outbreak of histoplasmosis associated with the 1970 earth day activities

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  • Outbreak of Histoplasmosis Associated with the 1970 Earth Day Activities

    ALAN L. BRODSKY, M.D.*

    MICHAEL B. GREGG, M.D.

    MATTHEW S. LOEWENSTEIN, M.D.t

    LEO KAUFMAN, Ph.D.

    GEORGE F. MALLISON, M.P.H.

    Atlanta, Georgia

    An outbreak of histoplasmosis occurred in early May 1970 at a junior high school in Delaware, Ohio; clinical illness occurred in 384 (40 per cent) of the students and faculty, with probably an equal number of subclinical cases. The mode of spread was airborne and was shown epidemiologically to be related to ac- tivities on Earth Day, April 22, 1970, when the courtyard in the center of the school, an old bird roost, was raked and swept. Contamination of the entire school building with courtyard air occurred via the schools forced air ventilation system with in- takes in the courtyard. Soil samples from the courtyard were positive for Histoplasma capsulatum, but random samples from other areas around the building were negative. In two persons in the building only on April 22, the typical illness developed. Features of the outbreak have important implications for clini- cians and public health officials.

    From the Viral Diseases Branch, Epidemiol- ogy Program, Center for Disease Control, Health Services and Mental Health Adminis- tration, Public Health Service, U.S. Depart- ment of Health, Education and Welfare, At- lanta, Georgia 30333. Requests for reprints should be addressed to Dr. Michael B. Gregg, Viral Diseases Branch, Epidemiology Program, Center for Disease Control, Atlan- ta, Georgia 30333. Manuscript received NO- vember 2, 1972; accepted November 9, 1972. ._.-.

    *Present address: Rheumatology Division, University of Texas Southwestern Medical School, Dallas, Texas 75235.

    tPresent address: Boston City Hospital, 818 Harrison Avenue, Boston, Massachu- setts 02118.

    Contaminated starling roosts, particularly in urban areas, are now among the major sources of epidemic histoplasmosis [l] in contrast to the chicken and pigeon roosts in rural settings implicated in earlier studies [2]. An explosive outbreak of respi- ratory illness localized at a junior high school was recently in- vestigated and found to be an epidemic of histoplasmosis relat- ed to cleaning activities in a starling and blackbird roost area. The well defined nature of the outbreak provided an unusual opportunity to study the epidemiology of the airborne route of fungus dissemination as well as the clinical and laboratory di- agnostic features of acute histoplasmosis.

    It seems somewhat paradoxic in light of the current interest in environmental contamination that as the result of a well meant attempt at cleaning up the environment, the largest number of clinical cases of histoplasmosis ever to be reported in a single epidemic occurred.

    BACKGROUND

    Delaware, Ohio, a town of approximately 15,000 persons, is the county seat of Delaware County (population 45,000) and is lo- cated-in the central portion of the-state. The town has five ele- mentary schools, an intermediate school (the Willis Intermediate School, grades 6-8), a high school (Hayes High, grades g-12), a parochial school (grades l-8) and a liberal arts college (Ohio Wesleyan University) (Figure 1) .

    March 1973 The American Journal of Medicine Volume 54 333

  • HISTOPLASMOSIS ASSOCIATED WITH EARTH DAY ACTIVITIES-BRODSKY ET AL.

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    Figure 1. Schools in De/a ware, Ohio.

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    Figure 2. Layout of Willis Intermediate School.

    334 March 1973 The American Journal of Medicine Volume 54

  • The Willis School is housed in two buildings, a 2 l/2 new building (circa 1933) and a 3 story old building (circa 1867), which are connected by a long first floor hall (Figure 2). The sixth grade is housed in the old building, and each stu- dent has his own individual schedule of classes. The seventh and eighth grades are housed in the new building, and these students move as a unit to various classrooms throughout this building.

    The sixth grade uses the cafeteria, auditorium and gym in the new building.

    When an alarming increase in absenteeism oc-

    curred relatively suddenly and involved only the Willis School, local and state health officials were notified. Preliminary investigation conducted by

    the Ohio Department of Health on May 12, 1970, showed that the water in the Willis School was free of coliform contamination, and 18 throat-

    wash specimens processed virologically and bac-

    teriologically yielded no isolates.. Further epide- miologic investigation was then carried out.

    METHODS

    Questionnaire Data. A questionnaire was designed to obtain specific information regarding the nature and duration of the clinical illness, secondary spread and possible modes of spread. It was administered to all full-time and part-time students and faculty of the Wil- lis School, and to several other groups having varying degrees of contact with the affected school.*

    From the questionnaire data an attempt was made to divide the school population into those who were clinically ill and those who were well. Anyone who had any two of the three symptoms of fever, headache and chest pain was considered to be clinically ill. Absentee Data. Absenteeism by date was examined for each city school during the epidemic period; stu- dent visits to the student health service at Ohio Wes- leyan University were similarly analyzed. Serologic Data. Serum samples were obtained from 200 students selected at random at the Willis School and were screened by standard complement fixation technics [3] for antibodies to a battery of respiratory agents, including influenza, para influenza, adenovi- rus, Mycoplasma, selected Coxsackievirus and echo- virus strains, Cl fever, psittacosis and histoplasmosis. Serum was also tested by agar gel immunodiffusion

    *Specific groups questioned: (1) High school students who took shop and cosmetology at the Willis School half a day each day. The shop is located along the corridor be- tween the old and new buildings, and the cosmetology room is on the ground floor of the old building. Both groups ate lunch in the cafeteria. (2) Tutors from the college and high school who helped slow learners one afternoon a week. (3) Substitute teachers during the period between April 20 and May 8. (4) Person? living on the same block as the Willis school (the neighborhood category) who were available for questioning. (5) Faculty and staff from the high school.

    HISTOPLASMOSIS ASSOCIATED WITH EARTH DAY ACTIVITIES-BRODSKY ET AL.

    technics for the presence of histoplasmosis M and H precipitin bands [5]. Serum samples were also ob- tained from persons in groups 1,2,3 and 5 (as pre- viously described under questionnaire data) as well as from 50 ninth grade (high school) controls selected at random.

    For the purpose of this study a positive test for histoplasmosis was defined as complement fixation titer of 1:32 or greater for the yeast form and the my- celial (histoplasmin) antigens, and/or the presence in serum of M or H bands by immunodiffusion technics. Skin Test Data. A histoplasmosis skin test survey was conducted four and a half months after the epi- demic peak for all students in the school system to compare rates for the affected and nonaffected schools. In addition, an estimate of the degree of sus- ceptibility of the intermediate school students was de- duced by this method. A permission slip was sent home with each student in the school system; all stu- dents whose parents signed the slips were tested. Environmental Studies. Airflow studies were per- formed by smoke bomb technics to investigate possi- ble spread of contaminated air via the schools forced- air ventilation system as well as other modes of flow.

    A search for possible sources of fungal contamina- tion included collection of samples of soil and bird

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    Figure 3. Histoplasmosis cases, by date of onset, Willis students, April 29-May 16, 1970.

    March 1973 The American Journal of Medicine Volume 54 335

  • HISTOPLASMOSIS ASSOCIATED WITH EARTH DAY ACTIVITIES-BRODSKY ET AL.

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    Figure 4. Absenteeism by date, Willis School, April l-May 22, 1970.

    droppings from 73 sites around the Willis school build- ings, including each area of bushes and trees, the parking lots, the center courtyard and the air ducts.

    RESULTS

    The Epidemic. The epidemic was explosive in

    nature as can be seen from the epidemic curve

    by date of onset (Figure 3). Most cases occurred on May 6, 7 and 8, with the shape of the curve strongly suggesting a common source outbreak. Although fewer cases had their onset on May 9 and 10, this is probably an artifact due to the fact that these were weekend days and also that the questionnaire was filled out three weeks after the

    peak of the epidemic. The epidemic curve taken from the question-

    naire data is well corroborated by the absentee data (Figure 4) for the Willis School. The usual base line level of absenteeism appeared to be in the range of 45 to 85 students per day. However, on May 7, 144 students were absent, approxi- mately double the base line, and on May 8, 249 were absent, approximately four times the base line. Absenteeism remained elevated during the following week but declined to near base.line lev- els thereafter. These data underestimate absen-

    teeism, since they include only persons absent at the beginning of the day but not those who left during the day. It was estimated that more than 100 pers