Surveillance for Coccidioidomycosis, Histoplasmosis, and Blastomycosis During the COVID-19 Pandemic - United States, 2019-2021.

Coccidioidomycosis, histoplasmosis, and blastomycosis are lower respiratory tract fungal infections whose signs and symptoms can resemble those of other respiratory illnesses, including pneumonia caused by bacterial or viral etiologies; this overlap in clinical presentation might lead to missed or delayed diagnoses. The causative fungi live in the environment, often in soil or plant matter. To describe the epidemiologic characteristics of cases of coccidioidomycosis, histoplasmosis, and blastomycosis during the COVID-19 pandemic, CDC analyzed case surveillance data for 2019-2021. During this period, a total of 59,655 coccidioidomycosis cases, 3,595 histoplasmosis cases, and 719 blastomycosis cases were reported to CDC. In 2020, fewer cases of each disease occurred in spring compared with other seasons, and most cases occurred in fall; national seasonality is not typically observed, and cases were seasonally distributed more evenly in 2019 and 2021. Fewer cases coinciding with the start of the COVID-19 pandemic, along with an unusually high blastomycosis case fatality rate in 2021 (17% compared with more typical rates of 8%-10%), suggest that the pandemic might have affected patients' health care-seeking behavior, public health reporting practices, or clinical management of these diseases. Increased awareness and education are needed to encourage health care providers to consider fungal diseases and to identify pneumonia of fungal etiology. Standardized diagnostic guidance and informational resources for fungal testing could be incorporated into broader respiratory disease awareness and preparedness efforts to improve early diagnosis of coccidioidomycosis, histoplasmosis, and blastomycosis.

Case Report: Locally Acquired Leptospirosis in a Minnesota Boy and His Dog.

Leptospirosis affects numerous animal species, including domestic dogs, but documented transmission to humans is rare. Here, we describe epidemiologically linked cases in a 12-year-old Minnesota boy and his pet dog. While human leptospirosis is often thought of as a disease of tropical locations, this case report describes a rare documented example of local transmission in the northern United States, a region historically not perceived to be at high risk of Leptospira species transmission to humans. This case highlights an unusual presentation, with facial nerve palsy, underappreciated epidemiological risks, and diagnostic challenges of this reemerging infection.

A Phylogeographic Description of Histoplasma capsulatum in the United States.

Histoplasmosis is one of the most under-diagnosed and under-reported endemic mycoses in the United States. Histoplasma capsulatum is the causative agent of this disease. To date, molecular epidemiologic studies detailing the phylogeographic structure of H. capsulatum in the United States have been limited. We conducted genomic sequencing using isolates from histoplasmosis cases reported in the United States. We identified North American Clade 2 (NAm2) as the most prevalent clade in the country. Despite high intra-clade diversity, isolates from Minnesota and Michigan cases were predominately clustered by state. Future work incorporating environmental sampling and veterinary surveillance may further elucidate the molecular epidemiology of H. capsulatum in the United States and how genomic sequencing can be applied to the surveillance and outbreak investigation of histoplasmosis.

Fatal Human Rabies Infection With Suspected Host-Mediated Failure of Post-Exposure Prophylaxis Following a Recognized Zoonotic Exposure-Minnesota, 2021.

BACKGROUND: No human rabies post-exposure prophylaxis (PEP) failure has been documented in the United States using modern cell culture-based vaccines. In January 2021, an 84-year-old male died from rabies 6 months after being bitten by a rabid bat despite receiving timely rabies PEP. We investigated the cause of breakthrough infection. METHODS: We reviewed medical records, laboratory results, and autopsy findings and performed whole-genome sequencing (WGS) to compare patient and bat virus sequences. Storage, administration, and integrity of PEP biologics administered to the patient were assessed; samples from leftover rabies immunoglobulin were evaluated for potency. We conducted risk assessments for persons potentially exposed to the bat and for close patient contacts. RESULTS: Rabies virus antibodies present in serum and cerebrospinal fluid were nonneutralizing. Antemortem blood testing revealed that the patient had unrecognized monoclonal gammopathy of unknown significance. Autopsy findings showed rabies meningoencephalitis and metastatic prostatic adenocarcinoma. Rabies virus sequences from the patient and the offending bat were identical by WGS. No deviations were identified in potency, quality control, administration, or storage of administered PEP. Of 332 persons assessed for potential rabies exposure to the case patient, 3 (0.9%) warranted PEP. CONCLUSIONS: This is the first reported failure of rabies PEP in the Western Hemisphere using a cell culture-based vaccine. Host-mediated primary vaccine failure attributed to previously unrecognized impaired immunity is the most likely explanation for this breakthrough infection. Clinicians should consider measuring rabies neutralizing antibody titers after completion of PEP if there is any suspicion for immunocompromise.

Molecular Epidemiology of Blastomyces gilchristii Clusters, Minnesota, USA.

We characterized 2 clusters of blastomycosis cases in Minnesota, USA, using whole-genome sequencing and single-nucleotide polymorphism analyses. Blastomyces gilchristii was confirmed as the cause of infection. Genomic analyses corresponded with epidemiologic findings for cases of B. gilchristii infections, demonstrating the utility of genomic methods for future blastomycosis outbreak investigations.

Exposure Outcomes in Fully Vaccinated Healthcare Personnel With Known Severe Acute Respiratory Syndrome Coronavirus 2 Exposure-Minnesota, January-August 2021.

Healthcare personnel (HCP) are at potential risk for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in occupational and nonoccupational settings, even when fully vaccinated. This risk increased during Delta variant circulation. SARS-CoV-2 testing of fully vaccinated HCP working in the 14 days after exposure is important to prevent virus introduction into healthcare settings.

Analysis and modeling of Blastomyces dermatitidis environmental prevalence in Minnesota using soil collected to compare basal and outbreak levels.

Outbreaks of blastomycosis, caused by the fungus Blastomyces dermatitidis, occur in endemic areas of the United States and Canada but the geographic range of blastomycosis is expanding. Previous studies inferred the location of B. dermatitidis through epidemiologic data associated with outbreaks because culture of B. dermatitidis from the environment is often unsuccessful. In this study, we used a culture-independent, PCR-based method to identify B. dermatitidis DNA in environmental samples using the BAD1 promoter region. We tested 250 environmental samples collected in Minnesota, either associated with blastomycosis outbreaks or environmental samples collected from high- and low-endemic regions to determine basal prevalence of B. dermatitidis in the environment. We identified a fifth BAD1 promoter haplotype of B. dermatitidis prevalent in Minnesota. Ecological niche analysis identified latitude, longitude, elevation, and site classification as environmental parameters associated with the presence of B. dermatitidis Using this analysis, a Random Forest model predicted B. dermatitidis presence in basal environmental samples with 75% accuracy. These data support use of culture-independent, PCR-based environmental sampling to track spread into new regions and to characterize the unknown B. dermatitidis environmental niche.Importance Upon inhalation of spores from the fungus Blastomyces dermatitidis from the environment, humans and animals can develop the disease blastomycosis. Based on disease epidemiology, B. dermatitidis is known to be endemic in the United States and Canada around the Great Lakes and in the Ohio and Mississippi River Valleys but is starting to emerge in other areas. B. dermatitidis is extremely difficult to culture from the environment so little is known about the environmental reservoirs for this pathogen. We used a culture-independent PCR-based assay to identify the presence of B. dermatitidis DNA in soil samples from Minnesota. By combining molecular data with ecological niche modeling, we were able to predict the presence of B. dermatitidis in environmental samples with 75% accuracy and to define characteristics of the B. dermatitidis environmental niche. Importantly, we showed the effectiveness of using a PCR-based assay to identify B. dermatitidis in environmental samples.

SARS-CoV-2 Exposure and Infection Among Health Care Personnel - Minnesota, March 6-July 11, 2020.

Health care personnel (HCP) are at increased risk for infection with SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), as a result of their exposure to patients or community contacts with COVID-19 (1,2). Since the first confirmed case of COVID-19 in Minnesota was reported on March 6, 2020, the Minnesota Department of Health (MDH) has required health care facilities* to report HCP† exposures to persons with confirmed COVID-19 for exposure risk assessment and to enroll HCP with higher-risk exposures into quarantine and symptom monitoring. During March 6-July 11, MDH and 1,217 partnering health care facilities assessed 21,406 HCP exposures; among these, 5,374 (25%) were classified as higher-risk§ (3). Higher-risk exposures involved direct patient care (66%) and nonpatient care interactions (e.g., with coworkers and social and household contacts) (34%). Within 14 days following a higher-risk exposure, nearly one third (31%) of HCP who were enrolled in monitoring reported COVID-19-like symptoms,¶ and more than one half (52%) of enrolled HCP with symptoms received positive SARS-CoV-2 test results. Among all HCP with higher-risk exposures, irrespective of monitoring enrollment, 7% received positive SARS-CoV-2 test results. Compared with HCP with higher-risk exposures working in acute care settings, those working in congregate living or long-term care settings more often returned to work (57%), worked while symptomatic (5%), and received a positive test result (10%) during 14-day postexposure monitoring than did HCP working outside of such settings. These data highlight the need for awareness of nonpatient care SARS-CoV-2 exposure risks and for targeted interventions to protect HCP, in addition to residents, in congregate living and long-term care settings. To minimize exposure risk among HCP, health care facilities need improved infection prevention and control, consistent personal protective equipment (PPE) availability and use, flexible sick leave, and SARS-CoV-2 testing access. All health care organizations and HCP should be aware of potential exposure risk from coworkers, household members, and social contacts.

Enhanced Surveillance for Histoplasmosis-9 States, 2018-2019.

BACKGROUND: Histoplasmosis is often described as the most common endemic mycosis in the United States, but much remains unknown about its epidemiology among the general population. METHODS: We conducted enhanced surveillance in 9 states during 2018-2019 by identifying cases through routine surveillance and interviewing 301 patients about their clinical features and exposures. RESULTS: Before being tested for histoplasmosis, 60% saw a health care provider ≥3 times, and 53% received antibacterial medication. The median time from seeking health care to diagnosis (range) was 23 (0-269) days. Forty-nine percent were hospitalized, and 69% said that histoplasmosis interfered with their daily activities (median [range], 56 [2-3960] days). Possible exposures included handling plants (48%) and bird or bat droppings (24%); 22% reported no specific exposures. Only 15% had heard of histoplasmosis before their illness. CONCLUSIONS: Histoplasmosis can be severe and prolonged. Additional educational efforts to increase public and provider awareness and reduce delays in diagnosis are needed.

Blastomycosis in Minnesota, USA, 1999-2018.

Blastomycosis is a systemic disease caused by Blastomyces spp. fungi. To determine its epidemiology in blastomycosis-endemic Minnesota, USA, we evaluated all cases reported to public health officials during 1999-2018. We focused on time to diagnosis, exposure activities, and exposure location. A total of 671 cases and a median of 34 cases/year were reported. Median time to diagnosis was 31 days; 61% of patients were not tested for blastomycosis until they were hospitalized. The case-fatality rate was 10%, and patients who died were 5.3 times more likely to have a concurrent medical condition. Outdoor activities and soil exposure were reported by many patients, but no specific activity or exposure was common to most. Almost one third of patients were probably exposed in geographic areas other than their home county. Providers should consider alternative etiologies for patients with pneumonia not responding to antibacterial treatment, and public health officials should increase awareness in blastomycosis-endemic areas.

Enhanced Surveillance for Coccidioidomycosis, 14 US States, 2016.

Although coccidioidomycosis in Arizona and California has been well-characterized, much remains unknown about its epidemiology in states where it is not highly endemic. We conducted enhanced surveillance in 14 such states in 2016 by identifying cases according to the Council of State and Territorial Epidemiologists case definition and interviewing patients about their demographic characteristics, clinical features, and exposures. Among 186 patients, median time from seeking healthcare to diagnosis was 38 days (range 1-1,654 days); 70% had another condition diagnosed before coccidioidomycosis testing occurred (of whom 83% were prescribed antibacterial medications); 43% were hospitalized; and 29% had culture-positive coccidioidomycosis. Most (83%) patients from nonendemic states had traveled to a coccidioidomycosis-endemic area. Coccidioidomycosis can cause severe disease in residents of non-highly endemic states, a finding consistent with previous studies in Arizona, and less severe cases likely go undiagnosed or unreported. Improved coccidioidomycosis awareness in non-highly endemic areas is needed.

Multistate Epidemiology of Histoplasmosis, United States, 2011-2014

Histoplasmosis is one of the most common mycoses endemic to the United States, but it was reportable in only 10 states during 2016, when a national case definition was approved. To better characterize the epidemiologic features of histoplasmosis, we analyzed deidentified surveillance data for 2011-2014 from the following 12 states: Alabama, Arkansas, Delaware, Illinois, Indiana, Kentucky, Michigan, Minnesota, Mississippi, Nebraska, Pennsylvania, and Wisconsin. We examined epidemiologic and laboratory features and calculated state-specific annual and county-specific mean annual incidence rates. A total of 3,409 cases were reported. Median patient age was 49 (interquartile range 33-61) years, 2,079 (61%) patients were male, 1,273 (57%) patients were hospitalized, and 76 (7%) patients died. Incidence rates varied markedly between and within states. The high hospitalization rate suggests that histoplasmosis surveillance underestimates the true number of cases. Improved surveillance standardization and surveillance by additional states would provide more comprehensive knowledge of histoplasmosis in the United States.