LDH, CDC partner up on histoplasmosis outbreak investigation at Louisiana campsite

By JOSE SERRANO, MPH | LDH Public Health Epidemiologist Specialist; POOJA GANDHI, MPH, CHES | CDC Mycotic Diseases Branch Health Communication Specialist; and KAITLIN BENEDICT, MPH | CDC Mycotic Diseases Branch Epidemiologist

“Fungal diseases have taken a backseat to bacterial and viral infections, to the point where mycotics are left out of many doctors’ diagnoses. Awareness efforts, such as multiple statewide surveillance projects and outbreak findings, show the growing concern of invasive fungal diseases in the general population.” 

— Jose Serrano, MPH, epidemiologist specialist and lead investigator of this outbreak from the Louisiana Department of Health

In November 2018, what seemed like a normal camping trip led to a group of campers in Louisiana getting sick with what was later discovered to be histoplasmosis, an infection caused by Histoplasma capsulatum, a fungus that lives in soil.

The Louisiana Department of Health got a call about two patients — a teenage girl who was thought to have viral pneumonia, and a middle-aged man with an unknown respiratory illness — who were hospitalized with symptoms that weren’t improving after being treated with antibacterials. After their doctors consulted with an infectious disease specialist, the two patients were eventually tested, diagnosed with and treated for histoplasmosis. Both people have recovered from the illness.

Both of them had traveled to a campsite in a rural area in southern Louisiana in the three weeks prior to falling ill. LDH contacted campsite officials to get a list of fellow campers who might have also gotten sick and began an investigation, with support from the Centers for Disease Control and Prevention’s Mycotic Diseases Branch, to figure out if others were infected and how these campers became sick in the first place.

Investigating the outbreak

LDH’s interviews with the campers revealed that about half of the people on this camping trip were sick. They asked the CDC to test the campers’ urine samples, which confirmed histoplasmosis.

“The rapid and robust public health response to this outbreak highlights the importance of partnership and enhanced collaboration between CDC and state health departments,” said Nancy Chow, PhD, a molecular epidemiologist with the Mycotic Diseases Branch. 

The fungus lives in the environment, particularly in soil that contains large amounts of bird or bat poop.  But, none of the sick people remembered any bird or bat poop at the campsite. Or, at least that’s what LDH initially believed. The team searched the entire campsite looking for clues about where these campers could have become exposed to the fungus.

After more investigation, LDH learned that the campers participated in many different activities, including hiking, collecting firewood, digging soil and geocaching. Geocaching is a digital scavenger hunt-like game played through a smartphone app. The app directed the campers to different objects and locations throughout the campsite, which soon became key to the investigation, getting public health officials one step closer to the source of the outbreak.

This hollowed-out tree was found to be the source of Histoplasma at a Louisiana campsite.

The Mycotic Diseases Branch laboratory tested soil samples from areas surrounding a few of the geocaching sites and found that one of the samples tested positive for Histoplasma. The sample was from a hollowed-out tree that reportedly had bats living inside, based on photos. This site was one of the geocaching sites many of the campers had visited, making all the more sense that it was the source of infection.

After uncovering the site of this fungus, LDH worked to identify any potential high-risk areas to prevent others from becoming exposed, and told campers to avoid activities involving soil disturbance. Additionally, a summary risk reduction document was provided to camp officials for all future campsite visitors.

Preventing future outbreaks

The investigation team recommended that future campers consider the following to help prevent people from getting histoplasmosis:

• Avoid soil disruption activities (including geocaching) and contact with hollow trees.
• Teach campers about the risks for histoplasmosis and other fungal diseases, especially those who are weakened immune systems and at high risk.
• Spread more awareness about histoplasmosis throughout Louisiana.

“Fungal disease outbreaks are relatively rare — this investigation confirmed that histoplasmosis is endemic to Louisiana, and that disruption of soil is still a significant health risk for both sick and healthy individuals,” said Jose Serrano, MPH, an LDH epidemiologist specialist and lead investigator of this outbreak.

“Once this outbreak was confirmed, every single epidemiologist dropped what he or she were doing to lend a helping hand in the investigation. Our strength comes from our teamwork, and no investigation is ever handled alone,” he said.

Learn more about histoplasmosis here.

Health equity: Informing LDH staff, practices and protocols to improve services, health and health outcomes

By DR. EARL BENJAMIN-ROBINSON, D.H.Sc. | LDH Deputy Director of Community Partnerships

In LDH’s Friday, April 26 blog, “Making 2019 the Year of Public Health for Louisiana,” Dr. Alexander Billioux noted that despite some improvements regarding Louisiana’s health outcomes and healthcare access, Louisiana continues to rank among the unhealthiest states in America. He then posed a rhetorical question: “Why does Louisiana continue to be ranked low with these improvements?” His answer: “Achieving and maintaining good health requires more than healthcare.”

Dr. Billioux’s answer is poignant and right!

Human beings cannot and do not live on bread alone, neither do they acquire or sustain wellness and well-being just by having access to healthcare. There are factors that affect people, populations and communities’ health and wellness. These factors are barriers to health, also referred to as social determinants of health: economic and social factors that contribute to and/or shape a person’s health and health outcomes. The World Health Organization defines barriers to health as “the conditions in which people are born, grow, live, work and age.”

Culture, social norms and policies affect the conditions in which people are born, grow, live, work and age. Conditions are further compounded by a society’s distribution of money, power and resources resulting in differences in health and healthcare between population groups — health disparities. Many of these health disparities occur across a number of demographics, including socioeconomic status, age, location, gender, disability status, race/ethnicity and sexual orientation. Additionally, many health disparities experienced and observed in Louisiana are seen as unnecessary, avoidable and unjust — health inequities.

Given these factors, concepts and Louisiana’s health inequities, LDH continues in its commitment to support all Louisianans in achieving their best, fullest health outcomes — health equity. According to the Robert Wood Johnson Foundation, “Health equity means that everyone has a fair and just opportunity to be as healthy as possible.” In an effort to achieve and sustain this, LDH will focus more intentionally on the words of Dr. Georges C. Benjamin, executive director of the American Public Health Association: "Eighty percent of what makes us healthy happens outside the doctor’s office.”

With this in mind, LDH is presently working to put practices and protocols in place that are informed by people, populations and communities’ behavior, social environment, physical environment and their experiences with health services.

We are excited about this work, and more equitably meeting the needs and supporting the wellness and well-being of the citizens of Louisiana. Stay tuned for more to come!

Protect the skin you're in

It’s summer in Louisiana and the heat is on.

Did you know daytime weather from June through August averages around 90 degrees Fahrenheit? On top of that, humidity hovers in the 90 percent range most days. Between the heat and the humidity, it’s no surprise that we feel hot and sweaty on a daily basis.

June, July and August are also among the sunniest months Louisiana sees all year, which makes it so important to protect yourself from harmful sun exposure. Skin cancer was the ninth most commonly diagnosed cancer in Louisiana between 2010 and 2014, according to the Louisiana Tumor Registry, which collects information about all cancers diagnosed and/or treated in Louisiana.

Ultraviolet (UV) radiation, which comes from the sun, reaches us whether the weather is sunny, cloudy or hazy. The most hazardous hours for UV exposure in the lower 48 states are from 10 a.m. to 4 p.m. CST.

What is skin cancer?

Cancer is a catch-all term for a disease in which abnormal cells in the body divide uncontrollably and invade other tissues, spreading throughout the body through the blood and lymph systems.

Skin cancer, the fourth most common form of cancer in the U.S., is usually caused by overexposure to UV light. It is commonly classified into three types.

• Basal cell carcinoma begins in the basal cell layer of the skin. The bad news is it can be disfiguring and expensive to treat, but the good news is that it’s highly curable.
• Squamous cell carcinoma begins in the squamous layer of the skin. Like basal cell carcinoma, it’s highly curable though it can be expensive to treat and cause disfigurement.
• Melanoma begins in the melanocytes, the cells that produce the pigment that gives skin its color. It is the third most common skin cancer, but it’s the most dangerous and the most deadly.

Skin cancer doesn’t discriminate against anybody, but it’s more likely to develop in people with these characteristics, according to the Centers for Disease Control and Prevention (CDC):

• A lighter natural skin color
• Skin that burns, freckles, reddens easily or becomes painful in the sun
• Blue or green eyes
• Blond or red hair
• Certain types and a large number of moles
• A family history of skin cancer
• A personal history of skin cancer

If you have any of these characteristics — and even if you have none — it’s vital that you protect yourself when being exposed to the sun.

Safety in the sun

The CDC recommends these simple steps to protect yourself from UV radiation:

• Stay in the shade, especially during midday hours. If you’re outdoors, sit beneath an umbrella, a shady tree or other shelter.
• Wear clothing that covers your arms and legs. Choose tightly woven fabrics for the best protection. Keep in mind that a typical T-shirt has a sun protection factor (SPF) lower than 15, so use other types of protection as well.
• Wear a hat with a wide brim to shade your face, head, ears and neck. Hats made of tightly woven fabric, such as canvas, are preferable. Avoid straw hats with holes that let sunlight through. If you wear a baseball cap, you should also protect your ears and the back of your neck by wearing clothing that covers those areas, using sunscreen with an SPF of 15 or higher or by staying in the shade.
• Wear sunglasses that wrap around and block both UVA and UVB rays. Most sunglasses sold in the U.S. block both UVA and UVB rays.
• Use sunscreen with an SPF of 15 or higher, and both UVA and UVB (broad spectrum) protection. Apply a thick layer on all parts of exposed skin. Get help for hard-to-reach places like your back. Reapply sunscreen if you stay out in the sun for more than two hours and after swimming, sweating or toweling off.

Sunscreen safety concerns

Sunscreen has been making headlines recently after a pilot study found it takes just one day of sunscreen use for several common ingredients to enter a person’s bloodstream at worrisome levels and for some to continue to build in the blood as daily use continued.

The Center for Drug Evaluation and Research, an arm of the United States Food and Drug Administration (FDA), conducted the study, published in the medical journal JAMA. The study concluded four common sunscreen chemicals — avobenzone, oxybenzone, ecamsule and octocrylene — are among 12 chemicals in need of further research by manufacturers before they can be considered “generally regarded as safe and effective.”

That doesn’t mean you should stop using sunscreen, because we don’t yet know whether these ingredients have any harmful effects after they are absorbed. We do know, though, that overexposure to the sun is harmful, so continue to protect your skin.

Let’s talk indoor tanning

If you think indoor tanning is a safe alternative, think again. The CDC says indoor tanning — whether it’s a tanning bed, booth, sunbed or sunlamp — should be avoided. All of these methods expose users to high levels of UV radiation, which may result in skin cancer. Just because it’s from a mechanical source doesn’t make it any safer than the UV radiation you’re exposed to when out in the sun.

Screening saves lives

The importance of getting screened for cancer cannot be overstated. Through screening, doctors can help find and treat a number of cancers at an early state, before symptoms show up. Cancer that is detected after symptoms appear may have begun to spread and therefore be harder to treat.

Talk to your doctor if you’re concerned about skin cancer — or any other type of cancer, for that matter.

Tackling cancer in Louisiana

The Louisiana Department of Health’s Taking Aim at Cancer in Louisiana (TACL) initiative launched last year and is working toward improving cancer outcomes in the state. TACL’s goals are increasing access to care, improving the quality of care and reducing the costs of care.

To learn more from the Department of Health about cancer in Louisiana, click here.

The bottom line

So, what’s the bottom line when it comes to sun exposure and tanning, according to the CDC? Every time you tan, you increase your risk of getting skin cancer. Take steps to avoid those harmful UV rays. And remember, skin safety isn’t just for the summer months. Protect the skin you’re in — every day.

Say cheese! Well-Ahead Louisiana aims for healthy smiles across the state

By MeCHAUNE BUTLER, MPA | Oral Health Promotion Manager, Well-Ahead Louisiana;  GEORGENA DESROSIER, MPH | Oral Health Promotion Coordinator, Well-Ahead Louisiana; and ANGELA VANVECKHOVEN | Health Education Manager, Well-Ahead Louisiana 

Oral disease is almost completely preventable, but it still affects children and adults throughout Louisiana every day. Oral health has a direct impact on many other diseases and conditions, including diabetes, heart disease and stroke. Additionally, gum disease in pregnant women is associated with premature births and low birth weight.

Along with those risks, 83% of the state’s parishes have a shortage of dental care providers. That is why Well-Ahead Louisiana, an initiative of the Louisiana Department of Health, focuses on promoting oral health through expanded access to preventive dental services, specifically through school dental sealant programs.

Dental sealants

Dental sealants prevent 80% of cavities on the back teeth, where 9 out of 10 cavities occur. These thin plastic coatings are applied to the chewing surfaces of the first and second molars, where food and bacteria are not easily removed, acting as a barrier to protect the teeth from plaque and acids that cause tooth decay. When correctly applied, dental sealants last several years before reapplication is needed.

School dental sealant programs

Tooth decay causes pain, and children suffering from dental pain cannot focus or be productive, particularly during school. School dental sealant programs are an evidence-based best practice for preventing tooth decay among children who are less likely to see dentists in a private practice. Schools are an ideal place to reach children, and they play a pivotal role in affecting children’s health. In Louisiana, a dentist must first perform an oral health screening; a dentist, dental hygienist or other qualified dental professional can then apply sealants.

These programs are either school-based or school-linked. School-based are conducted completely within the school setting using portable dental equipment. School-linked can include transporting the children to a linked federally qualified health center, having a mobile bus or van at the school, or holding the program in a school-based health center.

Louisiana Seals Smiles

Well-Ahead Louisiana is excited to continue its Louisiana Seals Smiles program, which is a replicable program that provides free oral health screenings and dental sealants to eligible students ages 6 to 14.  Recently, the Louisiana Seals Smiles Toolkit was added to Well-Ahead’s website to provide guidance and resources for any provider who wants to implement a school dental sealant program in his or her community. It includes step-by-step instructions for implementation and printable, ready-to-use downloads like parent flyers, a clinic charting form, a dental report card and more.

Children who have good oral health are better able to learn, grow and play. Be a leader in ensuring youth in your community have healthy smiles by using the toolkit to start a school sealant program. Together, we can move Louisiana’s health forward.

For more information

To learn more about oral health, visit Well-Ahead Louisiana or email wellahead@la.gov.

Mental health affects everyone, not just those with a mental illness

By DR. REBEKAH GEE | Louisiana Department of Health Secretary

Last fall, NOLA.com | The Times-Picayune's series “A Fragile State” placed a spotlight on one of our most vulnerable populations. Full of heartbreak and sometimes hope, these courageous stories reminded us of the tragic impact of mental illness on families and individuals in our state. Because May is National Mental Health Month, I turn to these stories once more as a call to awareness and action.

“A Fragile State” vividly portrayed the enduring impact of years of financial cuts and psychiatric hospital closures that occurred under the Jindal administration, actions that left thousands of people without some vital services. Now, however, the ball is in our court, and Louisiana can and must do better. 

These individual stories are heartbreaking and the solutions are complex. More inpatient beds are needed as well as adequate numbers of doctors who can treat patients who have mental health and substance use illnesses. True solutions start with addressing poverty, health disparities, early childhood trauma and violence – issues beyond the walls of a doctor’s office or hospital. The seeds of mental illness and addiction are sown in the pain of trauma and neglect. Louisiana must also invest new funds and renewed dedication to ensuring quality care options in the community – more crisis services and greater access to these services – are available for people when they need them most.

A lifetime of care

We need to demand care that occurs throughout the life course. This means a pregnant mom with mental illness is treated and there is help available as she parents her child. When and if a school-age child suffers from mental illness, she is diagnosed and treated instead of failing and dropping out.

It means that a family with a son in a sudden crisis is treated for mental illness instead of ending up in the criminal justice system, leaving a trail of pain in his wake. It means that individuals and families always know who to call and what to expect when help is needed.

Care throughout a person’s life, with a strong focus on immediately helping those who are facing a crisis, is the mental health system Louisiana must commit to building. This system will require more providers, more resources and greater investments from our communities.

An ideal system includes easily accessible mental health services in the community. Inpatient beds will be a component of this continuum, but not its foundation. We must address crises via mobile crisis response or specialized drop-in centers, for example, and the system should address homelessness and lack of transportation that can get in the way of recovery.

The Louisiana Department of Health is focusing on four critical areas: ensuring there is a full continuum of care, implementing effective crisis services, improving the access to and quality of care, and making the mental care system easier to navigate.

First and foremost, under Gov. John Bel Edwards’ leadership, we led the charge for coverage under Medicaid expansion. Prior to expansion, most low-income adults in Louisiana had no health insurance and no access to treatment for mental health. Rather than treating mental illness, it fell to the correctional system to remove mentally ill individuals from society, rather than treating people and preventing harm to others.

Since Medicaid expansion, more than 485,000 adults are now covered, of whom more than 65,000 have received specialized outpatient mental health services and more than 15,000 have received inpatient mental health care at a psychiatric facility. Tens of thousands of people have received treatment for addiction. We have sought and received millions of new federal dollars for addiction treatment and are rebuilding our system of mental health care in partnership with local human service districts that serve as the safety net for mental health care.

The way forward

The journey for families with a loved one with mental illness can be excruciating, even for our citizens with high incomes and the means to pay for care. The Louisiana Department of Health is charged with taking care of those in the shadows, individuals who are sometimes forgotten, neglected, the most vulnerable and complex. We are failing in that charge.

“A Fragile State” is a raw and honest account of a system that needs to change. That change will be led by the Department of Health, but it is bigger than a single state agency. Change will come only when we work in tandem with the community, with law enforcement, with the judicial system and any other stakeholders in mental health.

We commit that as a Department we will continue to fight this battle on all available fronts — to rebuild and strengthen a system of care that too often fails those who are desperately in need of help. This will not be easy, but we commit to fight for the systems of care and the resources needed to win the struggle against mental illness and addiction so that people can thrive. Only then will our communities reach their full potential.