Histoplasma Capsulatum Exposure/Injury Response Protocol

Organism or Agent:

Histoplasma Capsulatum

Exposure Risk:

Histoplasmosis

UCSF Occupational Health Services:

415-885-7580 (work hours, 8am to 5pm)

Exposure Hotline Pager:

415-353-3898 (24 hours)

Office of Environment Health & Safety:

415-476-1300 (work hours) 

UCSF Police Department:

415/476-1414 or 9-911 (In case of emergency, 24 hours)

EH&S Public Health Officer:  

415-514-3531(work hours)

Biosafety Officer 415-514-2824 (work hours)

Occ Hlth Proto Button

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In the event of an accidental exposure or injury, the protocol is as follows:

1. Modes of Transmission:

  1. Skin puncture or injection
  2. Ingestion
  3. Contact with mucous membranes (eyes, nose, mouth)
  4. Contact with non-intact skin
  5. Exposure to aerosols
  6. Respiratory exposure involving inhalation of the mold form

2. First Aid:

  1. Skin Exposure, immediately go to the sink and thoroughly wash the skin with soap and water. Decontaminate any exposed skin surfaces with an antiseptic scrub solution.
  2. Skin Wound, immediately go to the sink and thoroughly wash the wound with soap and water and pat dry.
  3. Splash to Eye(s), Nose or Mouth, immediately flush the area with running water for at least 5-10 minutes.
  4. Splash Affecting Garments, remove garments that may have become soiled or contaminated and place them in a double red plastic bag.

3. Treatment:

  1. In the event of an acute injury resulting from a laboratory incident which requires immediate medical care, the injured employee/student should report to the emergency department for medical treatment. The injured individual must take a copy of this entire protocol document to the Emergency Department, including information regarding the specific strain associated with exposure.
  2. In the event of exposure, with or without an injury, call the Needlestick Exposure Hotline in order to get access to medical care for the exposure. The needlestick exposure hotline responder will provide guidance to the injured individual on necessary medical treatment and post exposure follow-up.
  3. Post exposure prophylaxis with itraconazole is recommended for inhalational exposure to spores/conidia and exposure to the yeast form from percutaneous injury or mucous membrane exposure.  See ISDS for details.

 

4. Follow up is needed in the event of any Laboratory Exposure: 

  1. After first aid has been administered, immediately inform your supervisor of the exposure.
  2. In the event of a large spill, contact the emergency response team (9-911) for clean-up.
  3. Contact Occupational Health Services, after first aid is complete, for follow-up care.
  4. Contact the Biosafety Officer at 415/514-2824 to report the injury or exposure.

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Roles and responsibilities after an accidental exposure:

1.  EMPLOYEE'S RESPONSIBILITIES (Worker/Student Initial Self-Care)

  1. First Aid: Perform the recommended first aid and decontamination according to the posted instructions.
  2. Treatment: i) In the event of an acute injury resulting from a laboratory incident which requires immediate medical care, the injured individual should report to the Emergency Department for acute medical treatment. ii) In the event of an exposure, with or without an injury, call the Needlestick Exposure Hotline in order to get access to medical care for the exposure and evaluation for possible post exposure prophylaxis.
  3. Access to Needlestick Hotline: Call the Exposure Hotline pager in order to get access to medical care for the exposure. Dial 415 /353-7842; If there is no call back in 15 minutes, call again. If there is no call back the second time, proceed to the Emergency Department with a copy of this protocol.
  4. Reporting: Inform your laboratory supervisor / principal investigator of the exposure. Complete an Employee Incident Report Form (http://ucsfhr.ucsf.edu/files/EIR.pdf). 
  5. Secure the laboratory: Identify the equipment involved in the exposure and the mechanism of exposure. Make sure that the laboratory area has been secured and that notification of contamination has been posted to prevent other individuals from entering the area. 
  6. Follow up: Students and workers should contact Occupational Health Services (OHS) at 415 / 885-7580 for any needed follow up care.

2. SUPERVISOR’S/PI’S RESPONSIBILITIES 

  1. First Aid and Decontamination: Verify that the worker has washed and decontaminated himself/herself. Ensure that appropriate medical treatment has been received.
  2. Secure the laboratory: Confirm that the laboratory area has been secured and that notification of contamination has been posted to prevent other individuals from entering the area.
  3. Laboratory clean-up (as needed): Contact the Office of Environment Health & Safety (EH&S) through the UC Police Department Emergency Dispatch (from a campus telephone 9-911, from a non-campus phone 415/476-1414).
  4. Report the exposure: Call the Biosafety Officer at 415/476-2097 during regular hours to discuss the exposure. A report summarizing any suspected Histoplasma exposure needs to be submitted to the Biosafety Committee by the Principal Investigator (PI). The report must include the following:

-          A brief description of the exposure event, a description of the area involved, and the extent of the employee’s exposure.

-      If applicable, specification of the amount of infectious material released, time involved, and explanation of procedures used to determine the amount involved

-          Corrective action taken to prevent the re-occurrence of the incident.

-          Decontamination procedures.

-          Histoplasma decontamination procedures

e. Follow Up: Confirm that the worker has called for an appointment at the UCSF Occupational Health Clinic.

f. Report the Injury: Within 24 hours, report the injury to the UCSF Human Resources Disability Management Services (HR DMS) Office on the Supervisor’s Report of Injury (SRI) form, available here: http://ucsfhr.ucsf.edu/files/SIR.pdf

 

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Infectious Substance Data Sheet: Histoplasma Capsulatum

SECTION I – Infectious Agent

Organism or Agent: HISTOPLASMA CAPSULATUM

Synonym or Cross Reference: Histoplasmosis; Ajecllomyces capsulatus

Characteristics: Dimorphic fungus, mold form in soil, yeast form in animals and human hosts

SECTION II – Recommended Precautions

Containment Requirements: Biosafety level 2 practices, safety equipment and facilities for specimens or cultures known or suspected to contain the yeast form. Biosafety level 3 practices, safety equipment and facilities for specimens known or suspected to contain the mold form. ABSL-2 practices, containment equipment and facilities for activities involving animals experimentally infected with the yeast form. ABSL-3 practices, containment equipment and facilities for activities involving animals experimentally infected with the mold form.

UCSF Required Personal Protective Equipment: BSL2 practices for work with the yeast form. BSL 3 procedures for work involving the mold form. Use personal protective equipment standards as detailed in the Biosafety Use Authorization (BUA).

SECTION III – Handling Information

Spills: Allow aerosols to settle; wearing protective clothing, gently cover spill with paper towel and apply 10% bleach (0.5% sodium hypochlorite) solution, starting at perimeter and working towards the center; allow sufficient contact time (30 min) before clean up.

Disposal: Decontaminate waste contaminated with known or suspected H. capsulatum in the mold form before disposal. Dispose as biohazardous waste.

Storage: Store in sealed containers that are appropriately labeled.

SECTION IV – Health Hazards

Pathogenicity: Systemic mycosis of varying severity with primary lesion in lungs; disease appears as a mild, flu-like respiratory illness with symptoms including malaise, fever, chest pain, dry or non-productive cough, headache, loss of appetite, shortness of breath, joint and muscle pain, chills; five clinical forms - asymptomatic, acute benign respiratory, acute disseminated, chronic disseminated, chronic pulmonary; some forms can be fatal; asymptomatic infection provides partial resistance to re-infection

Epidemiology: Focal infections are common worldwide; clinical disease and severe progressive disease less frequent; 80% of population show hypersensitivity to H. capsulatum in eastern and central North America; outbreaks have occurred in families or groups exposed to bird or bat droppings or recently disturbed contaminated soil; prevalence increases from childhood to 15 years of age.

Host Range: Humans, dogs, cats, cattle, horses, rats, skunks, opossums, foxes and other animals.

Infectious Dose: As low as 10 spores is a lethal inoculum in mice per Canadian MSDS.

Modes of Transmission: Inhalation of airborne conidia; small size of infective conidia (< 5 µm) is conducive to airborne dispersal and intrapulmonary retention. The spores of H. capsulatum are of a respirable size.

Incubation Period: Symptoms appear within 3-18 days after exposure, commonly 10 days.

Communicability: Not transmitted from person-to-person.

SECTION V – Viability

Drug Susceptibility: Sensitive to amphotericin B, ketoconazole, itraconazole, fluconazole, posaconazole, voriconazole.

Susceptibility to Disinfectants: Susceptible to 1% sodium hypochlorite, phenolics, glutaraldehyde, formaldehyde; susceptibility to 70% ethanol questionable.

Physical Inactivation: Inactivated by moist heat (121° C for at least 15 min).

Survival Outside Host: Spores are resistant to drying and may remain viable for long periods of time.

FOR THE USE OF THE NEEDLESTICK EXPOSURE HOTLINE

SECTION VI – Medical

Surveillance: Monitor for symptoms; confirm by culture, microscopic examination of specimens, and serologic response. Any pregnant or immune compromised worker should be evaluated by an infectious disease specialist. 

First Aid/Treatment: Itraconazole is the preferred drug for prophylaxis. After consultation with Infectious Disease for complicated cases, other drugs such as Amphotericin B may be used for treatment in disseminated or chronic pulmonary cases. Conazole drugs may be added or used in rotation for therapy in immunocompromised patients because relapse is common.

Immunization: None.

Prophylaxis: Evaluate all exposures for prophylaxis .. Prophylaxis should be started the day of exposure, but can be started up to 2 weeks after acute exposure. The rationale for this is that most severe cases would likely produce symptoms within 2 weeks. After 2 weeks, prophylaxis should be started with the development of symptoms, since severe disease would not be likely.

1. Prophylaxis Recommended For:

  • Significant inhalational exposure to spores/conidia.
  • Percutaneous injury with Histoplasma, materials contaminated by Histoplasma, or mucous membrane exposure.

2. Prophylaxis Considered For:

  • Potential inhalational exposures to spores/conidia in individuals with risk factors for development of systemic disease.
  • Potential mucous membrane exposure to either form of Histoplasma.

3. Prophylaxis Not Recommended For:

  • Intact skin exposure associated with the yeast form of Histoplasma, where there is no inhalation or percutaneous or mucous membrane exposure.

Medication: Itraconazole – load with 200 mg TID for three days, then treat with 200 mg once daily for 30 days. Provide one week supply of medication. This drug may have significant side effects and multiple drug interactions. Itraconazole is contraindicated in pregnancy. If there is any question regarding early pregnancy, a pregnancy test should be performed before starting prophylaxis.

The exposed patient will need close follow up in UCSF Occupational Health Services. 

Reporting: All laboratory exposures must be reported to the Biosafety Officer. Any known cases of histoplasmosis exposure must be reported to the Public Health Officer. Histoplasmos is a communicable disease, but reporting to the San Francisco Department of Public Health is not required.

SECTION VII – Laboratory Hazards

Laboratory-Acquired Infections: Documented hazard in laboratories conducting diagnostic or investigative work; 71 reported cases with 1 death - pulmonary infection from handling mold from cultures, local infection from skin puncture during autopsy, accidental needle inoculation of viable culture.

Sources/Specimen: Infective stage (conidia) present in sporulating mold from cultures and in soil from endemic areas; yeast form in tissues or fluids from infected animals or humans (may produce local infection following parental inoculation).

Primary Hazards: Inhalation of infective conidia, contact with broken skin or mucus membranes, accidental parenteral inoculation.

Special Hazards: Collecting and processing soil samples from endemic areas has caused pulmonary infections in laboratory workers.

FOR THE USE OF THE EMERGENCY DEPARTMENT

SECTION VIII – Emergency Medical Treatment

Treatment Indications: Emergency department treatment will be required for injuries that require immediate medical care. The treatment needs to consist of the following: 1) decontaminate and debride wound, 2) repair wound, 3) consult with infectious disease specialist for high risk exposure, 4) contact the Exposure Hotline to discuss the need to start post exposure prophylaxis, if indicated (see section VI above), and 4) have patient follow up with UCSF-OHS. For significant exposures, baseline labs should be drawn. Serum samples for fungal titers should be submitted. Repeat serology should be performed in two weeks to identify possible conversions. See Appendix II: Diagnostic Tests.

Exposure Indications: In the event of an exposure, with or without an injury, the Needlestick Exposure Hotline must be called. 

SECTION VIII – References

http://www.phac-aspc.gc.ca/msds-ftss/msds82e-eng.php

http://www.cdc.gov/od/ohs/biosfty/bmbl5/BMBL_5th_Edition.pdf