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A LARGE OUTBREAK OF HISTOPLASMOSIS AMONG AMERICAN TRAVELERS ASSOCIATED WITH A HOTEL IN ACAPULCO, MEXICO, SPRING 2001

During spring 2001, college students from Pennsylvania reported an acute febrile respiratory illness after returning from spring break vacation in Acapulco, Mexico. Acute pulmonary histoplasmosis was presumptively diagnosed and the cluster of illness was reported to the Centers of Disease Control and Prevention. A large investigation then ensued, which included finding student-travelers for interviews and requesting sera for histoplasmosis testing. We defined a clinical case by fever and at least one of the following: cough, shortness of breath, chest pain, or headache, in an Acapulco traveler during March–May 2001. A laboratory-confirmed case had positive serology. An initial study determined that the likely site of histoplasmosis exposure was Hotel H; we therefore performed a large cohort study among travelers who stayed at Hotel H. Of 757 contacted, 262 (36%) met the clinical case definition. Of 273 serum specimens tested, 148 (54%) were positive. Frequent use of Hotel H’s stairwells, where construction was ongoing, was associated with increased risk of illness (relative risk = 10.5, 95% confidence interval = 3.7–30.5; P < 0.001). This is the first histoplasmosis outbreak associated with a hotel undergoing construction. Hotels in endemic areas should consider construction precaution measures to prevent histoplasmosis among their guests.

Received July 7, 2003. Accepted for publication September 17, 2003.

Acknowledgments: We thank the following individuals for participating in the study: State/Local Health Officials: Maria E. Moll, MD, Assistant State Epidemiologist, Pennsylvania Department of Health; Alfred DeMaria, Jr., MD, State Epidemiologist, Giuseppe Conidi and Emily Harvey, MD, Massachusetts Department of Health; Perry F. Smith, MD, State Epidemiologist, Marilyn Kacica, MD, Medical Director, Bureau of Communicable Disease Control, New York State Department of Health; Eddy Bresnitz, MD, Tina Tan, MD, Epidemic Intelligence Service (EIS) Officer, New Jersey Department of Health; Martin E. Levy, MD, MPH, State Epidemiologist, District of Columbia; Dennis M. Perrotta, PhD, State Epidemiologist, Katherine Hendricks, MD, MPHTM, Division Director, Infectious Disease Epidemiology and Surveillance, James Morgan MD, Regional Director, Janet Matthews, MD, Tejpratap Tiwari, MD, EIS Officer, Texas Department of Health; Mark Dworkin, MD, MPHTM, State Epidemiologist, Connie Austin, DVM, State Public Health Veterinarian, Illinois Department of Health; Eduardo Simoes, MD, State Epidemiologist, Harvey Marx, Missouri Department of Health; Eddy Bresnitz, MD, Utpala Bandyopadhyay, MD, MPH, Tara Cooper, MPH, Rhode Island Department of Health; Matthew Boulton, MD, State Epidemiologist, Melinda Wilkins, DVM., MPH, EIS Officer, Michigan Department of Public Health; Robert Teclaw, MD, State Epidemiologist, James Howell, DVM, Indiana State Department of Health; Larry A. Shireley, MS, MPH, State Epidemiologist, Kirby Krueger, North Dakota State Department of Health; Kathleen F. Gensheimer, MD, MPH, State Epidemiologist, Maine Department of Health; Jeffrey Davis, MD, State Epidemiologist, Thomas Haupt, Donita Croft, MD, MS, EIS Officer, Wisconsin Department of Health; Jeffrey Roche, MD, MPH, State Epidemiologist, Maryland Department of Health; Forrest Smith, MD, State Epidemiologist, Barbara Bradley, MD, Chief, Bureau of Infections, Scott Nowicki, MPH, Ohio Department of Health; Harry Hull, MD, State Epidemiologist, Mei Castor, MD, EIS Officer, Minnesota Department of Health; James Hadler, MD, MPH, State Epidemiologist, Pat Mshar, Epidemiologist, Connecticut Department of Public Health; J. Steve Cline, DDS, MPH, State Epidemiologist, Newt McCormack, MD, Epidemiologist, North Carolina Department of Health; Sara Patrick, PhD, MPH, South Dakota State Department of Health; Richard Hopkins, MD, MSPH, State Epidemiologist, Lisa Conti, DVM, State Public Health Veterinarian, Steven Weirsma, MD, Florida Department of Health; Robert Murray, DrPH, Epidemiologist, California Department of Health Services; Norman Petersen, State Epidemiologist, David Engelthaler, Ken Komatsu, Arizona Department of Health Services; M. Patricia Quinlist, MD, MPH, State Epidemiologist, Judy Goddard, Iowa Department of Public Health; Other (non-CDC) Federal Officials: Donna Knudson, Council of State and Territorial Epidemiologists; Others: Jose Luis Defabio, MD and Marlo Libel, MD, Pan-American Health Organization.

Financial support: Peter G. Spitzer and Hans H. Liu were supported by John S. Sharpe Research Foundation of the Bryn Mawr Hospital (Bryn Mawr, PA).

^* Members of the Acapulco Histoplasmosis Working Group who participated in the study: Centers for Disease Control and Prevention: Jeanette Guarner, Sherif Zaki, Gwen Smith, Mindy Perilla, Gabriel Ponce de Leon, Susanna Schmink, Ward Meyers, Leonard W. Mayer, Perry Brice, Wendy Lee-Yang, Tim Lott, Lynette Benjamin, Madiha Shakir, Randy Kuykendall, Anil Panackal, and Steve Hurst; Physicians and others: Chinhak Chun, MD and Gerri Taylor, RN, Deaconess-Waltham Hospital, Waltham, MA; Richard Pacropis, MD, Villanova University, Philadelpia, PA; Theresa R. Spalding, MD, University of Texas, Austin, TX; David P. Lawrance, MD and Dondald Greeley, University of Illinois, Urbana, IL; Jane Halpern, MD DrPH, Towson University, Towson, MD; Victoria J. Frazier, Washington University, St. Louis, MO; E. F. Joseph Siebold, DO, University of Delaware, Newark, DE; and Karen Ingram, MD, Rutgers University, New Brunswick, NJ.

Author’s addresses: Juliette Morgan, CDC 1600 Clifton Road, Mailstop C-09, Atlanta, GA, 30333. Maria V. Cano, CDC, 1600 Clifton Road, Mailstop E-03, Atlanta, GA, 30333, Telephone: 404-639-1668, Fax: 404-639-1633. Daniel R. Feikin, CDC, 1600 Clifton Road, Mailstop C-23, Atlanta, GA, 30333, Telephone: 404-639-1592, Fax: 404-639-3970. Maureen Phelan, CDC, 1600 Clifton Road, Mailstop C-09, Atlanta, GA, 30333, Telephone: 404-639-4715, Fax: 404-639-0817. Oscar Velazquez Monroy, Benjamin Franklin No. 132, Col. Escandón, Deleg. Miguel Hidalgo, CP 11800, Mexico City, Mexico, Telephone: 52-5-2614-6324, 52-5-2614-6323, and 52-5-2614-6438. Pablo Kuri Morales, Francisco de P. Miranda No. 177 4° Piso, Col. Lomas de Plateros Deleg. Alvaro Obregon CP 01480, Mexico City, Mexico, Telephone: 52-5-5593-0824, 52-5-5593-0922, and 52-5-5593-9771, Fax: 52-5-5593-0786. Joseph Carpenter, CDC, 1600 Clifton Road, Mailstop C-16, Atlanta, GA, 30333, Telephone: 404-639-3900, Fax: 404-639-3822. Andre Weltman, Pennsylvania Department of Health, PO Box 90, Room 933, Health and Welfare Building, Harrisburg, PA 17108, Telephone: 717-787-3350, Fax: 717-772-6975. Peter G. Spitzer and Hans H. Liu, 933 Haverford Road, Bryn Mawr, PA, 19010, Telephone: 610-527-8118, Fax: 610-527-3296. Sara A. Mirza, CDC, 1600 Clifton Road, Mailstop G-11, Atlanta, GA, 30333, Telephone: 404-639-3548, Fax: 404-639-3059. David E. Bronstein, CDC, 1600 Clifton Road, Mailstop C-09, Atlanta, GA, 30333, Telephone: 404-639-3548, Fax: 404-639-3059. Daniel J. Morgan, CDC, 1600 Clifton Road, Mailstop C-09, Atlanta, GA, 30333, Telephone: 404-639-3548, Fax: 404-639-3059. Laura A. Kirkman, CDC, 1600 Clifton Road, Mailstop C-09, Atlanta, GA, 30333, Telephone: 404-639-3548, Fax: 404-639-3059. Mary E. Brandt, CDC, 1600 Clifton Road, Mailstop G-11, Atlanta, GA, 30333, Telephone: 404-639-0281, Fax: 404-639-3546. Naureen Iqbal, CDC, 1600 Clifton Road, Mailstop G-11, Atlanta, GA, 30333, Telephone: 404-639-3464, Fax: 404-639-3546. Mark D. Lindsley, CDC, 1600 Clifton Road, Mailstop G-11, Atlanta, GA, 30333, Telephone: 404-639-4340, Fax: 404-639-3546. David W. Warnock, CDC, 1600 Clifton Road, Mailstop G-11, Atlanta, GA, 30333, Telephone: 404-639-3053, Fax: 404-639-3021. Rana A. Hajjeh, CDC, 1600 Clifton Road, Mailstop C-09, Atlanta, GA, 30333, Telephone: 404-639-4753, Fax: 404-639-3970.

Reprint requests: Juliette Morgan, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop C-09, Atlanta, GA, 30333, Telephone: 404-639-4723, Fax: 404-639-3059, E-mail: JMorgan1{at}cdc.gov.

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