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Public and Medical Misinformation on Valley Fever By David Filip Presented 4/23/2014 Public and Medical Misinformation on Valley Fever By David Filip Presented 4/23/2014

Although a discussion of misinformation may sound controversial, this presentation is founded on information Although a discussion of misinformation may sound controversial, this presentation is founded on information in peer reviewed medical journals and historical accounts. The only controversy should be the fact that this information is not already common knowledge.

Conventional Wisdom Conventional Wisdom

Sometimes the conventional wisdom on Valley Fever is not only baseless but is misinformation Sometimes the conventional wisdom on Valley Fever is not only baseless but is misinformation that whitewashes the truth and would lead people astray unless they chose to dig into the research themselves

Consider the Emperor's New Clothes Consider the Emperor's New Clothes

A frightening example of misinformation: A frightening example of misinformation: "Doctor [name withheld] says washing your hands is the best way to prevent valley fever. " Valley Fever cases on the upswing locally KOB Albuquerque, NM April 1, 2013

Common Valley Fever Common Valley Fever "Sound Bites" How true are they? Infected people have a lifelong immunity Most people won't know they have the disease It is a small problem It is important to focus on specific risk factors Masks can protect people from Valley Fever It is only a local problem

I will deconstruct each of these statements to show even accurate statements could be I will deconstruct each of these statements to show even accurate statements could be misinterpreted and misused to the detriment of public health, as well as to show ways to share the whole and useful truth quickly and effectively.

Do infected people have a lifelong immunity? Once infected, a person with Valley Fever Do infected people have a lifelong immunity? Once infected, a person with Valley Fever will have lifelong immunity – that is said everywhere from doctors offices to medical journals to the evening news. It is the basis of a vaccine It is the reason much of the Southwest's population is not debilitated Based on the peer reviewed literature, it is not always true as a blanket statement. In fact, in some cases it has been proven false.

Do infected people have a lifelong immunity? Do infected people have a lifelong immunity? "Relapse rates in prospective studies of the [azole drugs for Valley Fever] have ranged from 16% to 67%, with a reasonable estimate of 25%-35% after therapy. ” “The overall response to treatment with azoles appears somewhat less than that to treatment with amphotericin B; relapses occur in about one-third of patients treated with azoles. ” Einstein HE, Johnson RH. Coccidioidomycosis: new aspects of epidemiology and therapy. Clin Infect Dis 1993; 16: 349 -56.

Do infected people have a lifelong immunity? In a review of 223 cases across Do infected people have a lifelong immunity? In a review of 223 cases across a decade, 24% with dissemination relapsed and 71% with Central Nervous System involvement such as meningitis relapsed. Even “following apparently successful treatment” patients relapse one third of the time. Crum NF, Lederman ER, Stafford CM, Parrish JS, Wallace MR. Coccidioidomycosis: A Descriptive Survey of a Reemerging Disease. Clinical Characteristics and Current Controversies. Medicine. 83(3): 149 -175, May 2004.

Do infected people have a lifelong immunity? “Relapse remains one of the most significant Do infected people have a lifelong immunity? “Relapse remains one of the most significant problems in the treatment of coccidioidomycosis. ” Oldfield EC 3 rd, Bone WD, Martin CR, Gray GC, Olson P, Schillaci RF. Prediction of relapse after treatment of coccidioidomycosis. Clin Infect Dis. 1997 Nov; 25(5): 1205 -10.

Do infected people have a lifelong immunity? People contacting Valley. Fever. Survivor. com often Do infected people have a lifelong immunity? People contacting Valley. Fever. Survivor. com often tell us that their doctors won't treat them as symptoms return and the doctors often refuse to test for Valley Fever to begin with. However, “rising titers warrant the administration of therapy, even in the absence of evident disease, since relapse is likely. ” Stevens DA. Adequacy of therapy for coccidioidomycosis. Clin Infect Dis 1997 Nov; 25(5): 1211 -2.

Do infected people have a lifelong immunity? Do infected people have a lifelong immunity? "Coccidioidomycosis is a systemic fungal infection and is frequently refractory to treatment. Unfortunately, conventional antifungal therapy is associated with therapeutic failures, relapses, and toxicity. " Gonzalez GM, Tijerina R, Najvar LK, Bocanegra R, Luther M, Rinaldi MG, Graybill JR. Correlation between antifungal susceptibilities of Coccidioides immitis in vitro and antifungal treatment with caspofungin in a mouse model. Antimicrob Agents Chemother. 2001 Jun; 45(6): 1854 -9.

Do infected people have a lifelong immunity? “The disease may recur years after exposure Do infected people have a lifelong immunity? “The disease may recur years after exposure or treatment. ” Caraway NP, Fanning CV, Stewart JM, Tarrand JJ, Weber KL. Coccidioidomycosis osteomyelitis masquerading as a bone tumor. A report of 2 cases. Acta Cytol. 2003 Sep-Oct; 47(5): 777 -82. “Reactivation of a previously disseminated coccidioidal infection, even after apparently successful antifungal therapy, is not uncommon. ” Pappagianis D. Coccidioides immitis. In Collier L, Balows A, Sussman M, Ajello L, Hay RJ, eds. 9 th ed. Topley and Wilson's microbiology and microbial infections, Vol. 4, Medical Mycology. London: Arnold 1998. p 357 -371.

Do infected people have a lifelong immunity? Even in those who are not treated, Do infected people have a lifelong immunity? Even in those who are not treated, Valley Fever’s lung lesions are known to expand, sometimes years later. Coccidioidomycosis. Medline. Plus Medical Encyclopedia. This makes it important for Valley Fever patients to keep track of their x-rays of lung nodules, since they have frequently been mistaken as cancer. Arizona Respiratory Center. What you Should Know About Valley Fever (Coccidioidomycosis). University of Arizona Health Sciences Center

Do infected people have a lifelong immunity? “Despite the prevalent belief that primary attack Do infected people have a lifelong immunity? “Despite the prevalent belief that primary attack of coccidioidomycosis confers a lasting immunity, there are many cases which do not follow this simple concept. Examples have been presented illustrating that the disease can resolve and then reappear; that residual nodules and cavities can reactivate; that surgery and debilitating conditions can produce reactivations; and that late disseminations can occur. In addition, exogenous reinfection can also occur by both pulmonary and extrapulmonary routes. ” Salkin D. Clinical examples of reinfection in coccidioidomycosis. Am Rev Respir Dis. 1967 Apr; 95(4): 603 -11.

Do infected people have a lifelong immunity? Testimony about Valley Fever to the Arizona Do infected people have a lifelong immunity? Testimony about Valley Fever to the Arizona State Senate committee on health "pointed out the problems with current therapy, noting that less than 70% of patients respond to therapy. However, when therapy is stopped, relapses occur. " Galgiani, JN. Minutes of the Arizona State Senate Committee on Health. Phoenix, AZ 4 Feb 2002. http: //www. azleg. state. az. us/Format. Document. asp? in. Doc=/legtext/46 leg/1 R/comm_ min/Senate/0213+HEA%2 EDOC. htm Accessed 8/01/2003.

Do infected people have a lifelong immunity? “Unfortunately, the rates of failure and relapse Do infected people have a lifelong immunity? “Unfortunately, the rates of failure and relapse after treatment of chronic pulmonary or disseminated Coccidioidomycosis are disappointingly high. ” Laniado-Laborín R. Cost-benefit analysis of treating acute coccidioidal pneumonia with azole drugs. In: Proceedings of the Forty-Fifth Annual Coccidioidomycosis Study Group Meeting. March 31, 2001. The University of Arizona. Tucson, Arizona.

Do infected people have a lifelong immunity? There are no major long term studies Do infected people have a lifelong immunity? There are no major long term studies specifically following people with dormant Valley Fever to observe how they are struck by it later in life. There are many studies and case reports following patients who relapsed severely after seemingly defeating the disease with medication.

Documentation has also proven that patients’ infections relapsed (or activated for the first time) Documentation has also proven that patients’ infections relapsed (or activated for the first time) years after leaving the endemic zones where they contracted Valley Fever. Antony SJ, Jurczyk P, Brumble L. Successful use of combination antifungal therapy in the treatment of coccidioides meningitis. J Natl Med Assoc. 2006 Jun; 98(6): 940 -2. Bellin HJ, Bhagavan BS. Coccidioidomycosis of the prostate gland. Report of a case and review of the literature. Arch Pathol. 1973 Aug; 96(2): 114 -7. Catanzaro A, Cloud GA, Stevens DA, Levine BE, Williams PL, Johnson RH, Rendon A, Mirels LF, Lutz JE, Holloway M, Galgiani JN. Safety, tolerance, and efficacy of posaconazole therapy in patients with nonmeningeal disseminated or chronic pulmonary coccidioidomycosis. Clin Infect Dis. 2007 Sep 1; 45(5): 562 -8. Epub 2007 Jul 23. Cole GT, Xue JM, Okeke CN, Tarcha EJ, Basrur V, Schaller RA, Herr RA, Yu JJ, Hung CY. A vaccine against coccidioidomycosis is justified and attainable. Med Mycol. 2004 Jun; 42(3): 189 -216. Crum NF, Lederman ER, Stafford CM, Parrish JS, Wallace MR. Coccidioidomycosis: A Descriptive Survey of a Reemerging Disease. Clinical Characteristics and Current Controversies. Medicine (Baltimore). 2004 May; 83(3): 149 -175. Johnson RH, Einstein HE. Forty-five years of disseminated coccidioidomycosis. In: Proceedings of the Forty-Sixth Annual Coccidioidomycosis Study Group Meeting. March 31, 2001. The University of Arizona. April 6, 2002. Davis, California. VFCE. Oldfield EC 3 rd, Bone WD, Martin CR, Gray GC, Olson P, Schillaci RF. Prediction of relapse after treatment of coccidioidomycosis. Clin Infect Dis. 1997 Nov; 25(5): 1205 -10.

A Severe Reactivation When he was infected in 1957 he experienced pneumonia and appeared A Severe Reactivation When he was infected in 1957 he experienced pneumonia and appeared to recover. In 1958 he had a reactivation of his Valley Fever that required the removal of a testicle and other parts of his genitourinary tract. Again the Valley Fever went dormant, until it reactivated over four decades later as meningitis in 2002 to kill him. Even when an infected person does not look or feel sick, reactivation is always a dangerous lingering possibility with this disease. Johnson RH, Einstein HE. Forty-five years of disseminated coccidioidomycosis. In: Proceedings of the Forty-Sixth Annual Coccidioidomycosis Study Group Meeting. March 31, 2001. The University of Arizona. April 6, 2002. Davis, California.

Do infected people have a lifelong immunity? Lab accidents and animal data proving that Do infected people have a lifelong immunity? Lab accidents and animal data proving that reinfection is possible Salkin D. Clinical examples of reinfection in coccidioidomycosis. Ajello L, ed. Coccidioidomycosis. Papers from the second symposium on coccidioidomycosis. Tucson: University of Arizona Press, 1967: 11 -18. Shubitz LF, Peng T, Perrill R, Simons J, Orsborn K, Galgiani JN. Protection of mice against Coccidioides immitis intranasal infection by vaccination with recombinant antigen 2/PRA. Infect Immun. 2002 Jun; 70(6): 3287 -9.

Do infected people have a lifelong immunity? Fifteen trillion Coccidioides arthroconidia can fit into Do infected people have a lifelong immunity? Fifteen trillion Coccidioides arthroconidia can fit into a cubic inch. Valley Fever Center for Excellence. Frequently Asked Questions. http: //www. vfce. arizona. edu/FAQ. htm It is impossible to predict when any breath of air in an endemic area might contain enough spores to demolish an infected person’s immune resistance. Reinfection with Valley Fever may be something commonly regarded by some as impossible, but it is also a proven fact

Do infected people have a lifelong immunity? Reinfections and Reactivations Do infected people have a lifelong immunity? Reinfections and Reactivations

Do infected people have a lifelong immunity? Dose dependence: The question is not whether Do infected people have a lifelong immunity? Dose dependence: The question is not whether experimental vaccines are protective, but at what dose are they protective? Concerns of reinfection and reactivation could follow a similar line of thought.

Reactivations and Locus Minoris Resistentiae (LMR) It has been shown that dormant Coccidioides in Reactivations and Locus Minoris Resistentiae (LMR) It has been shown that dormant Coccidioides in some patients activated as “lesions that occurred after various forms of trauma, including those ensuing on medical-surgical procedures. What factors may contribute to such local proliferation of C. immitis are not yet explained. ” Pappagianis D. The phenomenon of locus minoris resistentiae in coccidioidomycosis. In: Einstein HE, Catanzaro A, eds. Coccidioidomycosis. Proceedings of the 4 th International Conference on Coccidioidomycosis. Washington, DC. National Foundation for Infectious Diseases; 1985: 319329.

Reactivations and Locus Minoris Resistentiae (LMR) It has also been reported that other active Reactivations and Locus Minoris Resistentiae (LMR) It has also been reported that other active bacterial and viral diseases can lead to the reactivation of dormant Valley Fever. Cole GT, Xue JM, Okeke CN, Tarcha EJ, Basrur V, Schaller RA, Herr RA, Yu JJ, Hung CY. A vaccine against coccidioidomycosis is justified and attainable. Med Mycol. 2004 Jun; 42(3): 189 -216.

Reactivations and Locus Minoris Resistentiae (LMR) Reactivations like these “indicate that relatively silent dissemination Reactivations and Locus Minoris Resistentiae (LMR) Reactivations like these “indicate that relatively silent dissemination from a primary pulmonary focus does occur. However, many of the present episodes of peripheral coccidioidal lesions could not be associated with a recent respiratory infection. Thus, C. immitis may have been present in the blood at the time of injury and settled in the injured site, or it may have previously been deposited via the circulation in the tissue which was later injured, setting the stage for fungal replication and development of a lesion. ” Pappagianis D. The phenomenon of locus minoris resistentiae in coccidioidomycosis. In: Einstein HE, Catanzaro A, eds. Coccidioidomycosis. Proceedings of the 4 th International Conference on Coccidioidomycosis. Washington, DC. National Foundation for Infectious Diseases; 1985: 319 -329.

Reactivations and Locus Minoris Resistentiae (LMR) Dr. Demosthenes Pappagianis was the first to describe Reactivations and Locus Minoris Resistentiae (LMR) Dr. Demosthenes Pappagianis was the first to describe this phenomenon in Valley Fever with the term “locus minoris resistentiae. ” LMR is based on an old laboratory term meaning “lessened resistance at a local area. ”

Reactivations and Locus Minoris Resistentiae (LMR) One example was a man who was struck Reactivations and Locus Minoris Resistentiae (LMR) One example was a man who was struck in the shoulder by a tree branch while riding on a tractor, and had Valley Fever activate in his shoulder. Another was a dock worker outside the endemic area who had a heavy weight fall on his foot, and soon had his latent Valley Fever activate in that foot. Pappagianis, D. Personal Communication.

Reactivations and Locus Minoris Resistentiae (LMR) LMR has also been known to occur in Reactivations and Locus Minoris Resistentiae (LMR) LMR has also been known to occur in other diseases, like bacterial osteomyelitis and syphilis. Pappagianis D. The phenomenon of locus minoris resistentiae in coccidioidomycosis. In: Einstein HE, Catanzaro A, eds. Coccidioidomycosis. Proceedings of the 4 th International Conference on Coccidioidomycosis. Washington, DC. National Foundation for Infectious Diseases; 1985: 319 -329.

Reactivations and Locus Minoris Resistentiae (LMR) More Valley Fever examples include an infection in Reactivations and Locus Minoris Resistentiae (LMR) More Valley Fever examples include an infection in the leg, Pappagianis D, Welland F, Jordan G. Backache and Ulcer of Calf in a human. In: Ajello L, ed. Coccidioidomycosis. Papers from the second symposium on coccidioidomycosis. Tucson: University of Arizona Press, 1967: 19 -22. a disseminated infection of the epididymis that apparently spread to the testicle after a blunt trauma, Fiese MJ. Coccidioidomycosis. Springfield, Charles C. Thomas, 1958: Ch 8 Pathology and pathogenesis of Coccidioidomycosis. P 104 -126. and the upper chest where a man was punched in a Judo class Caraway NP, Fanning CV, Stewart JM, Tarrand JJ, Weber KL. Coccidioidomycosis osteomyelitis masquerading as a bone tumor. A report of 2 cases. Acta Cytol. 2003 Sep-Oct; 47(5): 777 -82.

Reactivations and Locus Minoris Resistentiae (LMR) LMR may also apply in the cases of Reactivations and Locus Minoris Resistentiae (LMR) LMR may also apply in the cases of children who fell and subsequently developed osteomyelitis from Valley Fever at the site of their injuries. Iger M. Coccidioidal osteomyelitis. In: Ajello L, ed. Coccidioidomycosis: Current clinical and diagnostic status. Miami: Symposia Specialists; 1977: 177 -190. Bried JM, Speer DP, Shehab ZM. Coccidioides immitis osteomyelitis in a 12 -month-old child. J Pediatr Orthop 1987 May-Jun; 7(3): 328 -30. “Several anatomical sites have been involved upper and lower extremities, face, thorax, and an internal surgical site. ” Pappagianis D. The phenomenon of locus minoris resistentiae in coccidioidomycosis. In: Einstein HE, Catanzaro A, eds. Coccidioidomycosis. Proceedings of the 4 th International Conference on Coccidioidomycosis. Washington, DC. National Foundation for Infectious Diseases; 1985: 319 -329.

Reactivations and Locus Minoris Resistentiae (LMR) Reactivations of “surgical cases are of special interest Reactivations and Locus Minoris Resistentiae (LMR) Reactivations of “surgical cases are of special interest because operative trauma and post-operative pulmonary mechanical changes form an extraneous force which can upset a tenuous immunity. ” Salkin D. Clinical examples of reinfection in coccidioidomycosis. In: Ajello L, ed. Coccidioidomycosis. Papers from the second symposium on coccidioidomycosis. Tucson: University of Arizona Press, 1967: 11 -18.

Do infected people have a lifelong immunity? Having Valley Fever's symptoms once does NOT Do infected people have a lifelong immunity? Having Valley Fever's symptoms once does NOT guarantee total protection for the future. For the sake of accuracy and honesty in communications, "immune resistance" is better than saying "total immunity" because there are many ways that this resistance can be overcome.

Do infected people have a lifelong immunity? Many patients have mentioned their doctor told Do infected people have a lifelong immunity? Many patients have mentioned their doctor told them once they had a case of Valley Fever that they would never suffer symptoms again, and any sickness they experienced was from something else. This caused years of improper medical care until future doctors ultimately were willing to listen and work on the real problem. The difference between "immune resistance" and "total immunity" must be made clearer in the future for the medical community and lay audience alike.

"Most people won't know they have Valley Fever" Is this true? The estimate that 60% of cases would be asymptomatic came from military studies during World War II Smith CE, Beard RR. Varieties of coccidioidal infection in relation to the epidemiology and control of diseases. Am J Public Health 1946; 36: 1394 -402.

In today's population, the more important question is whether we should assume so many In today's population, the more important question is whether we should assume so many infections will not have symptoms.

According to the Arthritis Foundation, 50 million Americans have arthritis. This is 1/6 th According to the Arthritis Foundation, 50 million Americans have arthritis. This is 1/6 th of the population. How much of this is from fungal disease in general or Valley Fever in particular? The data is incomplete.

How accurate has Valley Fever testing been? The blood tests are among the most How accurate has Valley Fever testing been? The blood tests are among the most commonly used form of diagnosis. False positives had been noted under the particular circumstance of an EIA test with positive Ig. M antibodies but negative Ig. G antibodies. Kuberski T, Herrig J, Pappagianis D. False-positive Ig. M serology in coccidioidomycosis. J Clin Microbiol. 2010 Jun; 48(6): 2047 -9. doi: 10. 1128/JCM. 01843 -09. Epub 2010 Mar 31. Blair JE, Currier JT. Significance of isolated positive Ig. M serologic results by enzyme immunoassay for coccidioidomycosis. Mycopathologia. 2008 Aug; 166(2): 77 -82. doi: 10. 1007/s 11046 -008 -9129 -9. Epub 2008 Jun 4.

False negatives are a greater concern among the variety of blood tests for valley False negatives are a greater concern among the variety of blood tests for valley fever. In a 2006 study that evaluated tests in people already known to have Valley Fever, how often were blood tests accurate? EIA tests were positive 82% of the time Immunodiffusion tests: 71% of the time Complement fixation: 56% of the time Pollage CR, et al. Revisiting the sensitivity of serologic testing in culture positive coccidioidomycosis. Presented at the 106 th Annual Meeting of the American Society of Microbiology. Orlando, FL. 2006. Cited in: Saubolle MA. Laboratory aspects in the diagnosis of coccidioidomycosis. Ann N Y Acad Sci. 2007 Sep; 1111: 301 -14. Epub 2007 Mar 15.

In a case report, the patient had a lumbar puncture to test for cocci, In a case report, the patient had a lumbar puncture to test for cocci, but it was not found there. However, a blood test had a colossally high titer of 1: 512. This and similar cases illustrate the need for ongoing testing, repeated testing and often more than one type of testing. Gibbs BT, Neff RT. A 22 -year-old Army private with chest pain and weight loss. Mil Med. 2004 Feb; 169(2): 157 -60.

One study was a specific attempt to find Valley Fever in Arizona by testing One study was a specific attempt to find Valley Fever in Arizona by testing hospitalized patients with community acquired pneumonia. It led to a discovery that 29% were Valley Fever infections and not the expected influenza or bacterial pneumonia cases. Valdivia L, Nix D, Wright M, Lindberg E, Fagan T, Lieberman D, Stoffer T, Ampel NM, Galgiani JN. Coccidioidomycosis as a common cause of community-acquired pneumonia. Emerg Infect Dis. 2006 Jun; 12(6): 958 -62.

The rate of testing for Valley Fever ranges from 13% to as little as The rate of testing for Valley Fever ranges from 13% to as little as 2% of pneumonia cases, so the question of a subclinical case may be up to the doctors' willingness to consider Valley Fever at all. Chang DC, Anderson S, Wannemuehler K, Engelthaler DM, Erhart L, Sunenshine RH, Burwell LA, Park BJ. Testing for coccidioidomycosis among patients with communityacquired pneumonia. Emerg Infect Dis. 2008 Jul; 14(7): 1053 -9. doi: 10. 3201/eid 1407. 070832.

Peer review should be an answer to the release of bad data and bad Peer review should be an answer to the release of bad data and bad decisions. It could get every doctor and epidemiologist on the same page with all the right answers so they can share perfection with the media. . . in theory.

Benefits of peer review are. . . 1) It filters out the generally uneducated Benefits of peer review are. . . 1) It filters out the generally uneducated 2) It sets a standard of communication 3) Professionals familiar with the topic can point to holes in a theory 4) Peer pressure for accuracy

"Valley Fever is not a small problem" In the general public, there seems to be a horrible misconception that Valley Fever is just like a cold, or that if it WERE serious, it would already be under control. Questionnaire respondents have often said they had no idea how serious the disease was, and point to the estimates released to the news about the overall scope of the epidemic.

Different journal articles from the 1950's to the 2000's repeatedly estimated 100, 000 people Different journal articles from the 1950's to the 2000's repeatedly estimated 100, 000 people in the USA were infected each year.

Seemingly without regard to circumstances, the numbers stayed the same. In fact, you could Seemingly without regard to circumstances, the numbers stayed the same. In fact, you could follow a chain of citations from one journal article to the next, repeating that same number, and not one ever stated exactly how it arrived at that conclusion in the journal.

I asked Dr. John Galgiani at the Valley Fever Center for Excellence about his I asked Dr. John Galgiani at the Valley Fever Center for Excellence about his current estimate of 150, 000 annual infections, and his previous 100, 000 infection estimate in 1999. His estimates were in-line with some of the final surveys taken before the skin test was unavailable, accounting for the population in the six most endemic counties of the country. Larwood TR. Coccidioidin skin testing in Kern County, California: decrease in infection rate over 58 years. Clin Infect Dis. 2000 Mar; 30(3): 612 -3.

A discussion with Dr. Hans Einstein. . . A discussion with Dr. Hans Einstein. . .

With a laugh Dr. Einstein told me about a dust bowl era radiologist in With a laugh Dr. Einstein told me about a dust bowl era radiologist in California. Flush with new respiratory illnesses to diagnose from the Okies entering the San Joaquin Valley for work, he estimated 35, 000 lung lesions from Valley Fever were seen in California in a single year. So how did the estimate go from 35, 000 to 100, 000 people? Arizona has about twice as many diagnosed cases as California. So there was no peer review. No journal entry. No statistical model. One radiologist with an estimate gave us 100, 000 people every year.

That was the established That was the established "truth" for decades, even in peer reviewed articles that should have done their homework, until the new VFCE model matched and later exceeded that number to 150, 000.

What changed? Physicist Max Plank's perspective took hold: What changed? Physicist Max Plank's perspective took hold: "A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it. "

Peer Review's Benefits Vs. Reality 1) It filters out the generally uneducated. . . Peer Review's Benefits Vs. Reality 1) It filters out the generally uneducated. . . but without printing a statistical model or naming the radiologist, was any writer truly educated on the matter?

Peer Review's Benefits Vs. Reality 2) It sets a standard of communication. . . Peer Review's Benefits Vs. Reality 2) It sets a standard of communication. . . but the chain of citations led nowhere and were not checked - can you imagine the time it would take for dozens of citations for each article? Journals don't have enough staff for that level of quality assurance.

Peer Review's Benefits Vs. Reality 3) Professionals familiar with the topic can point to Peer Review's Benefits Vs. Reality 3) Professionals familiar with the topic can point to holes in a theory. . but if the right expert is not a reviewer, only an extensive historical review would show where the data came from.

Peer Review's Benefits Vs. Reality 4) Peer pressure for accuracy. . . but if Peer Review's Benefits Vs. Reality 4) Peer pressure for accuracy. . . but if a previous expert put his reputation on an estimate, the assumption is that he did not make a mistake. Is that assumption always fair?

Today's most commonly used estimate of the nation's annual infection rate is 150, 000 Today's most commonly used estimate of the nation's annual infection rate is 150, 000 per year, based on the population of the six most endemic counties and historical skin test infection rates. Table 1. Populations (in millions of persons) of endemic for coccidioidomycosis. Year State County (City) 1970 1990 Totals 2. 5 4. 5 Arizona 1. 5 2. 9 Maricopa (Phoenix) 1. 0 2. 1 Pima (Tucson) 0. 4 0. 7 Pinal 0. 1 California 0. 6 1. 0 San Louis Obispo 0. 1 0. 2 Kern (Bakersfield) 0. 3 0. 5 Tulare 0. 2 0. 3 Texas El Paso (El Paso) 0. 4 0. 6 Sources: US Bureau of the Census selected counties within regions highly 2010 6. 7 5. 2 3. 8 1. 0 0. 4 1. 5 0. 3 0. 8 0. 4 0. 7 This also assumes 30% are already infected and a 3% annual infection rate. This estimate model is unpublished data from Dr. John Galgiani, VFCE.

There is also a less famous statistical model in the CDC publication Emerging Infectious There is also a less famous statistical model in the CDC publication Emerging Infectious Diseases in 2001. Cost-effectiveness of a potential vaccine for Coccidioides immitis. Barnato AE, Sanders GD, Owens DK. Emerg Infect Dis. 2001 Sep-Oct; 7(5): 797 -806. Over time it can be harsher than any of the 100, 000 or 150, 000 estimates.

Comparative Data: Centers for Disease Control and Prevention (CDC). Increase in reported coccidioidomycosis--United States, Comparative Data: Centers for Disease Control and Prevention (CDC). Increase in reported coccidioidomycosis--United States, 1998 -2011. MMWR Morb Mortal Wkly Rep. 2013 Mar 29; 62 (12): 217 -21. Total Diagnoses 1998 2011 % Increase Arizona 1, 474 16, 467 +1017% California 719 5, 697 +692% NV, NM, UT 72 237 +229%

By case rates per 100, 000 population, even accounting for the tremendous population increase By case rates per 100, 000 population, even accounting for the tremendous population increase in these states, rates of Valley Fever diagnosis still outstripped population growth. Diagnosed cases per 100, 000 population 1998 2011 % Increase Arizona 30. 5 247. 7 +712% California 2. 1 14. 9 +610% NV, NM, UT 1. 4 3. 1 +121%

If this CDC report had gone back earlier in Arizona's records to 1990, with If this CDC report had gone back earlier in Arizona's records to 1990, with only 280 reported cases, the difference between that and Arizona's 2011 reported caseload of 16, 474 would show a cocci diagnosis increase of 5, 784%!

In the past decade and beyond, nearly every year in Arizona and California had In the past decade and beyond, nearly every year in Arizona and California had been the worst epidemic in that state's Valley Fever history in total cases or the rate of infection based on population, if not both.

The speed of this epidemic's increase outstrips the statistical models we have. Why? - The speed of this epidemic's increase outstrips the statistical models we have. Why? - The study was based on infection rates in soldiers from WWII. These were young healthy men, but in a general population otherwise, people today would have a greater severity of illness that may not be measured properly. - Our present day has people with more immunocompromised conditions, diabetes, chemical sensitivities, and environmental toxins than ever before. - The population boom has brought in new residents, expansion to new desert areas, and more soil-disturbing construction to those areas. - Man-made drought could affect the life cycle in agricultural areas where this had not previously been a concern.

When diagnoses are occurring thousands of percent higher now than in the past, it When diagnoses are occurring thousands of percent higher now than in the past, it may not be outlandish to see more accurate models that may estimate even a million people newly infected in a year. Valley Fever is no stranger to large numbers. Dr. David Stevens' landmark textbook Coccidioidomycosis estimated there were 10 million people living with Valley Fever in America in 1980. A simplified underestimate of the 2001 EID model would still lead to hundreds of thousands of annual infections when applying the equation to the caseload and calculating to find the number of infected people overall.

Is there a good reason NOT to use higher estimates? - Politicians might fear Is there a good reason NOT to use higher estimates? - Politicians might fear economic disaster - Awareness of legal liabilities - Orphan drug research concerns - The increase in case reporting does not match the previous trend of decreasing skin test data from over two decades ago. The first three do not have a basis in science

Risk Factors Race: Native American, African-American, Asian (particularly Filipinos) Age: Children under five and Risk Factors Race: Native American, African-American, Asian (particularly Filipinos) Age: Children under five and the elderly Environmental/occupational: Working outdoors and In dusty environments Immunocompromised conditions

Risk Factors A discussion of risk factors, no matter how simple, can make matters Risk Factors A discussion of risk factors, no matter how simple, can make matters unclear for general audiences.

Risk Factors A discussion about Valley Fever risk factors can be true at face Risk Factors A discussion about Valley Fever risk factors can be true at face value, but people who are not part of the risk groups notice the lack of attention the report gives to them and believe they could have an illusion of safety.

The risk to the immunocompromised should not be overstated to the general population because The risk to the immunocompromised should not be overstated to the general population because virtually any disease is worse when the immune system is not functioning normally. “Mortality rates are 40 to 60 percent for patients without concomitant HIV infection” in Valley Fever patients with meningitis. (1) This complication is clearly serious even for patients who do not have HIV/AIDS. In a study of Valley Fever pneumonia autopsies from the San Joaquin Valley, 98% of the victims did not have an immunocompromised condition. The conclusion is clear: “Fatal coccidioidal pneumonia is certainly not confined to the immunocompromised host. ” (2) (1) Kelly PC. Coccidioidal meningitis. In: Einstein HE, Catanzaro A, eds. Coccidioidomycosis. Proceedings of the 5 th International Conference on Coccidioidomycosis. Stanford University, 2427 August, 1994. Washington, DC. National Foundation for Infectious Diseases; 1996: 373 -384. (2) Stevens DA. Immunology of coccidioidomycosis. In: Stevens DA. Coccidioidomycosis. A Text. New York, London: Plenum Medical Book Company, 1980: 87 -95.

Before the increased use of immunosuppressive drug therapy and the appearance of HIV/AIDS, only Before the increased use of immunosuppressive drug therapy and the appearance of HIV/AIDS, only 2% of Valley Fever cases had an underlying illness. Coccidioides clearly threatens public health regardless of any individual’s immune status. (1) A 2006 study of hospitalization data found that only 12% of hospitalized Valley Fever patients had an underlying immunocompromising condition. (2) From our own questionnaires at www. valleyfeversurvivor. com to date, the vast majority of people had healthy immune systems when they contracted Valley Fever. (1) Bouza E, Dreyer JS, Hewitt WL, Meyer RD. Coccidioidal meningitis. An analysis of thirty-one cases and review of the literature. Medicine (Baltimore) 1981 May; 60(3): 139 -72 citing Hart PD, Russell E, Remington JS: The compromised host and infection. II. Deep fungal infection. J Infect Dis. , 120: 169, 1969. (2) Chu JH, Feudtner C, Heydon K, Walsh TJ, Zaoutis TE. Hospitalizations for endemic mycoses: a population-based national study. Clin Infect Dis. 2006 Mar 15; 42(6): 822 -5.

Considerations About Racial Risk Factors Even when immune system problems are ruled out, it Considerations About Racial Risk Factors Even when immune system problems are ruled out, it is clear from studies that race is a risk factor. Some studies even seem to show that being an otherwisehealthy African-American with Valley Fever can be as problematic as having AIDS or other immune diseases with Valley Fever. Seitz AE, Prevots DR, Holland SM. Hospitalizations associated with disseminated coccidioidomycosis, Arizona and California, USA. Emerg Infect Dis. 2012 Sep; 18(9): 1476 -9. doi: 10. 3201/eid 1809. 120151.

Considerations About Racial Risk Factors Racial risk factors in Valley Fever are not always Considerations About Racial Risk Factors Racial risk factors in Valley Fever are not always clear. No racial differences found in a 30% dissemination rate at Lemoore NAS Lee R, Crum-Cianflone N. Increasing incidence and severity of coccidioidomycosis at a naval air station. Mil Med. 2008 Aug; 173(8): 769 -75. 45% of a Navy SEAL squad fell ill with Valley Fever in Coalinga, CA, with no risk groups infected. Crum N, Lamb C, Utz G, Amundson D, Wallace M. Coccidioidomycosis outbreak among United States Navy SEALs training in a Coccidioides immitis-endemic area--Coalinga, California. J Infect Dis. 2002 Sep 15; 186(6): 865 -8. Epub 2002 Aug 16.

Considerations About Racial Risk Factors Ironically, for all the race-based risk factors, Caucasians are Considerations About Racial Risk Factors Ironically, for all the race-based risk factors, Caucasians are almost always the most affected by Valley Fever—Even in the classic study that first demonstrated dramatically higher death rates in other groups, the total number of Caucasians killed by Valley Fever was higher than any other race. Gifford MA, Buss WC, Douds RJ. Data on coccidioides fungus infection. Kern County, 19011936. In: Annual Report of the Kern County Department of Public Health, 1936 -37, p 39 -54.

Considerations About Racial Risk Factors Considering that whites and Hispanics may not have the Considerations About Racial Risk Factors Considering that whites and Hispanics may not have the same risk factors of other groups, it is interesting to note that from the years 2000 -2011, both of these groups supposedly at lower risk of developing Valley Fever illnesses in fact had 78% of California's infections overall. Sondermeyer G, Lee L, Gilliss D, Tabnak F, Vugia D. Coccidioidomycosis-associated hospitalizations, California, USA, 2000 -2011. Emerg Infect Dis. 2013 Oct; 19(10): 1590 -7. doi: 10. 3201/eid 1910. 130427.

Considerations About Racial Risk Factors As racial diversity increases, it may be possible to Considerations About Racial Risk Factors As racial diversity increases, it may be possible to expect a corresponding increase in the overall severity and death toll of the Valley Fever epidemic. However, demography shows the people who are least likely to suffer per capita will suffer from the illness the most by the force of numbers alone.

Considerations about Age Related Risk Factors Extremes of age are said to be a Considerations about Age Related Risk Factors Extremes of age are said to be a risk factor

Considerations about Age Related Risk Factors One study in California showed children under the Considerations about Age Related Risk Factors One study in California showed children under the age of five to be the least likely age group to be infected. (1) In Los Angeles County in 2006, the most frequently infected age group was 15 -34 years old, and the second most infected age group was 45 -54 years old. (2) (1) Rosenstein NE, Emery KW, Werner SB, Kao A, Johnson R, Rogers D, Vugia D, Reingold A, Talbot R, Plikaytis BD, Perkins BA, Hajjeh RA. Risk factors for severe pulmonary and disseminated coccidioidomycosis: Kern County, California, 1995 -1996. Clin Infect Dis. 2001 Mar 1; 32(5): 708 -15. Epub 2001 Feb 28. (2) Los Angeles County. Tables of Notifiable Diseases 2006. http: //www. lapublichealth. org/acd/docs/Tablesnotifynew 06%5 B 1%5 D. pdf

Mac. Lean M. The Epidemiology of Coccidioidomycosis – 15 California Counties, 2007 -2011. Produced Mac. Lean M. The Epidemiology of Coccidioidomycosis – 15 California Counties, 2007 -2011. Produced for the California Coccidioidomycosis Collaborative. Jan 2014

More data supports this, showing that the increased incidence of reported Valley Fever by More data supports this, showing that the increased incidence of reported Valley Fever by age is mitigated by the sheer numbers of people infected in younger adult risk groups. In a 1998 -2011 of age groups. . . 6, 352 infections in ages 20 -39 7, 684 infections in ages 40 -59 Either of these two groups were higher than any other age group by a margin of over 1300, and together represented more than half of the study's 22, 401 reported cases. Centers for Disease Control and Prevention (CDC). Increase in reported coccidioidomycosis--United States, 1998 -2011. MMWR Morb Mortal Wkly Rep. 2013 Mar 29; 62 (12): 217 -21.

A simple analysis of the numbers shows again that those at the greatest risk A simple analysis of the numbers shows again that those at the greatest risk per capita are not the ones being infected the most overall. If the most important thing is to notify the people at greatest risk, who is that?

Don't bury the lead Don't bury the lead

Does this bury the lead? Snyder CH. Coccidioidal meningitis presenting as memory loss. J Does this bury the lead? Snyder CH. Coccidioidal meningitis presenting as memory loss. J Am Acad Nurse Pract. 2005 May; 17(5): 181 -6. PURPOSE: This case study is designed to help the nurse practitioner recognize atypical symptoms of coccidioidal meningitis, particularly in high-risk groups that require further diagnostic treatment. DATA SOURCES: Selected research, clinical articles, and case studies. CONCLUSIONS: Coccidioidal meningitis is a potentially lethal infection unless recognized and treated. Unlike other infectious meningitides that present with more acute meningeal symptoms, disseminated coccidioidomycosis can present insidiously. When it presents as cognitive dysfunction, it may be mistaken for early dementia and if undiagnosed can result in death. While it is an infectious disease that is endemic to a small number of southwestern states, these areas see a high volume of tourists who can unwittingly become infected. Knowledge of this infectious disease and the many ways it can imitate other diseases is critical to its early recognition and treatment. IMPLICATIONS FOR PRACTICE: Failure to recognize this reemerging, endemic fungal infection in high-risk groups can result in death.

Compare the two warnings: 1) Compare the two warnings: 1) "Groups that are particularly likely to have dissemination are Native Americans, African Americans, Asians, the elderly, and workers in close contact with soil or dusty conditions. " 2) "Groups that are particularly likely to have dissemination are Native Americans, African Americans, Asians, the elderly, and workers in close contact with soil or dusty conditions but Caucasians, Hispanics and any race can suffer a severe or fatal case of Valley Fever. Chronic Valley Fever conditions are not race specific. "

Considerations About Risk Factor Warnings Even in a dust storm, people tend not to Considerations About Risk Factor Warnings Even in a dust storm, people tend not to abandon their daily routine. It may not be realistic or useful to highlight risk factors at all. Race and age discussions may be a distraction from the fundamental truth that will protect everyone. It would be simpler and just as true to to highlight only the behavioral risk: "Avoid dusty conditions and work in the soil because anyone can suffer a severe or fatal case of Valley Fever. "

Masks and Protective Measures Only a miner's mask will provide a seal that is Masks and Protective Measures Only a miner's mask will provide a seal that is tight enough to offer protection Cocci arthroconidia have blown up to 500 miles outside of endemic areas. Di. Salvo A. Dimorphic Fungi. Microbiology and Immunology On-Line. http: //www. med. sc. edu: 85/mycology-6. htm

Masks and Protective Measures One of our questionnaire respondents had soil testing done and Masks and Protective Measures One of our questionnaire respondents had soil testing done and found it right outside her front door. Contrast this with the historical experience of researchers who had difficulty finding a soil sample but happened to be infected during the search for it. Egeberg RO. Socioeconomic impact of coccidioidomycosis. In Einstein HE, Catanzaro A, eds. Coccidioidomycosis. In: Einstein HE, Catanzaro A, eds. Coccidioidomycosis. Proceedings of the 4 th International Conference on Coccidioidomycosis. Washington, DC. National Foundation for Infectious Diseases; 1985

Masks and Protective Measures “Roads were paved, air strips were hard-surfaced and swimming pools Masks and Protective Measures “Roads were paved, air strips were hard-surfaced and swimming pools replaced dusty athletic fields. Lawns were planted by the acre, and military personnel were ordered, at risk of court martial, to avoid unprotected areas” Fiese, MJ: Coccidioidomycosis 1958 Springfield, Ill. Thomas

Protective Measures Keep kids, pets and yourself indoors during windstorms Close all vents, windows, Protective Measures Keep kids, pets and yourself indoors during windstorms Close all vents, windows, and doors during times of high wind. Industrial work crews use the wetting of soil as a dust control measure outdoors. During World War II training in the desert even sprays of oil on sand were used to reduce the infection rate. Water can be used as a dust control measure to help with outdoor furniture as well after a storm.

The Biggest Valley Fever Misperception Valley Fever is not just a local disease! The Biggest Valley Fever Misperception Valley Fever is not just a local disease!

Valley Fever is not just a local problem Millions of people visit the endemic Valley Fever is not just a local problem Millions of people visit the endemic areas every year. As in the past, our military are hit hard. With bases comprising approximately 300, 000 personnel in the endemic areas, many of them from home cities and states that are not endemic, they are a large population being exposed to Valley Fever.

Valley Fever is not just a local problem A sample of military reviews with Valley Fever is not just a local problem A sample of military reviews with different perspectives but similar comments across the decades are listed in this slide. Smith CE, Beard RR. Varieties of coccidioidal infection in relation to the epidemiology and control of diseases. Am J Public Health. 1946; 36: 1394– 402. Olivere JW, Meier PA, Fraser SL, Morrison WB, Parsons TW, Drehner DM. Coccidioidomycosis--the airborne assault continues: an unusual presentation with a review of the history, epidemiology, and military relevance. Aviat Space Environ Med. 1999 Aug; 70(8): 790 -6. Crum-Cianflone NF. Coccidioidomycosis in the U. S. Military: a review. Ann N Y Acad Sci. 2007 Sep; 1111: 112 -21. Epub 2007 Apr 13 Lee R, Crum-Cianflone N. Increasing incidence and severity of coccidioidomycosis at a naval air station. Mil Med. 2008 Aug; 173(8): 769 -75. Coccidioidomycosis, active component, U. S. Armed Forces, January 2000 -June 2012. MSMR. 2012 Sep; 19(9): 10

Valley Fever is not just a local problem Fomites are objects that can harbor Valley Fever is not just a local problem Fomites are objects that can harbor spores to infect people at long distances

A mechanic in Oregon was “totally disabled” from Valley Fever after working under a A mechanic in Oregon was “totally disabled” from Valley Fever after working under a truck that had driven through endemic areas. Marmor D. “Fungus among us” and Workmen’s Compensation. Med Trial Tech Q. 1976 Spring; 22(4): 385 -402. Cotton factory workers in Japan and non-endemic parts of the United States were sickened (with some fatalities) in outbreaks of Valley Fever due to Coccidioides spores brought to them on cotton. Ogiso A, Ito M, Koyama M, Yamaoka H, Hotchi M, Mc. Ginnis MR. 1997. Pulmonary coccidioidomycosis in Japan: case report and review. Clin. Infect. Dis. 25: 1260 -1261. Gelhlbach SH, Hamilton JD, Connant NF. Coccidioidomycosis-an occupational disease in cotton mill workers. Arch Intern Med 1973; 131: 254 -5.

Iranian soldiers who had purchased imported American clothing were infected in Iran. Asgari M, Iranian soldiers who had purchased imported American clothing were infected in Iran. Asgari M, Owrang A. Results of skin test surveys for systemic mycoses in Iran. Mycopathol Mycol Appl 1970; 41(1): 91 -106. A 23 -year-old steam boat crewman who had not been to endemic areas was found with Valley Fever lesions in both lungs and osteomyelitis, ultimately requiring the amputation of both feet. Rothman PE, Graw RG Jr, Harris JC Jr, Onslow JM. Coccidiodomycosis--possible fomite transmission. A review and report of a case. Am J Dis Child. 1969 Nov; 118(5): 792 -801.

A woman in Europe became infected with Valley Fever because someone mailed her a A woman in Europe became infected with Valley Fever because someone mailed her a cactus from Arizona as a gift. Coccidioides spores were later found inside its pot. Brauer RJ, VFCE Executive Director personal communication, Sept 2002. A European traveler to Africa and Asia was also sickened. His doctors believed his dose of Coccidioides spores might have been “harboured in the airconditioning system of an aircraft arriving from an endemic area” since the man had never visited North or South America, let alone the specific endemic areas. Papadopoulos KI, Castor B, Klingspor L, Dejmek A, Loren I, Bramnert M. Bilateral isolated adrenal coccidioidomycosis. J Intern Med. 1996 Mar; 239(3): 275 -8.

Valley Fever might have achieved major visibility in the late 1980 s from a Valley Fever might have achieved major visibility in the late 1980 s from a Department of Transportation report. They knew even in 1989 that commercial airliner cabin environments could hold and transport infectious organisms and specifically named coccidioidomycosis as a potential problem. Rather than making this a discussion of fomites and Valley Fever, this report achieved greater fame by its mention of tobacco smoke in the air cabin. Television and newspaper reporting focused on health concerns from second hand smoke, leaving major Valley Fever headlines for a future time. Nagda, Niren Laxmichand, United States Department of Transportation. Airliner cabin environment : contaminant measurements, health risks, and mitigation options. Germantown, Md. : GEOMET Technologies ; Washington, D. C. : U. S. G. P. O. , 1989

Finally, to show its nationwide reach, Medicare is responsible for 23 -25% of payment Finally, to show its nationwide reach, Medicare is responsible for 23 -25% of payment of Valley Fever related hospital costs in recent studies in California. Mac. Lean M. The Epidemiology of Coccidioidomycosis – 15 California Counties, 20072011. Produced for the California Coccidioidomycosis Collaborative. Jan 2014 Sondermeyer G, Lee L, Gilliss D, Tabnak F, Vugia D. Coccidioidomycosis-associated hospitalizations, California, USA, 2000 -2011. Emerg Infect Dis. 2013 Oct; 19(10): 15907. doi: 10. 3201/eid 1910. 130427. The financial cost of Valley Fever has been borne nationwide and will continue to be.

Flashpoints Local media and health departments Do not refer to Coccidioides as the most Flashpoints Local media and health departments Do not refer to Coccidioides as the most virulent fungal parasite known to man, even if biological warfare information does. Dixon DM. Coccidioides immitis as a Select Agent of bioterrorism. J Appl Microbiol. 2001 Oct; 91(4): 602 -5. Perhaps there is a "seriousness gap" between the common reporting of Valley Fever and the way the military and many peer-reviewed journals handle it.

I have never been able to find the term I have never been able to find the term "fungal parasite" spoken when Valley Fever appears on any media broadcast and reporting unless I have been quoted. This term helps people understand the seriousness of the disease and may shake people from their illusion of safety. The word "fungus" on its own does seem to make people associate it with the severe symptoms. It makes people think of something that gets killed off when they put powder on their feet. Perhaps the term "systemic fungal infection" would also be appropriate.

The selective use of words can make people respect the importance of the disease The selective use of words can make people respect the importance of the disease or ignore it. If someone says most people won't notice they are infected, says the risk group is "someone else" and claims Valley Fever is only a local problem affecting a small number of people, you can practically guarantee the disease will be swept under the rug – After all, it is still practically unknown to the general American public for over a century.

This This "seriousness gap" will inevitably be bridged by a cold slap of reality as the Valley Fever epidemic continues. With the booming population in the Southwest, the increasing number of tourists, and attention focused on the disease like never before, professionals will be faced with flashpoints that will inevitably occur in the epidemic.

Natural disasters have already occurred to focus attention on Valley Fever. With the windstorm Natural disasters have already occurred to focus attention on Valley Fever. With the windstorm over the Tehachapis in late 1977, the Northridge Earthquake of 1994, and other disasters sharply increasing the Valley Fever caseload. While sickness is always devastating, Valley Fever is not often seen as a drain on the economy. Consider what natural disasters might add to the following cost estimates:

In 2001 the national medical treatment cost of Valley Fever was estimated at $120 In 2001 the national medical treatment cost of Valley Fever was estimated at $120 million dollars. Laniado-Laborín R. Cost-benefit analysis of treating acute coccidioidal pneumonia with azole drugs. In: Proceedings of the Forty-Fifth Annual Coccidioidomycosis Study Group Meeting. March 31, 2001. The University of Arizona. Tucson, Arizona. A 2014 analysis for average annual Valley Fever hospitalization charges in California from 2000 to 2010 averaged over 171 million dollars annually. Mac. Lean M. The Epidemiology of Coccidioidomycosis – 15 California Counties, 20072011. Produced for the California Coccidioidomycosis Collaborative. Jan 2014 Despite the severity of this incredible jump in one state's averages alone, another recent analysis also took on California's 2011 charges as well. Rather than using the average, it showed the increase in costs that have occurred over time. Its findings follow. . .

"During 2000– 2011, the total charges for all coccidioidomycosis-associated hospitalizations in California was US $2. 2 billion, and the average annual total was US $186 million. After we adjusted for inflation, the annual total charges increased from US $73 million in 2000 to US $308 million in 2011. " Sondermeyer G, Lee L, Gilliss D, Tabnak F, Vugia D. Coccidioidomycosis-associated hospitalizations, California, USA, 2000 -2011. Emerg Infect Dis. 2013 Oct; 19(10): 1590 -7. doi: 10. 3201/eid 1910. 130427.

Arizona is known to have twice as many cases as California. There are other Arizona is known to have twice as many cases as California. There are other endemic states. There are travelers to these areas who become infected, many of whom must seek medical care elsewhere. There is also the fact that many would face medical expenses that would be unrelated to the specific hospitalization charges studied, such as those diagnosed who did not require hospitalization. Therefore, adding a little more than twice these expenses to the previous total could be reasonable for the country. That comes to one billion dollars in annual medical costs for Valley Fever, and could be a very conservative estimate of medical expenses when ongoing antifungal drug costs are considered. The cost of lost productivity could be left to actuaries, and the personal suffering is, of course, incalculable.

Transmission by fomites would be a different form of disaster. Deaths and illness have Transmission by fomites would be a different form of disaster. Deaths and illness have occurred from sending potted plants, sending agricultural products like cotton, and even clothing exported from the endemic areas. Nurseries do not test whether the soil they export in plants may harbor Valley Fever, cotton farms do not test, and even simple items being sold from retail outlets may ultimately spread these spores. Tourists who buy from outdoor vendors, automobiles, and virtually anything imaginable could become a public focus for this. Inevitably, an export of Valley Fever from the area will become publicized.

Biological Warfare: After events such as the Japanese sarin gas attack, the attack on Biological Warfare: After events such as the Japanese sarin gas attack, the attack on Oklahoma City, and the attacks of September 11 th, the fungus that causes Valley Fever was federally regulated as a Select Agent in the Antiterrorism and Effective Death Penalty Act of 1996 and the Public Health Security and Bioterrorism Preparedness and Response Act of 2002.

Cocci was regulated as a select agent of biological terrorism for 16 years. Then Cocci was regulated as a select agent of biological terrorism for 16 years. Then in late 2012 it was dropped from the list, even though the reasons for its inclusion had never changed: It is still difficult to treat, it can be chronic or reactivate over time, it causes major economic damage, and it is still an ongoing problem at our military installations.

Specific outbreaks could also draw attention to the disease. Infections at the Kern Model Specific outbreaks could also draw attention to the disease. Infections at the Kern Model Airplane Championship and California's prisons are among the most well known. Archaeologists and missionaries also have experienced some local outbreaks. Off-road parks, solar stations, and other construction projects have become areas of specific outbreaks that draw specific attention – legal attention

Lester Randolph's lawsuit against Arizona. . . Explaining their reasons to reject Randolph's case, Lester Randolph's lawsuit against Arizona. . . Explaining their reasons to reject Randolph's case, Judges Krucker, Hathaway, and Howard said that if a duty to warn about Valley Fever existed, "the stream of cases would be endless, the financial burden imposed upon such parties in defendant’s position catastrophic; the workability of the rule impractical; and the availability of means by which loss may be shifted impractical. ” Randolph v. Arizona Bd. of Regents, 19 Ariz. App. 121, 505 P. 2 d 559 (1973)

The judges essentially admitted there would be an “endless” stream of people would be The judges essentially admitted there would be an “endless” stream of people would be so debilitated by Valley Fever that any attempt to compensate them fairly would be a “catastrophic” pull on the state’s purse strings. Then, because the judges recognized the size of the Valley Fever problem, they decided it was “impractical” to require warnings or to compensate those who suffer. According to these judges, then, responsibility decreases as damages increase.

The impact of this reasoning inside a courtroom was to dismiss Randolph's case. Outside The impact of this reasoning inside a courtroom was to dismiss Randolph's case. Outside the courtroom, in today's media climate, even a little media coverage would guarantee a stunning national outrage.

The recent movement of Californian prisoners seemed like an attempt to avoid this kind The recent movement of Californian prisoners seemed like an attempt to avoid this kind of outrage. However, the story of Arjang Panah explains its urgency.

The $425, 000 payout to Panah may have come because there is a unique The $425, 000 payout to Panah may have come because there is a unique duty to protect people who are brought into areas against their will by the state. Panah was a federal prisoner originally from New York. There must have been a realization that if one federal prisoner were able to sue successfully, an avalanche of other infected prisoners would realize they could sue. Settling out of court was a handy way of avoiding a precedent-setting ruling.

It is not without precedent to move prisoners. After all, during World War II, It is not without precedent to move prisoners. After all, during World War II, captured Germans in Florence, Arizona were moved because they were contracting Valley Fever, and Nazi Germany invoked the Geneva Convention to have the prisoners moved. Deresinski SC. History of coccidioidomycosis: Dust to Dust. in Stevens DA, ed. Coccidioidomycosis. A Text. New York, London: Plenum Medical Book Company, 1980: p 1 -20. Smith CE. Reminisces of the Flying Chlamydospore and its allies. In Ajello L, ed. Coccidioidomycosis. Papers from the second symposium on coccidioidomycosis. Tucson: University of Arizona Press, 1967: xiii-xxii.

On the subject of human rights, a focus could be moved away from adult On the subject of human rights, a focus could be moved away from adult prisoners to our most precious asset, our children. I was surprised to find a medical journal article titled "Focal Endemic Coccidioidomycosis in Los Angeles County. " This title regrettably buries the lead. Rao S, Biddle M, Balchum OJ, Robinson JL. Focal endemic coccidioidomycosis in Los Angeles County. Am Rev Respir Dis 1972 Mar; 105(3): 410 -6. A more appropriate title would be "Experimentation on Children in California. "

Economic consequences may come from completely unexpected organizations with no specific legal authority. Consider Economic consequences may come from completely unexpected organizations with no specific legal authority. Consider the SARS epidemic of 2003 in Toronto, Canada. "On April 23, 2003, the World Health Organization issued an advisory against travel to Toronto. Although it was withdrawn six days later, the advisory had a costly effect. The tourism industry lost $260 million (Canadian), and 11 percent of businesses related to tourism reported layoffs. In Ontario, provincial government costs of coping with SARS have been estimated at $1. 13 billion (Canadian). " Svoboda T, Henry B, Shulman L, Kennedy E, Rea E, Ng W, Wallington T, Yaffe B, Gournis E, Vicencio E, Basrur S, Glazier RH. Public health measures to control the spread of the severe acute respiratory syndrome during the outbreak in Toronto. N Engl J Med. 2004 Jun 3; 350(23): 2352 -61.

Now consider any of the Valley Fever disaster scenarios. Publicity can shape public opinion Now consider any of the Valley Fever disaster scenarios. Publicity can shape public opinion and the need for groups to act. Is it inconceivable that any of these scenarios might prompt the World Health Organization or another group to react with a travel advisory against Valley Fever's endemic areas?

Dealing with Flashpoints When politicians are accused of something bad, it hurts them in Dealing with Flashpoints When politicians are accused of something bad, it hurts them in polls. Then when they deny it, the denial hurts them again in public opinion. Professor Kathleen Fearn-Banks, author of' "Crisis Communication" In the court of public opinion as well as in any legal proceedings that may occur against government offices, publicity could worsen for those holding information back.

The clearest political move is to The clearest political move is to "get out in front" of any issue and create a track record. But to work it can never be a half measure. Half-hearted efforts will not earn full respect, and no amount of public relations can overcome a history of inaction or misinformation.

Those who shape public policy have to focus on the most severe aspects of Those who shape public policy have to focus on the most severe aspects of the data and the most serious problems Valley Fever can cause or they will be caught completely unprepared. The states, counties, and cities whose work focuses on information that could be seen as making the disease look less serious than it truly is would magnify their publicity problem as the truth gradually trickles out during a crisis.

Churchhill said the truth is so important that it must be protected by a Churchhill said the truth is so important that it must be protected by a bodyguard of lies, but when so many falsehoods about Valley Fever are so common, using outdated or unclear information in the middle of a crisis actually creates a panic scenario. When expert commentary can be disproven in a crisis, experts lose control and people will be inclined to believe the worst thing they can imagine. No matter how harsh it may sound on its face, truth is an antidote to panic. When your comments can be independently verified as true you establish a foundation of trust.

The most useful response to a crisis depends on one's job in communications: Medical The most useful response to a crisis depends on one's job in communications: Medical doctors – aside from the treatments specific to the individual patient, you can mention the possibility of reactivation and patient-specific risks as something calmly to watch for. It is neither a death sentence nor the common cold to a given patient, but there is value in being prepared.

Employers – Everyone has seen a construction site with terrible dust control or an Employers – Everyone has seen a construction site with terrible dust control or an uncovered dump truck, even when dust control measures require they be covered. Prepare with dust control measures and education ahead of time so when a crisis hits, your people and the people nearby can be as protected as possible.

Public Officials and Educators – Telling the whole truth, especially when it is unpleasant Public Officials and Educators – Telling the whole truth, especially when it is unpleasant and harsher than expected, builds credibility. Aside from the fact that it is the only way to motivate funding for the vaccine and cure projects, it is the best policy for the long term because it shows a history of honesty.

The positive example set at Kern County's Valley Fever web site: http: //kerncountyvalleyfever. com/ The positive example set at Kern County's Valley Fever web site: http: //kerncountyvalleyfever. com/

Whatever problems occur from Valley Fever in the future, a major challenge is that Whatever problems occur from Valley Fever in the future, a major challenge is that few people even know about it, and those who do often believe some of the following statements in full: Infected people have a lifelong immunity Most people won't know they have the disease It's a small problem It is important to focus on specific risk factors Masks can protect people from Valley Fever It's only a local problem

A flashpoint will inevitably occur. People will demand clear and useful information when Valley A flashpoint will inevitably occur. People will demand clear and useful information when Valley Fever is in the spotlight. We need to present facts that are free from misperceptions of the past, and the time to prepare ourselves is now.

For more information about our work: http: //www. valleyfeversurvivor. com Please send comments about For more information about our work: http: //www. valleyfeversurvivor. com Please send comments about this speech to [email protected] com