1. Coccidioidomycosis in New Mexico: The Epidemiology of Valley Fever Beyond the Valley
Catherine Bledsoe
Public Health Associate
Office for State, Tribal, Local and Territorial Support
Centers for Disease Control and Prevention
2016 PHAP Spring Seminar
April 5, 2016
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2. Objectives Define coccidioidomycosis, also known as Valley Fever
Provide national context of the condition
Describe the epidemiology of Valley Fever in New Mexico
Explain how New Mexico is working to better understand the disease

3. What is coccidioidomycosis?

4. What is Coccidioidomycosis?
Fungal condition caused by inhalation of spores
Typically a rare and mild condition
About 60% of those affected are asymptomatic1
Symptomatic people experience flu-like symptoms
Infection can become chronic or disseminate, causing more severe conditions including pneumonia, meningitis, or even death
Certain groups have an increased risk2
Immunocompromised people
Adults over 60 years old
Pregnant women
African Americans or Filipinos
Can be treated supportively or with antifungals
-60% of endemic cases from AZ—older, retired population there
-impact of tourism to endemic regions, taking infections to home state; though non-infectious, can create case in non-endemic areas
1Smith CE, Beard RR, Whiting EG, Rosenberger HG (1946) Varieties of coccidioidal infection in relation to the epidemiology and control of the diseases. Am J Public Health 36: 1394–1402.
2 Centers for Disease Control and Prevention. Increase in Reported Coccidioidomycosis—United States, MMWR 2013;62:

5. Life Cycles of Coccidioides
Hector RF, Laniado-Laborin R (2005) Coccidioidomycosis—A Fungal Disease of the Americas. PLoS Med 2(1): e2. doi: /journal.pmed

6. Where does valley fever occur?

7. Coccidioidomycosis in the Southwest
Endemic areas based on studies from 1940s and 1950s 1
Highest incidence in and around the San Joaquin Valley in California and in south-central Arizona1
Spores identified in soil as far north as Washington State (2013) 1
Grows best in soil after heavy rainfall; travels in hot, arid air 1
National incidence increasing, and still thought to be underestimated
5.3/100,000 in
42.6/100,000 in
1Sources of Valley Fevers (Coccidioidomycosis). Fungal Diseases. CDC, 22 June Web. 16 March 2016.
2 Centers for Disease Control and Prevention. Increase in Reported Coccidioidomycosis—United States, MMWR 2013;62:

8. Coccidioidomycosis Incidence per 100,000 Population by Age Group, 1998-2011
Centers for Disease Control and Prevention. Increase in Reported Coccidioidomycosis—United States, MMWR 2013;62:

9. What is the situation in new Mexico?

10. Reported Positive Lab Results by Jurisdiction, 2015
New Mexico Electronic Disease Surveillance System (NM-EDSS), New Mexico Department of Health.

11. Rates of Confirmed Cases, by Health Region, 2010-2015
Highest rates in the Southwestern Region and along Arizona border
Data based on resident address
Better data collection could answer other variables:
Travel
Location of sought care
Occupation
Race and ethnicity
State: 2.2/100,000
Confirmed Cases per 100,000
N=280
Population Estimates: University of New Mexico, Geospatial and Population Studies (GPS) Program, The Bureau of Business and Economic Research (BBER) and the Geospatial and Population Studies (GPS) are both housed within the UNM Institute for Applied Research Services (IARS).
New Mexico Electronic Disease Surveillance System (NM-EDSS), New Mexico Department of Health.

12. Demographic Information for Reported Positive Lab Results
Even nationally, 70% of cases are missing race and ethnicity data.
New Mexico Electronic Disease Surveillance System (NM-EDSS), New Mexico Department of Health.

13. Methods Matter and Case Definitions Make a Difference
The number of cases steadily increased over the years
Increasing “not a case” numbers
Decreasing “confirmed” and “suspect” cases
Changes in investigator(s), reporting protocols, and case definitions
Team of reviewers vs individual
Laboratories reporting all positive results, even for tests that have high false-positive yields
Interpreting Council of State and Tribal Epidemiologists (CSTE) case definition: laboratory and clinical components
The Cocci antibody test has been found to yield as much as an 82% false-positive rate ==Kuberski T, Herrig J, Pappagianis D. False-positive IgM serology in coccidioidomycosis. J Clin Microbiol 2010;48:2047e9.
New Mexico Electronic Disease Surveillance System (NM-EDSS), New Mexico Department of Health.

14. Coccidioidomycosis / Valley Fever 2011 Case Definition
Clinical Criteria
Infection may be asymptomatic or may produce an acute or chronic disease...An illness is typically characterized by one or more of the following:
Influenza-like signs and symptoms (e.g., fever, chest pain, cough, myalgia, arthralgia, and headache)
Pneumonia or other pulmonary lesion, diagnosed by chest radiograph
Erythema nodosum or erythema multiforme rash
Involvement of bones, joints, or skin by dissemination
Meningitis
Involvement of viscera and lymph nodes
Laboratory Criteria
A confirmed case must meet at least one of the following laboratory criteria for diagnosis:
Cultural, histopathologic, or molecular evidence of presence of Coccidioides species, OR
Positive serologic test for coccidioidal antibodies in serum, cerebrospinal fluid, or other body fluids by:
Detection of coccidioidal IgM
Detection of coccidioidal IgG OR
Coccidioidal skin-test conversion from negative to positive after onset of clinical signs and symptoms
"Coccidioidomycosis / Valley Fever (Coccidioides Spp.)." National Notifiable Diseases Surveillance System (NNDSS). Centers for Disease Control and Prevention, Web. 20 Mar

15. Coccidioidomycosis Case Investigation Process
Assess results*
Enter into New Mexico Electronic Disease Surveillance System (NM-EDSS)
Receive Laboratory Report
Contact hospital or provider
Verify case status*
Request Medical Records
Create investigation in NM-EDSS
Notify investigator or complete case report form
Complete Investigation

16. How do we better understand valley fever?
Subhead for Section – Calibri, 20pt
How do we better understand valley fever?

17. Next Steps in Valley Fever Surveillance
Conduct coordinated and thorough investigations of reported cases to better understand epidemiology and geography of condition
CDC’s Enhanced Surveillance of Coccidioidomycosis in Low- and Non-Endemic States (13 states)
Evaluate suitability of Council of State and Tribal Epidemiology case definition
Continue spreading awareness for those who live in or travel to endemic areas

18. Thank you! Centers for Disease Control and Prevention
Office for State, Tribal, Local and Territorial Support