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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.

Parenteral nutrition (PN) is widely used in healthcare settings to deliver critical nutrients to patients unable to tolerate enteral feeding. The intravenous formulation is intended to provide all daily nutritional requirements, such as electrolytes, amino acids, dextrose, and lipids, and is considered to be one of the most complex pharmaceuticals to prepare because of the need for careful titration and combination of multiple components [1, 2]. Preparation under rigorous sterile conditions is especially crucial as the nutrient-rich formulation can act as favorable growth media for microorganisms [3, 4] and because the process requires the multistep transfer of several ingredients into a single container, providing opportunities for microbial contamination during the compounding process [5]. In the United States, PN can be compounded in a healthcare facility, outsourced to a compounding pharmacy, or purchased as manufactured, premixed formulations [5]. Healthcare facilities that administer PN to patients often lack the time, expertise, and technology to produce these solutions in their own facilities. As a result, the preparation of PN is frequently outsourced to compounding pharmacies specializing in these practices. In 2011, approximately 43% of 556 US hospitals with >600 beds randomly surveyed reported outsourcing their nutrition support preparations [6]. Compounding pharmacies are expected to adhere to current standards for preparation and handling of compounded sterile preparations (CSPs). One such standard is the United States Pharmacopeia's (USP) General Chapter “Pharmaceutical Compounding—Sterile Preparations,” which details conditions and practices that minimize risks of contamination of CSPs, including PN [7]. Additional standards for compounding PN solutions also exist [8, 9]. The adoption of strict standards for sterile compounding have contributed to a decline in the burden of contaminated PN preparations, and US outbreaks related to mishandling of PN during compounding are rare [2]. However, compounding CSPs, especially using nonsterile active pharmaceutical ingredients (APIs), involves challenging and complex processes, and outbreaks associated with improperly compounded preparations are being increasingly reported [10–20]. In March 2011, the Centers for Disease Control and Prevention (CDC) was notified of 5 patients with Serratia marcescens bloodstream infection (BSI) in one hospital in Alabama. Receipt of PN from a single compounding pharmacy was identified as a potential common source. The pharmacy was an independent, state-licensed compounding pharmacy in Birmingham that was registered with the Alabama State Board of Pharmacy and subject to the state laws and regulations pertaining to the compounding of parenteral therapy [21]. During the outbreak period, the pharmacy supplied PN to 6 healthcare facilities (5 acute care hospitals and 1 long-term acute care hospital), all located within Alabama. Prescriptions for PN were received daily by the pharmacy, and compounded PN preparations were delivered to hospitals each night. On 15 March 2011, after being notified of these S. marcescens BSIs, the pharmacy voluntarily ceased all compounding activities and subsequently recalled all CSPs as a precautionary measure. An investigation was conducted by the Alabama Department of Public Health and CDC to determine the extent of the outbreak, identify risk factors for infection among PN recipients, and review PN compounding practices to identify potential sources of contamination.

CONTEXT In 2008, a lightning strike caused a leak of tert-butyl mercaptan from its storage tank at the Gulf South Natural Gas Pumping Station in Prichard, Alabama. On July 27, 2012, the Alabama Department of Public Health requested Centers for Disease Control and Prevention epidemiologic assistance investigating possible health effects resulting from airborne exposure to mercaptan from a contaminated groundwater spring, identified in January 2012. OBJECTIVE To assess the self-reported health effects in the community, to determine the scope of the reported medical services received, and to develop recommendations for prevention and response to future incidents. DESIGN In September 2012, we performed a representative random sampling design survey of households, comparing reported exposures and health effects among residents living in 2 circular zones located within 1 and 2 miles from the contaminated source. SETTING Eight Mile community, Prichard, Alabama. PARTICIPANTS We selected 204 adult residents of each household (≥ 18 years) to speak for all household members. MAIN OUTCOME MEASURES Self-reported mercaptan odor exposure, physical and mental health outcomes, and medical-seeking practices, comparing residents in the 1- and 2-mile zones. RESULTS In the past 6 months, 97.9% of respondents in the 1-mile zone and 77.6% in the 2-mile zone reported mercaptan odors. Odor severity was greater in the 1-mile zone, in which significantly more subjects reported exposures aggravating their physical and mental health including shortness of breath, eye irritations, and agitated behavior. Overall, 36.5% sought medical care for odor-related symptoms. CONCLUSIONS Long-term odorous mercaptan exposures were reportedly associated with physical and psychological health complaints. Communication messages should include strategies to minimize exposures and advise those with cardiorespiratory conditions to have medications readily available. Health care practitioners should be provided information on mercaptan health effects and approaches to prevent exacerbating existing chronic diseases.