Soraya Ghebleh
18 March 2013
ECS 151
Increased Incidence of Valley Fever in Arizona
Executive Summary
Infectious diseases ...
This is the most attractive and appropriate policy option as strides have been made
towards developing vaccines and it pro...
Should legislation be passed in the greater Metropolitan Area of Phoenix to
require more preventative measures and researc...
trends cannot only be explained by climate. There are other non-climactic issues related
to the increased incidence of dis...
climates with mild winters and hot summers.2
Coccidioidomycosis is associated with
community-acquired pneumonia (CAP) as w...
of contracting Valley Fever but that this is not sufficient for a worker to be
compensated.11
Evidence Table
Study Name St...
publications of
importance
diagnosis, special
hosts, clinical
presentation, and
therapy
- Enhanced
surveillance starting
i...
Community-
Acquired
Pneumonia9
analyzing data from
the National
Electronic
Telecommunication
s System for
Surveillance
- R...
benefits, and civil
actions against
businesses. Arizona
(as of 2007) did not
recognize
coccidioidmycosis
as a compensable
...
increases in
symptomatic disease
have substantially
increased
- Need greater
provider education
leading to stringent
surve...
opportunities for its
control5
by understanding of
coccidioidomycosis
as a medical
problem to improve
care of patients
coc...
sought treatment for
radiologically
confirmed CAP in an
endemic area
underscores the
likelihood that this
infection is a
c...
environmental
factors on the
number of monthly
cases; model
developed and
tested to predict
outbreaks
- Study may allow
pu...
timeseries of
monthly estimates
of exposure rates in
Marcipoa County
and Pima County in
AZ
exposure rates are
strongly rel...
have high index of
suspicion in persons
with recent travel or
resident within the
Southwest
A risk factor study of
coccidi...
virus-infected
persons in Arizona,
1994-1997:
incidence, risk
factors, and
prevention23
coccidioidomycosis
in HIV-infected...
The increase in coccidioidomycosis has been clearly established by the evidence
and the lack of a disproportionate public ...
coccidioidomycosis becoming a reportable disease in 1997, the numbers cannot be
ignored and there are various factors that...
teachers, and any other occupation that involves spending an extensive amount of time
outside regardless of season.
Arizon...
incidence is the Arizona Department of Health. They have been very involved in
increasing awareness of incidence and data ...
The second area where policy could be affected is where workplace hazards are
concerned. Implementing dust reduction measu...
Soraya Ghebleh - Valley Fever in Arizona
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Soraya Ghebleh - Valley Fever in Arizona

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This is an assessment of the public health program of valley fever in Arizona.

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Soraya Ghebleh - Valley Fever in Arizona

  1. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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

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