{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,10]],"date-time":"2026-03-10T03:59:50Z","timestamp":1773115190076,"version":"3.50.1"},"reference-count":29,"publisher":"Public Library of Science (PLoS)","issue":"9","license":[{"start":{"date-parts":[[2025,9,23]],"date-time":"2025-09-23T00:00:00Z","timestamp":1758585600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/publicdomain\/zero\/1.0\/"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Background<\/jats:title>\n<jats:p>Blastomycosis is a rare, potentially fatal fungal infection caused by inhalation of <jats:italic>Blastomyces<\/jats:italic> spores, typically acquired outdoors in the midwestern and eastern United States. In 2023, the largest recorded U.S. blastomycosis outbreak occurred among workers at a paper mill in Michigan\u2019s Upper Peninsula. Few data exist on occupational risk factors or indoor exposure to <jats:italic>Blastomyces<\/jats:italic>, limiting prevention efforts.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Objectives<\/jats:title>\n<jats:p>We assessed workplace environments and conditions associated with blastomycosis risk through a cross-sectional medical survey and environmental sampling.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Methods<\/jats:title>\n<jats:p>During April 22\u201328, 2023, we conducted a voluntary medical survey, including a work and health questionnaire and urine antigen testing, for 603 workers out of approximately 1,000 at the mill. We compared worker characteristics, work locations, and environmental exposures by blastomycosis case status and modeled disease risk using Poisson regression. We tested 533 environmental samples of outdoor soil, indoor surface dust, and raw materials for <jats:italic>Blastomyces<\/jats:italic> using polymerase chain reaction and culture-based methods.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec004\">\n<jats:title>Results<\/jats:title>\n<jats:p>Twenty percent of workers were classified as blastomycosis cases based on positive urine antigen testing during the survey, self-reported provider diagnoses, or confirmed or probable case status reported by state or local health departments. Prevalence was highest among workers in paper machine line #1 (27%) and maintenance areas (25%). Adjusted analyses indicated a 40% [Prevalence Ratio (PR): 1.40; 95% confidence interval (CI): 1.00, 1.95] and 53% (PR: 1.53; 95% CI: 1.04, 2.25) higher risk for workers in these locations, respectively, compared to workers working elsewhere. Working in both locations doubled blastomycosis risk. Daily exposure to indoor pooling water was associated with a nearly two-fold higher prevalence of blastomycosis (PR: 1.79; 95% CI: 1.25, 2.57). All indoor and outdoor environmental samples were negative for <jats:italic>Blastomyces<\/jats:italic>.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec005\">\n<jats:title>Discussion<\/jats:title>\n<jats:p>Blastomycosis was associated with specific indoor work locations and environmental conditions, suggesting the potential for occupational exposure to <jats:italic>Blastomyces<\/jats:italic> in indoor industrial settings. These findings may guide future outbreak investigations and occupational prevention strategies.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pone.0332398","type":"journal-article","created":{"date-parts":[[2025,9,23]],"date-time":"2025-09-23T17:33:01Z","timestamp":1758648781000},"page":"e0332398","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":1,"title":["Assessment of environmental risk factors for blastomycosis during a large outbreak at a Michigan paper mill"],"prefix":"10.1371","volume":"20","author":[{"given":"Allyson W.","family":"O\u2019Connor","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ju-Hyeong","family":"Park","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Marcia L.","family":"Stanton","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Xiaoming","family":"Liang","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8088-6427","authenticated-orcid":true,"given":"Dallas","family":"Shi","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Perri C.","family":"Callaway","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"R. 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