltd • Mycoses, 51 (Suppl. 4), 2–15
 Superficial dermatomycoses worldwide

Causative agents Table 1 Dominant species of dermatophytes according to clinical

localisation
Superficial fungi can be classified according to their usual
Condition Dominant species
habitat into anthropophilic, zoophilic and geo-philic
organisms. Tinea capitis (scalp) Trichophyton violaceum
T. tonsurans
Generally, anthropophilic fungi cause superficial der-
T. soudanense
matomycoses characterised by relatively low inflamma- Microsporum canis
tory activity because of an immunological arrangement M. audouinii
1,2
that exists between the fungus and its human host. Tinea pedis (feet) T. rubrum
Household dust may act as a reservoir of antropophilic T. mentagrophytes (var. interdigitale)
dermatophytes, preserving dermatophyte spores for years. Epidermophyton floccosum
Tinea cruris (groin) T. rubrum
T. mentagrophytes
Zoophilic germs are found in animals, but are also (var. interdigit et granulosum)
sporadically transmitted to humans by cats, dogs Tinea corporis T. rubrum
(Microsporum canis), guinea pigs and rabbits (Tricho- (arms, legs and trunk) M. canis
phyton mentagrophytes var. granulosum). T. tonsurans
Tinea unguium T. rubrum
Zoophilic germs can be referred to as cuddly toy
(finger-nails and toe-nails) T. mentagrophytes (var. interdigitale)
mycoses (because of the mode of infection in children and
adolescents) and have a high affinity to the hairy head of a
child. They are associated with highly inflammatory and
potentially highly contagious skin infections. Candida species are part of the transient or commensal
flora in specific regions of the body. They are opportu-
Geophilic fungi grow in the soil and only sporadically nistic pathogens that only become pathogenic to humans
2
infect humans. When they do, the result varies from high under particular systemic and local conditions.
to low inflammation. Strains of Microsporum gypseum, Candidiasis is predominantly a disease of the very old, the
the most common geophilic pathogen, cul-tured from very young and the very sick . In most cases, it is an
humans are more virulent than those from the soil, endogenous infection originating from the patient s own
accounting for occasional epidemic spread under flora and generally follows a shift in the existing host ⁄
appropriate conditions.
3 yeast relationship. Occasionally, a strain can spread
7
There are approximately 100 000 species of fungi between individuals or in hospitals.
distributed worldwide. The majority of fungal infections Tinea can be caused by obligatory pathogenic
seen in both temperate and tropical countries are dermatophytes such as M. canis or T. verrucosum. Non-
superficial infections of the skin. The most common dermatophytic moulds, such as Scopulariopsis brevicaulis
pathogens relevant in practice are dermatophytes, yeasts or Aspergillus species, can theoretically cause nail
and moulds. infections, albeit rarely.
There are approximately 40 different species of
dermatophytes, characterised by their capability to digest Clinical manifestations
keratin and divided among three genera: Trich-ophyton,
Microsporum and Epidermophyton. A majority of Most basic fungal skin infections are caused by derma-
superficial fungal infections of the skin are caused by five tophytes and the main clinical manifestations are detailed
or six species of dermatophyte, of which Trichophy-ton below.
4
rubrum is the most common.
The predominant species of dermatophytes vary Tinea pedis (athlete s foot)
according to their clinical localisation, as described in the
Clinical manifestations and global patterns of superficial This is a very common infection that occurs in one in five
fungal infections sections and listed in Table 1. The
5 adults and the incidence increases with age from
1
management of tinea of the glabrous skin, caused by adolescence. It occurs more frequently in people who
2
dermatophyte infections, is a common therapeutic wear occlusive shoes.
6
problem for dermatologists. However, unlike pathogenic It may be associated with several different fungi,
yeasts and non-dermatophytic moulds, these infections including yeasts, the most common being T. rubrum and T.
never disseminate systemically and therefore can never be interdigitale (formerly T. mentagrophytes var. interdig-
lethal. itale). During the past 30 years, the incidence of tinea

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B. Havlickova et al.
pedis has increased in the developed world and its
8
prevalence is around 10%.
One hand two feet syndrome is characterised by
dermatophyte infection of both feet and one hand and can
be found in patients with lower immunocompe-tence, such
as diabetics. The condition is frequently associated with T.
rubrum.
Tinea unguium (onychomycosis, nail infections)
The causative agents of onychomycosis include derma-
tophytes, Candida spp and non-dermatophytic moulds.
Dermatophytes are most commonly responsible for
onychomycosis in temperate western countries, whereas
Candida and non-dermatophytic moulds are more
frequently involved in countries with a hot and humid
9
climate.
Trichophyton rubrum is the most common dermato-
phyte associated with onychomycosis, others include
T. interdigitale, Epidermophyton floccosum, T. violaceum,
M. gypseum, T. tonsurans, T. soudanense (considered by
some to be an African variant of T. rubrum rather than a
full-fledged separate species) and the cattle ringworm
2
fungus, T. verrucosum. Note that T. interdigitale is still
sometimes referred to as T. mentagrophytes var. interdig-
itale. The latter should be used to describe the zoophilic
form of the dermatophyte, and T. interdigitale used to
describe its anthropophilic form. Recent genetic research
has shown that T. mentagrophytes var. granulosum is the
10
same as T. interdigitale.
2 T. tonsurans or T. violaceum. T. verrucosum is highly
Other causative agents include Candida spp. and non-
dermatophytic moulds, in particular members of the
genera Scytalidium (now Neoscytalidium), Scopulari-
opsis and Aspergillus. Scytalidium mainly affects people
in the tropics, although it can persist if they move to more
temperate areas.
Candida mainly causes proximal nail infections in
people whose hands are often submerged in water. Nail
infection caused by Candida subspecies – such as C.
albicans, C. parapsilosis and C. guilliermondii – is almost
always associated with paronychia. As a rule, C.
parapsilosis appears concomitantly with T. interdigitale (T.
mentagrophytes var. granulosum) in nail infections.
Tinea corporis (ringworm on the trunk)
This affects the trunk, often in exposed areas like the
abdomen or limbs, causing red patches. It is more
common in children than in adults and occurs most
2
frequently in hot climates. Dermatophytes of the genera
Trichophyton and Microsporum are the most common
causative agents.
4 Journal compilation
Dermatophyte infection affecting nearly the entire
integument is named tinea corporis generalisata. A
generalised dermatophytosis caused by T. rubrum can
occur as a result of mis-diagnosis or mis-treatment.
Misread tinea corporis generalisata caused by T. rubrum is
named tinea incognita .
Tinea cruris (ringworm of the groin)
This presents as an itchy, red rash in the groin and
surrounding area and is commonly seen in young men
2
living in a warm climate. Tinea pedis can co-exist if the
infection is spread by scratching the feet and then the
groin. Axillary infection can be seen as an analogous tinea
pattern in woman. The most common agents are E.
floccosum, T. mentagrophytes and T. rubrum.
Tinea capitis (ringworm of the scalp)
This is a dermatophyte infection of the scalp and hair and
2
tends to affect young children worldwide. Presen-tation
depends on the aetiology and can be non-inflammatory,
inflammatory or black dot type. The non-inflammatory
form is most commonly caused by M. audouinii or M.
ferrugineum and usually begins as a small erythematous
papule surrounding a single hair shaft, which spreads
centrifugally to other hairs. Scaling occurs and the hair
turns grey. The inflamma-tory type is usually associated
with zoophilic or geophilic germs such as M. canis and M.
gypseum respectively. Black dot tinea capitis is caused by
contagious and virulent and is the only dermatophyte able
to thrive at 37 LC. Tinea capitis caused by T. verrucosum
can result in irreversible scarring and alopecia. The
analogous clinical infection pattern in adults is sycosis
barbae, which corresponds to ring-worm in cattle. It is
widespread and a well-known occupational disease of
2
cattle keepers.
Candidiasis
This is a diverse group of infections caused by members of
1
the genus Candida, especially C. albicans. These
organisms typically infect the skin, nails, mucous
membranes and gastrointestinal tract. Cutaneous and
mucosal manifestations of candidiasis can be divided into
several distinct clinical syndromes (Table 2). Thirty years
ago, superficial fungal infections were common, but
systemic fungal infections were not as frequent as today.
The incidence of superficial and systemic fungal infection
has been increasing because of the increasing
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 Superficial dermatomycoses worldwide

Table 2 Mucocutaneous Candida infections

Disease Clinical appearance Causative agent

Oral candidiasis
Vaginal and vulvovaginal candidiasis
Balanitis
Cutaneous candidiasis
Disseminated candidiasis
Chronic mucocutaneous candidiasis
Discrete white patches that may confluence on the buccal mucosa, Candida albicans
tongue, palate and gingivae
Thick vaginal discharge associated with burning, itching and occasional C. albicans; C.
dysuria
Small papules or fragile papulopustules on the galns or in the coronal glabrata C. albicans
sulcus in men. Infection may spread to the scrotum and inguinal areas
Pruritic, erythematous, macerated skin in the intertriginous area with C. albicans
satellite vesicopustules. Pustules break open leaving a red, macular
base with a collarette of easily detachable necrotic epidermis
Organs most commonly involved: lungs, spleen, kidneys, liver, heart and C. albicans, C. tropicalis,
brain C. lustaniae, C. krusei,
C. parapsilosis Candida
Chronic superficial infections of the skin, nails and oropharynx. Broad species
range of syndromes involved

incidence of severe diseases (e.g. malignancies or HIV-
infection) or immunosuppressant therapies (sys-temic
1
steroids or chemotherapy). In normal popula-tions,
superficial skin candidiasis occurs because of a
combination of deficiency of the skin s barrier and an
endogenous yeast reservoir. Typically, Candida infection is
activated by antibiotic or steroid therapy. Obesity and
diabetes mellitus are leading predisposing factors for
cutaneuos candidiasis.
Intertrigo
Intertrigo is an inflammation of the body folds and can
result from bacterial, fungal or viral infection that has
developed at the site of broken skin, for example, the
chafing of warm, moist skin of the inner thighs and
genitalia, the armpits, under the breasts, the underside of
the belly, behind the ears and between the toes and fingers.
It occurs most frequently in overweight subjects,
diabetics, patients confined to bed, babies and those who
use medical devices like artificial limbs that trap moisture
on the skin. Several skin diseases predispose to intertrigo,
including dermatitis or inverse psoriasis. Candida albicans
is the pathogen usually associated with intertrigo.
Tinea versicolor (pityriasis versicolor)
This is a common skin disease caused by the overgrowth
of Pityrosporum orbiculare, also named Malassezia furfur.
Most adults harbour P. orbiculare on their skin; in a few
people, however, its presence results in a harmless skin
disease characterised by the development of either hypo-or
hyperpigmented patches covered with fine scales on the
upper trunk. It occurs less frequently on the neck,
1
face and upper arms. P. orbiculare is also associated with
the development of seborrhoeic dermatitis.
Global patterns of superficial fungal
infections
The clinical appearance and the causative species of
superficial fungal infections vary with geographic region,
socioeconomic conditions and habits. Some species of
fungi exhibit worldwide distribution, whereas others are
restricted to particular continents or geo-graphic regions
8
(Table 3).
Trichophyton rubrum is the most common cause
worldwide for tinea pedis, nail infection, tinea cruris and
tinea corporis. Tinea pedis and onychomycosis are
4,11
becoming more common.
More widespread travel (economic migration and mass
tourism), increased ownership of companion
Table 3 Distribution of anthropophilic species of fungi
Worldwide
Epidermophyton floccosum
Microsporum audouinii
Trichophyton mentagrophytes var. interdigitale
T. rubrum T.
tonsurans
Geographically limited
M. ferrungineum: Africa, India, E. Europe, Asia, S. America,
T. concentricum: Pacific Islands, Far East, India, Ceylon,
N., Central and S. America,
T. gourvilii: Central and W. Africa
T. megninii: Portugal, Sardinia
T. schoenleinii: Europe, Mediterranean,
Middle East, S. Africa, sporadically in US
T. soudanense: Central and W. Africa T.
violaceum: Africa, Europe, Asia

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B. Havlickova et al.
animals, increased use of public sports facilities (espe-
cially swimming pools), wearing occlusive training shoes,
the increasing incidence of diabetes mellitus and vascular
disease, such as arteriosclerosis and an ageing population
are contributing factors to the devel-opment of
dermatomycoses in socially and economically developed
1
countries. These are to be seen in addition to
well-established risk factors such as familiar disposition,
1,12,13
male gender, foot trauma and cigarette smoking.
Studies in Europe, Asia and Africa indicate that
anthropophilic agents of scalp infections are being
eradicated in developed nations and are now more typical
of countries with low socio-economic status. The
exception is T. tonsurans-related tinea capitis and tinea
corporis in North America.
In tropical and subtropical countries, infectious dis-
eases of the skin are not just more prevalent than in central
Europe; they are more frequent and more distinctive. This
is particularly true for certain areas in Asia (especially
India) and for the whole continent of Africa. Socio-
economic conditions tend to be poorer than in Europe and
the Americas and there are more problems with diagnosis
and therapy, but most of all, the humid and warm climatic
conditions encourage the extensive skin mycoses. In
Africa, a large number of HIV infections favour certain
fungal infections by reducing the cellular immunity
needed in the defence against fungi.
The following sections look at the main types and
incidence of superficial fungal infections and their
associated pathogens based on epidemiological studies (as
these are the only data available because there is no
requirement to notify dermatophyte infections) by
continent and country.
Europe
Currently, the most important dermatophytes isolated in
Europe are T. rubrum, M. canis, T. mentagrophytes var.
granulosum and T. verrucosum. Several of these are
believed to have spread from the Mediterranean countries.
Other dermatophytes such as M. audouinii, T. soudenense
and T. violaceum (causing so-called immigration
mycoses), which are endemic in Africa and some parts of
Asia, are currently rarely isolated in Europe. However,
their incidence may be expected to increase in the future
2
as a result of tourism and migration.
Trichophyton rubrum is the most frequently isolated
dermatophyte in cases of tinea corporis and cruris in
developed European countries. There is also a shift
towards tinea capitis caused by anthropophilic dermato-
phytes in urban areas in Europe. The largest overall
6 Journal compilation
increases in those agents have been noted in the UK (T.
14
tonsurans) and France (T. soudanense and M. audouinii).
Tinea capitis mostly affects children aged 3–7 years of
both genders, but recently an increased incidence has been
14
observed in adults and the elderly.
Eastern Europe seems to be characterised by a
dominance of tinea corporis and capitis caused by the
zoophilic germ M. canis and a related comparatively high
rate of infantile fungal infections. The effects of civil war
in some European countries in the 1980s and 1990s
resulted in low standards of medical care and outbreaks of
M. canis possibly related to increased numbers of feral
domestic animals. The end of war and subsequent
improvement in standards of living has led to a decline in
zoophyte infections and an increase in anthropophylic
dermatophyte infections.
The incidence of the various fungal species identified in
different epidemiological studies is summarised in Table 4
and a wider discussion follows.
France. Tinea pedis shows an infectious agents pattern
comparable to the one in other states of developed Europe.
Plantar dermatophytoses in association with onyxis and
intertrigo rank with leading fungal infections mainly
caused by T. rubrum. In a large French study, relating to
frequency of plantar dermatophytosis, dermatophytes was
isolated in 66.6% of patients with interdigital plantar
signs. Trichophyton rubrum was isolated most
15
frequently.
As mentioned above, there has been a significant
increase in the incidence of tinea capitis in Europe,
including France. In the more rural regions, e.g. north-east
France, dermatophytoses is mostly caused by zoophilic
dermatophyte fungi such as M. canis, T. ment-agrophytes
or T. verrucosum, whereas in urban areas, e.g. Paris, there
is a shift toward anthropophilic tinea capitis. Developed
urban regions of France as well as the UK are
characterised by the largest overall increase in anthrop-
ophilic tinea capitis infection. Besides T. tonsurans, T.
soudanense and M. audouinii are the main infectious
agents causing tinea capitis. This pattern of anthropo-
philic infections seems to be linked to immigration from
14
sub-Saharan Africa or from the Caribbean.
United Kingdom. Tinea capitis-causing anthropophilic
species predominate also in the urban regions of the UK.
Trichophyton tonsurans has been noted as the leading
pathogen causing tinea capitis in the UK, comparable to
Northern America. Other relevant anthropophilic fungi
include M. audouinii and M. rivalieri. The occurrence of
these anthropophilic germ-induced infections is statis-
tically related to ethnic groups originating from Africa.
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 Superficial dermatomycoses worldwide

Table 4 Summary of the European incidence of the most common mycoses identified in these epidemiological studies

Lange Monod Lehenkari Jeske Lupa

et al.26 Korstanje21 et al.23 Dolenc-Voljc37 et al.22 Prohic38 et al.27 et al.11
Microsporum canis 62 40.9 5 46.8 90.4 23.5
M. gypseum 5.3
M. equinum 0.7
M. cookei 0.14
Trichophyton mentagrophytes 24.5 26
T. mentagrophytes var. granulosum 21.6 30.9
T. mentagrophytes var. interdigitale 7.9 2.3 10.0
T. mentagrophytes var. mentagrophytes 11.4 4.9
T. mentagrophytes var. quinckeanum 6.0 6.9
T. rubrum 12 62.5 36.7 66 17.8 41.7
T. verrucosum 4.5 0.4
T. violaceum 29.6 1.9 3.7 0.1
T. tonsurans 6.8 10.4 2.3
T. terrestre 0.2
T. schoenleinii 2.3 2.4
Epidermophyton floccosum 6 7.7 7.4

All values are percentages.

Corresponding to the situation in Europe at large, tinea
capitis is a fungal infection that affects especially young
children. This has been demonstrated in a study by Hay et
16
al.. The study shows tinea capitis in school children in
south east London and the importance of new guidance to
general practitioners on treatment. Tinea pedis and
associated tinea capitis seem to be comparable with the
characteristics of developed Europe, with T. rubrum and T.
mentagrophytes var. interdigitale as the leading derma-
tophytes.
Germany. Trichophyton rubrum accounts for 80–90% of all
17
isolated strains in Germany. Trichophyton interdigitale (T.
mentagrophytes var. interdigitale) and E. floccosum are the
second and third most frequently isolated agents and tinea
pedis and unguium are most frequently diagnosed. The
German Mycologic Society estimates the prevalence of
onychomycosis to be 12.4%, whereas the incidence of tinea
12
cruris has declined in the last 70 years.
Investigations in miners indicate that the incidence of
1
tinea pedis and tinea unguium is up to 72.9% , primarily
because of their use of occlusive boots, the warm and
humid environment in the mine and shared use of washing
17,18
facilities.
Two studies of cases of tinea capitis have found that the
most prevalent causative agent of tinea capitis was
M. canis, followed by T. tonsurans, T. violaceum and T.
19,20
mentagrophytes.
As a result of an immunisation programme against T.
verrucosum in cattle, ringworm should have been
eradicated in Eastern Germany. However, inconsistent
immunisation of livestock and the removal of the
requirement to notify the disease mean that a further rise
in the number of cases in humans is to be expected.
Belgium and the Netherlands. In these countries, zoophilic
dermatophytes are supplanting anthropophilic strains as
the cause of tinea capitis. Samples of scales, pus and hair
collected from 435 patients with tinea capitis over a period
21
of 30 years have revealed that at the beginning of the
period, T. verrucosum was found most frequently, but
declined dramatically from the mid-1970s onwards. In
contrast, M. canis was found frequently over the years,
rising from 9% to 11% of cases in the 1960s to >40% in
the 1990s. This change is associated with increased
mechanisation in farming and increased numbers of
households keeping companion animals. The frequency of
T. violaceum has also increased significantly since the
1970s because of increased immigration from countries
21
such as Italy, Turkey, Morocco and Tunisia.
Finland. Trichophyton rubrum was the most common
species (66% of all positive cultures) isolated from 2101
22
samples in northern Finland between 1982 and 1990; T.
mentagrophytes was isolated from 815 samples (26%) and
E. floccosum from 193 samples (6%). T. verrucosum
caused an epidemic among cattle keepers in 1987–1990,
causing 47 infections. Microsporum canis, T. terrestre and
T. violaceum isolates were rare. The same species affected
both children and adults. Trichophyton rubrum and T.
mentagrophytes (T. interdigitale) occurred most frequently
(mostly as causative micro-organisms of foot infections)
in patients aged 41–45 years of age. Epidermophyton
floccosum usually affected the toes and ⁄ or the groin in

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B. Havlickova et al.
predominantly men aged 21–25 years. Overall, there was a
slight increase in tinea pedis during the study period and a
decrease in tinea cruris.
Switzerland. A survey of dermatophyte infections in the
Lausanne area during an 8-year period showed that 5–10%
of consultations in dermatology concern mycotic
infections. Trichophyton rubrum was the most frequently
isolated species (at 62.5%) followed by T. mentagrophytes
(24.5%) and M. canis (5.0%). Less frequent isolates
included E. floccosum, M. langeroni,
M.gypseum, T. soudanense, T. violaceum, T. verrucosum,
T. gourvili and T. tonsurans.
23
Italy. Panasiti et al. conducted a retrospective study of
dermatophytes causing superficial mycoses among
24
outpatients at one centre in Rome between 2002 and 2004.
With 3160 patients studied, the most frequently isolated
dermatophyte was M. canis, followed by M. audouinii. This
species was identified as an emerging species, being the
second most frequent aetiological agent of tinea capitis and
the fourth of tinea corporis in this study. It should be noted
that in the Mediterranean region – especially in Italy – M.
canis seems to be endemic in feral cats.
Poland. A survey in Gdan´sk between 1984 and 1995
showed that in 1544 patients, the most common types of
dermatophytoses were tinea cutis glabrae (32.3%), tinea
pedis (24%), onychomycosis (16.5%), tinea capitis
(11.7%), tinea inguinalis (8.9%) and tinea manus
25
(4.0%). Lange et al. reported that in children and
26
adolescents in Gdan´sk between 1999 and 2001, the
most frequent pathogens identified were M. canis (62%)
and T. rubrum (12%) and the most common
dermatophytoses were tinea cutis glabrae (42%) and tinea
capitis (30%) primarily due to M. canis. Glabrous skin
lesions were most frequent in children aged 8–15 years;
the incidence of scalp lesions peaked in children aged 4–7
years and tinea pedis, mostly caused by T. rubrum and T.
mentagrophytes var. granulosum, was observed mainly in
adolescents (aged over 12 years). Onychomycosis was
highly uncommon in children and was caused mainly by
T. rubrum.
Among 7393 dermatophytoses identified in central
Poland during 1987–1996, there were 2204 (29.8%) cases
27
of tinea cutis glabrae. Causative organisms included M.
canis (23.5%), T. mentagrophytes var. granulosum
(21.6%), T. rubrum (17.8%), T. tonsurans (10.4%), E.
floccosum (7.7%), T. mentagrophytes var. quinckeanum
(6.0%) and M. gypseum (5.3%). In the same population,
11
Lupa et al. reported 2025 (27.4%) cases of tinea pedis.
Causative organisms included: T. rubrum
8 Journal compilation
(41.7%), T. mentagrophytes var. granulosum (30.9%), T.
mentagrophytes var. interdigitale (10.0%), E. floccosum
(7.4%) and T. mentagrophytes var. quinckeanum (6.9%).
The incidence of tinea pedis increased substantially
between 1994 and 1996.
Russia. Several epidemiological studies confirm a higher
number of toenail infections and a more frequent
occurrence of severe toenail diseases, including mixed
fungal infections with yeasts and moulds, in Russia
compared to developed countries in Western Europe. The
prevalence of tinea pedis has been reported as at up to
28
83% in the Russian population.
Khaldin et al. found that in the Russian Federation, T.
rubrum was the predominant causative agent of
dermatomycoses, accounting for 65–75% of cases,
whereas Candida spp. were commonly detected in skin
29
fold infections.
These findings correlate with a study by Ja¨rv et al.
30
concerning toenail onychomycosis in Estonia from 2004,
in which nearly 70% of pathologic nail changes were
caused by dermatophytes, 10% by yeasts and 7% by
moulds. Trichophyton rubrum was the most-frequently
isolated pathogen. Mixed infections were found in 6% of
patients. Furthermore, the incidence of tinea corporis and
30,31
tinea faciei is also thought to be high.
Tinea pedis has been found not only in elderly or sick
people but also in a significantly high degree in the
working population. This is shown in a Russian study of
foot mycoses in workers at metallurgical plants. Trich-
ophyton rubrum (71.3%) and T. interdigitale (28.7%) were
the main pathogens. 18.3% of patients had mixed
infections with C. albicans. It was notable that Tricho-
32
phyton occurred as a complication in some cases.
Vakulova et al. have also reported a high incidence of
fungal skin and nail infections caused by Candida ssp. in
33
Russian submariners.
As in other parts of Eastern Europe, zoophilic infections
are more common in rural regions; M. canis, T. mentag-
rophytes and T. verrucosum are the predominant zoophilic
pathogens. The incidence of T. verrucosum and T.
34
mentagrophytes continued to rise until the late 1980s.
Effective antimycotic therapy has reduced the number
of trichophytoses in recent years. In Armenia, an
epidemiological study showed a reduction in the number
35
of trichophytosis patients.
Favus caused by T. schoenleinii, T. violaceum or M.
gypseum is now found only rarely, in areas with low social
36
conditions.
Slovenia. Results from patients with suspected
dermatophytoses in Slovenia for the period 1995–2002
2008 The Authors
2008 Blackwell Publishing Ltd • Mycoses, 51 (Suppl. 4), 2–15
 Superficial dermatomycoses worldwide

have shown that among 42 494 samples, M. canis was
isolated most frequently (46.8%) followed by T. rubrum
(36.7%), T. mentagrophytes var. interdigitale (7.9%) and
T. mentagrophytes var. mentagrophytes (4.9%). The most
common dermatophyte infections were tinea corporis,
37
onychomycosis, tinea pedis and tinea faciei.
Bosnia and Herzegovina. Tinea capitis was found in 241
(34.1%) patients in Sarajevo between 1997 and 2006;
38
causative agents were identified in 209 (29.6%) cases.
Zoophilic dermatophytes (91.8%) prevailed over
anthropophilic (7.2%) and geophilic (1.0%)
dermatophytes. Microsporum canis was isolated most
frequently (90.4%), followed by T. schoenleinii (2.4%)
and T. violaceum (1.9%). Most patients were male
(56.5%) and aged under 10 years (52.6%). Zoophilic
dermatophytes were most commonly recovered from
children and adolescents with tinea capitis, tinea corporis
and tinea faciei. Anthropophilic species were identified
mostly in adults with tinea pedis, onychomycosis and
tinea cruris. Interestingly, rates of M. canis infection
declined during the study period, while infections caused
by T. rubrum increased in frequency – possibly as the war
came to an end and quality of life began to improve again.
Asia and Australia
In Asia, T. rubrum and T. mentagrophytes are the most
commonly isolated pathogens, causing tinea pedis and
unguium, as is the case in Europe. In contrast to Europe,
the next most commonly isolated pathogen is T.
violaceum, the causative agent of tinea capitis and
corporis. Microsporum ferrugineum and T. concentricum
are also found in Asia, especially India. Trichophyton
concentricum causes tinea imbricata.
The prevalence of tinea pedis in Asia is similar to that in
Europe (approx. 20%); it is also common in Australia.
Tinea corporis and capitis are frequently found in children
and adolescents.
The incidence of the various fungal species identi-fied
in epidemiological studies is summarised in Table 5 and
the significance for the prevalence of associated
dermatomyces in different countries is discussed below.
Turkey. A study performed in a Turkish University
Hospital during 2001–2002 found the prevalence of
39
dermatophytoses to be 7.34% (68 out of 926).
Trichophyton rubrum was the most frequently isolated
dermatophyte (56%), followed by T. mentagrophytes
(38%), T. violaceum, T. verrucosum, M. canis and E.
floccosum. Tinea pedis (47%) was the most common
dermatophytosis, followed by tinea unguium (29%), tinea
inguinalis (15%), tinea corporis (7.4%) and tinea capitis
(1.6%).
S¸as¸maz et al. examined the frequency and spectrum of
superficial fungal infections among 925 consecutive
Turkish soldiers admitted to the dermatology outpatient
40
clinic in Northern Cyprus. Superficial mycotic infec-
tions were found in 185 soldiers (20%), of whom 151
(61.6%) had dermatophytosis, 32 (17.3%) had tinea
versicolor and two (1.1%) had candidiasis. A similar study
was conducted among workers in a Turkish textile factory
41
– an important industry in that country. Superficial
mycoses were found in 73 (16.9%) workers; of these, 56
(76.7%) cases were dermatophytoses and eight (11.0%)
were pityriasis versicolor. No causative

Table 5 Summary of the Asian incidence

of the most common mycoses identified in Prohic C¸ elik E Lari Tao-Xiang Kim Singal
these epidemiological studies et al.38 et al.41 et al.42 et al.46 et al.49 et al.43 Min48
Microsporum canis 1.5 15.1 65
M. audounii 34
M. gypseum 7.5 3
Trichophyton mentagrophytes 38 42.9 11.3 29.4 3
T. rubrum 56 57.1 13.2 43.9
T. verrucosum 1.5 5.7 3
T. violaceum 1.5 28.3 38 18
T. tonsurans 9 9
T. schoenleinii 10
T. asahii 62.1
T. mucoides 20.3
T. inkin 14.9
Epidermophyton floccosum 1.5 15.1
Candida spp. 14.0

All values are percentages.

2008 The Authors

Journal compilation 2008 Blackwell Publishing Ltd • Mycoses, 51 (Suppl. 4), 2–15 9
B. Havlickova et al.
agent could be identified in nine (12.3%) workers. T.
rubrum (57.1%) and T. mentagrophytes (42.9%) were two
of the most frequently isolated dermatophytes. The study
emphasised that textile workers should be considered as a
risk group for superficial mycoses, especially tinea pedis.
Iran. The characteristics of dermatophytoses among
children in an area south of Tehran were reported by Lari
et al. 382 children aged £16 years with suspected
dermatophytic lesions were examined between 1999 and
42
2001. The incidence rate of dermatophytoses was 6.6 per
100 000 person-years. Trichophyton violaceum (28.3%),
M. canis (15.1%), E. floccosum (15.1%), T. rubrum
(13.2%), T. mentagrophytes (11.3%), M. gypseum (7.5%)
and T. verrucosum (5.7%) were the most frequent isolates.
Tinea capitis (39.6%) was the most common
dermatophytosis, followed by tinea corporis (30.2%),
tinea faciei (18.9%) and tinea manuum (7.5%).
India. In northern India, anthropophilic dermatophytes are
the predominant pathogens causing tinea capitis. In a
study of 153 consecutive patients with tinea capitis, 90%
of the patients were aged less than 15 years; 75%
belonged to poor socio-economic groups and 19% had a
family history of tinea capitis. Trichophyton violaceum
(38%), M. audouinii (34%), T. schoenleinii (10%) and T.
tonsurans (10%) were the most commonly isolated
43
pathogens.
Tinea capitis caused by T. violaceum is endemic in
south India. A study conducted in 1978 suggested that
trauma to the scalp caused by ritual shaving may be one
explanation for this. Twenty one cases of tinea capitis
were found in boys aged 10–17 years in Purasawalkam,
Madras, who were shaved consecu-tively by the same
44
barber. The razors were cleaned only in soap and water.
Unlike in Europe, tinea pedis is comparatively rare in
India, especially in the poorer areas. As in Europe, the
most important causative agents are T. rubrum, T.
interdigitale and E. floccosum.
45
China. Tao-Xiang et al. conducted a 1-year analysis of
dermatomycoses in the Lanzhou district of northwestern
46
China. In 1443 suspected fungal infections, the fungi
were isolated in 221 cases, the most frequent being T.
rubrum (43.9%) T. mentagrophytes (29.4%) and Candida
spp. (14.0%). The incidence of tinea pedis,
onychomycosis and tinea manuum was 38.7%, 27.8% and
13.5% respectively.
Tinea capitis of children, primarily caused by T.
violaceum, is common in western China. Strains
10 Journal compilation
found in rural communities of this region tend to be
different from those found in other regions in the country,
indicating that dermatophytes in former rural societies
47
must have migrated extremely slowly. In developed
cities in China, as in Europe, zoophilic dermatophytes are
becoming the most important pathogens in the context of
tinea capitis. In 600 cases in Shanghai between 1993 and
2002, M. canis was identified as the main pathogen in 65%
of cases. The anthropophilic dermatophytes T. violaceum
(18%) and T. tonsurans (9%) were also important
48
species.
Korea. Tinea pedis is the most common dermatomycosis
in Korea and Kim et al. have shown that the most common
infectious agents in foot mycoses are T. rubrum, other
49
Trichosporon spp. and Candida spp. Jang et al. have
reported that the prevalence of tinea corporis is increasing
50
in Korea, but that it varies according to life style and
regional characteristics. Dermatophytes were isolated in
73 out of 105 cases of tinea corporis; T. rubrum (58 cases),
T. mentagrophytes (eight cases) and M. canis (five cases)
were the most common causative agents.
Singapore. Cutaneous fungal infections are common in
Singapore. Between 1999 and 2003, 12 903 cases of
superficial fungal infections were seen at the National Skin
51
Centre. A majority of patients (72.3%) were male. The
most common conditions were tinea pedis (27.3%),
pityriasis versicolor (25.2%) and tinea cruris
(13.5%). Tinea capitis is uncommon in Singapore.
Trichophyton rubrum was the most prevalent fungal
pathogen isolated, except in cases of tinea pedis, where T.
interdigitale was the most frequently isolated organism.
Candida infections were common (n = 1430) and were
manifested as candidal intertrigo. The incidence of
onychomycosis has increased over the past 5 years.
Dermatophytes remain the most commonly isolated fungal
pathogens isolated in toenail onychomycosis, whereas
Candida spp. accounted for the majority of isolates in
fingernail onychomycosis.
Japan. In an epidemiological investigation to determine the
prevalence and circumstances of untreated and
unsuspected tinea pedis and onychomycosis, the
prevalence of occult tinea pedis was 25%. Fifty nine per
52
cent of those patients had tinea unguium simultaneously.
Australia. In Australia, there is a high incidence of tinea
pedis. In a randomised sample of 2491 students with
2008 The Authors
2008 Blackwell Publishing Ltd • Mycoses, 51 (Suppl. 4), 2–15
 Superficial dermatomycoses worldwide

53 Table 6 Summary of the African incidence of the most common mycoses

confirmed tinea pedis an age- and gender-adjusted
identified in these epidemiological studies
prevalence of 5.2% was found; increasing with age from
2.1% in 4–6 year-old to 9.7% in 16–18 year-old Hay Enweani Ellabib Abu-Elteen
individuals. A higher proportion of males (6.0%) had tinea et al.55 et al.58 et al.60 & Malek61
pedis than females (4.3%). Trichophyton mentagrophytes Microsporum canis 8 11.1
and T. rubrum were the most common dermatophytes M. audouinii 46.8 46.8
isolated on culture. Only 20 isolates of T. violaceum, M. gypseum 0.5
associated with tinea capitis and tinea corporis, have been Trichophyton mentagrophytes 25.5 25.5 3 32.7
54 T. rubrum 21.3 28.6
identified in a 32-year period in Melbourne. As observed
T. verrucosum 14 2.0
in Europe and America, infection seems to occur almost T. violaceum 44 1.0
exclusively in African immigrants, not in the indigenous T. tonsurans 2.1
population. T. schoenleinii 4.0
Epidermophyton floccosum 4.3 7 20.1
Candida spp. 10
Africa
All values are percentages.
Fungal infections are among the most commonly
diagnosed skin diseases in Africa. Both the pathogen
spectrum and the clinical manifestations are totally dence of the various fungal species are summarised in
different from those seen in Europe. The anthropophilic Table 6.
dermatophyte T. audouinii is the most prevalent patho-
gen, together with T. violaceum and T. soudanense. South Africa. The incidence of dermatoses in 246 adults
Trichophyton gourvilii is an endemic, partly geographi- with HIV at a South African clinic was studied over a
cally restricted, anthropophilic dermatophyte, and its 56
period of 1 year. The most common cutaneous disease
predominance in tinea capitis is characterised by patches manifestation was herpes zoster (19%) and tinea corporis
of grey hair. The black dot type, caused by the endotrichus was found in 7% of patients. Opportunistic fungal
fungi T. tonsurans and T. violaceum (also endemic in infections, such as candidiasis, were present at 3%. In 100
Africa), is widespread. Favus, caused by T. schoenleinii, children (mean age of 4.6 years) in Kwa-Zulu ⁄ Natal,
has occasionally been observed. This pathogen was a dermatologists identified T. violaceum in 90% of positive
widespread trigger of family epidemics in Europe in the cultures, making it probably the most common cause of
18th century. Today, it has almost disappeared from 57
tinea capitis in South Africa. The most common clinical
developed European countries but is found in the densely manifestation was the black dot type, seen in 50% of
populated areas of Africa. Trichophyton soudanense seems patients.
to be a common cause of tinea capitis in north-western
tropical Africa. Tricho-phyton rubrum and T. Nigeria. A total of 188 (13.4%) mycotic infections were
mentagrophytes are less common and are associated with identified in a study among 1400 school children in
tinea corporis and, in particu-lar, tinea cruris (or tinea 58
Ekpoma, Nigeria. The causative agents included M.
axillaris in women). In 2005, Hay et al. estimated the audouinii in 88 cases (46.8%), T. mentagrophytes in 48
overall incidence of tinea in Sub-Saharan Africa to be 78 (25.5%), T. rubrum in 40 (21.3%), T. tonsurans in 4
55
million. Notably, tinea pedis and unguium are very (2.1%) and E. floccosum in 8 (4.3%) patients.
uncommon in rural areas in Africa – probably because of
the lack of risk factors. A large part of the population Malawi. In a survey conducted between 1987 and 1989,
walks bare foot; diabetes mellitus and adipositas are rare 59
Po¨nnighaus et al. looked at the spectrum of derma-
in these areas. tophytes in a northern Malawi population. Between 1.5%
Tinea faciei and barbae are caused by dermatophytes, and 2.5% of the population were diagnosed with tinea
including M. gypseum and M. ferrugineum. In some faciei, corporis or cruris. The authors noted the rarity of T.
regions of Africa, T. rubrum is rare. rubrum (around 1%) and the predominance of M.
Besides dermatophytoses, pityriasis versicolor is a audouinii (57%) in this part of Africa. Epidermophyton
typical dermatological diagnosis for African adolescents. floccosum was the most common isolate (56%) from the
Humidity seems to favour this endogenic infection. genital area.
Europeans travelling to Africa often develop this disease.
Candida infections are also highly prevalent given the Libya. In a study of the prevalence of skin infections and
high incidence of HIV infections. Some data on inci- their causative agents in 1180 patients with a

2008 The Authors

Journal compilation 2008 Blackwell Publishing Ltd • Mycoses, 51 (Suppl. 4), 2–15 11
B. Havlickova et al.
confirmed mycotic infection, tinea corporis was diagnosed
in 45.9% of cases (85% in children aged less than 15).
Other conditions included pityriasis versicolor (27.8%),
candidiasis (13.4%) and tinea pedis (8.1%). Trichophyton
violaceum was the most common aetiological agent,
responsible for 44% (300 cases) of dermatophyte
infections. Malassezia furfur was found in 27.8% of cases,
T. rubrum in 13.8%, C. albicans in 10%, M. canis in 8.1%,
60
E. floccosum in 6.6% and T. mentagrophytes in 3.1%.
Jordan. The Zarqa district of Jordan has an industrialised
area surrounded by farms and villages; the climate is
relatively hot and semi-arid. The most common
dermatophytes isolated were T. mentagrophytes, E.
floccosum, T. rubrum and M. canis. Tinea pedis (35% of
all cases) and cruris (10%) are found more frequently
during the summer months, whereas tinea capitis (23% of
all cases), corporis (10%) and unguium (22%) are more
61
frequent during the spring and winter. There is evidence
that the increasing prevalence of T. rubrum is because of
immigration from Mediterranean countries. Tinea pedis
(caused by T. mentagrophytes) is most prevalent in older
farmers. Tinea capitis is more common in children and
more common in girls because girls tend to have long hair,
which facilitates contact and spread of fungal species.
Americas
The most commonly observed fungal species in the
Americas are T. rubrum, T. tonsurans and T. mentagro-
phytes. Some data on the frequency of the various fungal
species are summarised in Table 7.
A dramatic increase in T. tonsurans infections has been
8
reported in the USA. The term tinea corporis gladiatorum
was created because T. tonsurans has high attack rates in
teams of wrestlers, high-level judo players and in other
combat sports. This may be because of a unique fungal
aetiology and the nature of the reservoir
Table 7 Summary of the incidence of the most common mycoses
identified in epidemiological studies in the Americas
Brilhante et al.68 Welsh et al.69
Microsporum canis 7 7.1
Trichophyton mentagrophytes 6.2 23.7
T. rubrum 49.6 45
T. tonsurans 34.4 21
Epidermophyton floccosum 2.5
All values are percentages.
12
and vector, leading to specific clinical presentations and
62
compliance difficulties for treatment.
American teams have taken T. tonsurans infections to
Europe and Asia. This is another example of traditionally
geographically confined pathogens spreading to new areas.
Conversely, T. violaceum and T. soudanense, which are
causes of tinea capitis in parts of Africa and West Asia,
have only rarely been reported to cause dermatophytoses
in the USA. However, sporadic cases provide evidence for
the emergence of these organisms as a result of changing
63
population demographics.
USA. An epidemiological survey of superficial fungal
64
diseases found that T. rubrum was the most commonly
isolated dermatophyte species. Trichophyton tonsurans
was more common in tinea capitis, and equally common in
tinea corporis and cruris. Dermatophytes appeared in
approximately 95% of tinea pedis isolates and 82% of
onychomycosis isolates. Candida albicans (7%) and non-
dermatophyte moulds (11%) played only a minor role in
onychomycosis. These findings were in general agreement
with other major epidemiological studies performed
outside the USA and confirm that dermatophyte fungi are
responsible for most superficial fungal infections.
Foster et al. carried out a survey of cutaneous fungal
65
infections between 1999 and 2002. Dermatophytes were
the most commonly isolated fungal organisms, except
suspected finger onychomycosis caused by Candida spp.
Trichophyton rubrum was the most prevalent fungal
pathogen (70%) and increased incidence of this species
was observed in finger and toenail onychomycosis, tinea
corporis and tinea cruris, tinea manuum and tinea pedis.
In the first half of the 20th century, the predominant
causative agent of tinea capitis was the anthropophilic
species M. audouinii. By the 1980s, however, T. tonsurans
had become the most common cause and today, more than
65
95% of tinea capitis cases are because of T. tonsurans.
Canada. The incidence of T. tonsurans in confirmed tinea
66
capitis cases increased from 9% in 1985 to 76% in 1996.
Prior to this, the more common agents were
T. verrucosum, M. canis and M. audouinii. This infection
pattern is most common in children of both genders under
14 years of age. Subjects are significantly more likely to
live in urban than in rural areas.
Brazil. A 5-year study examined dermatophytoses in 137
children below the age of 12 with clinically
2008 The Authors
Journal compilation 2008 Blackwell Publishing Ltd • Mycoses, 51 (Suppl. 4), 2–15

67
diagnosed tinea. Male children aged 2–12 years were the
most often affected. Tinea capitis (78 cases, 56.9%),
mainly caused by M. canis (46 cases), was the most
common clinical form, followed by tinea corporis (43
cases, 31.3%) mainly caused by T. rubrum (17 cases) and
tinea cruris (10 cases, 7.2%) caused by T. rubrum (five
cases). In another study with 2297 patients with suspected
68
clinical lesions of dermatophytosis, 534 (23.2%) patients
were tested positive for dermatophytes. Trichophyton
rubrum (49.6%), T. tonsurans (34.4%), M. canis (7%) and
T. mentagrophytes (6.2%) were the most prevalent
species. Correlating the species with the anatomical
localisation revealed that T. tonsurans was the most
frequent isolate in scalp lesions (73.9%), whereas T.
rubrum was the main species involved in body lesions
(72.8%).
Mexico. Welsh et al. have published data from Monterrey
involving 2397 cases of dermatophytosis from superficial
69
cutaneous lesions between 1978 and 1990. Seven
hundred and twenty-six (30.2%) cases of tinea pedis, 613
(25.6%) of tinea unguium, 441 (18.4%) of tinea capitis,
395 (16.4%) of tinea corporis and 222 (9.3%) of tinea
cruris were observed. The most commonly isolated
dermatophytes were
T. rubrum (45%), T. mentagrophytes (23.7%), T. tonsurans
(21%), M. canis (7.1%) and E. floccosum (2.5%). Most
cases of fungal infections were observed in the warmest
months of the year and were equally distributed among
men and women, except for tinea cruris, which was more
prevalent in men.
Conclusion
Most mycoses are caused by fungi that reside in nature,
but there appears to be a considerable inter-and intra-
continental variability in the incidence of fungal infections
throughout the world. Furthermore different geographical
locations favour different infection patterns. Trichophyton
rubrum, T. interdigitale (mentagrophytes var.
interdigitale), M. canis, M. audoui-nii, T. tonsurans and T.
verrucosum account for most dermatophytoses globally,
but the attack rates and incidence of specific mycoses can
vary widely. The highest incidence of T. rubrum was
reported in Europe, whereas T. mentagrophytes was more
commonly reported in Asia.
Increasingly frequent tinea pedis caused by T. rubrum
and T. interdigitale (mentagrophytes var. interdigitale)
infection seems to be a characteristic of highly devel-oped
countries with booming sport and fitness facilities,
2008 The Authors
Journal compilation 2008 Blackwell Publishing Ltd • Mycoses, 51 (Suppl. 4), 2–15
Superficial dermatomycoses worldwide
increasing prevalence of obesity and diabetes mellitus and
an ageing population. Microsporum canis is a prevalent
agent of tinea capitis in the developed world and this
could be related to mass tourism to endemic regions (such
as the Mediterranean area) and the close association
between humans and companion animals.
Several dermatophyte species are geographically
limited. Trichophyton violaceum is endemic in certain
parts of Eastern Europe, Africa, Asia and South America,
but not in North America. Trichophyton soudanense is a
common and endemic cause of tinea capitis in north-
western tropical Africa and West Asia. The sporadic
appearance of both in Western Europe and the USA
provides evidence for the ongoing evolution of dermato-
phytosis epidemiology in relation to international travel,
immigration and shifts in population demographics.
Conflict of interest
Dr B Havlickova and Dr M Friedrich are employees of
Intendis GmbH; Dr V Czaika has a consultancy agreement
with Intendis GmbH.
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