Surveillance for Coccidioidomycosis, Histoplasmosis, and Blastomycosis—United States, 2019.
Open accessAbstract
PROBLEM/CONDITION: Coccidioidomycosis, histoplasmosis, and blastomycosis are underdiagnosed fungal diseases that often mimic bacterial or viral pneumonia and can cause disseminated disease and death. These diseases are caused by inhalation of fungal spores that have distinct geographic niches in the environment (e.g., soil or dust), and distribution is highly susceptible to climate changes such as expanding arid regions for coccidioidomycosis, the northward expansion of histoplasmosis, and areas like New York reporting cases of blastomycosis previously thought to be nonendemic. The national incidence of coccidioidomycosis, histoplasmosis, and blastomycosis is poorly characterized. REPORTING PERIOD: 2019. DESCRIPTION OF SYSTEM: The National Notifiable Diseases Surveillance System (NNDSS) tracks cases of coccidioidomycosis, a nationally notifiable condition reported to CDC by 26 states and the District of Columbia. Neither histoplasmosis nor blastomycosis is a nationally notifiable condition; however, histoplasmosis is voluntarily reported in 13 states and blastomycosis in five states. Health departments classify cases based on the definitions established by the Council of State and Territorial Epidemiologists. RESULTS: In 2019, a total of 20,061 confirmed coccidioidomycosis, 1,124 confirmed and probable histoplasmosis, and 240 confirmed and probable blastomycosis cases were reported to CDC. Arizona and California reported 97% of coccidioidomycosis cases, and Minnesota and Wisconsin reported 75% of blastomycosis cases. Illinois reported the greatest percentage (26%) of histoplasmosis cases. All three diseases were more common among males, and the proportion for blastomycosis (70%) was substantially higher than for histoplasmosis (56%) or coccidioidomycosis (52%). Coccidioidomycosis incidence was approximately four times higher for non-Hispanic American Indian or Alaska Native (AI/AN) persons (17.3 per 100,000 population) and almost three times higher for Hispanic or Latino persons (11.2) compared with non-Hispanic White (White) persons (4.1). Histoplasmosis incidence was similar across racial and ethnic categories (range: 0.9-1.3). Blastomycosis incidence was approximately six times as high among AI/AN persons (4.5) and approximately twice as high among non-Hispanic Asian and Native Hawaiian or other Pacific Islander persons (1.6) compared with White persons (0.7). More than one half of histoplasmosis (54%) and blastomycosis (65%) patients were hospitalized, and 5% of histoplasmosis and 9% of blastomycosis patients died. States in which coccidioidomycosis is not known to be endemic had more cases in spring (March, April, and May) than during other seasons, whereas the number of cases peaked slightly in autumn (September, October, and November) for histoplasmosis and in winter (December, January, and February) for blastomycosis. INTERPRETATION: Coccidioidomycosis, histoplasmosis, and blastomycosis are diseases occurring in geographical niches within the United States. These diseases cause substantial illness, with approximately 20,000 coccidioidomycosis cases reported in 2019. Although substantially fewer histoplasmosis and blastomycosis cases were reported, surveillance was much more limited and underdiagnosis was likely, as evidenced by high hospitalization and death rates. This suggests that persons with milder symptoms might not seek medical evaluation and the symptoms self-resolve or the illnesses are misdiagnosed as other, more common respiratory diseases. PUBLIC HEALTH ACTION: Improved surveillance is necessary to better characterize coccidioidomycosis severity and to improve detection of histoplasmosis and blastomycosis. These findings might guide improvements in testing practices that enable timely diagnosis and treatment of fungal diseases. Clinicians and health care professionals should consider coccidioidomycosis, histoplasmosis, and blastomycosis in patients with community-acquired pneumonia or other acute infections of the lower respiratory tract who live in or have traveled to areas where the causative fungi are known to be present in the environment. Culturally appropriate tailored educational messages might help improve diagnosis and treatment. Public health response to these three diseases is hindered because information gathered from states' routine surveillance does not include data on populations at risk and sources of exposure. Broader surveillance that includes expansion to other states, and more detail about potential exposures and relevant host factors can describe epidemiologic trends, populations at risk, and disease prevention strategies.
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Several epidemiological studies reported higher incidence rates of coccidioidomycosis among racial and ethnic minorities in the US endemic regions.
“Several epidemiological studies reported higher incidence rates of coccidioidomycosis among racial and ethnic minorities in the US endemic regions [136–138].”
From Race and ethnicity: Risk factors for fungal infections? (2023) · cites this paper as [138]
Data on race and ethnicity were available in less than half (39%) of the reported coccidioidomycosis cases.
“However, data on race and ethnicity were available in less than half (39%) of the reported cases [138].”
From Race and ethnicity: Risk factors for fungal infections? (2023) · cites this paper as [138]
In a recent CDC study using data of reportable endemic mycoses from 26 states, American Indian/Alaska Native (AI/AN) cases and Hispanic cases had higher incidence rates of coccidioidomycosis (17.4 and 11.2 per 100,000, respectively) compared to non-Hispanic white cases (4.1 per 100,000).
“This was shown in a recent CDC study using data of reportable endemic mycoses from 26 states that found that American Indian/Alaska Native (AI/AN) cases and Hispanic cases had higher incidence rates of coccidioidomycosis (17.4 and 11.2 per 100,000, respectively) compared to non-Hispanic white cases (4.1 per 100,000).”
From Race and ethnicity: Risk factors for fungal infections? (2023) · cites this paper as [138]
In the 2019 survey, histoplasmosis incidence was similar across racial and ethnic categories (range: 0.9 to 1.3).
“In this survey, histoplasmosis incidence was similar across racial and ethnic categories (range: 0.9 to 1.3) [138].”
From Race and ethnicity: Risk factors for fungal infections? (2023) · cites this paper as [138]
In a 2019 survey of 240 case reports from 5 states, the overall blastomycosis incidence was 0.8 cases per 100,000 population, with Minnesota (rate 1.4) and Wisconsin (rate 1.7) accounting for 179 (75%) of total cases.
“A survey of 240 case reports of blastomycosis from 5 states (Arkansas, Louisiana, Michigan, Minnesota, and Wisconsin) in 2019 showed that the overall blastomycosis incidence in these states was 0.8 cases per 100,000 population, with Minnesota (rate 1.4) and Wisconsin (rate 1.7) accounting for 179 (75%) of the total cases [138].”
From Race and ethnicity: Risk factors for fungal infections? (2023) · cites this paper as [138]
In 2019, the overall incidence of histoplasmosis in 12 reportable states was 1.8 cases per 100,000 population.
“The overall incidence of histoplasmosis in these states was 1.8 cases per 100,000 population, including Illinois (292 cases (26%), rate: 2.3 cases per 100,000 persons), Michigan (225 cases (20%), rate 2.3 cases per 100,000 persons), and Minnesota (214 cases (19%), rate 3.8 cases per 100,000 persons).”
From Race and ethnicity: Risk factors for fungal infections? (2023) · cites this paper as [138]
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- Authors
- Smith, D. J., Williams, S. L., Endemic Mycoses State Partners Group, Benedict, K. M., Jackson, B. R., Toda, M., Endemic Mycoses State Partners Group, Adame, G., Rothfeldt, L., Cooksey, G. S., Rios, K., Austin, C., Steppig, M.-E., Tubach, S., Christophe, N., Lunquest, K., Reik, R., Ireland, M., Power, D., Bridges, D., Cronquist, L., Cibulskas, K., Cieslak, P., Warren, K., Gosciminski, M., Ortbahn, D., Osborn, B., Oltean, H., & Gibbons-Burgener, S.
- Affiliations
- Centers for Disease Control and Prevention (US)
- Arizona Department of Health Services (US)
- Arkansas Department of Health (US)
- California Department of Public Health (US)
- Delaware Division of Public Health (US)
- Illinois Department of Public Health (US)
- Indiana State Department of Health (US)
- Kansas Department of Health and Environment (US)
- Louisiana State Department of Health and Hospitals (US)
- Maryland Department of Health (US)
- Michigan Department of Health and Human Services (US)
- Minnesota Department of Health (US)
- Montana Department of Public Health and Human Services (US)
- New Hampshire Department of Health and Human Services (US)
- North Dakota Department of Health (US)
- Ohio Department of Health (US)
- Oregon Health Authority (US)
- Pennsylvania Department of Health (US)
- Rhode Island Department of Health (US)
- South Dakota Department of Health (US)
- Utah Department of Health (US)
- Washington State Department of Health (US)
- Wisconsin Department of Health Services (US)
- Corresponding author
- Smith, Dallas J.
- ORCID
- Venue
- MMWR. Surveillance Summaries
- Published
- 2022-08-19
- Volume
- 71
- Issue
- 7
- Pages
- 1-14
- ISSN
- 1545-8636 (ISSN-L)
- 1546-0738
- PMC
- PMC9575547
- OpenAlex
- W4293093163
- Cited by
- 75
- References
- 51
- Citations by year
- 2026: 15 · 2025: 16 · 2024: 28 · 2023: 15 · 2022: 1
- FWCI
- 10.83
- Type
- journal article
- Language
- en
- Open access
- diamond
- doi.org
- Licence
- public-domain
- Locations
- MMWR Surveillance Summaries (publishedVersion, public-domain)
- PubMed Central (publishedVersion, public-domain)
- PubMed (publishedVersion)
- Funders
- U.S. Department of Health and Human Services
- Pennsylvania Department of Health
- Minnesota Department of Health
- California Department of Public Health
- Utah Department of Health
- Arizona Department of Health Services
- Washington State University
- Michigan Department of Health and Human Services
- Ohio Department of Health
- Louisiana Department of Health
- Rhode Island Department of Health
- Centers for Disease Control and Prevention
- Topics
- Health Sciences › Medicine › Epidemiology › Fungal Infections and Studies
- Health Sciences › Medicine › Infectious Diseases › Antifungal resistance and susceptibility
- Health Sciences › Medicine › Microbiology › Actinomycetales infections and treatment
- Keywords
- coccidioidomycosis, histoplasmosis, blastomycosis, fungal infection, incidence trends, geographic distribution, American Indian and Alaska Native populations, Hispanic/Latino populations, sex differences, National Notifiable Diseases Surveillance System, California, Minnesota, Wisconsin, Illinois, New York, New Jersey, New Mexico
- MeSH terms
- Blastomycosis, Coccidioidomycosis, Histoplasmosis, Humans, Male, Population Surveillance, Travel, United States, Incidence
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