Disclosures: None Key Publications in Occupational & Environmental Health: the Year in Review Em Emerging and Re-Em Emerging Oc Occupational Disease 2018 Samuel M. Goldman, MD, MPH Associate Clinical Professor UCSF Division of Occupational & Environmental Medicine 2 Clinical Infectious Diseases Background M A J O R A R T I C L E • Case definition: Outbreak of Severe Histoplasmosis Among Tunnel ‒ worked in tunnels to hydroelectric dam during July 30-Sept 2, 2015 Workers—Dominican Republic, 2015 ‒ fever and > 2 of: chills, night sweats, weakness, joint pain, cough, headache, malaise, dyspnea, myalgias, diarrhea, vomiting Paige A. Armstrong, 1 John D. Beard, 2,a Luis Bonilla, 3 Nelson Arboleda, 3 Mark D. Lindsley, 4 Sae-Rom Chae, 5 Delia Castillo, 6 Ramona Nuñez, 6 Tom Chiller, 4 Marie A. de Perio, 7 Raquel Pimentel, 6 and Snigdha Vallabhaneni 4 • Case finding: 1 Epidemic Intelligence Service, Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases (DFWED), National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Centers for Disease Control and Prevention (CDC), Atlanta, Georgia; 2 Epidemic Intelligence Service, Industrywide Studies Branch, Division of Surveillance, Hazard Evaluations and Field Studies, National Institute for Occupational Safety and Health (NIOSH), Cincinnati, Ohio; 3 Centers for Disease Control and Prevention, Santo Domingo, Dominican Republic; 4 Mycotic ‒ Manual review of company payroll records Diseases Branch and 5 Epidemic Intelligence Service, Global Water, DFWED, NCEZID, CDC, Atlanta, Georgia; 6 Dirección General de Epidemiología, Santo Domingo, Dominican Republic; and 7 Hazard Evaluations and Technical Assistance Branch, Division of Surveillance, Hazard Evaluations and Field Studies, NIOSH, Cincinnati, Ohio ‒ Interviews with workers to identify any other workers • Questionnaire: § On September 16, 2015, Dominican Republic Ministry of ‒ Interviews in Spanish Health requested CDC investigation of an unknown severe febrile illness in tunnel workers ‒ Demographics, medical conditions ‒ Work history: days in tunnels, tasks, PPE • Medical record review • Cohort study to identify risk factors for severe disease (ICU admission) 3 4 1 3/8/18 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Tunnel Worker Characteristics (n = 36) Characteristic No. (%) Male sex 36 (100) § 36 men hired from local Age, y a village by private company 18–32 18 (51) 33–62 17 (49) § PPE: knee-high rubber boots, Asthma 5 (15) hard hat, some had loose Current cigarette smoking 15 (43) fitting paper masks Illicit drug use (noninjection) 12 (39) Type of work § Filled wheelbarrows with bat Shoveling/filling only 15 (43) guano, dumped at tunnel Transporting wheelbarrow only 5 (14) entrance Shoveling/filling and transporting wheelbarrow 11 (31) Supervising 3 (9) § 3-4 hours work/morning due Other 1 (3) to heat Tunnel of work • Hydroelectric dam built in 1972 Tunnel 1 only 10 (29) § Began 30 July, stopped 2 • 5 tunnels, 1-2 km long, 3m wide and tall, provide access for Tunnel 2 only 7 (20) Sept when several became ill inspection & maintenance Tunnels 1 and 2 18 (51) • No ventilation, hot, large bat colonies Median cumulative days worked in tunnels (range) 24 (1–25) Personal protective equipment use: surgical mask • 1m deep bat guano, last cleaned 30 years ago Never 16 (48) Sometimes 14 (42) 5 6 Always 3 (9) Histoplasmosis infection Distribution of Symptom Onset Dates • H. capsulatum most common pulmonary fungal infection 8 7 ‒ occurs worldwide, especially throughout Americas & Caribbean; no prior reports in DR 6 Physician suggests histoplasmosis 5 ‒ 500,000 annually in US, Ohio River valley Cases Began work 4 First patient admitted to 30-Jul ‒ 90% cases are self-limited and sub-clinical local hospital 3 First death 2 • Dimorphic soil saprophyte often found in association with bird or bat droppings (alkaline nitrogenous substrates) 1 0 • Occupations: farming, exposure to chicken coops or caves, remodeling or demolition of old buildings, cutting down trees or Date of Symptom Onset clearing brush from sites in which blackbirds have roosted • Leptospirosis initially suspected, but patients did not respond to penicillin • Exposure by inhalation of microconidia (asexual reproductive spores) • Histoplasmosis suggested on 8 September, and all 19 hospitalized • Transforms into yeast phase in the body, incubation ~1-3 weeks workers were transferred from local to regional hospitals • Acute/subacute/chronic pulmonary forms; disseminated 7 8 2 3/8/18 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
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