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Soraya Ghebleh
18 March 2013
ECS 151
Increased Incidence of Valley Fever in Arizona
Executive Summary
Infectious diseases are consistently an issue for public health departments around
the country and around the world. Coccidioidomycosis, colloquially known as valley
fever, is an infectious disease that has adverse health effects and is increasing in
incidence. Although the exposure to coccidioidoymocis is difficult to measure because of
the inhalation pathway, it estimated that infection rates are approximately 3% in Southern
Arizona.1
An estimated 150,000 people a year become infected with coccidioidomycosis
and of those approximately one third develop symptomatic disease. Those infected in
Arizona account for 60% of the afflicted population, indicating a serious need for
attention to be paid to this problem.2
Since 1997 when coccidioidomycosis became a reportable disease, incidence has
increased substantially. While this may be partly explained by an increase in reporting,
other risk factors have been determined to clearly be contributing to the increase in
disease. These risk factors include construction and soil disruption, increased vulnerable
populations in areas with dust, outdoor exposure, climactic change, and other workplace
hazards.
There are a variety of measures that can be taken to help abate the spread of
coccidoidomycosis. Because individuals become infected as a result of inhalation, it is a
very difficult disease to prevent even when care is taken to increase risk factors. This
points to a solution derived in a permanent solution such as development of a vaccine.
This is the most attractive and appropriate policy option as strides have been made
towards developing vaccines and it provides a stronger solution for the public.
Introduction of the Problem
The environmental health exposure being studied is the inhalation of airborne
spores from Coccidioides immitis, a fungus found in soil in arid, desert climates.
Infection occurs usually after activities or natural events that disrupt the soil, resulting in
aerosolization of the fungal arthrospores.
The human health effects of concern are infection with coccidioidomycosis, more
commonly known as valley fever. This disease has a very high rate of infection and is
one of the most common infectious diseases despite the fact that it is not well known
outside of the Southwest and California regions. Approximately 40% of infections result
in symptomatic disease, typically arising one to four weeks after exposure, and can
resemble ordinary influenza but also have many more severe symptoms.
The individuals bringing this issue forward are a patient support group for valley
fever victims and family members who want more research to be done for a vaccination
as well as more preventative measures to be put in place to reduce disease incidence of
coccidioidomycosis.
Since 1995, there has been a substantial increase in coccidioidomycosis incidence
in Arizona. While many of these cases are attributed to seasonal peaks and climate
change, there is an increasing concern that the expansion in the Metropolitan area of
Phoenix and the expansion in construction also has a role in the increased incidence of
coccidioidomycosis. This is one example of where policy could be implemented to
reduce disease incidence.
Should legislation be passed in the greater Metropolitan Area of Phoenix to
require more preventative measures and research be put in place to assist in reduction of
coccidioidomycosis incidence?
Background of Coccidioidomycosis Incidence in Arizona
Coccidioidomycosis, more commonly known as valley fever, is a systemic
infection that occurs upon airborne inhalation of Coccidioides, a soil-dwelling fungus
found in the southwestern United States, parts of Mexico, as well as Central and South
America.3
Coccidioides immitis is the species that is geographically limited to the San
Joaquin Valley and Coccidioides posadasii inhabits all other coccidioidal endemic
regions.4
The first patient to be described with coccidioidomycosis was an Argentinean
soldier in 1893, however until 1935 patients identified with this disease were still
extremely rare. Not much was known about the disease and due to lack of
epidemiological knowledge it was thought to always be a rare and severe infection. New
observations from the 1930s on, however, indicated that a large proportion of those who
undergo a coccidioidal infection do not develop symptoms or their symptoms resolve
without further issue.5
In Arizona, coccidioidomycosis immitis is the prevalent form of species that
causes infection. Coccidioidomycosis has been linked to climate change as one of the risk
factors. In order to grow, Coccidioides species need suitable temperatures and soil
moisture for growth making the most likely period for infection during the fall, winter,
and spring as opposed to the summer months in Arizona.6
Inhalation leads to infected
cases and the incidence of these cases oscillates with climactic change.6
While climate
has explained a large amount of differences in incidence in coccidioidomycosis, overall
trends cannot only be explained by climate. There are other non-climactic issues related
to the increased incidence of disease in Arizona.
The presentation of coccidioidomycosis is difficult to diagnose, as so many
patients are asymptomatic. Those patients who present will present with primary
pulmonary coccidioidomycosis. Of these, around one will develop extrathoracic
dissemeniation. Approximately four will develop chronic complications such as a nodule,
cavity, or chronic pneumonia.1
A definitive diagnosis is difficult without serologic testing
and frequently cannot be made on clinical observations alone. In approximately five
percent of cases, a rash such as erythema multiforme may appear and painful nodules of
erythema nodosum may appear on the lower extremities.1
Often many of these findings
are overlooked and this has led to misdiagnosis and underdiagnosis of the disease. The
clinical indications are also very similar to bacterial community-acquired pneumonia and
there is a strong correlation between those infected with coccidioidomycosis and those
who develop community-acquired pneumonia.
The Arizona Department of Health Services (ADHS) monitors
coccidioidomycosis and has attempted to increase knowledge and minimize disease
burden but incidence continues to increase.2
Valley fever incidence in Arizona has shown
a considerable increase since reporting requirements were instituted.6
Arizona has the
highest number of reported cases and accounts for sixty percent of all national cases.2
From 1990 to 1995, the number of annually reported cases doubled leading to increased
reporting in 1997.2
Since then, the number of cases has increased considerably from
approximately 16 per 100,000 to 155 per 100,000 in 2009.2
The highest rates of cases
occur in the most populated counties in Arizona as these areas experience arid to semiarid
climates with mild winters and hot summers.2
Coccidioidomycosis is associated with
community-acquired pneumonia (CAP) as well and a substantial portion of patients with
CAP had confirmed coccidioidomycosis.9
Economic analysis of the effects of
coccidioidomycosis has also revealed that there is an economic burden associated with
lack of effective preventive measures and a vaccine. A delay in education of the public
and of providers has also contributed to reduced delays in diagnosis that could lead to
earlier detection and treatment of valley fever.2
Another risk factor involves the recent
growth in population and influx of individuals who were never in areas endemic to
coccidioidomycosis. These individuals become at risk for primary infection. Another
environmental risk is local dust production associated with construction. The last twenty
years has seen tremendous growth in Arizona and this is also an associated work hazard
risk factor.10
Another area of change that may describe the rise in incidence could result
from increased reporting. Because coccidioidomycosis became a reportable disease in
1997, the increase in the number of reported cases could be a reason behind increased in
incidence as coccidioidomycosis may have been underreported more frequently previous
to this change in policy.10
The current system of surveillance in place in Arizona accurately reflects the
disease burden but there is a significant symptom duration and delayed diagnosis for
patients leading to suboptimal care and treatment.2
There also are considerable legal
barriers for those exposed to coccidioidomycosis in the workplace. For example,
construction workers who are exposed to excessive amounts of dust and soil and contract
valley fever are not privy to worker’s compensation. Case law has developed in contrast
to development of California case law that recognizes statistically increased probability
of contracting Valley Fever but that this is not sufficient for a worker to be
compensated.11
Evidence Table
Study Name Study Design Study Size Findings
Increase in
coccidioidomycosis
—Arizona, 1998-
200112
CDC data analysis
of Surveillance and
Hospitalization,
environmental and
climactic data, as
well as a cohort
study conducted by
the CDC of a
random sample of
patients with
coccidioidomycosis
- Surveillance (data
gathered by
Arizona
Department of
Health Services
(ADHS) compared
cases reported
between 1998
(1,551) and 2001
(2,203).
- Cohort study
looked at 208
randomly selected
persons contacted
by telephone
Indicate that the
recent Arizona
coccidioidomycosis
epidemic is
attributed to seasonal
peaks in incidence
that are probably
related to climate.
Health-care
providers in AZ
should be aware that
peak periods of
coccidioidomycosis
incidence occur
during winter and
should consider
testing patients
The Spectrum and
Presentation of
Disseminated
Coccidioidomycosis1
3
Retrospective
analysis
150 cases with
extrapulmonary
nonmeningeal
disease seen from
1996-2007 at a
referral medical
center in endemic
region
- Hematogenous
dissemination was
associated with high
mortality and
occurred primarily in
immunocompromise
d patients
- Serology was
frequently negative
in
immunocompromise
d patients- diagnosis
established by
isolation of organism
in culture
Coccidioidomycosis:
A Review of Recent
Advances4
Review of
resurgence of
Coccidioidomycosi
s in the southwest
United States
focusing on recent
N/A Reviews the
discovery, history,
organism, ecology
and climate,
epidemiology,
immunology,
publications of
importance
diagnosis, special
hosts, clinical
presentation, and
therapy
- Enhanced
surveillance starting
in 2007 by ASDH
has demonstrated
profound effect
disease has had on
state and on
individuals
What’s Behind the
Increasing Rates of
Coccidioidomycosis
in Arizona and
California?10
Journal Article N/A - Recent increase in
cases of
symptomatic disease
is multifactorial
- Predominant
factors include:
Climate change,
increased local
exposure, influx into
endemic region of
susceptible persons
with higher risk of
developing
symptomatic illness,
heightened
awareness and
reporting of the
disease
Coccidioidomycosis
in Elderly Persons14
Retrospective
review of data for
all patients with
coccidioidiomycosi
s treated at the
Mayo Clinic in
Scottsdale, AZ that
compared clinical
manifestations of
coccidioidomycosis
in patients >60
years with those in
patients <60 years
- 210 patients aged
>60 years
- 186 patients
aged<60 years
-
Coccidioidomycosis
is a serious illness in
all patients, but its
different
manifestations in
older-aged persons,
compared with those
in younger-aged
persons, may be
related to
immunosuppression
rather than age alone
Testing for
Coccidioidomycosis
among Patients with
- Descriptive
Epidemiology
performed by
- Descriptive
Epidemiology
calculated country-
-
Coccidioidomycosis
is a common cause
Community-
Acquired
Pneumonia9
analyzing data from
the National
Electronic
Telecommunication
s System for
Surveillance
- Retrospective
Cohort Study of 2
healthcare systems
in metropolitan
Phoenix with
different patient
demographics
- Case-Control
Study -
specific and age
group-specific
incidence rates for
1999-2004
- Retrospective
Cohort Study: 132
sampled for system
A and 159 were
sampled from
system B for chart
review
- Case-Control
Study: 60 case
patients and 76
control patients
of community-
acquired pneumonia
(CAP) in disease-
endemic areas like
metropolitan
Phoenix
- The proportion of
CAP caused by
coccidioidomycosis
is substantial but
because testing
among CAP patients
was infrequent,
reportable-disease
data greatly
underestimate the
true disease
prevalence
Assessment of
Climate-
Coccidioidomycosis
Model: Model
Sensitivity for
Assessing
Climatologic Effects
on the Risk of
Acquiring
Coccidioidomycosis6
Sensitivity of
seasonal modeling
approach is
examined as it
relates to data
quality control, data
trends, and
exposure
adjustment
methodologies
N/A - Overall increasing
trend in incidence is
beyond explanation
through climate
variability alone but
that climate accounts
for much of the
coccidioidomycosis
incidence variability
about the trend from
1992 to 2005
- Dual “grow and
blow” hypothesis for
climate-related
coccidioidomycosis
incidence risk
Compensability of,
and Legal Issues
Related to,
Coccidioidomycosis1
1
Report on legal
issues that may
develop when
treating patients
with
coccidioidomycosis
that include
allegations of
medical
malpractice, claims
for workers’
compensation
N/A - Medical
practitioners must
understand legal
liability around
treating
coccidioidomycosis
patients
- Failure to diagnose
is the number one
reason that gives rise
to medical
negligence and
benefits, and civil
actions against
businesses. Arizona
(as of 2007) did not
recognize
coccidioidmycosis
as a compensable
condition.
under AZ law,
medical practitioners
are at risk of being
accused
- AZ case law has
developed such that
it is not possible for
employees to sustain
their burden of
proving Valley
Fever resulted from
working conditions,
therefore workers’
compensation claims
have been denied
- Claimed that work
exposure only
“statistically
increased”
probability of
contracting Valley
Fever but does not
meet required
standards for proof
to show causal link
The Public Health
Impact of
Coccidioidomycosis
in Arizona and
California2
Review of data and
literature that
addresses the public
health impact of
coccidioidomycosis
in two endemic
regions
N/A - Increases in
incidence,
disproportionate
incidence in
racial/ethnic groups,
lack of early
diagnosis, the need
for more rapid and
sensitive tests, and
the inability of
currently available
therapeutics to
reduce duration and
morbidity of the
disease
- Highlights need for
improved
therapeutics and a
preventive vaccine
- Total economic
costs associated with
increases in
symptomatic disease
have substantially
increased
- Need greater
provider education
leading to stringent
surveillance and
timely use of
diagnostics
Expanding
Understanding of
Epidemiology of
Coccidioidomycosis
in the Western
Hemisphere15
Report synthesizing
data to improve
understanding of
how
coccidioidomycosis
spreads
N/A - Recent years, the
incidence of
coccidioidomycosis
has increased in
California/Arizona,
may be partially due
to massive migration
of Americans to
these states
- From 1997 to 2004,
there was a 281%
increase in incidence
New perspectives on
coccidioidomycosis1
Report reviewing
newer tests and
studies and
evaluating new
therapies
N/A - Growing problem
in endemic regions
of AZ & CA
- Presentation as
pulmonary process
makes accurate
diagnosis difficult
and serologic
sensitivity has not
been established
- Suggests that
antifungal therapy
may lead to
subsequent
complications once
this therapy is
discontinued
compared to those
who receive no
therapy at all
Coccidioidomycosis:
Changing
perceptions and
creating
Review that looks
at revisiting and
changing
perceptions formed
N/A - Information and
limited therapies
have influenced
perceptions around
opportunities for its
control5
by understanding of
coccidioidomycosis
as a medical
problem to improve
care of patients
coccidiodomycosis
and are limiting
development of new
therapies
- Suggests that new
therapies for Valley
Fever are likely to
hinge upon whether
or not they are
perceived to be
needed because such
a large portion of
patients are
asymptomatic
Coccidioidomycosis-
associated deaths,
United States, 1990-
200816
- Retrospective
analysis of multiple
cause-coded death
records for 1990-
2008 for
demographics,
secular trends, and
geographic
distribution
- Found 3,089
coccidioidomycosis
-associated deaths
among US
residents
- Analysis suggests
that the number of
deaths from
coccidioidomycosis
are greater than
currently appreciated
- Highest risk for
death were men,
persons over the age
of 65, Hispanics,
Native Americans,
and residents of
California and
Arizona
- Common
concurrent
conditions were HIV
and other
immunosuppressive
conditions
Coccidioidal
pneumonia, Phoenix,
Arizona, USA, 2000-
20048
- Prospective
evaluation of
patients with
community-
acquired
pneumonia in the
Phoenix, Arizona
area
- 59 patients with
CAP, 35 for whom
paired cocidioidal
serologic testing
was performed
- Coccidioidal
pneumonia can only
be identified with
appropriate
laboratory studies in
the absence of
distinguishing
clinical features
- Identified
coccidioidal
infection in at least 1
of 6 patients who
sought treatment for
radiologically
confirmed CAP in an
endemic area
underscores the
likelihood that this
infection is a
common cause of
CAP
Risk Factors for
Acute Symptomatic
Coccidioidomycosis
among Elderly
Persons in Arizona,
1996-199717
- Case-control study
conducted to look
at risk factors for
disease among the
elderly in Arizona
in response to the
increase in
incidence of
coccidioidomycosis
between 1990 and
1996
- Cases (89),
persons over 60
years with
laboratory-
confirmed
coccidioidomycosis
- 2 separate control
groups: (91)
selected by use of
random-digit
dialing and (58)
selected by use of
lists of persons
with negative
serologic
coccidioidomycosis
tests
- Elderly persons
with
coccidioidomycosis
had spent
significantly less
time in AZ than
persons in control
group
- Elderly persons
who recently move
to AZ or who have
chronic illness are at
a higher risk
- Recent migrations
to AZ and various
underlying medical
conditions are
associated with
increased risk
- Smoking is a
preventable cause of
acute symptomatic
coccidioidomycosis
in this at risk
population
- Costly public
health problem in
this age group
An Epidemic of
Coccidioidomycosis
in Arizona associated
with Climatic
Changes, 1998-
200118
- Statistical analysis
of NETSS data
from 1998 to 2001
performed to map
high-incidence
areas in Maricopa
County to assess
the effect of
climatic and
- Incidence in 2001
was 43/100,000
with a significant
increase from 1998
(33/100,000)
- Coccidioidomyc
osis in AZ has
increased
- Part of increase in
incidence is driven
by seasonal
outbreaks associated
with environmental
and climatic changes
environmental
factors on the
number of monthly
cases; model
developed and
tested to predict
outbreaks
- Study may allow
public health
officials to predict
seasonal outbreaks
in AZ and to alert
the public and
physicians early so
that appropriate
measures can be
implemented
Coccidioidomycosis
among Scholarship
Athletes and Other
College Students,
Arizona, USA19
- Medical chart
review for serologic
testing and coding
- Charts were
reviewed from
1998 to 2006 for
serologic testing
and for ICD-9
coding for
coccidioidomycosis
- More complete
testing for
community acquired
pneumonia
associated with
valley fever results
in considerably
higher estimates of
case rates for this
fungal infection
- Case rates among
scholarship athletes
were
underrepresented in
oudoor sports and
spectrum of disease
severity was in line
with that found in
past studies of
student population as
a whole
- Many scholarship
athletes come from
regions where
coccidioidomycosis
is not endemic
- Findings
underscore the need
to routinely test
patients for
coccidioidomycosis
Coccidioidomycosis
incidence in Arizona
predicted by seasonal
precipitation20
- Study utilizing
Arizona
coccidioidomycosis
case data for 1995-
2006 to generate a
- N/A - Revealed a
seasonal
autocorrelation
structure for
exposure rates where
timeseries of
monthly estimates
of exposure rates in
Marcipoa County
and Pima County in
AZ
exposure rates are
strongly related from
fall to the spring and
relationship abruptly
ends near the onset
of summer
precipitation
- Builds on previous
studies examining
the causes of
fluctuations in
coccidioidomycosis
rates in AZ and
corroborates the
“blow and grow”
hypothesis
- Recognizes that
human factors such
as construction may
play a role
Coccidioidomycosis
in African
Americans21
- PubMed review of
English-language
medical literature
on
coccidioidomycosis
in African
Americans and
summarized
pertinent literature
N/A - Increased
predilection for
severe
coccidioidomycosis,
coccidioidomycosis-
related
hospitalizations, and
extrapulmonary
dissemination in
persons of African
descent
- Immunologic
mechanism for
predilection is
unclear
- Suggests a
prospective,
controlled,
epidemiological
study to give a
clearer picture of the
true risk of
complicated
coccidioidomycosis
among racial groups
- Clinicians should
have high index of
suspicion in persons
with recent travel or
resident within the
Southwest
A risk factor study of
coccidioidomycosis
by controlling
differential
misclassifications of
exposure and
susceptibility using a
landscape ecology
approach22
- Stratified, two-
stage, cross-
sectional study
evaluating inherent
socio-economic,
and environmental
risk factors of
coccidioidomycosis
from information
collected during an
address-based
telephone survey
- Describes
individual and
group-level risks of
coccidioidomycosis
using a cross-
sectional sample
stratified by
location of resident
on the landscape
using geomorphic
types and
neighborhood
ethnicity
- Survey of 5460
households
containing 14,105
individuals in the
greater Tucson area
of Arizona
- Consistent with
findings on known
risk factors such as
cigarette smoking,
older age groups,
and being African
American
- Association
between disease and
geomorphic strata in
multivariate analysis
was weak and did
not indicate a
significant
relationship between
disease and
residence locations
by soil types
- Assertion was
supported that
geographic-based
stratification can
reduce differential
misclassification
- Strong associations
of disease and
residence locations
by neighborhood
ethnicity and
anthropogenic soil
disturbances support
use of a landscape
epidemiological
approach for
diseases with strong
environmental
determinants such as
valley fever
Coccidioidomycosis
in human
immunodeficiency
- Case-control study
to evaluate risk
factors for
- 77 cases - Much higher
incidence of
coccidioidomycosis
virus-infected
persons in Arizona,
1994-1997:
incidence, risk
factors, and
prevention23
coccidioidomycosis
in HIV-infected
persons
- HIV cohort
determined
retrospectively
using HARS
Registry of AZ
in HIV-infected
persons than
Arizona’s general
population
- Population
attributable risk
estimates for blacks
and persons with
previous fungal
infections account
for nearly half of
HIV-infected
persons who develop
coccidioidomycosis
in AZ
- Future studies need
to address efficacy
of different agents in
a prospective faction
and cost-effective
analysis of various
therapies need to be
conducted
Summary of the Evidence
The evidence overwhelmingly indicates that there has been an increase in
incidence of coccidioidomycosis in the Arizona region that has been noted from the early
1990s and continues to increase now. There are different risk factors associated with the
increase in incidence. Arizona is an endemic region for coccidioidomycosis and the risk
of incidence increases from the fall to the spring with an abrupt decline in the summer,
indicating that there is a climatic component to the increase in incidence. There are
specific populations that are more susceptible and at a higher-risk of infection. These
include elderly individuals, individuals who have spent limited time in endemic regions,
HIV-infected patients, individuals who are exposed to dust and the outdoors, and certain
ethnic minorities such as African Americans.
The increase in coccidioidomycosis has been clearly established by the evidence
and the lack of a disproportionate public health, research, and policy initiative to address
this increase in incidence has also been made clear. Many of the different research
initiatives suggest that there is a need for more prospective analysis of the risk factors,
therapies, and preventative measures associated with coccidioidomycosis.8
There is local
attention placed on coccidioidomycosis in blogs, support groups, and increased research
efforts but the importance of this disease has not been addressed by many health
policymakers.27
Although this is a disease endemic to the Arizona and other areas in the
Southwest, individuals who travel through this area or recently migrate are at a increased
risk of infection making this a disease relevant to the nation, not just endemic regions.
Misdiagnosis and underdiagnosis is widespread and associations with other diseases are
not well-understood and the evidence clearly reflects that there needs to be more attention
placed on the policies associated with the prevention and diagnosis of this disease and
that there is a cost-burden associated with increased incidence that is important in the
current climate of unmanageable healthcare costs.
Characterization of the Risk
Arizona represents sixty percent of nationally reported cases of
coccidioidomycosis. Living in the region and going outside automatically places
individuals in a position to inhale the spores that cause infection. Individuals that have
lived in the region for a long time are not as susceptible to infection as those who move to
the region.24
Over the last two decades, Arizona has experienced an influx of individuals
moving to the region and this has corresponded with an increase in coccidioidomycosis
infection. While this recorded increase in incidence can be correlated to
coccidioidomycosis becoming a reportable disease in 1997, the numbers cannot be
ignored and there are various factors that are contributing to this increase in risk.10
The
increase is incidence has not only changed from the time period before reporting was
required but has also increased in the last fifteen years as data has been collected from
reporting.10
Because coccidioidomycosis is associated with many different forms of
exposure, it is difficult to accurately assess a specific measure of exposure. It is relevant,
however, to assess the risk factors associated with exposure as well as the increase in
incidence among vulnerable populations and from these factors policy recommendations
can be made.1
Arizona has experienced variations in climate over the last two decades that may
be the cause of increased exposure. Environmental reports have indicated an increase in
the occurrence of dust storms during periods where there is a lack of precipitation,
consequently creating the perfect conditions for the spores to be kicked into the
atmosphere and increasing risk of inhalation.29
Connecting the increase in dust storms
directly to increases in exposure is difficult to measure but it is known that these climatic
situations cause an increase in dust in the air and dust is the main risk factor in inhaling
spores that cause coccidioidomycosis. Some believe that certain human activities like an
increase in agricultural land use and a rise in construction also contribute to the dust in
the air.29
Work place hazards provide another risk factor. Construction workers, for
example, work outside and are directly exposed to increased amounts of dust due to the
shifting of land occurring at the construction site.11
Other workers that have a potentially
increased risk may include electricians, cable workers, landscapers, physical education
teachers, and any other occupation that involves spending an extensive amount of time
outside regardless of season.
Arizona has experienced an influx of individuals who are not endemic to the
region and this increases an individual’s chance of being infected. Many of these
individuals are elderly which also increases risk.
The Landscape
There are a variety of stakeholders who would be interested in implementing
policy aimed at reducing coccidioidomycosis incidence in the Arizona area. Patient
advocacy groups for victims of valley fever and loved ones of those infected are active
and strong in Arizona. Some of these groups include the Valley Fever Survivor Patient
Advocacy Group, AZ Victims of Valley Fever, and the Valley Fever Alliance.27
The
medical community at large is also extremely important in pressuring to increase funding
and affect policy change. This includes physicians who treat coccidioidomycosis, resident
physicians, nurses and other providers who encounter this disease. The medical
community also extends to the research community who need funding to continue
developing vaccinations and improved therapeutic agents. Arizona has recently begun
taking steps towards increased attention and collaboration directed at treating
coccidioidomycosis with the opening of the University of Arizona Valley Fever Center
for Excellence. More funding and legislative policies are needed, however, to support the
findings of the Center for Excellence.30
Because of the high costs associated with hospital
stays, diagnosis, and treatment of valley fever, taxpayers are relevant because their tax
dollars are paying for the high cost of care associated with coccidioidomycosis.
The most relevant governmental agency that deals with coccidioidomycosis
incidence is the Arizona Department of Health. They have been very involved in
increasing awareness of incidence and data collection.31
Another governmental agency is
the Center for Disease Control and Prevention because coccidioidomycosis is one of the
top infectious diseases in the country and they are also concerned with monitoring,
prevention, and treatment. Government healthcare payers, such as Medicare and
Medicaid, should also be concerned about an increase in incidence because
hospitalization, misdiagnosis, and immune-compromised patients who are infected are a
cost burden to the system.
Options and Recommendations
There has been an increasing amount of attention paid to valley fever in the
Southwest that has corresponded with the increased reporting in incidence. There are a
variety of policy options that could inform next steps to reducing the incidence of valley
fever that range from individual protective measures to large-scale policy action that
requires funding and political support.
The first recommendation would be to improve education about individual
measures that can be taken to reduce exposure. This could include reducing the amount
of time spent outside during months of increased exposure. It could also involve
increasing awareness around the risk factors and the symptoms associated with valley
fever so the general public can be more aware and see a provider more quickly if they
believe they may have valley fever. Another area where education could play a key role
is in the school systems. Information about valley fever risks and symptoms could be
disseminated during health education classes, in parent meetings, and to the general
community.
The second area where policy could be affected is where workplace hazards are
concerned. Implementing dust reduction measures, specifically in work environments
that involve soil disruption such as construction work or electricians that perform work
outside has the potential to reduce the risk of obtaining valley fever.
The third area where policy could be affected is in the research space. Finding a
vaccination for valley fever has been spoken about for some length of time in Arizona
and with the opening of the University of Arizona Valley Fever Center for Excellence
there is a real opportunity to work towards developing a vaccination. If funding can be
found to support the Center’s initiatives and a vaccine is developed, it will be a very way
to curb increased incidence of the disease.
The most promising of all of these potential policy recommendations is to raise
money for researching a vaccination. Because the risk of exposure to valley fever is
difficult to quantify and the actual dose-response relationship is difficult to assess, there
is more potential in determining an effective preventative measure in the form of
vaccination compared to education. This will be more effective in the long run and will
be a more effective way of utilizing resources. The cost of treating valley fever and the
hospitalizations associated with valley fever are high and if a vaccine can be produced it
has the potential to greatly reduce costs, which is an attractive policy option in the current
healthcare space.31
While for many diseases there are substantial barriers and difficulties
in approaching vaccine development, strides have already been made towards developing
a vaccine and the University of Arizona Center for Excellence is committed to solidifying
the development of the Nikkomycin Z vaccine meant to prevent against infection.31
References
Soraya Ghebleh - Valley Fever in Arizona

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Soraya Ghebleh - Valley Fever in Arizona

  • 1. Soraya Ghebleh 18 March 2013 ECS 151 Increased Incidence of Valley Fever in Arizona Executive Summary Infectious diseases are consistently an issue for public health departments around the country and around the world. Coccidioidomycosis, colloquially known as valley fever, is an infectious disease that has adverse health effects and is increasing in incidence. Although the exposure to coccidioidoymocis is difficult to measure because of the inhalation pathway, it estimated that infection rates are approximately 3% in Southern Arizona.1 An estimated 150,000 people a year become infected with coccidioidomycosis and of those approximately one third develop symptomatic disease. Those infected in Arizona account for 60% of the afflicted population, indicating a serious need for attention to be paid to this problem.2 Since 1997 when coccidioidomycosis became a reportable disease, incidence has increased substantially. While this may be partly explained by an increase in reporting, other risk factors have been determined to clearly be contributing to the increase in disease. These risk factors include construction and soil disruption, increased vulnerable populations in areas with dust, outdoor exposure, climactic change, and other workplace hazards. There are a variety of measures that can be taken to help abate the spread of coccidoidomycosis. Because individuals become infected as a result of inhalation, it is a very difficult disease to prevent even when care is taken to increase risk factors. This points to a solution derived in a permanent solution such as development of a vaccine.
  • 2. This is the most attractive and appropriate policy option as strides have been made towards developing vaccines and it provides a stronger solution for the public. Introduction of the Problem The environmental health exposure being studied is the inhalation of airborne spores from Coccidioides immitis, a fungus found in soil in arid, desert climates. Infection occurs usually after activities or natural events that disrupt the soil, resulting in aerosolization of the fungal arthrospores. The human health effects of concern are infection with coccidioidomycosis, more commonly known as valley fever. This disease has a very high rate of infection and is one of the most common infectious diseases despite the fact that it is not well known outside of the Southwest and California regions. Approximately 40% of infections result in symptomatic disease, typically arising one to four weeks after exposure, and can resemble ordinary influenza but also have many more severe symptoms. The individuals bringing this issue forward are a patient support group for valley fever victims and family members who want more research to be done for a vaccination as well as more preventative measures to be put in place to reduce disease incidence of coccidioidomycosis. Since 1995, there has been a substantial increase in coccidioidomycosis incidence in Arizona. While many of these cases are attributed to seasonal peaks and climate change, there is an increasing concern that the expansion in the Metropolitan area of Phoenix and the expansion in construction also has a role in the increased incidence of coccidioidomycosis. This is one example of where policy could be implemented to reduce disease incidence.
  • 3. Should legislation be passed in the greater Metropolitan Area of Phoenix to require more preventative measures and research be put in place to assist in reduction of coccidioidomycosis incidence? Background of Coccidioidomycosis Incidence in Arizona Coccidioidomycosis, more commonly known as valley fever, is a systemic infection that occurs upon airborne inhalation of Coccidioides, a soil-dwelling fungus found in the southwestern United States, parts of Mexico, as well as Central and South America.3 Coccidioides immitis is the species that is geographically limited to the San Joaquin Valley and Coccidioides posadasii inhabits all other coccidioidal endemic regions.4 The first patient to be described with coccidioidomycosis was an Argentinean soldier in 1893, however until 1935 patients identified with this disease were still extremely rare. Not much was known about the disease and due to lack of epidemiological knowledge it was thought to always be a rare and severe infection. New observations from the 1930s on, however, indicated that a large proportion of those who undergo a coccidioidal infection do not develop symptoms or their symptoms resolve without further issue.5 In Arizona, coccidioidomycosis immitis is the prevalent form of species that causes infection. Coccidioidomycosis has been linked to climate change as one of the risk factors. In order to grow, Coccidioides species need suitable temperatures and soil moisture for growth making the most likely period for infection during the fall, winter, and spring as opposed to the summer months in Arizona.6 Inhalation leads to infected cases and the incidence of these cases oscillates with climactic change.6 While climate has explained a large amount of differences in incidence in coccidioidomycosis, overall
  • 4. trends cannot only be explained by climate. There are other non-climactic issues related to the increased incidence of disease in Arizona. The presentation of coccidioidomycosis is difficult to diagnose, as so many patients are asymptomatic. Those patients who present will present with primary pulmonary coccidioidomycosis. Of these, around one will develop extrathoracic dissemeniation. Approximately four will develop chronic complications such as a nodule, cavity, or chronic pneumonia.1 A definitive diagnosis is difficult without serologic testing and frequently cannot be made on clinical observations alone. In approximately five percent of cases, a rash such as erythema multiforme may appear and painful nodules of erythema nodosum may appear on the lower extremities.1 Often many of these findings are overlooked and this has led to misdiagnosis and underdiagnosis of the disease. The clinical indications are also very similar to bacterial community-acquired pneumonia and there is a strong correlation between those infected with coccidioidomycosis and those who develop community-acquired pneumonia. The Arizona Department of Health Services (ADHS) monitors coccidioidomycosis and has attempted to increase knowledge and minimize disease burden but incidence continues to increase.2 Valley fever incidence in Arizona has shown a considerable increase since reporting requirements were instituted.6 Arizona has the highest number of reported cases and accounts for sixty percent of all national cases.2 From 1990 to 1995, the number of annually reported cases doubled leading to increased reporting in 1997.2 Since then, the number of cases has increased considerably from approximately 16 per 100,000 to 155 per 100,000 in 2009.2 The highest rates of cases occur in the most populated counties in Arizona as these areas experience arid to semiarid
  • 5. climates with mild winters and hot summers.2 Coccidioidomycosis is associated with community-acquired pneumonia (CAP) as well and a substantial portion of patients with CAP had confirmed coccidioidomycosis.9 Economic analysis of the effects of coccidioidomycosis has also revealed that there is an economic burden associated with lack of effective preventive measures and a vaccine. A delay in education of the public and of providers has also contributed to reduced delays in diagnosis that could lead to earlier detection and treatment of valley fever.2 Another risk factor involves the recent growth in population and influx of individuals who were never in areas endemic to coccidioidomycosis. These individuals become at risk for primary infection. Another environmental risk is local dust production associated with construction. The last twenty years has seen tremendous growth in Arizona and this is also an associated work hazard risk factor.10 Another area of change that may describe the rise in incidence could result from increased reporting. Because coccidioidomycosis became a reportable disease in 1997, the increase in the number of reported cases could be a reason behind increased in incidence as coccidioidomycosis may have been underreported more frequently previous to this change in policy.10 The current system of surveillance in place in Arizona accurately reflects the disease burden but there is a significant symptom duration and delayed diagnosis for patients leading to suboptimal care and treatment.2 There also are considerable legal barriers for those exposed to coccidioidomycosis in the workplace. For example, construction workers who are exposed to excessive amounts of dust and soil and contract valley fever are not privy to worker’s compensation. Case law has developed in contrast to development of California case law that recognizes statistically increased probability
  • 6. of contracting Valley Fever but that this is not sufficient for a worker to be compensated.11 Evidence Table Study Name Study Design Study Size Findings Increase in coccidioidomycosis —Arizona, 1998- 200112 CDC data analysis of Surveillance and Hospitalization, environmental and climactic data, as well as a cohort study conducted by the CDC of a random sample of patients with coccidioidomycosis - Surveillance (data gathered by Arizona Department of Health Services (ADHS) compared cases reported between 1998 (1,551) and 2001 (2,203). - Cohort study looked at 208 randomly selected persons contacted by telephone Indicate that the recent Arizona coccidioidomycosis epidemic is attributed to seasonal peaks in incidence that are probably related to climate. Health-care providers in AZ should be aware that peak periods of coccidioidomycosis incidence occur during winter and should consider testing patients The Spectrum and Presentation of Disseminated Coccidioidomycosis1 3 Retrospective analysis 150 cases with extrapulmonary nonmeningeal disease seen from 1996-2007 at a referral medical center in endemic region - Hematogenous dissemination was associated with high mortality and occurred primarily in immunocompromise d patients - Serology was frequently negative in immunocompromise d patients- diagnosis established by isolation of organism in culture Coccidioidomycosis: A Review of Recent Advances4 Review of resurgence of Coccidioidomycosi s in the southwest United States focusing on recent N/A Reviews the discovery, history, organism, ecology and climate, epidemiology, immunology,
  • 7. publications of importance diagnosis, special hosts, clinical presentation, and therapy - Enhanced surveillance starting in 2007 by ASDH has demonstrated profound effect disease has had on state and on individuals What’s Behind the Increasing Rates of Coccidioidomycosis in Arizona and California?10 Journal Article N/A - Recent increase in cases of symptomatic disease is multifactorial - Predominant factors include: Climate change, increased local exposure, influx into endemic region of susceptible persons with higher risk of developing symptomatic illness, heightened awareness and reporting of the disease Coccidioidomycosis in Elderly Persons14 Retrospective review of data for all patients with coccidioidiomycosi s treated at the Mayo Clinic in Scottsdale, AZ that compared clinical manifestations of coccidioidomycosis in patients >60 years with those in patients <60 years - 210 patients aged >60 years - 186 patients aged<60 years - Coccidioidomycosis is a serious illness in all patients, but its different manifestations in older-aged persons, compared with those in younger-aged persons, may be related to immunosuppression rather than age alone Testing for Coccidioidomycosis among Patients with - Descriptive Epidemiology performed by - Descriptive Epidemiology calculated country- - Coccidioidomycosis is a common cause
  • 8. Community- Acquired Pneumonia9 analyzing data from the National Electronic Telecommunication s System for Surveillance - Retrospective Cohort Study of 2 healthcare systems in metropolitan Phoenix with different patient demographics - Case-Control Study - specific and age group-specific incidence rates for 1999-2004 - Retrospective Cohort Study: 132 sampled for system A and 159 were sampled from system B for chart review - Case-Control Study: 60 case patients and 76 control patients of community- acquired pneumonia (CAP) in disease- endemic areas like metropolitan Phoenix - The proportion of CAP caused by coccidioidomycosis is substantial but because testing among CAP patients was infrequent, reportable-disease data greatly underestimate the true disease prevalence Assessment of Climate- Coccidioidomycosis Model: Model Sensitivity for Assessing Climatologic Effects on the Risk of Acquiring Coccidioidomycosis6 Sensitivity of seasonal modeling approach is examined as it relates to data quality control, data trends, and exposure adjustment methodologies N/A - Overall increasing trend in incidence is beyond explanation through climate variability alone but that climate accounts for much of the coccidioidomycosis incidence variability about the trend from 1992 to 2005 - Dual “grow and blow” hypothesis for climate-related coccidioidomycosis incidence risk Compensability of, and Legal Issues Related to, Coccidioidomycosis1 1 Report on legal issues that may develop when treating patients with coccidioidomycosis that include allegations of medical malpractice, claims for workers’ compensation N/A - Medical practitioners must understand legal liability around treating coccidioidomycosis patients - Failure to diagnose is the number one reason that gives rise to medical negligence and
  • 9. benefits, and civil actions against businesses. Arizona (as of 2007) did not recognize coccidioidmycosis as a compensable condition. under AZ law, medical practitioners are at risk of being accused - AZ case law has developed such that it is not possible for employees to sustain their burden of proving Valley Fever resulted from working conditions, therefore workers’ compensation claims have been denied - Claimed that work exposure only “statistically increased” probability of contracting Valley Fever but does not meet required standards for proof to show causal link The Public Health Impact of Coccidioidomycosis in Arizona and California2 Review of data and literature that addresses the public health impact of coccidioidomycosis in two endemic regions N/A - Increases in incidence, disproportionate incidence in racial/ethnic groups, lack of early diagnosis, the need for more rapid and sensitive tests, and the inability of currently available therapeutics to reduce duration and morbidity of the disease - Highlights need for improved therapeutics and a preventive vaccine - Total economic costs associated with
  • 10. increases in symptomatic disease have substantially increased - Need greater provider education leading to stringent surveillance and timely use of diagnostics Expanding Understanding of Epidemiology of Coccidioidomycosis in the Western Hemisphere15 Report synthesizing data to improve understanding of how coccidioidomycosis spreads N/A - Recent years, the incidence of coccidioidomycosis has increased in California/Arizona, may be partially due to massive migration of Americans to these states - From 1997 to 2004, there was a 281% increase in incidence New perspectives on coccidioidomycosis1 Report reviewing newer tests and studies and evaluating new therapies N/A - Growing problem in endemic regions of AZ & CA - Presentation as pulmonary process makes accurate diagnosis difficult and serologic sensitivity has not been established - Suggests that antifungal therapy may lead to subsequent complications once this therapy is discontinued compared to those who receive no therapy at all Coccidioidomycosis: Changing perceptions and creating Review that looks at revisiting and changing perceptions formed N/A - Information and limited therapies have influenced perceptions around
  • 11. opportunities for its control5 by understanding of coccidioidomycosis as a medical problem to improve care of patients coccidiodomycosis and are limiting development of new therapies - Suggests that new therapies for Valley Fever are likely to hinge upon whether or not they are perceived to be needed because such a large portion of patients are asymptomatic Coccidioidomycosis- associated deaths, United States, 1990- 200816 - Retrospective analysis of multiple cause-coded death records for 1990- 2008 for demographics, secular trends, and geographic distribution - Found 3,089 coccidioidomycosis -associated deaths among US residents - Analysis suggests that the number of deaths from coccidioidomycosis are greater than currently appreciated - Highest risk for death were men, persons over the age of 65, Hispanics, Native Americans, and residents of California and Arizona - Common concurrent conditions were HIV and other immunosuppressive conditions Coccidioidal pneumonia, Phoenix, Arizona, USA, 2000- 20048 - Prospective evaluation of patients with community- acquired pneumonia in the Phoenix, Arizona area - 59 patients with CAP, 35 for whom paired cocidioidal serologic testing was performed - Coccidioidal pneumonia can only be identified with appropriate laboratory studies in the absence of distinguishing clinical features - Identified coccidioidal infection in at least 1 of 6 patients who
  • 12. sought treatment for radiologically confirmed CAP in an endemic area underscores the likelihood that this infection is a common cause of CAP Risk Factors for Acute Symptomatic Coccidioidomycosis among Elderly Persons in Arizona, 1996-199717 - Case-control study conducted to look at risk factors for disease among the elderly in Arizona in response to the increase in incidence of coccidioidomycosis between 1990 and 1996 - Cases (89), persons over 60 years with laboratory- confirmed coccidioidomycosis - 2 separate control groups: (91) selected by use of random-digit dialing and (58) selected by use of lists of persons with negative serologic coccidioidomycosis tests - Elderly persons with coccidioidomycosis had spent significantly less time in AZ than persons in control group - Elderly persons who recently move to AZ or who have chronic illness are at a higher risk - Recent migrations to AZ and various underlying medical conditions are associated with increased risk - Smoking is a preventable cause of acute symptomatic coccidioidomycosis in this at risk population - Costly public health problem in this age group An Epidemic of Coccidioidomycosis in Arizona associated with Climatic Changes, 1998- 200118 - Statistical analysis of NETSS data from 1998 to 2001 performed to map high-incidence areas in Maricopa County to assess the effect of climatic and - Incidence in 2001 was 43/100,000 with a significant increase from 1998 (33/100,000) - Coccidioidomyc osis in AZ has increased - Part of increase in incidence is driven by seasonal outbreaks associated with environmental and climatic changes
  • 13. environmental factors on the number of monthly cases; model developed and tested to predict outbreaks - Study may allow public health officials to predict seasonal outbreaks in AZ and to alert the public and physicians early so that appropriate measures can be implemented Coccidioidomycosis among Scholarship Athletes and Other College Students, Arizona, USA19 - Medical chart review for serologic testing and coding - Charts were reviewed from 1998 to 2006 for serologic testing and for ICD-9 coding for coccidioidomycosis - More complete testing for community acquired pneumonia associated with valley fever results in considerably higher estimates of case rates for this fungal infection - Case rates among scholarship athletes were underrepresented in oudoor sports and spectrum of disease severity was in line with that found in past studies of student population as a whole - Many scholarship athletes come from regions where coccidioidomycosis is not endemic - Findings underscore the need to routinely test patients for coccidioidomycosis Coccidioidomycosis incidence in Arizona predicted by seasonal precipitation20 - Study utilizing Arizona coccidioidomycosis case data for 1995- 2006 to generate a - N/A - Revealed a seasonal autocorrelation structure for exposure rates where
  • 14. timeseries of monthly estimates of exposure rates in Marcipoa County and Pima County in AZ exposure rates are strongly related from fall to the spring and relationship abruptly ends near the onset of summer precipitation - Builds on previous studies examining the causes of fluctuations in coccidioidomycosis rates in AZ and corroborates the “blow and grow” hypothesis - Recognizes that human factors such as construction may play a role Coccidioidomycosis in African Americans21 - PubMed review of English-language medical literature on coccidioidomycosis in African Americans and summarized pertinent literature N/A - Increased predilection for severe coccidioidomycosis, coccidioidomycosis- related hospitalizations, and extrapulmonary dissemination in persons of African descent - Immunologic mechanism for predilection is unclear - Suggests a prospective, controlled, epidemiological study to give a clearer picture of the true risk of complicated coccidioidomycosis among racial groups - Clinicians should
  • 15. have high index of suspicion in persons with recent travel or resident within the Southwest A risk factor study of coccidioidomycosis by controlling differential misclassifications of exposure and susceptibility using a landscape ecology approach22 - Stratified, two- stage, cross- sectional study evaluating inherent socio-economic, and environmental risk factors of coccidioidomycosis from information collected during an address-based telephone survey - Describes individual and group-level risks of coccidioidomycosis using a cross- sectional sample stratified by location of resident on the landscape using geomorphic types and neighborhood ethnicity - Survey of 5460 households containing 14,105 individuals in the greater Tucson area of Arizona - Consistent with findings on known risk factors such as cigarette smoking, older age groups, and being African American - Association between disease and geomorphic strata in multivariate analysis was weak and did not indicate a significant relationship between disease and residence locations by soil types - Assertion was supported that geographic-based stratification can reduce differential misclassification - Strong associations of disease and residence locations by neighborhood ethnicity and anthropogenic soil disturbances support use of a landscape epidemiological approach for diseases with strong environmental determinants such as valley fever Coccidioidomycosis in human immunodeficiency - Case-control study to evaluate risk factors for - 77 cases - Much higher incidence of coccidioidomycosis
  • 16. virus-infected persons in Arizona, 1994-1997: incidence, risk factors, and prevention23 coccidioidomycosis in HIV-infected persons - HIV cohort determined retrospectively using HARS Registry of AZ in HIV-infected persons than Arizona’s general population - Population attributable risk estimates for blacks and persons with previous fungal infections account for nearly half of HIV-infected persons who develop coccidioidomycosis in AZ - Future studies need to address efficacy of different agents in a prospective faction and cost-effective analysis of various therapies need to be conducted Summary of the Evidence The evidence overwhelmingly indicates that there has been an increase in incidence of coccidioidomycosis in the Arizona region that has been noted from the early 1990s and continues to increase now. There are different risk factors associated with the increase in incidence. Arizona is an endemic region for coccidioidomycosis and the risk of incidence increases from the fall to the spring with an abrupt decline in the summer, indicating that there is a climatic component to the increase in incidence. There are specific populations that are more susceptible and at a higher-risk of infection. These include elderly individuals, individuals who have spent limited time in endemic regions, HIV-infected patients, individuals who are exposed to dust and the outdoors, and certain ethnic minorities such as African Americans.
  • 17. The increase in coccidioidomycosis has been clearly established by the evidence and the lack of a disproportionate public health, research, and policy initiative to address this increase in incidence has also been made clear. Many of the different research initiatives suggest that there is a need for more prospective analysis of the risk factors, therapies, and preventative measures associated with coccidioidomycosis.8 There is local attention placed on coccidioidomycosis in blogs, support groups, and increased research efforts but the importance of this disease has not been addressed by many health policymakers.27 Although this is a disease endemic to the Arizona and other areas in the Southwest, individuals who travel through this area or recently migrate are at a increased risk of infection making this a disease relevant to the nation, not just endemic regions. Misdiagnosis and underdiagnosis is widespread and associations with other diseases are not well-understood and the evidence clearly reflects that there needs to be more attention placed on the policies associated with the prevention and diagnosis of this disease and that there is a cost-burden associated with increased incidence that is important in the current climate of unmanageable healthcare costs. Characterization of the Risk Arizona represents sixty percent of nationally reported cases of coccidioidomycosis. Living in the region and going outside automatically places individuals in a position to inhale the spores that cause infection. Individuals that have lived in the region for a long time are not as susceptible to infection as those who move to the region.24 Over the last two decades, Arizona has experienced an influx of individuals moving to the region and this has corresponded with an increase in coccidioidomycosis infection. While this recorded increase in incidence can be correlated to
  • 18. coccidioidomycosis becoming a reportable disease in 1997, the numbers cannot be ignored and there are various factors that are contributing to this increase in risk.10 The increase is incidence has not only changed from the time period before reporting was required but has also increased in the last fifteen years as data has been collected from reporting.10 Because coccidioidomycosis is associated with many different forms of exposure, it is difficult to accurately assess a specific measure of exposure. It is relevant, however, to assess the risk factors associated with exposure as well as the increase in incidence among vulnerable populations and from these factors policy recommendations can be made.1 Arizona has experienced variations in climate over the last two decades that may be the cause of increased exposure. Environmental reports have indicated an increase in the occurrence of dust storms during periods where there is a lack of precipitation, consequently creating the perfect conditions for the spores to be kicked into the atmosphere and increasing risk of inhalation.29 Connecting the increase in dust storms directly to increases in exposure is difficult to measure but it is known that these climatic situations cause an increase in dust in the air and dust is the main risk factor in inhaling spores that cause coccidioidomycosis. Some believe that certain human activities like an increase in agricultural land use and a rise in construction also contribute to the dust in the air.29 Work place hazards provide another risk factor. Construction workers, for example, work outside and are directly exposed to increased amounts of dust due to the shifting of land occurring at the construction site.11 Other workers that have a potentially increased risk may include electricians, cable workers, landscapers, physical education
  • 19. teachers, and any other occupation that involves spending an extensive amount of time outside regardless of season. Arizona has experienced an influx of individuals who are not endemic to the region and this increases an individual’s chance of being infected. Many of these individuals are elderly which also increases risk. The Landscape There are a variety of stakeholders who would be interested in implementing policy aimed at reducing coccidioidomycosis incidence in the Arizona area. Patient advocacy groups for victims of valley fever and loved ones of those infected are active and strong in Arizona. Some of these groups include the Valley Fever Survivor Patient Advocacy Group, AZ Victims of Valley Fever, and the Valley Fever Alliance.27 The medical community at large is also extremely important in pressuring to increase funding and affect policy change. This includes physicians who treat coccidioidomycosis, resident physicians, nurses and other providers who encounter this disease. The medical community also extends to the research community who need funding to continue developing vaccinations and improved therapeutic agents. Arizona has recently begun taking steps towards increased attention and collaboration directed at treating coccidioidomycosis with the opening of the University of Arizona Valley Fever Center for Excellence. More funding and legislative policies are needed, however, to support the findings of the Center for Excellence.30 Because of the high costs associated with hospital stays, diagnosis, and treatment of valley fever, taxpayers are relevant because their tax dollars are paying for the high cost of care associated with coccidioidomycosis. The most relevant governmental agency that deals with coccidioidomycosis
  • 20. incidence is the Arizona Department of Health. They have been very involved in increasing awareness of incidence and data collection.31 Another governmental agency is the Center for Disease Control and Prevention because coccidioidomycosis is one of the top infectious diseases in the country and they are also concerned with monitoring, prevention, and treatment. Government healthcare payers, such as Medicare and Medicaid, should also be concerned about an increase in incidence because hospitalization, misdiagnosis, and immune-compromised patients who are infected are a cost burden to the system. Options and Recommendations There has been an increasing amount of attention paid to valley fever in the Southwest that has corresponded with the increased reporting in incidence. There are a variety of policy options that could inform next steps to reducing the incidence of valley fever that range from individual protective measures to large-scale policy action that requires funding and political support. The first recommendation would be to improve education about individual measures that can be taken to reduce exposure. This could include reducing the amount of time spent outside during months of increased exposure. It could also involve increasing awareness around the risk factors and the symptoms associated with valley fever so the general public can be more aware and see a provider more quickly if they believe they may have valley fever. Another area where education could play a key role is in the school systems. Information about valley fever risks and symptoms could be disseminated during health education classes, in parent meetings, and to the general community.
  • 21. The second area where policy could be affected is where workplace hazards are concerned. Implementing dust reduction measures, specifically in work environments that involve soil disruption such as construction work or electricians that perform work outside has the potential to reduce the risk of obtaining valley fever. The third area where policy could be affected is in the research space. Finding a vaccination for valley fever has been spoken about for some length of time in Arizona and with the opening of the University of Arizona Valley Fever Center for Excellence there is a real opportunity to work towards developing a vaccination. If funding can be found to support the Center’s initiatives and a vaccine is developed, it will be a very way to curb increased incidence of the disease. The most promising of all of these potential policy recommendations is to raise money for researching a vaccination. Because the risk of exposure to valley fever is difficult to quantify and the actual dose-response relationship is difficult to assess, there is more potential in determining an effective preventative measure in the form of vaccination compared to education. This will be more effective in the long run and will be a more effective way of utilizing resources. The cost of treating valley fever and the hospitalizations associated with valley fever are high and if a vaccine can be produced it has the potential to greatly reduce costs, which is an attractive policy option in the current healthcare space.31 While for many diseases there are substantial barriers and difficulties in approaching vaccine development, strides have already been made towards developing a vaccine and the University of Arizona Center for Excellence is committed to solidifying the development of the Nikkomycin Z vaccine meant to prevent against infection.31 References