Overview of Coccidioidomycosis (Valley Fever) Stephen Munday, MD MPH Imperial County Public Health May 21, 2013

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1 Overview of Coccidioidomycosis (Valley Fever) Stephen Munday, MD MPH Imperial County Public Health May 21, 2013

2 Objectives Assess the epidemiology of Coccidioidomycosis (aka Valley Fever) Describe the clinical signs and symptoms Describe how Valley Fever is diagnosed and managed Report on Public Health work to enhance surveillance and increase health-care provider awareness of the disease

3 Valley Fever: From Soil to Lungs Coccidioidomycosis (Valley Fever) is caused by a fungus in soil in the Southwest region (primarily Arizona and parts of California), Mexico, Central and South America Fungus gets into the air from wind, dust storms, digging, and other activities Coccidioides fungus spores can be inhaled and infect lungs and other parts of the body

4 Coccidioidomycosis Life Cycle Source: Centers for Disease Control

5 Valley Fever SIGNS AND SYMPTOMS

6 Signs and Symptoms Most people (60%) have mild or no symptoms at all Some people get a flu-like illness that can last weeks to many months Disease usually affects the lungs but can spread to other parts of the body including bones, skin, joints, or brain

7 Common Symptoms Fever Cough Fatigue Headache Joint / muscle aches Rash Night sweats Weight loss or lack of appetite

8 Signs and Symptoms Severe symptoms can be similar to community-acquired pneumonia or tuberculosis 5% - 10% have lung nodules or cavitation 1% or less result in infection spread to other parts of body Complications can cause chronic morbidity deaths annually in United States

9 People at Risk Anyone who visits or lives in areas where Valley Fever (VF) occurs can become infected People who work in construction, farming, and other outdoor activities (military, Border Patrol) and are exposed to dirt and dust may be at increased risk Pets and other animals Note: VF is not contagious and cannot be spread from person to person

10 Risk Factors Certain conditions increase risk of complications Weak immune system Diabetes mellitus Third trimester of pregnancy Life-threatening infections more common in elderly and certain racial groups (African Americans and Filipinos)

11 Diagnosis Routine laboratory tests are not a good indicator Physicians can order a blood test for coccidioidomycosis Tests for other body fluids Chest X-ray or biopsy Laboratory culture of Coccidioides immitis (CDC)

12 Importance of Diagnosis Early detection can decrease anxiety, eliminate unwarranted diagnostic testing, and avoid unnecessary exposure to antibiotics Early diagnosis is important to ensure more rapid detection and proper management of complications should they arise

13 Treatment Most patients with Valley Fever recover with no treatment and will have lifelong immunity Anti-fungal therapy is used for severe coccidioidal infections and for those who are at risk for dissemination of disease

14 Prevention No vaccine available at this time Dampen soil when digging or doing other soil-disturbing activities to minimize airborne dust If you need to work outdoors during periods of blowing dirt, consider wearing a mask

15 Valley Fever LOCAL AND REGIONAL EPIDEMIOLOGY

16 Distribution of Valley Fever More than 70% of US cases occur in Arizona and 25% in California Reported cases have increased over the past decade in California A significant increase in California cases reported in past two years, primarily in the Central Valley region Imperial County is in a suspected endemic area

17 Endemic Areas Source: Centers for Disease Control

18 Valley Fever Outbreaks in California 1994: Ventura County 203 cases and 3 deaths after Northridge earthquake 2001: Kern County 7 cases among persons after attending World Championship of Model Airplane Flying : Taft Correctional Facility (Kern) 88 cases among inmates 2013: Outbreaks among prison inmates (Kern) and solar power construction crew (San Luis Obispo)

19 Reemergence in California Annual number of reported cases in California increased six-fold from 816 in 2000 to 5,366 in 2011 Factors may include changes in climate and rainfall patterns, soil-disturbing construction activities, and an increase in susceptible persons moving to diseaseendemic areas

20 Valley Fever in Imperial County Imperial County has lower rates of reported cases compared to other areas in California Reported cases have increased moderately in past two years

21 Rates by Year of Onset Rate per 100,000 population Coccidioidomycosis Rates Imperial County and California, California Imperial Year of Estimated Illness Onset Source: California Department of Public Health, Imperial County Public Health Dept.

22 Valley Fever IMPERIAL COUNTY PROJECTS AND INVESTIGATIONS

23 Focus on Valley Fever In , Public Health initiated a series of projects to identify possible factors that could contribute to lower reported rates of Valley Fever in Imperial County Enhanced surveillance of cases using a more detailed questionnaire to learn more about possible exposures Version created specifically for prison inmates

24 Enhanced Surveillance: Findings Cases reside throughout the county 6 of 14 in El Centro Age range (median age: 46 years) Nearly all cases were hospitalized due to pneumonia Many were diagnosed with other illnesses such as diabetes, liver disease, cancer

25 Serosurveys Two serosurveys to determine prevalence of antibodies to coccidioidomycosis from random samples Leftover serum from both hospital labs Serum from patients in Winterhaven Serosurveys showed that prevalence of antibodies against Valley Fever is very low

26 Health-care Provider Survey A provider survey was conducted in to assess and measure: clinicians knowledge of Valley Fever disease level of confidence in diagnosing and treating cases diagnosis and management practices based on current Infectious Disease Society of America guidelines

27 Provider Survey: Findings 102 clinicians completed survey Only 23% believed Valley Fever is a problem in California 23% did not know VF is a reportable disease in California 41% felt confident to diagnose VF 48% felt confident to treat VF 43% considered VF as a potential diagnosis in patients with symptoms of respiratory disease

28 Provider Survey: Conclusions Opportunities for improvement exist among providers in identification, diagnosis, and treatment of patients with Valley Fever disease Targeted education for local clinicians would enhance provider knowledge and guide practice

29 Provider Survey: Follow up Presentations were made to staff at a local hospital (PMH), as well as to a local nursing group Information about Valley Fever and local projects was published in the Public Health Bulletin in 2012

30 Summary Over past 2 years, Public Health has worked to identify VF cases and source of exposure, assess the prevalence of the disease, and raise awareness among health-care providers to improve case identification and reporting Those efforts to date have not identified evidence of high prevalence or local hot spots for disease

31 Next Steps Publish updated information on Valley Fever in upcoming Bulletin Continue to increase awareness among health-care providers and community residents Maintain enhanced surveillance of cases Add a reminder for coccidioidomycosis testing on forms for Severe Acute Respiratory Infection surveillance conducted in local hospitals

32 References and Resources Valley Fever Center for Excellence California Department of Public Health ages/coccidioidomycosis.aspx Centers for Disease Control (CDC)

33 For more information: Contact the Epidemiology section at (760) or (760)