Pediatric Coccidioidomycosis: Case Series From a California Pediatric Infectious Diseases Clinic.

BACKGROUND: Coccidioidomycosis is not as well described in the pediatric population as it is in the adult population. We describe clinical findings, diagnosis and management of coccidioidomycosis in 108 pediatric patients seen in an outpatient clinic in the California Central Valley, an area endemic for coccidioidomycosis. METHODS: We reviewed medical records of a convenience sample of pediatric patients (≤17 years of age) diagnosed with coccidioidomycosis who visited an infectious diseases clinic in Madera, CA, during January 1 to October 1, 2012. We described demographic characteristics, symptoms, diagnostic testing, extent of infection (acute/pulmonary or disseminated), treatment and management. RESULTS: Of 108 patients, 90 (83%) had acute/pulmonary coccidioidomycosis and 18 (17%) had disseminated disease. The median age at diagnosis was 9 years (range, 5 months to 17 years). Only 3 (3%) patients were immunocompromised. Before coccidioidomycosis diagnosis, 72 (82%) patients received antibiotics, and 31 (29%) had at least 1 negative coccidioidomycosis serology at the time of or before diagnosis. Coccidioidomycosis was diagnosed significantly later after symptom onset among patients with disseminated (median, 57 days) than with acute/pulmonary (median, 16 days) disease (p < 0.01). A total of 104 (96%) patients received antifungal therapy, 51 (47%) visited an emergency room and 59 (55%) were hospitalized with a median stay of 44 days (range, 1-272 days). CONCLUSIONS: Substantial acute/pulmonary and disseminated coccidioidomycosis was seen among pediatric patients at this infectious disease clinic in California. In endemic areas, increased coccidioidomycosis awareness and vigilance among families and providers is necessary to facilitate early diagnosis and appropriate management.

Dust Exposure and Coccidioidomycosis Prevention Among Solar Power Farm Construction Workers in California.

OBJECTIVES: To investigate if work activities, dust exposure, and protection measures were associated with a 2011 to 2014 coccidioidomycosis outbreak among workers constructing 2 solar farms in California. METHODS: In 2013, we mailed self-administered questionnaires to employees who were onsite at the solar farms where the outbreak occurred to identify cases of clinical coccidioidomycosis and compare with asymptomatic workers by using multivariate logistic regression. RESULTS: When we compared 89 workers with clinical coccidioidomycosis to 325 asymptomatic workers, frequently being in a dust cloud or storm (odds ratio [OR] = 5.93; 95% confidence interval [CI] = 3.18, 11.06) significantly increased the odds of clinical coccidioidomycosis, whereas frequently wetting soil before soil-disturbing activity (OR = 0.42; 95% CI = 0.24, 0.75) was protective. When we controlled for being in a dust cloud or storm, frequent soil disturbance significantly increased the odds of clinical coccidioidomycosis only among those who reported wearing a respirator infrequently (OR = 2.31; 95% CI = 1.27, 4.21). CONCLUSIONS: Utilization of personal and employer-driven safety practices and increased coccidioidomycosis awareness among construction workers should be considered during the planning of any construction work in coccidioidomycosis-endemic regions to prevent occupational infections and outbreaks.

Coccidioidomycosis-Associated Deaths in California, 2000-2013.

The number of cases of coccidioidomycosis and associated hospitalizations increased in California during 2000-2013. During that period, a total of 1,098 death records listed coccidioidomycosis as a cause, averaging 78 deaths annually (range: 43-108). The death rate peaked in 2006 and was significantly higher among males than among females, among African American patients than among white patients, and among residents of the coccidioidomycosis-endemic region of California than among residents of the less endemic regions (p<0.001). A higher death rate was associated with increasing age and was highest (8.8 per 1 million population) among adults aged ≥75 years. Of coccidioidomycosis-associated deaths, 31.9% had a contributing cause of death of severe/disseminated disease, 31.8% of unspecified -coccidioidomycosis, and 28.3% of pulmonary unspecified coccidioidomycosis, per International Classification of Diseases codes. Diabetes was a contributing cause in 19.3% of deaths, and other immunocompromising conditions were a contributing cause in 15.9% of deaths. Populations at higher risk for coccidioidomycosis--associated deaths are similar to those at higher risk for coccidioidomycosis-associated hospitalizations and infection. Awareness for coccidioidomycosis among these groups and their providers is important for proper diagnosis and care.

Epidemiology of Pediatric Coccidioidomycosis in California, 2000-2012.

BACKGROUND: Reported coccidioidomycosis cases have increased in the southwestern US since 2000. However, there are few publications on pediatric coccidioidomycosis. We sought to describe the epidemiology of coccidioidomycosis in the California pediatric population during 2000-2012. METHODS: We reviewed surveillance and hospitalization datasets for years 2000-2012 and death datasets for years 2000-2010 to identify coccidioidomycosis-associated cases, hospitalizations and deaths in pediatric (≤17 years old) California residents. We calculated rates and described demographic characteristics of cases and hospitalized patients and, using Poisson regression, calculated bivariate relative risks to identify potential demographic risk factors. We identified immunocompromising conditions associated with hospitalization and death and calculated hospitalization charges. RESULTS: We identified 3453 cases, 1301 hospitalizations and 11 deaths associated with coccidioidomycosis in the California pediatric population. During 2000-2012, annual case and hospitalized patient rates increased and were highest in males, those in the 12-17 age group, and residents of the California endemic region. Compared with White children, African-American children were significantly more likely to be hospitalized (relative risk = 1.4, P = 0.01). Approximately 12.0% of those hospitalized and 27% of those who died had an immunocompromising condition. Hospitalized patients accrued $149 million in total hospital charges. CONCLUSIONS: Similar to recent increases among adults, reported pediatric coccidioidomycosis cases and hospitalizations have increased in California since 2000, disproportionately affecting certain demographic groups. The burden of coccidioidomycosis among California children emphasizes the need for more awareness and research into this reemerging fungal disease in endemic and nonendemic areas.

Coccidioidomycosis among Workers Constructing Solar Power Farms, California, USA, 2011-2014.

Coccidioidomycosis is associated with soil-disruptive work in Coccidioides-endemic areas of the southwestern United States. Among 3,572 workers constructing 2 solar power-generating facilities in San Luis Obispo County, California, USA, we identified 44 patients with symptom onset during October 2011-April 2014 (attack rate 1.2 cases/100 workers). Of these 44 patients, 20 resided in California outside San Luis Obispo County and 10 resided in another state; 9 were hospitalized (median 3 days), 34 missed work (median 22 days), and 2 had disseminated disease. Of the 25 patients who frequently performed soil-disruptive work, 6 reported frequent use of respiratory protection. As solar farm construction in Coccidioides-endemic areas increases, additional workers will probably be exposed and infected unless awareness is emphasized and effective exposure reduction measures implemented, including limiting dust generation and providing respiratory protection. Medical providers, including those in non-Coccidioides-endemic areas, should suspect coccidioidomycosis in workers with compatible illness and report cases to their local health department.

Preliminary incidence and trends of infection with pathogens transmitted commonly through food - Foodborne Diseases Active Surveillance Network, 10 U.S. sites, 2006-2014.

Foodborne illnesses represent a substantial, yet largely preventable, health burden in the United States. In 10 U.S. geographic areas, the Foodborne Diseases Active Surveillance Network (FoodNet) monitors the incidence of laboratory-confirmed infections caused by nine pathogens transmitted commonly through food. This report summarizes preliminary 2014 data and describes changes in incidence compared with 2006-2008 and 2011-2013. In 2014, FoodNet reported 19,542 infections, 4,445 hospitalizations, and 71 deaths. The incidence of Shiga toxin-producing Escherichia coli (STEC) O157 and Salmonella enterica serotype Typhimurium infections declined in 2014 compared with 2006-2008, and the incidence of infection with Campylobacter, Vibrio, and Salmonella serotypes Infantis and Javiana was higher. Compared with 2011-2013, the incidence of STEC O157 and Salmonella Typhimurium infections was lower, and the incidence of STEC non-O157 and Salmonella serotype Infantis infections was higher in 2014. Despite ongoing food safety efforts, the incidence of many infections remains high, indicating that further prevention measures are needed to make food safer and achieve national health objectives.

Incidence and trends of infection with pathogens transmitted commonly through food--Foodborne Diseases Active Surveillance Network, 10 U.S. sites, 2006-2013.

Foodborne disease continues to be an important problem in the United States. Most illnesses are preventable. To evaluate progress toward prevention, the Foodborne Diseases Active Surveillance Network (FoodNet) monitors the incidence of laboratory-confirmed infections caused by nine pathogens transmitted commonly through food in 10 U.S. sites, covering approximately 15% of the U.S. population. This report summarizes preliminary 2013 data and describes trends since 2006. In 2013, a total of 19,056 infections, 4,200 hospitalizations, and 80 deaths were reported. For most infections, incidence was well above national Healthy People 2020 incidence targets and highest among children aged <5 years. Compared with 2010-2012, the estimated incidence of infection in 2013 was lower for Salmonella, higher for Vibrio, and unchanged overall.† Since 2006-2008, the overall incidence has not changed significantly. More needs to be done. Reducing these infections requires actions targeted to sources and pathogens, such as continued use of Salmonella poultry performance standards and actions mandated by the Food Safety Modernization Act (FSMA). FoodNet provides federal and state public health and regulatory agencies as well as the food industry with important information needed to determine if regulations, guidelines, and safety practices applied across the farm-to-table continuum are working.

Coccidioidomycosis-associated hospitalizations, California, USA, 2000-2011.

In the past decade, state-specific increases in the number of reported cases of coccidioidomycosis have been observed in areas of California and Arizona where the disease is endemic. Although most coccidioidomycosis is asymptomatic or mild, infection can lead to severe pulmonary or disseminated disease requiring hospitalization and costly disease management. To determine the epidemiology of cases and toll of coccidioidomycosis-associated hospitalizations in California, we reviewed hospital discharge data for 2000-2011. During this period, there were 25,217 coccidioidomycosis-associated hospitalizations for 15,747 patients and >$2 billion US in total hospital charges. Annual initial hospitalization rates increased from 2.3 initial hospitalizations/100,000 population in 2000 to 5.0 initial hospitalizations/100,000 population in 2011. During this period, initial hospitalization rates were higher for men than women, African Americans and Hispanics than Whites, and older persons than younger persons. In California, the increasing health- and cost-related effects of coccidioidomycosis-associated hospitalizations are a major public health challenge.

Gastrointestinal disease outbreak detection using multiple data streams from electronic medical records.

BACKGROUND: Passive reporting and laboratory testing delays may limit gastrointestinal (GI) disease outbreak detection. Healthcare systems routinely collect clinical data in electronic medical records (EMRs) that could be used for surveillance. This study's primary objective was to identify data streams from EMRs that may perform well for GI outbreak detection. METHODS: Zip code-specific daily episode counts in 2009 were generated for 22 syndromic and laboratory-based data streams from Kaiser Permanente Northern California EMRs, covering 3.3 million members. Data streams included outpatient and inpatient diagnosis codes, antidiarrheal medication dispensings, stool culture orders, and positive microbiology tests for six GI pathogens. Prospective daily surveillance was mimicked using the space-time permutation scan statistic in single and multi-stream analyses, and space-time clusters were identified. Serotype relatedness was assessed for isolates in two Salmonella clusters. RESULTS: Potential outbreaks included a cluster of 18 stool cultures ordered over 5 days in one zip code and a Salmonella cluster in three zip codes over 9 days, in which at least five of six cases had the same rare serotype. In all, 28 potential outbreaks were identified using single stream analyses, with signals in outpatient diagnosis codes most common. Multi-stream analyses identified additional potential outbreaks and in one example, improved the timeliness of detection. CONCLUSIONS: GI disease-related data streams can be used to identify potential outbreaks when generated from EMRs with extensive regional coverage. This process can supplement traditional GI outbreak reports to health departments, which frequently consist of outbreaks in well-defined settings (e.g., day care centers and restaurants) with no laboratory-confirmed pathogen. Data streams most promising for surveillance included microbiology test results, stool culture orders, and outpatient diagnoses. In particular, clusters of microbiology tests positive for specific pathogens could be identified in EMRs and used to prioritize further testing at state health departments, potentially improving outbreak detection.

Adipose levels of dioxins and risk of breast cancer.

OBJECTIVE: Our objective was to evaluate the breast cancer risk associated with body burden levels of polychlorinated dibenzo-p-dioxins (PCDDs) and polychlorinated dibenzofurans (PCDFs). METHODS: We conducted a hospital-based case-control study among 79 women diagnosed with invasive breast cancer and 52 controls diagnosed with benign breast conditions. We collected breast adipose tissue and analyzed it for all 17 2,3,7,8-substitituted PCDD/PCDFs. We used unconditional logistic regression to calculate age- and race-adjusted exposure-specific odds ratios (ORs) and 95% confidence intervals (CI) for each individual PCDD/PCDF congener as well as for the summary measures (I-TEQ, Adj-TEQ). RESULTS: Dioxin levels were consistent with reports from other small, contemporary studies of body burdens in the U.S. None of the odds ratios for any of the congeners or summary measures differed significantly from one. Especially for the PCDF congeners, point estimates tended to be below one. One notable exception was octachlorodibenzo-p-dioxin (OCDD), for which the odds ratio for the second and third tertiles appeared modestly elevated (OR = 1.22, 95% CI: 0.47:3.16 and OR = 1.62, 95% CI: 0.64:4.12, respectively), though the test for trend was not significant (p = 0.36). CONCLUSION: Breast cancer risk was not associated with adipose levels of PCDD/PCDFs. More study is suggested among women of color who may have higher body burden levels of these compounds.

Distribution of persistent, lipid-soluble chemicals in breast and abdominal adipose tissues: lessons learned from a breast cancer study.

OBJECTIVES: We sought to determine differences between concentrations of persistent, lipid-soluble chemical contaminants in breast and abdominal adipose tissues and to explore whether concentrations measured in one tissue could predict concentrations in the other tissue. METHODS: We analyzed surgical specimens and measured concentrations of prevalent dioxins, furans, polychlorinated biphenyls, organochlorine pesticides, and brominated diphenyl ethers to determine their partitioning between breast and abdominal adipose tissues of 21 women. The women constituted a subgroup, undergoing mastectomies with simultaneous breast reconstruction, of a case-control study evaluating links between breast cancer and body burdens of organohalogen contaminants. RESULTS: For every contaminant, differences between concentrations in breast and abdominal adipose tissues did not exceed the analytical error. Results indicated that, with some notable exceptions, measurements in breast and abdominal adipose tissues were correlated and that concentrations of target chemicals in one tissue could be derived from measurements in the other tissue. CONCLUSIONS: This information will allow comparison of results from body burden studies that used different tissues. It may also facilitate future breast cancer studies by allowing selection of controls among patients undergoing surgical procedures other than breast surgery, minimizing concerns about overmatching. We also observed large differences in the lipid content of surgical specimens. These differences underscore the need for lipid adjustment of concentrations to avoid misclassification.