Sociodemographic factors associated with patients hospitalised for coccidioidomycosis in California and Arizona, State Inpatient Database 2005-2011.

Coccidioidomycosis is endemic in the Southwestern United States. Disseminated infection can be life-threatening and is responsible for hospitalisation and significant healthcare resource utilisation. There are limited data evaluating factors associated with hospitalisation for coccidioidomycosis. We conducted a cross-sectional study to assess incidence and factors associated with coccidioidomycosis-associated hospitalisation in California and Arizona. We analysed hospital discharge data obtained from the State Inpatient Dataset for California and Arizona between 2005 and 2011 and performed multivariable logistic regression examining factors associated with coccidioidomycosis-associated hospitalisation. During our time frame, we found 23 758 coccidioidomycosis-associated hospitalisations. Coccidioidomycosis incidence was over sixfold higher in Arizona compared to California (198.9 vs. 29.6/100 000 person-years). In our multivariable model, coccidioidomycosis-associated hospitalisation was associated with age group 40-49 years (referent group: age 18-29 years, adjusted odds ratio (aOR) = 1.50 (95% confidence interval (CI) 1.43-1.59)), African American race (referent group: Caucasian, aOR = 1.98 (95% CI 1.89-2.06)), residing in a large rural town (referent group: urban area, aOR = 2.28 (95% CI 2.19-2.39)), uncomplicated diabetes (aOR = 1.47 (95% CI 1.41-1.52)) chronic obstructive pulmonary disease (aOR = 1.59 (95% CI 1.54-1.65)) and higher number of comorbidities (aOR = 1.02 (95% CI 1.02-1.03) for each point in the Elixhauser score). Identifying persons at highest risk for hospitalisation with coccidioidomycosis may be helpful for future prevention efforts.

Surveillance for Coccidioidomycosis - United States, 2011-2017.

PROBLEM/CONDITION: Coccidioidomycosis (Valley fever) is an infection caused by the environmental fungus Coccidioides spp., which typically causes respiratory illness but also can lead to disseminated disease. This fungus typically lives in soils in warm, arid regions, including the southwestern United States. REPORTING PERIOD: 2011-2017. DESCRIPTION OF SYSTEM: Coccidioidomycosis has been nationally notifiable since 1995 and is reportable in 26 states and the District of Columbia (DC), where laboratories and physicians notify local and state public health departments about possible coccidioidomycosis cases. Health department staff determine which cases qualify as confirmed cases according to the definition established by Council of State and Territorial Epidemiologists and voluntarily submit basic case information to CDC through the National Notifiable Diseases Surveillance System. RESULTS: During 2011-2017, a total of 95,371 coccidioidomycosis cases from 26 states and DC were reported to CDC. The number of cases decreased from 2011 (22,634 cases) to 2014 (8,232 cases) and subsequently increased to 14,364 cases in 2017; >95% of cases were reported from Arizona and California. Reported incidence in Arizona decreased from 261 per 100,000 persons in 2011 to 101 in 2017, whereas California incidence increased from 15.7 to 18.2, and other state incidence rates stayed relatively constant. Patient demographic characteristics were largely consistent with previous years, with an overall predominance among males and among adults aged >60 years in Arizona and adults aged 40-59 years in California. INTERPRETATION: Coccidioidomycosis remains an important national public health problem with a well-established geographic focus. The reasons for the changing trends in reported cases are unclear but might include environmental factors (e.g., temperature and precipitation), surveillance artifacts, land use changes, and changes in the population at risk for the infection. PUBLIC HEALTH ACTION: Health care providers should consider a diagnosis of coccidioidomycosis in patients who live or work in or have traveled to areas with known geographic risk for Coccidioides and be aware that those areas might be broader than previously recognized. Coccidioidomycosis surveillance provides important information about the epidemiology of the disease but is incomplete both in terms of geographic coverage and data availability. Expanding surveillance to additional states could help identify emerging areas that pose a risk for locally acquired infections. In Arizona and California, where most cases occur, collecting systematic enhanced data, such as more detailed patient characteristics and disease severity, could help clarify the reasons behind the recent changes in incidence and identify additional opportunities for focused prevention and educational efforts.

Risk Stratification With Coccidioidal Skin Test to Prevent Valley Fever Among Inmates, California, 2015.

Two California state prisons (A and B) have very high rates of coccidioidomycosis (Valley Fever). The prison health care service sought to improve their prevention strategy by risk stratification with a newly available spherulin-based Coccidioides delayed-type hypersensitivity test. Of the 36,789 voluntarily screened inmates, 4.7% experienced adverse reactions. A positive test (8.6% of those tested) was independently associated with (1) incarceration at prisons A and B, (2) admission to prison from a Coccidioides-endemic county, (3) length of stay at prisons A and B, and (4) increasing age. These findings suggest that the test is safe and performing well at risk stratification; the prison system now restricts inmates with negative tests from prisons A and B. This novel use of the test might benefit other coccidioidomycosis prevention programs.

Enhanced Surveillance for Coccidioidomycosis, 14 US States, 2016.

Although coccidioidomycosis in Arizona and California has been well-characterized, much remains unknown about its epidemiology in states where it is not highly endemic. We conducted enhanced surveillance in 14 such states in 2016 by identifying cases according to the Council of State and Territorial Epidemiologists case definition and interviewing patients about their demographic characteristics, clinical features, and exposures. Among 186 patients, median time from seeking healthcare to diagnosis was 38 days (range 1-1,654 days); 70% had another condition diagnosed before coccidioidomycosis testing occurred (of whom 83% were prescribed antibacterial medications); 43% were hospitalized; and 29% had culture-positive coccidioidomycosis. Most (83%) patients from nonendemic states had traveled to a coccidioidomycosis-endemic area. Coccidioidomycosis can cause severe disease in residents of non-highly endemic states, a finding consistent with previous studies in Arizona, and less severe cases likely go undiagnosed or unreported. Improved coccidioidomycosis awareness in non-highly endemic areas is needed.

Effect of Geography on the Analysis of Coccidioidomycosis-Associated Deaths, United States.

Because coccidioidomycosis death rates vary by region, we reanalyzed coccidioidomycosis-associated mortality in the United States by race/ethnicity, then limited analysis to Arizona and California. Coccidioidomycosis-associated deaths were shown to increase among African-Americans but decrease among Native Americans and Hispanics. Separately, in a Native American cohort, diabetes co-varied with coccidioidomycosis-associated death.

Coccidioidomycosis: Experience From a Children's Hospital in an Area of Endemicity.

The incidence of coccidioidomycosis is increasing, and published pediatric experience is limited. This study further characterizes pediatric coccidioidomycosis by describing experience with 64 patients cared for at Children's Hospital of Los Angeles over 20 years, with focus on sites of involvement and severity, as well as serologic profiles of affected children.

The Changing Epidemiology of Coccidioidomycosis in Los Angeles (LA) County, California, 1973-2011.

Coccidioidomycosis, also known as Valley Fever, is often thought of as an endemic disease of central California exclusive of Los Angeles County. The fungus that causes Valley Fever, Coccidioides spp., grows in previously undisturbed soil of semi-arid and arid environments of certain areas of the Americas. LA County has a few large areas with such environments, particularly the Antelope Valley which has been having substantial land development. Coccidioidomycosis that is both clinically- and laboratory-confirmed is a mandated reportable disease in LA County. Population surveillance data for 1973-2011 reveals an annual rate increase from 0.87 to 3.2 cases per 100,000 population (n = 61 to 306 annual cases). In 2004, case frequency started substantially increasing with notable epidemiologic changes such as a rising 2.1 to 5.7 male-to-female case ratio stabilizing to 1.4-2.2. Additionally, new building construction in Antelope Valley greatly rose in 2003 and displayed a strong correlation (R = 0.92, Pearson p<0.0001) with overall LA County incidence rates for 1996-2007. Of the 24 LA County health districts, 19 had a 100%-1500% increase in cases when comparing 2000-2003 to 2008-2011. Case residents of endemic areas had stronger odds of local exposures, but cases from areas not known to be endemic had greater mortality (14% versus 9%) with notably more deaths during 2008-2011. Compared to the 57 other California counties during 2001-2011, LA County had the third highest average annual number of cases and Antelope Valley had a higher incidence rate than all but six counties. With the large number of reported coccidioidomycosis cases, multi-agency and community partnering is recommended to develop effective education and prevention strategies to protect residents and travelers.

Vertebral coccidioidomycosis: presentation and multidisciplinary management.

BACKGROUND: Vertebral involvement is a severe complication of infection caused by Coccidioides species. METHODS: We conducted a retrospective review of patients diagnosed with vertebral coccidioidomycosis at an academic medical center between 1996 and 2009. RESULTS: We identified 39 cases of vertebral coccidioidomycosis. Thirty-four patients (79%) were male, and 23 patients (61%) were black. Black patients were overrepresented in comparison with all other patients by a 50-fold odds ratio (95% confidence interval, 26-95). Only 8 patients (20%) were immunocompromised, including 7 who had received systemic steroids. The number of infected vertebrae ranged from 1 to 24; 8 patients (21%) had epidural involvement. All patients received a triazole as part of medical therapy, and 20 patients also received amphotericin B, typically early in the course. Twenty-six patients (67%) required surgery, 18 of whom also required hardware placement. The most common indication for surgery was pain, but 7 patients had neurologic compromise. No patients developed recurrent or refractory infection at the site of surgical debridement, but 6 patients experienced disease relapse after stopping antifungal therapy. CONCLUSION: Vertebral infection caused by Coccidioides species requires a multispecialty approach that always includes medical therapy and frequently requires surgical intervention for debridement or stabilization. A favorable outcome can usually be achieved, but discontinuation of medical therapy is associated with a high risk of relapse, which can occur years later.

Coccidioidomycosis in African Americans.

Coccidioidomycosis is caused by Coccidioides species, a fungus endemic to the desert regions of the southwestern United States, and is of particular concern for African Americans. We performed a PubMed search of the English-language medical literature on coccidioidomycosis in African Americans and summarized the pertinent literature. Search terms were coccidioidomycosis, Coccidioides, race, ethnicity, African, black, and Negro. The proceedings of the national and international coccidioidomycosis symposia were searched. All relevant articles and their cited references were reviewed; those with epidemiological, immunologic, clinical, and therapeutic data pertaining to coccidioidomycosis in African Americans were included in the review. Numerous studies documented an increased predilection for severe coccidioidal infections, coccidioidomycosis-related hospitalizations, and extrapulmonary dissemination in persons of African descent; however, most of the published studies are variably problematic. The immunologic mechanism for this predilection is unclear. The clinical features and treatment recommendations are summarized. Medical practitioners need to be alert to the possibility of coccidioidomycosis in persons with recent travel to or residence in an area where the disease is endemic.

Landscape-epidemiological study design to investigate an environmentally based disease.

Cost-effective approaches for identifying and enrolling subjects in community-based epidemiological studies face many challenges. Additional challenges arise when a neighborhood scale of analysis is required to distinguish between individual- and group-level risk factors with strong environmental determinants. A stratified, two-stage, cross-sectional, address-based telephone survey of Greater Tucson, Arizona, was conducted in 2002-2003. Subjects were recruited from direct marketing data at neighborhood resolution using a geographic information system (GIS). Three geomorphic strata were divided into two demographic units. Households were randomly selected within census block groups, selected using the probability proportional to size technique. Purchased direct marketing lists represented 45.2% of Census 2000 households in the surveyed block groups. Survey design effect (1.6) on coccidioidomycosis prevalence (88 per 100,000 per year) was substantially reduced in four of the six strata (0.3-0.9). Race-ethnicity was more robust than age and gender to compensate for significant selection bias using poststratification. Clustered, address-based telephone surveys provide a cost-effective, valid method for recruiting populations from address-based lists using a GIS to design surveys and population survey statistical methods for analysis. Landscape ecology provides effective methods for identifying scales of analysis and units for stratification that will improve sampling efficiency when environmental variables of interest are strong predictors.

Mannose-binding lectin serum levels are low in persons with clinically active coccidioidomycosis.

BACKGROUND: Mannose-binding lectin (MBL) is a circulating collectin that is part of the innate immune response. We explored the serum levels of MBL in persons with different forms of coccidioidomycosis. METHODS: Serum MBL was measured by ELISA from samples obtained from healthy donors with immunity to Coccidioides, and those with various forms of active coccidioidomycosis. Blood cell specimens from a subgroup of subjects with active coccidioidomycosis were examined for single nucleotide polymorphisms of the MBL gene and promoter regions. RESULTS: The control group comprised 29 healthy immune subjects. Patient groups with active coccidioidomycosis consisted of 20 patients with symptomatic primary pulmonary coccidioidomycosis, 26 with non-meningeal disseminated coccidioidomycosis, and nine with coccidioidal meningitis. The group with active coccidioidomycosis was significantly older and more likely to be male than the control group (for both, P < 0.001). The mean +/- SEM level of serum MBL in the healthy controls was 169.4 +/- 28.6 ng/ml, significantly higher than the 79.2 +/- 10.9 ng/ml for all active groups (P < 0.001). Moreover, the active coccidioidomycosis group was significantly more likely to have serum MBL level

Testicular coccidioidomycosis.

Coccidioidomycosis (Valley fever) is a systemic fungal infection endemic to the southwestern United States. Incidence has risen in the past decade, with more than 100,000 cases diagnosed annually. This case study discusses a 46-year-old male who presented to the author's outpatient urology clinic in central California with painful left scrotal swelling and who was eventually diagnosed with testicular coccidioidomycosis. While testicular coccidioidomycosis is not common, the case is presented because consideration as a differential diagnosis for scrotal masses or lesions in patients who live in endemic areas is essential.

Coccidioidomycosis infection in a predominantly Hispanic population.

In Texas there are limited data on the epidemiology of coccidioidomycosis. Our goal is to determine the prevalence of coccidioidomycosis in a county hospital in El Paso, Texas. The charts of all patients with coccidioidomycosis admitted to the hospital in the past 9 years was retrospectively reviewed statistical analysis performed. Forty-one cases were identified, giving a prevalence of 3.2 cases per 10,000 discharges. Pneumonic consolidation occurred in 14 (44%), miliary pattern in 6 (19%) and cavitation in 6 (19%) cases. Pulmonary involvement occurred in 32 patients (78%) and meningeal involvement in 3 patients. Six patients had disseminated disease. The mortality rate was higher with disseminated disease (50% compared to 3.6%, P = 0.04). Four had concomitant pulmonary tuberculosis. Diabetes mellitus was found in 17 patients (41.4%), followed by HIV infection in 15 (36.5%). Patients with HIV had a higher incidence of disseminated disease (36.4% vs. 0%, P = 0.01). Four patients died, and the risk of death was increased in disseminated disease (P < 0.05). Coccidioiomycosis is not as frequent in El Paso, and for that matter in Texas, as in other states, but still has to be taken into consideration both in HIV and in diabetic patients.

Epidemiology of coccidioidomycosis.

Coccidioides immitis naturally occurs in the soil and air of certain areas of the New World. These are generally arid to semiarid areas that have relatively modest rainfall, mild winters, and prolonged hot seasons. Coccidioidomycosis is usually a disease of human and nonhuman residents of these areas; but visitors may develop the disease after entering these areas and returning home long distances from the endemic areas. Inhalation (rarely percutaneous introduction) of arthroconidia of C. immitis leads to usually benign but occasionally severe and even fatal infection. Recovery from or asymptomatic infection leads to resistance to reinfection. Exposure to soil (dust) means that certain occupations are more likely to be exposed to C. immitis. Persistence of the organism in the soil means that infections will be encountered in the future, particularly as long as susceptible newcomers continue to enter endemic areas. Those who have been infected and recovered generally will be resistant to later infection, although exacerbation may occur as a result of superimposed immunosuppression.