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.

Nontuberculous Mycobacterial Infection in Wisconsin Adults and Its Relationship to Race and Social Disadvantage.

Rationale: Population-based data on the epidemiology of nontuberculosis mycobacterial (NTM) infections are limited, particularly with respect to variation in NTM infection among racial groups and socioeconomic strata. Wisconsin is one of a handful of states where mycobacterial disease is notifiable, allowing large, population-based analyses of the epidemiology of NTM infection in this state. Objectives: To estimate the incidence of NTM infection in Wisconsin adults, describe the geographic distribution of NTM infection across the state, identify the frequency and type of infection caused by different NTM species, and investigate associations between NTM infection and demographics and socioeconomic status. Methods: We conducted a retrospective cohort study using laboratory reports of all NTM isolates from Wisconsin residents submitted to the Wisconsin Electronic Disease Surveillance System from 2011 to 2018. For the analyses of NTM frequency, multiple reports from the same individual were enumerated as separate isolates when nonidentical, collected from different sites or collected more than one year apart. Results: A total of 8,135 NTM isolates from 6,811 adults were analyzed. Mycobacterium avium complex accounted for 76.4% of respiratory isolates. The M. chelonae-abscessus group was the most common species isolated from skin and soft tissue. The annual incidence of NTM infection was stable over the study period (from 22.1 per 100,000 to 22.4 per 100,000). The cumulative incidence of NTM infection among Black (224 per 100,000) and Asian (244 per 100,000) individuals was significantly higher compared with that among their White counterparts (97 per 100,000). Total NTM infections were significantly more frequent (P < 0.001) in individuals from disadvantaged neighborhoods, and racial disparities in the incidence of NTM infection generally remained consistent when stratified by measures of neighborhood disadvantage. Conclusions: More than 90% of NTM infections were from respiratory sites, with the vast majority caused by M. avium complex. Rapidly growing mycobacteria predominated as skin and soft tissue pathogens and were important minor respiratory pathogens. We found a stable annual incidence of NTM infection in Wisconsin between 2011 and 2018. NTM infection occurred more frequently in non-White racial groups and in individuals experiencing social disadvantage, suggesting that NTM disease may be more frequent in these groups as well.

Human-to-Cattle Mycobacterium tuberculosis Complex Transmission in the United States.

The Mycobacterium tuberculosis complex (MTBC) species includes both M. tuberculosis, the primary cause of human tuberculosis (TB), and M. bovis, the primary cause of bovine tuberculosis (bTB), as well as other closely related Mycobacterium species. Zoonotic transmission of M. bovis from cattle to humans was recognized more than a century ago, but transmission of MTBC species from humans to cattle is less often recognized. Within the last decade, multiple published reports from around the world describe human-to-cattle transmission of MTBC. Three probable cases of human-to-cattle MTBC transmission have occurred in the United States since 2013. In the first case, detection of active TB disease (M. bovis) in a dairy employee in North Dakota prompted testing and ultimate detection of bTB infection in the dairy herd. Whole genome sequencing (WGS) demonstrated a match between the bTB strain in the employee and an infected cow. North Dakota animal and public health officials concluded that the employee's infection was the most likely source of disease introduction in the dairy. The second case involved a Wisconsin dairy herd with an employee diagnosed with TB disease in 2015. Subsequently, the herd was tested twice with no disease detected. Three years later, a cow originating from this herd was detected with bTB at slaughter. The strain in the slaughter case matched that of the past employee based on WGS. The third case was a 4-month-old heifer calf born in New Mexico and transported to Texas. The calf was TB tested per Texas entry requirements and found to have M. tuberculosis. Humans are the suspected source of M. tuberculosis in cattle; however, public health authorities were not able to identify an infected human associated with the cattle operation. These three cases provide strong evidence of human-to-cattle transmission of MTBC organisms and highlight human infection as a potential source of introduction of MTBC into dairy herds in the United States. To better understand and address the issue, a multisectoral One Health approach is needed, where industry, public health, and animal health work together to better understand the epidemiology and identify preventive measures to protect human and animal health.

Clinical Manifestations and Outcomes in Immunocompetent and Immunocompromised Patients With Blastomycosis.

BACKGROUND: Blastomyces is a dimorphic fungus that infects persons with or without underlying immunocompromise. To date, no study has compared the clinical features and outcomes of blastomycosis between immunocompromised and immunocompetent persons. METHODS: A retrospective study of adult patients with proven blastomycosis from 2004-2016 was conducted at the University of Wisconsin. Epidemiology, clinical features, and outcomes were analyzed among solid-organ transplantation (SOT) recipients, persons with non-SOT immunocompromise (non-SOT IC), and persons with no immunocompromise (NIC). RESULTS: A total of 106 cases met the inclusion criteria including 74 NIC, 19 SOT, and 13 non-SOT IC (malignancy, HIV/AIDS, idiopathic CD4+ lymphopenia). The majority of patients (61.3%) had at least 1 epidemiologic risk factor for acquisition of Blastomyces. Pneumonia was the most common manifestation in all groups; however, immunocompromised patients had higher rates of acute pulmonary disease (P = .03), more severe infection (P = .007), respiratory failure (P = .010), and increased mortality (P = .02). Receipt of SOT primarily accounted for increased severity, respiratory failure, and mortality in immunosuppressed patients. SOT recipients had an 18-fold higher annual incidence of blastomycosis than the general population. The rate of disseminated blastomycosis was similar among NIC, SOT, and non-SOT IC. Relapse rates were low (5.3-7.7%). CONCLUSIONS: Immunosuppression had implications regarding the acuity, severity, and respiratory failure. The rate of dissemination was similar across the immunologic spectrum, which is in sharp contrast to other endemic fungi. This suggests that pathogen-related factors have a greater influence on dissemination for blastomycosis than immune defense.

COVID-19 Outbreak at an Overnight Summer School Retreat - Wisconsin, July-August 2020.

During July 2-August 11, 2020, an outbreak of coronavirus disease 2019 (COVID-19) occurred at a boys' overnight summer school retreat in Wisconsin. The retreat included 152 high school-aged boys, counselors, and staff members from 21 states and territories and two foreign countries. All attendees were required to provide documentation of either a positive serologic test result* within the past 3 months or a negative reverse transcription-polymerase chain reaction (RT-PCR) tests result for SARS-CoV-2 (the virus that causes COVID-19) ≤7 days before travel, to self-quarantine within their households for 7 days before travel, and to wear masks during travel. On July 15, the Wisconsin Department of Health Services (WDHS) began an investigation after being notified that two students at the retreat had received positive SARS-CoV-2 RT-PCR test results. WDHS offered RT-PCR testing to attendees on July 28 and serologic testing on August 5 and 6. Seventy-eight (51%) attendees received positive RT-PCR results (confirmed cases), and 38 (25%) met clinical criteria for COVID-19 without a positive RT-PCR result (probable cases). By the end of the retreat, 118 (78%) persons had received a positive serologic test result. Among 24 attendees with a documented positive serologic test result before the retreat, all received negative RT-PCR results. After RT-PCR testing on July 28, WDHS recommended that remaining susceptible persons (asymptomatic and with negative RT-PCR test results) quarantine from other students and staff members at the retreat. Recommended end dates for isolation or quarantine were based on established guidance (1,2) and determined in coordination with CDC. All attendees were cleared for interstate and commercial air travel to return home on August 11. This outbreak investigation documented rapid spread of SARS-CoV-2, likely from a single student, among adolescents and young adults in a congregate setting. Mitigation plans that include prearrival quarantine and testing, cohorting, symptom monitoring, early identification and isolation of cases, mask use, enhanced hygiene and disinfection practices, and maximal outdoor programming are necessary to prevent COVID-19 outbreaks in these settings (3,4).

Evaluation of modified Wright-staining of dried urinary sediment as a method for accurate detection of bacteriuria in cats.

BACKGROUND: Urinary sediment examination and quantitative urinary culture results are frequently discordant. OBJECTIVES: The aims of this study were to compare accuracy of light microscopic examination of wet-mounted unstained (wet-unstained) and air-dried modified Wright-stained (dry-stained) sedimented preparations of urine with results of quantitative aerobic bacterial culture for detection and characterization of bacteriuria in cats. In addition, the presence of pyuria detected by urinalysis and potential risk factors were assessed. METHODS: A blinded prospective study was conducted on 472 urinary samples collected from 410 cats by cystocentesis. The age and sex of each cat were recorded. Complete urinalyses were performed and included quantification of WBCs. Quantity and morphology of bacteria in each specimen were determined by light microscopic examination of wet-unstained (performed by certified medical technologists) and dry-stained (performed by a veterinary clinical pathologist) sedimented preparations of urine and compared with results of quantitative bacterial cultures. RESULTS: Of 472 urinary specimens, 29 were positive for bacteriuria by culture and considered true positives and 443 were considered true negatives. Compared with these results, examination of wet-unstained and dry-stained urines had sensitivities of 75.9% and 82.8%, specificities of 56.7% and 98.7%, and test efficiencies of 57.8% and 97.7%, respectively. Positive likelihood ratios were 1.8 and 63.7 and negative likelihood ratios were 0.42 and 0.17 for wet-unstained and dry-stained examinations, respectively. Compared with 29 culture-positive samples, the wet-unstained method had morphologic concordance and misclassification rates of 37.9% and 62.1%, respectively, whereas the dry-stained method had morphologic concordance and misclassification rates of 65.5% and 34.5%, respectively. Only 34% of samples with bacteriuria had pyuria. Frequency of bacteriuria was not significantly different based on age and sex of the cats, but there was a tendency for increased frequency in female cats and in cats >10 years old. CONCLUSIONS: Staining dried urinary sediment with a modified Wright-stain significantly improved sensitivity, specificity, and test efficiency of microscopic detection and classification of bacteriuria compared with the wet-unstained method. Pyuria should not be a criterion for determining the presence or absence of bacteriuria.

Evaluation of modified Wright-staining of urine sediment as a method for accurate detection of bacteriuria in dogs.

OBJECTIVE: To compare the findings of light microscopic evaluation of routine unstained wet-mounted preparations and air-dried, modified Wright-stained preparations of urine sediment with results of quantitative aerobic bacteriologic culture of urine. DESIGN: Masked prospective study. SAMPLE POPULATION: 459 urine samples collected by cystocentesis from 441 dogs. PROCEDURE: Urinalyses and quantitative bacteriologic cultures of urine were performed. Unstained wet-mounted preparations and air-dried, modified Wright-stained urine sediment preparations were examined by light microscopy for the presence of bacteria. RESULTS: Compared with results of quantitative bacteriologic culture, routine unstained preparations and modified Wright-stained preparations had sensitivities of 82.4% and 93.2%, specificities of 76.4% and 99.0%, positive predictive values of 40.1% and 94.5%, negative predictive values of 95.8% and 98.7%, and test efficiencies of 77.3% and 98.0%, respectively. Compared with 74 samples that yielded growth on bacteriologic culture, the routine unstained method had concordance and misclassification rates of 39.2% and 60.8%, respectively, whereas the Wright-stained method had concordance and misclassification rates of 78.4% and 21.6%, respectively. Significant associations between each of occult blood in urine, pyuria, female sex, and lower urine specific gravity with bacteriuria detected by Wright-stained sediment examination and quantitative bacteriologic culture of urine were identified. CONCLUSIONS AND CLINICAL RELEVANCE: Examination of modified Wright-stained preparations of urine sediment appeared to be a rapid, cost effective method that significantly improved the sensitivity, specificity, positive predictive value, and test efficiency of light microscopic detection of bacteriuria, compared with that of the routine unstained method.