Valley Fever
Valley Fever is the common name for the disease called coccidioidomycosis caused by the fungus Coccidioides immitis(2). This fungus grows in the San Joaquin Valley and south central California, Arizona, New Mexico, western Texas, southern Nevada, the south western corner of Utah, and northern Mexico (1). First reported in the United States in 1894, Valley Fever was officially declared an epidemic by the Arizona health department in 2006 after 5,500 cases were reported that year, including 33 deaths (3). In approximately 60 percent of the time the infection is asymptomatic and the host has no idea that they had contracted it. The other forty percent get symptoms ranging from mild to severe, including death. This emerging disease has had a great effect on the human and animal populations in the endemic areas.
When soil containing these fungal spores is disturbed they become airborne and can be inhaled by humans and animals. This disturbance can be caused by anything from humans digging and animals playing in the soil to dust storms and earthquakes. Immunocompromised patients, young children, the elderly and members of several ethnic minorities have a higher risk of contracting Valley Fever (4). Although these groups have a higher level of risk, coccidioidomycosis has been known to affect a wide range of individuals from prison inmates and archaeologists, to drug sniffing dogs along the Mexican border. In recent years, cases in prisoners at a California Central Valley correctional have reached as high as 1 inmate in every 10 tested (4).
The important things to understand when learning about this disease are its cause, what is being done to prevent and cure it, its prevalence, and risk factors. This paper has been assembled to address these issues regarding Valley Fever. This paper focuses on four main stakeholders in this Valley Fever epidemic, the medical industry, infected individuals and insurance companies, infected animals and construction companies.
Medical Industry
Valley Fever is a respiratory disease caused by airborne fungi spores from Coccidioides immitis that enter and grow inside the lungs and cause infections. About 60% of the people do not realize that they have this disease because it can cause no recognizable symptoms and can only be positively identified by a skin test. The 40% of the remaining population can get composed to severe symptoms. The disease can manifest in three different types of forms; acute, chronic, or disseminated. Each form ranges from minor to severe consequences. Most significant of all, is to know what the symptoms of Valley Fever are. There are ways to tell if someone might be infected and those symptoms include chest pain-which is a constriction that makes it difficult to breath, fever, muscle stiffness, joint stiffness, wheezing, cough, loss of appetite, chills, and change in mental situation. Those symptoms appear any where from 10-30 days after exposure to the spores. After one or two weeks some people will start to develop painful rashes and or lumps on the lower region of the legs. Symptoms that can be linked with the disease once contacted include joint swelling, joint pain, arthritis, ankle, feet, leg swelling. All of theses symptoms may not accrue in everyone and can vary from composed in some people to severe in others. Showing more then one of these symptoms should be a good indicator that the person has contracted the disease and should consult a doctor.
Once a body is infected, Valley Fever will show up in one of three forms acute, chronic, or disseminated. Some of the forms are more rare then others. Depending on the perform that Valley Fever takes, the severity of the effects on the body and how risky it can be will vary. The acute form is rare and about 3% of the people that live in places with coccidiomycosis found in the dirt, will show the development of the disease. This can happen at any time during the year or any season. It affects both men and women equally and the systems will proceed like the body has caught the flu. Chronic get is rarer and less common then the acute earn. It is more unsafe than the acute form and can cause more problems. The chronic fabricate can become evident and develop after 20 or more years from when the person first got the infection. This may not have been found, treated, or even discovered by the person with the disease.
Valley Fever can cause infections in the body and effect lung abscesses. These abscesses can pop and erupt, releasing pus into the lungs. This pus then travels to the pleural space or the area between the lungs and the ribs. This can cause serious distress to the lungs and the person will have a difficult time breathing. Other symptoms include vulgar grade fever, weight loss, and nodules in the lungs. The disseminated form is the most dangerous and severe out of the three. This is when the disease spreads to the different parts of the body. The infection gets into the person’s bones, lungs, liver, meninges, brain, skin, heart, and around the heart. It is found that 30% to 50% of those people infected with this get also get meningitis. This earn can be very deadly as it can cause swelling around the brain and spinal cord. With this form, healthcare providers often see ulcers and skin lesions, painful lesions in the skull and spine or bones, and painful, swollen joints. This is a life threatening form and can cause death if not treated correctly. It can cause brain damage as well and can affect the brain/mental status of the person.
Everyone in the world is different and so not every person is going to be infected the same plot. People of different color or speed can contract the disease more readily then others of another race can. The people of Asian, Hispanic and African descent are more susceptible to the diseases than Caucasians. Even though it is really unclear why, those of color are 10-20 times more likely to get the disease. Most cases that ended up in the emergency rooms were of Hispanic or African origin. Other people that have a high infection rate are people that are diabetics or weakened immune systems such as those with AIDS. Also women that are pregnant, in their third trimester or right after their babies are born, are at an increased risk of getting Valley Fever. All of these factors will make it easy for them to glean the disease because their bodies can’t resist the initial infection. As well as with the lower immunity’s the body can’t fight befriend as well causing them to net worse quicker and will be more severe. Age is a big factor as well seeing as older adults have a higher chance of developing Valley Fever then an younger age. This is because their immune systems are less active or have other medical conditions that lower their ability to fight off the infection. Individuals with weak immune systems are at higher risk for complications which may lead to the disseminated design. It lets the disease spread easier through out the body and lets it get into the vital systems of the body. This can build the body more susceptible to other types of infections because of the further weakening in the immunity from Valley Fever.
Valley Fever, as stated, gets stirred up into the air from new construction or gardening, allowing one to breathe it in. Once it gets into the lungs it sticks in the inner part of the lungs. There it will grow and multiply inside the lungs. Depending on what form it takes it can clear up from there or release pus. This pus then can get absorbed into the body and stick to different types of organs. It can especially target places where it can build up in such as joints, feet, and legs. This is because the fungi get into the blood stream which will get absorbed by muscles, bones, and under the skin where it can deposit and grow. If the immune system is not strong enough, it can not kill the infection which allows it to further mitigate as it builds in different spots of the body. Since it goes into the body’s blood stream it can get to where ever the blood is flowing. This includes vessels around brain and the spine. This will cause different reactions such as the person affected might lose some perception and awareness because of the lack of trim blood being given to the brain. With the fungi being deposited in places such as the feet or skin it causes swelling because it will produce liquid or more pus-like substance. This will cause the joints to swell up because of excess liquid causing arthritis. Besides looking at the symptoms of the person there are many other ways to determine if there is a Valley Fever infection. Different medical professions use different ways to determine the infection in the body and depending on the degree of the disease.
A chest x-ray can be taken to figure out if one is infected. In the x-ray the doctor would be looking for light areas in the lungs that are poorly defined or patch areas. The place where disease is growing will show up usually near or next to the ribs as most of it grows and deposits there. A skin test can be given as well and it is called the spheriulin skin test. This test looks to see if the person is infected with the fungus and since it is more sensitive it can pick up signs of an earlier infection accurately. Spheriulin is an antigen that is connected with the fungi that causes Valley Fever. This substance is injected objective a little below the skin, preferably in the forearm similar to a TB (PPD) test. Then the doctor will look at the arm or the site it was injected at 24 and 48 hours after the test. If the body has antibodies to the fungus, and it is in their system, the body with react and the position will become red and swollen. Although this test is not being used as much anymore because it is not as specific, it however is veteran in researching to understand the disease. A more common test is a sputum culture. This is where the doctor or nurse retrieves sputum from the patient. Sputum is the mucus-like secretion in the bronchi tubes or where the air goes to the lungs, and comes up with deep coughing. The doctor or nurse will ask the patient to cough deeply and spit up any sputum into a sterile cup. This will be taken to a lab that allows it to grow to see if Valley Fever is present. The doctor my tap on the chest or have the person inhale steam-like mist to help cough up the sputum in order to get a better sample. One of the last tests that may be done is a coccidiodes antibody test. This test is where the blood is taken to analyze if there are any antibodies to the fungus in the body. If the antibodies are present it can mean that there is an ongoing infection or a prior one. The test and blood may be taken a couple of weeks after to eye if there is a rise in the antibody count which determines the infection and how severe it may be. The higher the titer or antibody counts the worse the infection it is. These are all tests that the doctors may use in determining more accurately if the disease is present in the body. This is the only way to be 100% sure that there is an infection.
Depending on the magnitude of the infection different treatment options will be provided by the doctors. Some of the forms may even dissipate with no medical interactions as well. The acute disease will usually go away without medical intervention. Popular management is bed rest and treatment for flu symptoms until the fever goes away. With any of the other forms, medication would be needed to take care of the disease. If the problem persists or if there is a higher possibility of complications and it is in its more severe form, antifungal medications would be required to be taken. These medications would include amphotericin B, ketoconazole, fluconazole, or itraconazole. In a chronic form or more acute form that won’t go away, amphotericin B is usually the medication given to help fight off the disease. Then the person is monitored as to make sure the condition does not worsen which might last from a couple months to a year. Surgical action may be an option to take care of lesions that are localized. For the disseminated develop fluconazole or itraconzole is commonly stale. The dosage is usually 400mg per day and in some cases 2000 mg of fluconazole or 800mg of itraconzole per day may have to be taken in 200mg doses. Amphoterican B may be outmoded as an alternate in this location if lesions are getting worse more rapidly and is old to diffuse pneumonia. Surgery is essential in this case and in most reports at this stage it is necessary. This is used to take care of large abscesses, destructive lesions or bony sequestrations instability of the spine or the movement on critical organs such as the heart or tissues such as the spine. Since this form is the worst and in most of the time fatal more actions are required in recovery as compared to the more acute forms. Treatment of the disease does not make it go away for good as relapses can occur or the person can get it again.
The disease can have short affects and long term effects on the body. Depending on the person or the amount of spores inhaled, this will determine the longevity and affects of the person. The short affects include flu like symptoms and will go away. It is an annoyance just like any time someone gets sick and the person can go on with their life with no harm. These people probably have higher immune systems. However, the longer the disease stays around in the body the more harm it will do. If it is prolonged in the body for an extended time it will start having more harsh affects on the body. The infection can spread to the bones in the body and cause deterioration or holes in the bones. This will stay with the patient through out their life. If it is in the body for the extended time it can cause variations of getting better then getting worse fluctuations as well as can cause relapses of the disease where it can come back. If not treated, the non-acute form will worsen over time and in most cases get into other organs of the body and form the disseminated type. Taking care of the infection early on would be a good strategy as Valley Fever can cause death if not treated at the right time. If the disease is prolonged it can cause other diseases or illnesses. These include forming pneumonia and meningitis which make the condition that much more deadly and difficult to treat. As both of those diseases are fatal as well and can form bad mixes with Valley Fever. Bleeding and lung abscesses could form which have to be medically treated and in some cases have to be done with surgery. Prolonged exposure can place the person at extreme discomfort as the pus gets into the lungs and fills the lungs making them feel like they’re drowning and can’t breathe. This can cause many terrible effects as the body can’t get enough oxygen into the body. People that already have respiratory problems such as asthma can be compromised and hinder the lungs from working efficiently. This can cause a more acute form such as short of breath to something more dangerous as not getting any air in and cessation breathing without medication or immediate treatment. Most importantly the disease should not be taken as lightly as it can cause death if overly prolonged or gets into its most dangerous forms in the body. Many problems and complications would have to happen in order for it to accept to that severe of stage. As long as the disease is recognized and treated (if need be) then the affected person can easily recover.
Many people who have Valley Fever don’t even know they have had it because the severity changes in everyone and 40% of the people would show symptoms and require tiny to major treatment. This disease changes over longer periods of time. A person may have some time to go see a doctor before they feel the severity of the disease. Though, as stated earlier, waiting for long periods of time to seek medical care would not be beneficial to one’s health. This disease is taken in most of the medical field taken very lightly even though misdiagnosis and prolonged exposure to the disease can be fatal to the person’s health. It can have affects on the body that stay with them for years at a time or even there entire life. This is something that if in expect consulting a doctor would be the best course of action so treatment can commence so complications don’t arise.
Infected Individuals & Insurance Companies
There are many notable stakeholders that would be affected, at least in some capacity, if an executive decision were to be made with regards to the issue of Valley Fever. Arguably, the role of infected persons or those that hold a unique vulnerability to the disease is top priority on the decision-maker’s list. Each year, thousands of people are diagnosed with Coccidioidomycosis in Arizona alone. In a 2007 article, the Washington Post wrote that Valley Fever cases diagnosed in 2006 were up fifty-six percent from a year earlier. This prompted Arizona health officials to label the disease at, “epidemic proportions,” as thousands of other cases likely went undocumented. It has also been reported that anyone who has spent enough time in Arizona, or any other fraction of the Southwestern United States where soils contain the Valley Fever fungus, will contract the disease at some point. Only a small percentage of people, however, are diagnosed with a severe enough form of the infection where medical treatment is needed. Anti-fungal medication is the most common treatment for Valley Fever. But, there are rare cases where surgery is required to fully recover from the disease. Overall, tens of thousands of cases are reported around the United States annually and the number of Valley Fever-related deaths is estimated at 50-100 each year. It is important to recognize individuals currently struggling with the disease as well as those who have recovered from a serious form of Coccidioidomycosis as a stakeholder with regards to this issue because there exist many factors that affect the lifestyles of those individuals, their families and their friends. In an effort to better support this claim, the lives of two patients that contracted a serious form of the infection, will be addressed and analyzed in the following paragraphs.
Before introducing specific cases, it is important to review some recent facts and figures with regards to the disease. The Arizona Department of Health Services released their annual Valley Fever Narrate in October 2008. The report, co-compiled by the Office of Infectious Disease Services and the Bureau of Epidemiology and Disease Control, presents the amount of Coccidioidomycosis cases reported in 2007 through a myriad of graphs. These graphs convey the research information in a thorough and comprehensive way to the reader by dividing up Valley Fever statistics for the 2007 year in a multitude of categories. Some of these categories include: cases reported in ‘07 according to specific age groups compared years past and a five-year average, separating the number of Valley Fever cases reported by counties in Arizona, and separating the number of Valley Fever cases reported in both mining and non-mining areas within the state. Although many people think of this disease as a mild illness similar to the approved cold, Valley Fever is a key issue amongst Arizona residents as well as both local and national governments. In 2008, the Arizona Department of Health Services received funds for Valley Fever prevention and control from a legislative appropriations committee. The Center for Disease Control and Prevention (CDC) also awarded the department funds for continued research. As part of the 2007 report, Health Services interviewed roughly ten percent of all Arizonans diagnosed with Coccidioidomycosis during that year. According to the ADHS, the following are some of the most alarming facts that were discovered from the interviews:
• People missed an average of 1 month of work, for a total of 4,918 days
• People with Valley Fever could not perform daily activities for an average of 3 months or a total of 92 years
• People with the disease waited an average of 44 days before seeking healthcare
• Patients saw their doctors three times before they were tested for Valley Fever
• There were $86 million dollars in hospital charges for Valley Fever in 2007
Furthermore, Arizona has the highest number of reported Valley Fever cases annually in the United States, accounting for sixty percent nationwide. In total, more than 150,000 people across the country are estimated to contract some form of Coccidioidomycosis each year. The Arizona Department of Health Services reports that the severity of Valley Fever in the state continues to grow as do the overall number of persons infected each year. Due to the fact that currently there is no cure or vaccine for the disease, every person that is susceptible to the effects of Valley Fever certainly shares some kind of stake in the debates of the issue. Examining the personal accounts of two anonymous patients afflicted with a serious form of Coccidioidomycosis can bring further clarity to this claim. Any and all personal information for the following accounts has either been fictionalized, changed or generalized to maintain complete anonymity.
The first case will examine the despicable effects of Coccidioidomycosis on a male patient of early adulthood age. This individual will be referred to as Patient “V” throughout this paragraph. Patient “V” began his ordeal with Valley Fever in the summer months of 2001. A younger man in the final years of adolescence, Patient “V” experienced generic, flu-like symptoms, which he disregarded as nothing important like most other sufferers choose to do. “At first, I noticed that my lymph nodes in my neck were unusually swollen…I figured it was fair a cold or some limited infection or something like that.” Soon after the initial stages of the disease, Patient “V” began experiencing constant, severe pain in the left side of his chest. Although he made numerous medical appointments for this problem, the distress would subside by the time Patient “V” arrived, making it difficult to diagnose the problem. “What was happening was my left lung had a hole in it and it kept collapsing and then re-inflating by the time I got to the doctor’s office.” Eventually, a chest x-ray was performed on Patient “V” and this revealed a diminutive, gloomy spot on his left lung. The plot indicated a relatively small, but significant hole through the lung. The pickle required corrective surgery and Patient “V” was admitted to one of Arizona’s hospitals in August, 2001. Surgeons sewed up the hole in Patient “V’s” left lung and released him after a day of recovery. Within weeks following the surgery, Patient “V” experienced a relapse of his earlier symptoms. “…I was playing Volleyball one night and in an instant, there was this intense pain in my chest…I felt dizzy and could hardly breathe.” Patient “V” immediately returned to the hospital sometime in November of that year where further tests concluded that the infected part of his left lung was, indeed, Coccidioidomycosis. Another surgery to completely remove this piece of infected lung was performed successfully and Patient “V” spent more time recovering in the hospital. “The effects from the disease itself were painful enough, but the worst pain came from the chest tubes that were inserted into me in the hospital…At one point, they shoved one of the tubes through my ribcage and into my lung and I wasn’t even on pain medication.” Fortunately for Patient “V”, the second surgery was successful and he survived his brush with Valley Fever. In many cases, patients who contract and fend off the infectious spore build up life-long immunities. However, reports have also shown that patients in remission from Coccidioidomycosis can be more vulnerable to a reoccurrence of the disease than those that have never contracted it. Following his surgical recovery, Patient “V” was prescribed an anti-fungal medication called Diflucan, a common drug distributed to sufferers of the infection. Patient “V” was required to select this medication daily for 2-3 years. He now receives chest x-rays once a year to check for any returning signs of the fungus. Patient “V’s” scar tissue has also become virtually unrecognizable after nearly a decade of recovery.
The second case to be analyzed will be that of a middle-aged female patient. Appropriately, this patient will be referred to as Patient “F” throughout the analysis. Patient “F” contracted Valley Fever in late 1995. Early symptoms experienced in this patient included chronic loss of breath and extreme joint discomfort. The form of Coccidioidomycosis contracted by Patient “F” was not diagnosed correctly until 2 ½ years after symptoms began. Before visiting a pulmonologist, Patient “F” was given a chest x-ray, where a large, round nodule was located somewhere on her left lung. The patient was admitted to the hospital in 1998 and underwent a wedge resection, to lift the infected part (removed in wedge form) of the lung. After the first surgery, Patient “F” was prescribed anti-fungal medication similar to Diflucan at full strength for six stout months; and then half the dosage for another six months. The patient continued to have fevers following the surgery. She also had an excess amount of fluid in her lung. Patient “F” returned for a second surgery to further shapely the infected area and completed another sequence of antibiotics afterwards. The time spent in the hospital for recovery totaled at six days for each surgery. Patient “F” was fortunate enough to have flexible employment benefits to fully recover. “My company provided short-term disability; up to 6 months with 100% pay…I was very lucky.” As far as medical coverage is concerned, Patient “F” had little out-of-pocket costs through United American. However, she was level-headed shocked to perceive the total amount owed from her stay in the hospital. “The bill after six days in the hospital, which included one day in ICU and five days on a regular floor, was astonishing. Just for room and board and a little medication, the bill was $28,000.00.” Today, Patient “F” has fully recovered from the infection and only has one suggestion with regards to the convey of Valley Fever. “Educate physicians on the east coast and west coast, all over the Untied States to properly test for Valley Fever.”
Needless to say, there are always financial burdens associated with any type of surgery as well as prescription medication. In the case of Patient “V”, a total of nearly $180,000.00 was accrued in hospital bills after the two surgeries were performed. Additionally, the drug Diflucan can range from 36 dollars to 60 dollars for 100mg/10 pills depending on the location of purchase. It is considerable to recognize medical insurance companies as a stakeholder with regards to the issue of Valley Fever as well. Because there is no cure or vaccination for the infection, insurance companies limit the amount of coverage to persons with preexisting conditions. If a cure were to be developed and released into the market, insurance companies would most likely include Valley Fever coverage into any plan. Unfortunately, without medical insurance, the overall amount of money needed to recover from a serious infection like Valley Fever is simply insurmountable for the majority of Americans. Even with sufficient medical insurance, however, people who have had Valley Fever in the past are typically not covered for a relapse of the infection. Patient “V” currently receives individual health insurance under a PPO from Blue Cross Blue Shield of Arizona. As mentioned earlier, however, major insurance companies like this one tend to limit coverage to individuals with preexisting conditions. According to an article on www.howstuffworks.com, a preexisting condition is a health condition or illness that you have had before your first day of coverage on a recent plan with an insurance company. Typically under group coverage, such as that offered by a corporation under an employee’s benefits, a person with a preexisting condition can obtain full coverage, but will have to wait anywhere from nine months to a year before it kicks in. This period is enforced by insurance companies to insure that a patient is not constantly having relapses of the same condition. However, a person with a preexisting condition will rarely receive private health coverage that includes their condition. This is referred to as the preexisting conditions exclusion. Our attempts to contact major medical insurance companies or medical insurance agents for further clarity on this issue went unanswered. Unfortunately, people like Patient “V” who have preexisting conditions, are self-employed and do not qualify for group medical insurance will have to pay out-of-pocket if their conditions return. “I would have to declare bankruptcy if that happened…” Patient “V” explained. “I live in fear because I know that if I were to win it again, that would be disastrous.”
Currently, a vaccination for Coccidioidomycosis is under development at the BIO5 Institute on the campus of the University of Arizona. Leading the development is Dr. John Galgiani, Director of the Valley Fever Center for Excellence and Chief Medical Officer for Valley Fever Solutions, Inc. This vaccination will be intended for both humans and dogs, which can also contract deadly forms of Valley Fever (this topic will be further discussed in later sections of this behold). In March, 2008, Dr. Galgiani teamed up with fellow BIO5 colleague Dr. David Nix of the Department of Pharmacy Practice and Science to research the vaccination. “We had some complimentary expertise and mine’s mainly in the area of drug development and drug development science and so on. And Dr. Galgiani is kind of the world’s expert on Valley Fever,” Dr. Nix reported in a 2008 Valley Fever instructional video produced by the University of Arizona. The two physicians, under the company name Valley Fever Solutions Inc., are financially backed by the University, private donors and C-Path, a New York based foundation. They are currently testing an anti-fungal called Nikkomycin Z, which was first used to prevent fungal degradation in produce. With approval from the U.S. Food and Drug Administration, Nikkomycin Z is in Phase 1 of drug safety trials. According to a news release published on the BIO5 Institute’s website, “The company has already obtained a Science and Translational Technology Research (STTR) grant from the National Institutes for Health that will help fund pharmacology studies that will help design future clinical trials. The first phase of that grant is worth more than $100,000, with the potential for an additional $700,000.” If this vaccination proves to be a viable cure for Coccidioidomycosis, many aspects of the issue of Valley Fever would certainly change. Once a cure hits the market, the number of deaths and serious cases as a result of Valley Fever would drop significantly. Debates between the government, politicians and special interest groups would decrease as well if no one were in any real threat of the infection anymore. Briefly returning to the topic of medical insurance, people with Valley Fever as a preexisting condition will be able to feel more secure because of the availability to a cure, and possibly insurance that covers that cure. Major medical insurance companies like Aetna, Blue Cross Blue Shield, Cigna and Humana will more freely distribute full coverage in instances of Valley Fever. Like most vaccinations and cures to common infections or diseases, there would be many positive outcomes to releasing this drug into the medical market, pending the completion of all drug safety trials.
As primary stakeholders with regards to the issue of Valley Fever, both infected persons and medical insurance companies would be greatly affected if an executive decision were to be made, or possibly a vaccination released into the market. While the future looks good with regards to a feasible solution to the Coccidioidomycosis fungus, it is imperative that all people pick up a way to get health insurance coverage to some capacity. It is also important that individuals with preexisting conditions that aren’t on group medical plans lobby for their rights to complete insurance coverage. In considering the harmful effects of Valley Fever, there are many people who think this topic is just as important to the animal world as well.
Infected Animals
Valley Fever does not only affect people but it is now more commonly being found in animals. Animals are just as likely to pick up Valley Fever as humans are. Animals get Valley Fever in the same way as humans do, by breathing the fungus. It has been found that more and more animals are being reported of becoming ill due to this fungus. It has been found the 30-40% of animals who breathe in the fungus get sick. Some of the most common animals to be reported with Valley Fever are dogs, cats, llamas, non human primates, horses, and zoo animals (3).
A golden retriever went into the vet’s office; the dog wasn’t feeling well and wasn’t acting himself. The vet takes an x-ray of the dog’s lungs and sees white spots in the lung area where there should normally be dark patterns. The white spots indicate that the dog might have cancer in its lungs. The dog is only four years old, which is when a dog should be at its prime and not getting lung cancer. Lung cancer isn’t usually found at this young of an age and doesn’t seem to get as fast as it has in this golden retriever. The owner had said objective two weeks prior to going to the vet that the dog was full of energy on their vacation. The veterinarian doesn’t all the facts add up for the dog to have cancer so she decided to run a few more test before she starting treatment for lung cancer. The dog’s health over the course of time starts to go downhill and very fast. The dog starts to cough, has a loss of appetite, and little to no energy. The vet then found out where the human family had recently traveled and they were in the Southwest. After hearing this, the vet determined that it must be a fungal disease and it was just that, it was Valley Fever (1).
Dogs are the largest infected and most commonly reported animals with Valley Fever. Dogs get Valley Fever in the same way that humans do and in the same regions as humans do. The fungus is spread through spores which dogs can easily inhale. Once the fungus is inhaled, the spores grow into spherules which enlarge and eventually burst into hundreds of endospores (3). This causes the spreading of the infection into the lungs. A dog’s immune system should respond and surround the infection to destroy it. Dogs that do not become sick due to the fungus are considered to be asymptomatic (2). When a dog does become sick from Valley Fever, their immune system fails to demolish off the infection and the infection continues to spread into the lungs and then can travel throughout the dog’s body (3).
Once a dog is infected with Valley Fever, there are certain symptoms that become present. Some of the symptoms that are seen in dogs are weight loss, coughing, fever, lack of appetite, and lack of energy (3). The cough in dogs can be seen as early as the first week of getting the infection to as late as 3 weeks. The cough that dogs get is due to the development of pneumonia which is visible on x-rays. The coughing can be caused due to pressure on the lymph node arrive the heart and puts pressure on the dogs windpipe which as a result irritates it (3). After the cough is present the loss of appetite and energy is soon to follow. If the infection is not controlled it can become much worse and spread throughout the body. When the fungus is spread throughout the body it causes systemic or disseminated disease (3). When this happens the symptoms and condition of the dog becomes much worse. The symptoms that become present are: swelling of the limbs, abet and neck harm, seizures, soft swelling under the skin that resembles abscesses, swollen lymph nodes, witness inflammation, and non-healing skin ulcerations (3). Not all symptoms are present right away and it can take several months before certain symptoms appear. It can be several months after a cough appears that other symptoms become present. There is typically an order that the fungus spreads throughout the dog’s body. The first organ to be effected is lung, and then the infection usually spreads into the bone, than eyes, heart, testicles, brain, spinal cord, and finally abdominal organs (2).
To determine if a dog has Valley Fever there are different test that can be done. Some of the most common test done to determine if a dog has been infected is blood tests, chest x-rays, bone and joint x-rays, and Valley Fever blood test (3). Test results may show up negative up to 3-4 weeks of receiving the infection so in some cases test need to be repeated to confirm that the dog does or does not have Valley Fever (2).
There are different treatments that be done to help fight the fungus. The process of treating Valley Fever may be long; medication can be given for up to one year (2). The length of time that the treatment will buy usually depends on how far the fungus has spread throughout the body. Most commonly oral antifungal medication is given to the dog. These antifungal medications are ketoconazole, itraconazole, and fluconazole (2). Ketoconazole is the most commonly prescribed medication due to the fact that is it the least expensive. This drug is usually given twice daily and with food. Itraconazole is a more expensive medication but has fewer side effects than ketoconazole. Itraconazole is also better for dogs that are having problems keeping their food down because it has a faster absorption rate (3). The third medicine most commonly given out for treatment is Fluconazole and it is also expensive with little side effects. This is usually given to dogs that have damage done to their spinal cord and nervous system (3).
Cats, llamas, non human primates, horses, and zoo animals are other animals that have been reported with Valley Fever. Cats that have Valley Fever show the same symptoms as dogs do but it less likely for a cat to get Valley Fever than it is for a dog. Cats get Valley Fever about every 1 case compared to 50 cases in dogs (3). When cats get the fungus their symptoms are usually a little more advanced than dogs. Two of the major symptoms seen in cats that have Valley Fever are unexplained weight loss and skin ulcerations that won’t go device. The same treatment for dogs can be stale to treat cats with Valley Fever (3).
Horses are another animal that have been found to get Valley Fever. There have not been very many cases reported but in the ones that have only one horse has survived Valley Fever with treatment. All the other horses that were reported with Valley Fever had to be euthanized. The reports of these cases are not very unique though, and with medical technology improvement chance of survival with new medicine is much better for horses today (3). Llamas are another animal that have been infected with Valley Fever. Llamas are very sensitive to this fungus. In most cases, if a llama has Valley Fever death is almost always the outcome.
Zoo’s that are located in the Southwest are very aware of Valley Fever. Many zoos have lost animals due to Valley Fever before they were aware of what is was and how to treat for it. When animals become sick, Valley Fever is something that is tested early so treatment can be started. In zoos, the most common animals to get Valley Fever are: Monkeys, Apes, and other primates. These animals use the same treatment process as dogs and cats but is usually consists of a lifetime treatment (3).
Valley Fever is a very serious issue that is rising in animals. Currently there are no preventatives for Valley Fever. The treatments for Valley Fever for animals has become better and better over time. The advance in technology has allowed for veterinarians to be able to detect Valley Fever at a less advance stage. The early stage that Valley Fever is caught at allows for a better chance of survival of animals infected with the fungus.
Construction
There is no doubt that construction companies contribute significantly to Valley Fever. According to the MayoClinic, institution known for prominence in the medical field recognized the increase in real estate has contributed to the spew of “thousands of tons” of dust carrying this fungus into the air. The article looks at how in the 1990s the accounts of Valley Fever increase in the states of Arizona and California due to some distinguished factors. Among those factors like dry climate, the recent building booms have been one of the most critical factors that have contributed to such increases. The quick clearing and building were a significant source for the increase in reported cases of Valley Fever. Among all the contributing factors of Valley Fever, environmental exposure ranks high, if not the famous cause. Experts also added that almost half of the people who live in areas where Valley Fever is prevalent have contracted the disease. Interestingly, people who are at most risk are those who are exposed to directly to dust like those who perform jobs in the field of construction, ranching and agricultural work (1).
The decade following the 90’s has had a great increase in reported cases of Valley Fever. Those areas that have reported such increases are the states of California and Arizona. These states have been induced with a massive building boom. The mass migration to these “sun belt” states made for a widespread land clearing and construction, which ultimately directly contributed the spread of the air borne fungus (2). Importantly, some measures are currently in residence to purposely lop the amount of dust construction companies contribute to the environment.
The Environmental Protection Agency (EPA) is an agency of the federal government of the United States who is in charge of protecting human health by maintaining the natural environment safe (3). This implies its commitment and dedication to monitoring and posing regulations for anything threatening the quality of the air. The EPA has set limits on how much pollution is allowed to be in the air. In its goal to believe and manage the air we breathe, EPA has passed several pieces of legislation that have reduced the amount of smog and pollutants in the air. Among important legislation is the Clean Air Act which has been passed to enforce neat air standards and improve human health. The Clean Air Act is an outline for what national, state, and local authorities must follow in order to protect air quality. Under the Clean Air Act, local and state authorities are responsible for abiding by the national ambient air quality standards. The Environmental Protection Agency states Maricopa Country cannot exceed the federal health standard for particulate pollution more than three times in a three year period (4).
According to the Environmental Protection Agency (EPA), Maricopa County has been in violation of particulate pollution since 1996. Particularly 2008, there have been nine different days where at least one of the monitors exceeded the federal health standard for particulate pollution. The health standard for particulate pollution is that it cannot exceed more than 150 micrograms per cubic meter measured over a 24 hour period of time. It’s important to know Maricopa County has 24 air monitoring sites in the Valley. The status of Arizona, under the Arizona department of environmental quality has its occupy air monitoring sites as well. If any of these monitors exceeds the federal health standard for a given pollutant, the EPA will hold Maricopa County accountable. According to the Environmental Protection Agency (EPA), Maricopa County failed to reach attainment for particulate pollution and thus is under federal orders to slice particulate matter pollution. In an attempt to address the issue, Maricopa County, the Maricopa Association of Governments (MAG) and local cities and towns submitted a plan to the EPA to demonstrate how the county plans to reduce PM10 emissions by five percent each year until reliable levels are reached. The Five Percent Plan outlined more than 50 commitments to sever dust. Of these commitments, some affect the procedures and guidelines on construction entities (4).
Speaking with Erin Dunsey of Maricopa County Air Quality Department, the county is currently working hard to pose regulations on construction companies in order to lower dust emissions and ultimately lowering the potential threats from Valley Fever. The principle responsibility for The Maricopa County Air Quality Department’s Dust Compliance Division is to protect the public from the dangers that come from airborne particulate matter (7). This division of dust compliance deals with fugitive dust sources and the rules to minimize the production of it. This means that fugitive dust from any source, including constructions areas, must be restricted in their construction operations to maintain within safe dust standards. As part of the compliance, Maricopa County has devised that all sites with disturbed surface areas of dust must comply with “Rule 310″ (5).
Under Rule 310, the Dust Compliance Division has established limitations and requirements for the implementation of process controls as well as other guidelines that will help enforce proper fugitive dust control measures. One of the first major steps for construction companies to follow is the obtainment of a permit. The Air Quality Department requires a construction permit for companies who plan to conduct activities any that will disturb a surface area equal to or greater than 0.1 acre. Complying with the construction permit requirements is often a significant and daunting task. Before applying for a permit, a belief that outlines the measures that will prevent the creation of dust must be presented. This plan also describes all the measures that will be implemented at anytime during the phase of construction. Therefore, this guideline requires dust generating sources to meet standards and at the same time apply best the available control measures in order to attempt to minimize fugitive dust emissions. This arrangement being the first of many that have been imposed on construction companies, entitles that all workers or subcontractors on site understand their responsibility while on site (6).
Another hassle that companies have to deal with is the logging of control measures. Once again, under Maricopa County’s Rule 310, construction companies who conduct a dust generating operations that require a Dust Control Conception must keep a written log recording the actual application and execution of the control measures previously outlined and approved by the Dust Control Plan. This is a daily detailed recordkeeping which records what actions are being conducted in dust-generating operations in what may include daily inspections for crusted or damp soil. Another piece of record keeping is the trackout conditions. This rule also requires that all work sites that are more than two acres and have terrified surfaces must install a trackout control devise. These devises are huge contributors to the retention of fugitive dust. Trackout is simply the particulate matter from tires and other sources that have fallen onto paved areas that are accessible to the public. The rule states that trackout must be limited to 25 cumulative linear feet (6).
Rule310 is an extensive and overwhelming set of requirements established to lower dust emissions. Section 309 list another requirement under Rule310 that companies must abide by. The rule says that if the site of interest is more than one acre a series of dust control training must take place. All workers directly involved in the containment of dust like the water truck drivers and water pull drivers must take a basic dust control training class in which attendees will ultimately become certified if successfully completed the training class. An extension from this piece lists that a dust control coordinator must be present on job site if the dimension of the job site is five acres and up (5). These onsite coordinators must have completed a comprehensive dust control training in which they are given proper training on regulating emission of fugitive dust and learn practical methods to do so, such as clean up, water and dust suppressant applications (6).
Construction companies are required by state and federal law to implement a diligent effort to control dust pollution. If at any time violations are committed, these companies will be subject a fines and penalties. This has been yet another problem companies have had to face on a regular basis. The penalty policy held by the Maricopa County Air Quality Department seeks to prevent future violations. Fines that are placed upon companies are determined by the severity of the violation committed. Several factors are used to calculate the amount of a penalty. In case there has been an economic benefit of noncompliance by the company, the penalty will consist of weighing out the benefits that were looked to have been extracted.
Dust control compliance has also become a financial setback for construction entities. The Maricopa County Air Quality Department announced that in the month of October $452,589.90 in air quality violations was collected (9). In the month of September, the amount of $471,613.30 was collected in violations all related in one arrangement or another to air quality control. This is the trouble construction company’s face for not correctly using effective measures to reduce dust in the construction sites, therefore causing potential problems to near residents and workplaces, eventually becoming a financial problem due to fines.
There is no better way to understand how troublesome the strict regulations have become a burden for construction companies. While searching for construction companies within the valley, Turner Construction Inc. drew attention as it is well known as a big construction company that has a corporate office in Tempe, AZ. With a request to speak to a construction manager, a brief conversation was held with a construction project manager from Turner Construction. The conversation revolved around how Valley Fever has affected their procedures during construction or related tasks. Immediately it became distinct just how much companies who are in the construction industry are affected by laws to help reduce the incidents of Valley Fever. Jason Jones, who is a project manager at Turner Construction Company, explained that all construction companies have been hit hard by Maricopa County. Amongst the things mentioned was the fact that the main concern for the county is dust control. As a result for the growing concern over dust control, they have to follow a “rigorous dust program” to comply with regulations. Jason explained how they are currently working on a 242 acre development complex and have had to use around 400,000-750,000 gallons of water to control dust governed by Maricopa country. He added that this adds to the costs of the construction project as trucks and workers are broken-down to have fugitive dust. If they ever do not comply with these regulations, fines initiate from about $1,000 to 10’s of thousands of dollars. He added that Maricopa is the “worst county in America for dust regulations” (8).
The main problem is that construction companies have to follow strict regulations on their dust production. The county of Maricopa has been enforcing even stricter laws to prevent and benefit maintain dust levels to a minimum as they have recently been under serious scrutiny from the Environmental Protection Agency. If for some reason these companies are not correctly using effective measures to reduce dust in the construction sites, grand fines will follow. This is yet another yell companies are dealing with. To the load even greater, these companies also deal with the economical space backs from following these regulations. For companies to cut and comply with county regulation, thousands of dollars are being forcefully spent by such companies. The contributions construction companies accomplish to Valley Fever is not underestimated. As a result, strict regulations are followed and posed upon companies to reduce the incidence of Valley Fever cases. Valley Fever has come to cost companies thousands of dollars and is becoming every day more of an anguish.
Conclusion
After studying the stakeholders involved in Valley Fever, it is easy to see common themes between them. There is no doubt that while not known as a perilous disease, Valley Fever has the potential to be one. With the number of cases increasing each year and relatively minute research being done for prevention and cures, Valley Fever has earned the title as an emerging epidemic. While Coccidioides immitis only lives in a few select areas of the United States, it poses a threat to people throughout the country due to the increasing popularity of visiting and moving to endemic areas. It also must not be forgotten that Valley Fever has the capability to affect animals as well humans increasing the cost of the disease for these species. It is obvious that because of this, action must be taken in order to reduce the number of cases and to decrease the severity of the cases.
This case study points to a few relatively easy steps to take in order to decrease the severity of Valley Fever cases. The most important and most obvious step is early detection. It was shown that the earlier that the disease is diagnosed, the less severe the symptoms and the less impact it has on the infected individual. Despite this easy solution, doctors saw their patients and average of three times before they tested for Valley Fever and the patients on average waited 44 days before treatment. These statistics point to a general lack of awareness this disease in both the patient and the medical world. In order to promote early detection, there must be better instruction of symptoms and complications involved in prolonged disease available to both the medical community and the population of endemic areas. This in theory would do an awareness of the disease and encourage earlier testing for it.
There are a few steps that can be taken in order to crop the number of cases of Valley Fever. As well as promoting early detection, public awareness of the disease could also help cleave the number of cases. Public awareness of Valley Fever would reduce the number of cases by providing the people with knowledge of its causes and ways to avoid exposure to the Coccidioides immitis spores. The second step that should be taken is a national focus on research in vaccines and cures for this disease. From this case study it is obvious that contracting this disease could potentially be very costly. The financial burden will then be on either the infected individual themselves or on the status in some circumstances. These high costs are unacceptable when relatively little investment is being made in the research of a cure or vaccination.
When considering these recommendations, it is essential to review the facts about this disease. Valley Fever is caused by the spores of a fungus that can become airborne when soil is disturbed. This fungus is endemic to large portions of the American southwest including Phoenix, Arizona, the nation’s fifth largest city. Statistically, anyone living in endemic areas is likely to get this disease at least once in their lifetime. On top of those living in endemic areas, those visiting the area have a high chance of contracting the disease. The number of cases has risen consistently each year for at least the last seven years. After reviewing these facts it is obvious that Valley Fever has had a principal impact on our society and that steps need to be taken to reduce its prevalence.
References
Introduction
(1) Chuang, Amy. “Disseminated Coccidioidomycosis in an Immunocompetent Person Living in New York City”. Journal of Urban Health: Bulletin of the New York Academy of Medicine, Vol. 82, No. 2, doi:10.1093/jurban/jti057
(2) Comrie, Andrew C. “Climate factors influencing coccidioidomycosis seasonality and outbreaks. Environmental Health Perspectives. June 2005 http://findarticles.com/p/articles/mi_m0CYP/is_/ai_n14816419
(3) DiSalvo, Dr. Arthur. Mycology – Chapter Six Dimorphic Fungi. 21 Nov. 2008 http://pathmicro.med.sc.edu/mycology/mycology-6.htm
(4) McKinley, Jesse. “Valley Fever hits epidemic numbers from Texas to Northern California”. New York Times. 30 Dec. 2007 http://www.sfgate.com/cgi bin/article.cgi? f=/c/a/2007/12/30/MN12U6OGF.DTL&feed=rss.news
(5) Smith, Scott. “MedlinePlus Medical Encyclopedia: Coccidioidomycosis.” National Library of Medicine – National Institutes of Health. 9 Oct. 2006. 22 Nov. 2008 .
Medical Industry
(1) “Coccidioidomycosis..” NGC – National Guideline Clearinghouse . 1 Nov. 2005. 2 Nov. 2008
(2) Smith, Scott. “MedlinePlus Medical Encyclopedia: Coccidioidomycosis.” National Library of Medicine – National Institutes of Health. 9 Oct. 2006. 22 Nov. 2008 .
(3) “Valley Fever – Valley Fever Connections.” Valley Fever – Valley Fever Connections. 22 Nov. 2008 .
(4) “Valley fever – MayoClinic.com.” Mayo Clinic medical information and tools for healthy living – MayoClinic.com. 15 Mar. 2008. 22 Nov. 2008 .
(5) Interview Roni Cummings, Quality risk management: Notes in hand
Infected Individuals & Insurance Companies
(1) Arizona Department of Health Services. (2008). Valley Fever Annual Report 2007 (1st ed.). Phoenix, AZ: Arizona Department of Health Services, Division of Public Health Services.
(2) Interview with Anonymous Patient #1: Patient “V”. (Personal Communication, November 15, 2008).
(3) Interview with Anonymous Patient #2: Patient “F”. (Personal Communication, November 17, 2008).
(4) The Associated Press (2007, January 11). Ariz. Valley Fever Cases Soared in 2006. The Washington Post. All Pages.
(5) Unknown Author. (2008, October 29). Arizona Company Seeks Valley Fever Cure. BIO5 Institute News Archives. All Pages.
(6) Arizona Department of Health Services Webmaster. (2008, November 3). Infectious Disease Epidemiology. Retrieved November 15, 2008, from http://azdhs.gov/phs/oids/epi/disease /cocci/index.htm
(7) Author Unknown. (Last modified October 30, 2008). How Pre-Existing Conditions Work. Retrieved November 15, 2008, from http://health.howstuffworks.com/pre-existing-condition.htm
(8) BIO5 Institute at the University of Arizona. (2008). BIO5 Institute Home Page. Retrieved November 15, 2008, from http://bio5.arizona.edu/index.php
(9) Pfizer Inc. (Unknown Date). Pfizer Products. Retrieved November 15, 2008, from http://www.pfizer.com/products/rx/rx_product_diflucan.jsp
(10) Roerig, Division of Pfizer. (Last revised March 2008). Diflucan (LAB-0099-10.0). Retrieved November 15, 2008, from http://media.pfizer.com/files/products/uspi_diflucan.pdf
(11) The Mayo Clinic. (2006, March 17). Diseases and Conditions Valley Fever. CNN.com & MayoClinic.com. Retrieved from http://azdhs.gov/phs/oids/epi/disease/cocci/index.htm
(12) The University of Arizona. (Video Production). (2008, March 8). Innovation Day at UA 2008, UA @ the Leading Edge [Episode 1]. Development of the Valley Fever Vaccine. Video retrieved from http://www.youtube.com/watch? v=kgT0hFo49G4
(13) Valley Fever Center for Excellence at the University of Arizona. (2003). Valley Fever Center for Excellence: Coccidioidomycosis. Retrieved November 15, 2008, from http://www.vfce.ar izona.edu/
Infected Animals
(1) Mitchell, Chris. Blastomycosis, Cryptococcosis, Coccidioidomycosis (Valley Fever), Histoplasmosis, Disease and more. Animal Shelter Org. 2004. November 4, 2008.
(2) Valley Fever (Coccidiodomycosis). Mar Vista Animal Medical Center. 2006. November 5, 2008. http://www.marvistavet.com/index.html
(3) Valley Fever in Dogs. Valley Fever Center for Excellence. 2008. October 18, 2008.
Construction
(1) “Valley Fever” 1998-2008 Mayo Foundation for Medical Education and Research. Outbreak grips Arizona. March 17, 2006
(2) Benjamin J. Park, Keith Sigel, Victorio Vaz, Ken Komatsu, Cheryl McRill, Maureen Phelan, Timothy Colman, Andrew C. Comrie, David W. Warnock, John N. Galgiani, and Rana A. Hajjeh. “An Epidemic of Coccidioidomycosis in Arizona”, 1998-2001. The Journal of Infectious Diseases, 2005. 1 June.
(3) U.S Environmental Protection Agency. The clean air act amendments of 1990. Clean Air Act. November 10th, 2008.
(4) MAG 2007 Five Percent Plan For PM-10 For The Maricopa County Nonattainment Area. December 2007. Maricopa Association of Governments. < (www.mag.maricopa.gov)>
(5) Maricopa Air Quality Department. (2008). Dust Control. [Brochure]. Dust Compliance Resources Maricopa County.
(6) Maricopa County Air Pollution Control Regulations, Regulation III-Control of Air Contaminants Rule 310.
(7) Toribio, Jeovanny. “Maricopa County and dust regulations.” E-mail to Erin Dunsey. Oct. 21, 2008.
(1) Jason Jones, Turner Construction Inc, Oral interview, Done 10-21-2008
Notes in Authors hand
(2) Maricopa County Air Quality Department. “Air Quality Violators pay over $452K in October”. November 3, 2008. News.
