Advocates for valley fever research give California Assemblyman Rudy Salas (D-Bakersfield) an “A” for effort for what they call the most robust legislative effort to address the disease in California history. But public health officials and disease experts are split on whether the remedies proposed by Salas will bring improvements.
Salas’ package of bills takes aim at disease reporting standards, physician training and workplace safety with promises of a budget resolution to bring more funding to the disease. Experts are happy about the money and attention valley fever is receiving, but are divided about one of the four bills Salas introduced.
That bill, AB 1788, would change how public health officials must count cases and report on the disease, which is endemic to the San Joaquin Valley.
The current standard for disease reporting for valley fever requires a detailed, resource intensive process designed to avoid errors. But because county health departments don’t have the resources to go through the two rounds of verification required for each case, they often fail to account for cases all together.
The bill aims to create a streamlined reporting system that delivers statewide case counts faster. To do so, Salas has eliminated a time consuming step in counting cases to increase the likelihood that cases are recorded at a time when valley fever is on the rise. The legislation also would bring California in line with the practice in Arizona, another state where valley fever is widespread.
Skeptics say the proposed reforms could inadvertently reduce the chances of local health departments spotting outbreaks by trading accuracy for speed.
“I think it would be chaos,” said Jeff Engel, the executive director of the Council and State of Territorial Epidemiologists, the nonprofit group that wrote the current state guidelines.
Meanwhile, those supporting the legislation say the state should assume new responsibilities now left to cash-strapped county health departments.
“There’s nothing wrong with doing surveillance. It needs to be done. But why not at the state level in occupational health since they’re compiling and scrubbing the data?” asked Rob Purdie, vice-president of the Bakersfield-based Valley Fever Americas Foundation.
Salas said underfunded public health departments in endemic areas don’t have the resources to investigate cases under the current standard. As a result, cases are sometimes marked as “probable” or “suspect” and not counted by the state, he said. Streamlining the process of verifying cases, he said, would increase the case count and raise the disease’s profile.
“If I go to the governor and ask him for additional resources, he’ll say there’s not many affected — (but) I can say there is,” Salas said. “He’s going to want the numbers.”
Undercount lowers disease profile
With his legislation, Salas aims to address an undercount that makes it harder to shake loose government funding for treatments and a vaccine under development. Despite federal data showing that cocci has never infected more than 23,000 people, valley fever researchers estimate that more than 150,000 annually get valley fever in the United States. Cases have been increasing to epidemic proportions this year in California, prompting the state health officer to issue warnings as the disease sprawls outside of its traditionally endemic regions.
Valley fever, or Coccidioidomycosis, is caused by the Coccidioides fungus, which grows in the loamy soil of the southwestern United States. When disturbed, often through agricultural tilling, construction and high wind, microscopic fungal spores can become airborne and, once inhaled, cause valley fever. Most people are asymptomatic, but others develop flu-like symptoms, including fever, cough, headaches and chills. In some cases, when left untreated, the fungal spore can spread throughout the body and cause a lifetime of health issues, and in rare cases, death.
Valley fever is already seen as an orphan disease that is found only in a narrow band of states. Yet public health officials cannot grasp the full scale of the disease in endemic regions because of the need for a more robust count.
Devil is in the details
Under current state standards, before public health agencies can report a valley fever case to the California Department of Public Health, they confirm it through a laboratory process and a clinical follow-up with physicians to determine symptoms.
Many cases are not counted, however, because cash-strapped health departments don’t have the time to conduct clinical confirmations, a process that requires epidemiologists, at a minimum, contact doctors to ensure it’s a cocci case and not a misdiagnosis.
The Center for Health Journalism Collaborative surveyed seven counties in the San Joaquin Valley and along the coast and found a lack of consistency in how cases are reported. Kern, Tulare, Stanislaus, and San Joaquin counties do not conduct any clinical confirmation for valley fever. Merced, Monterey and San Luis Obispo counties do.
Even before the legislation, state public health leaders seem to be backing away from the more rigorous verification process.
“Local health departments in California are not required to review clinical information when confirming cases of valley fever. Local health departments can adopt their own practices to determine which cases they consider as confirmed,” California Department of Public Health officials said in a statement.
State Public Health officials added that there’s a workgroup of local health officials working to standardize reporting practices.
All of the counties the Collaborative surveyed said they struggle to conduct these types of investigations. That’s because departments have been given no additional resources to tackle counts even as valley fever cases have been rising.
“It’s very research intensive to call every patient and ask these questions,” said Kern County Epidemiology Manager Kim Hernandez, whose county recorded 2,310 cases in 2016 . “For us, we can’t sustain that, and other counties are finding with these increasing cases that they can’t sustain it, either.”
Stricter methods can stop worker exposures
Some counties, during this process, also investigate cases to determine where the patient was exposed to the fungal spore, whether they had been treated, and perhaps most importantly, their occupation.
“What they do for a living has led us in the past to at least three outbreaks associated with a work site,” said Ann McDowell, an epidemiologist at San Luis Obispo County Health Department.
In one case, 11 of 12 crew members replacing a busted water pipe in 2007 at Camp Roberts, a California National Guard military base, got sick. Public health nurses spotted the cluster during the clinical confirmation process and found that none of the workers were using respiratory protection. They also found during the investigation that a military instructor working on base was exposed to fungal spores and got sick.
Those investigations helped spur the department to work with their local building departments to ensure that contractors provide valley fever education to workers before issuing a permit.
Just two months ago, Monterey and San Luis Obispo public health officials spotted a cluster of cases at the California Flats Solar Project in Cholame Hills, which straddles the two counties. The departments, working with the California Occupational Safety and Health Administration, found that six construction companies were not protecting workers from the risk of valley fever by taking common sense prevention measures, including soaking soil before digging and ensuring workers wore respirator masks. One company, Papich Construction, was a repeat offender. The six were fined a combined $240,000.
“We feel that clinical investigation helps us if there’s a problem with a work site,” McDowell said. “Doing away with it would probably not get us as much visibility on some of these sites.”
Still, she acknowledges that public health departments have fewer resources and less time to carry out valuable investigations. San Luis Obispo had 330 confirmed cocci cases in 2017, with scores more still under investigation. Two years earlier, they had fewer than 49 cases.
“It’s been a very busy year for valley fever and it’s really stressed our nurses to have to do these clinical investigations,” McDowell said.
A lack of resources, however, is no reason to change the state standards for verifying cases and tracking the disease, said Engel, the nonprofit director.
“If the problem is resources at the local health department, then California legislators should be focusing on making sure that they’re adequately resourced for the burden of disease,” Engel said. Reforms “could provide misleading data that would harm surveillance efforts.”
But Arizona officials have conducted studies after changing their standards and have found a slim margin of error — less than 3 percent.
Dr. John Galgiani, executive director of the Valley Fever Center for Excellence at University of Arizona, considered the nation’s top valley fever researcher, said he’s willing to accept that margin for a more cost-effective data reporting method.
Stephanie Innes of the Arizona Daily Star contributed to this report.