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 Presenters that do not want to use the CDC 24/7 cover, can use the basic title slide with lockup. Note—There are only three acceptable options for text in the lockup bars: Option 1—Use this if the presentation is a collaboration with other CIOs U.S. Department of Health and Human Services Centers for Disease Control and Prevention Option 2—Standard choice for the majority of OSTLTS presentations Office for State, Tribal, Local and Territorial Support Option 3—Use if presentation is specific to a division or office within OSTLTS <insert office or division name only—branch names are not acceptable per CDC guidelines> Centers for Disease Control and Prevention Office for State, Tribal, Local and Territorial Support

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

What is coccidioidomycosis?

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, 1998-2011. MMWR 2013;62: 217-218

Life Cycles of Coccidioides Hector RF, Laniado-Laborin R (2005) Coccidioidomycosis—A Fungal Disease of the Americas. PLoS Med 2(1): e2. doi:10.1371/journal.pmed.0020002 http://journals.plos.org/plosmedicine/article?id=info:doi/10.1371/journal.pmed.0020002

Where does valley fever occur?

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 1998 2 42.6/100,000 in 2011 2 1Sources of Valley Fevers (Coccidioidomycosis). Fungal Diseases. CDC, 22 June 2015. Web. 16 March 2016. 2 Centers for Disease Control and Prevention. Increase in Reported Coccidioidomycosis—United States, 1998-2011. MMWR 2013;62: 217-218.

Coccidioidomycosis Incidence per 100,000 Population by Age Group, 1998-2011 Centers for Disease Control and Prevention. Increase in Reported Coccidioidomycosis—United States, 1998-2011. MMWR 2013;62: 217-218.

What is the situation in new Mexico?

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

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 0.7-1.4 1.4-1.9 1.9-2.6 2.6-4.7 N=280 Population Estimates: University of New Mexico, Geospatial and Population Studies (GPS) Program, http://bber.unm.edu/bber_research_demPop.html. 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.

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.

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.

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, 2011. Web. 20 Mar. 2016.

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

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

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

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