Outbreak Reports: An Outbreak of Febrile Histoplasmosis Among Chinese Manganese-Mine Workers in Cooperative Republic of Guyana in 2019

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• Summary

What is already known on this topic?

Cases of histoplasmosis have been reported in every continent except Antarctica but are fairly rare in China. High prevalence of histoplasmosis has been observed in Central America, Caribbean, and South America. Infections of Histoplasma are acquired through a respiratory route, particularly inhalation of aerosols from disturbed soils enriched with excreta from birds and bats. These infections are most common in persons involved with removing soil, visiting caves, cleaning old houses, or felling trees, etc.

What is added by this report?

This is the first report of cluster infections of Histoplasma among overseas Chinese workers. A strong dose-dependent association of illness onset and disease severity with the exposure intensity to the soils and wastes possibly contaminated by the Histoplasma has been proposed. Long labor times, repeated entering of contaminated tunnels, working in high-dust environments are likely to result in earlier illness onsets, more severe clinical courses, and even fatal outcomes. More importantly, none of the patients used reliable personal protection equipment (PPE), such as common masks while working, that would prevent the inhalation of more Histoplasma spores.

What are the implications for public health practice?

The epidemiological findings of this outbreak investigation highlight a probable risk of infection with Histoplasma when entering without PPE into the environment with bats living around, such as caves or mines. Effective education and communication might be needed among residents and travelers. This outbreak expands our knowledge of the control and prevention of fungal disease in China.

•  [1] Brandt ME, Gómez BL, Warnock D. Histoplasma, Blastomyces, Coccidioides, and other dimorphic fungi causing systemic mycoses. In: Versalovic J, Warnock D, editors. Manually of Clinical Microbiology, 10th edition. Volume 2, Section VI, Chapter 120. ASM Press, Washington DC; 2011. p 1902 − 18. [2] Colombo AL, Tobón A, Restrepo A, Queiroz-Telles F, Nucci M. Epidemiology of endemic systemic fungal infections in Latin America. Med Mycol 2011;49(8):785 − 98. http://dx.doi.org/10.3109/13693786.2011.577821CrossRef [3] Rios Fabra A, Restrepo A, Isturiz R. Fungal infection in Latin American countries. Infect Dis Clin N Am 1994;8:129 − 54. [4] Kauffman CA. Histoplasmosis. In: Kauffman CA, Pappas PG, Sobel JD, Dismukes WE, editors. Essentials of Clinical Mycology. 2nd ed. Springer; 2011. p. 321 − 35. [5] Deepe GS, Jr. Histoplasma capsulatum. In: Mandell GL, Bennett JE, Dollin R, editors. Mandell, Douglas and Bennett’s principles and practice of infectious diseases. 7th ed. Philadelphia: Elsevier Churchill Livingstone; 2010. p 3305 − 18. [6] Kauffman CA. Histoplasmosis: a clinical and laboratory update. Clin Microbiol Rev 2017;20:115 − 32. [7] Cuellar Rodriguez J, Avery RK, Lard M, Budev M, Gordon SM, Shrestha NK, et al. Histoplasmosis in solid organ transplant recipients: 10 years of experience at a large transplant center in an endemic area. Clin Infect Dis 2009;49:710 − 6. http://dx.doi.org/10.1086/604712CrossRef [8] Gao GF. From " A”IV to " Z”IKV: attacks from emerging and re-emerging pathogens. Cell 2018;172:1157 − 9. http://dx.doi.org/10.1016/j.cell.2018.02.025CrossRef
• FIGURE 1.  The date of illness onset of the Chinese-manganese-miner male case-patients in the outbreak of febrile illness in Matthews Ridge, Cooperative Republic of Guyana in 2019

FIGURE 2.  The dose-response exposures associated with severity of illness among 15 Chinese-manganese-miner male case-patients in the outbreak of febrile illness in Matthews Ridge, Cooperative Republic of Guyana in 2019

TABLE 1.  The epidemiological and clinical characteristics of the 15 Chinese manganese-miner male case-patients in the outbreak of febrile illness in Matthews Ridge, Cooperative Republic of Guyana in 2019*

 Case No. Age (years) Date of Onset Type of diagnosis Clinical Outcome Clinical evaluation score† Details of exposure in the four old mines Date of first entry Date of last entry Times of entry No. of mines Type of work Place of work Hours of stay per time Other miner's working§ Exposure intensity¶ 1 47 Mar 22 Laboratory confirmed Dead 100 Mar 16 Mar 22 7 4 Shovel Bottom 2 Yes 189 2 44 Mar 26 Laboratory confirmed Dead 100 Mar 16 Mar 25 7 4 Shovel Bottom 2 Yes 270 3 42 Mar 27 Laboratory confirmed Coma, ICU 90 Mar 16 Mar 27 5 4 Shovel, crush Bottom, middle 2 Yes 175 4 51 Mar 25 Laboratory confirmed ICU 90 Mar 17 Mar 23 5 4 Shovel Bottom 2 Yes 171 5 49 Mar 29 Laboratory confirmed Hospitalization 70 Mar 16 Mar 27 7 4 Shovel, crush Bottom, middle 2 Yes 249 6 33 Mar 29 Clinical diagnosis Hospitalization 1 Mar 18 Mar 18 1 1 Check around Bottom 0.1 Yes 0.113 7 44 Mar 28 Laboratory confirmed Hospitalization 1 Mar 24 Mar 27 4 4 Crush, check around Bottom 1.5 No 9.6 8 56 Mar 30 Clinical diagnosis Hospitalization 20 Mar 16 Mar 24 2 4 Check around Bottom 0.1 No 0.525 9 34 Mar 30 Clinical diagnosis Hospitalization 30 Mar 18 Mar 28 1 2 Crush Bottom 1.5 Yes 5.625 10 48 Mar 30 Clinical diagnosis Hospitalization 1 Mar 16 Mar 16 2 1 Check around Bottom 0.1 Yes 0.225 11 43 Mar 30 Clinical diagnosis Hospitalization 5 Mar 17 Mar 27 1 2 Check around Bottom 0.1 Yes 0.3 12 38 Mar 31 Clinical diagnosis Discharge 0.5 Mar 16 Mar 16 1 1 Check around Entrance 0.5 No 0.094 13 50 Mar 26 Laboratory confirmed ICU 80 Mar 16 Mar 24 7 4 Shovel Bottom, middle 2 Yes 198 14 41 Apr 11 Clinical diagnosis Hospitalization 30 Mar 28 Mar 28 1 1 Crush Middle 1.5 Yes 2.25 15 23 Apr 11 Clinical diagnosis Hospitalization 30 Mar 28 Mar 29 2 2 Crush Entrance 6 Yes 12 Abbreviation: ICU = intensive care unit. All 15 cases were male. Next-generation sequencing (NGS) technology based on Illumina MiSeq platform identified different lengths of specific gene sequences of Histoplasma capsulatum in 7 different samples of 2 fatal cases and one severe case, including lung and blood samples. Up to April 15, 2019, 7 cases were laboratory confirmed being infected with Histoplasma capsulatum.* All data were updated as of April 15, 2019 when the special Chinese medical team departed from Guyana back to China.† A clinical evaluation score (range: 0.5 to 100) was assigned to each of the 15 Chinese cases by clinical experts according to their illness severity. The more severe the illness was, the higher score was. § Were other miners working close by? ¶ The exposure intensity was a score representing the exposure degree and risk of infection according to the detailed exposure information of the case-patients. It was calculated by using the equation of $\sum\nolimits_{F = 1}^n {\left( {{{twTLE}}} \right)}$; n was the number of the abandoned tunnels (range: 1-4), F was the times of entry, t was hours of stay per entry, w was the type of work including shovel (score=1.5), crush (score=1) and inspection (score=0.5), T was the date of entry including Period 1 (score=1.5) from March 13 to 22, 2019 and Period 2 (score=1) from March 23 to 29, 2019, L was the place of work including the bottom (score=1.5), middle (score=1) and entrance (score=0.5) of the tunnels, and E indicated whether other work was performed during the stay (Yes scoring 1, No scoring 0.5).

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通讯作者: 陈斌, bchen63@163.com
• 1.

沈阳化工大学材料科学与工程学院 沈阳 110142

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Article Contents

An Outbreak of Febrile Histoplasmosis Among Chinese Manganese-Mine Workers in Cooperative Republic of Guyana in 2019

View author affiliations

Summary

What is already known on this topic?

Cases of histoplasmosis have been reported in every continent except Antarctica but are fairly rare in China. High prevalence of histoplasmosis has been observed in Central America, Caribbean, and South America. Infections of Histoplasma are acquired through a respiratory route, particularly inhalation of aerosols from disturbed soils enriched with excreta from birds and bats. These infections are most common in persons involved with removing soil, visiting caves, cleaning old houses, or felling trees, etc.

What is added by this report?

This is the first report of cluster infections of Histoplasma among overseas Chinese workers. A strong dose-dependent association of illness onset and disease severity with the exposure intensity to the soils and wastes possibly contaminated by the Histoplasma has been proposed. Long labor times, repeated entering of contaminated tunnels, working in high-dust environments are likely to result in earlier illness onsets, more severe clinical courses, and even fatal outcomes. More importantly, none of the patients used reliable personal protection equipment (PPE), such as common masks while working, that would prevent the inhalation of more Histoplasma spores.

What are the implications for public health practice?

The epidemiological findings of this outbreak investigation highlight a probable risk of infection with Histoplasma when entering without PPE into the environment with bats living around, such as caves or mines. Effective education and communication might be needed among residents and travelers. This outbreak expands our knowledge of the control and prevention of fungal disease in China.

• 1. Public Health Emergency Center, Chinese Center for Disease Control and Prevention, Beijing, China
• 2. Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China
• 3. National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
• 4. Institute for Viral Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
• 5. Beijing Ditan Hospital, Capital Medical University, Beijing, China
• 6. Global Public Health Center, Chinese Center for Disease Control and Prevention, Beijing, China
• 7. State Key Laboratory for Infectious Disease Prevention and Control, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases (Zhejiang University), National Institute for Viral Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
• 8. Chinese Center for Disease Control and Prevention, Beijing, China
doi: 10.46234/ccdcw2019.013
• At the beginning of April 2019, China National Health Commission (NHC) and China Center for Disease Control and Prevention (China CDC) received reports of a cluster of febrile illness involving about ten Chinese workers in a manganese ore in Cooperative Republic of Guyana. The enterprise applied to NHC for permission for evacuating the patients back to China for further treatment. A special Chinese medical team composed of the experts of epidemiology, medical bacteriology, clinical and emergency medicines was deployed to Georgetown, Guyana on April 6, 2019 to provide the support in clinical and public health, to identify the potential etiology and to assess the potential threat, especially the risk of international transmission.

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