Public and Medical Misinformation on Valley Fever By David Filip Presented 4/23/2014.

Public and Medical Misinformationon Valley Fever

By David Filip

Presented 4/23/2014

Although a discussion of misinformation may sound controversial, this presentation is founded on

information in peer reviewed medical journals and historical accounts.

The only controversy should be the fact that this information is not already common knowledge.

Conventional Wisdom

Sometimes the conventional wisdom on Valley Fever is not only baseless but is misinformation that

whitewashes the truth and would lead people astray unless they chose to dig into the research themselves

Consider the Emperor's New Clothes

A frightening example of misinformation:

"Doctor [name withheld] says washing your hands is the best way to prevent valley fever."

Valley Fever cases on the upswing locallyKOB Albuquerque, NM

April 1, 2013

Common Valley Fever "Sound Bites"How true are they?

Infected people have a lifelong immunity

Most people won't know they have the disease

It is a small problem

It is important to focus on specific risk factors

Masks can protect people from Valley Fever

It is only a local problem

I will deconstruct each of these statements to show how even accurate statements could be misinterpreted and misused to the detriment of public health, as well as to show ways to share the whole and useful truth

quickly and effectively.

Once infected, a person with Valley Fever will have lifelong immunity – that is said everywhere

from doctors offices to medical journals to the evening news.

It is the basis of a vaccineIt is the reason much of the Southwest's population is not debilitatedBased on the peer reviewed literature, it is not always true as a blanket statement. In fact, in some cases it has been proven false.

Do infected people have a lifelong immunity?


"Relapse rates in prospective studies of the [azole drugs for Valley Fever] have ranged from 16% to 67%, with a reasonable estimate of 25%-35% after therapy.”

“The overall response to treatment with azoles appears somewhat less than that to treatment with amphotericin B; relapses occur in about one-third of patients treated with azoles.”

Einstein HE, Johnson RH. Coccidioidomycosis: new aspects of epidemiology and therapy. Clin Infect Dis 1993;16:349-56.


In a review of 223 cases across a decade, 24% with dissemination relapsed and 71% with Central Nervous System involvement such as meningitis relapsed. Even “following apparently successful treatment” patients relapse one third of the time.

Crum NF, Lederman ER, Stafford CM, Parrish JS, Wallace MR. Coccidioidomycosis: A Descriptive Survey of a Reemerging Disease. Clinical Characteristics and Current Controversies. Medicine. 83(3):149-175, May 2004.


“Relapse remains one of the most significant problems in the treatment of coccidioidomycosis.”

Oldfield EC 3rd, Bone WD, Martin CR, Gray GC, Olson P, Schillaci RF. Prediction of relapse after treatment of coccidioidomycosis.

Clin Infect Dis. 1997 Nov;25(5):1205-10.


People contacting ValleyFeverSurvivor.com often tell us that their doctors won't treat them as symptoms

return and the doctors often refuse to test for Valley Fever to begin with. However, “rising titers warrant the administration of therapy, even in the absence of

evident disease, since relapse is likely.”

Stevens DA. Adequacy of therapy for coccidioidomycosis. Clin Infect Dis 1997 Nov;25(5):1211-2.


"Coccidioidomycosis is a systemic fungal infection and is frequently refractory to treatment.

Unfortunately, conventional antifungal therapy is associated with therapeutic failures, relapses, and

toxicity."

Gonzalez GM, Tijerina R, Najvar LK, Bocanegra R, Luther M, Rinaldi MG, Graybill JR. Correlation between antifungal susceptibilities of Coccidioides immitis in vitro and antifungal treatment with caspofungin in a mouse model.

Antimicrob Agents Chemother. 2001 Jun;45(6):1854-9.


“The disease may recur years after exposure or treatment.”

Caraway NP, Fanning CV, Stewart JM, Tarrand JJ, Weber KL. Coccidioidomycosis osteomyelitis masquerading as a bone tumor. A report of

2 cases. Acta Cytol. 2003 Sep-Oct;47(5):777-82.

“Reactivation of a previously disseminated coccidioidal infection, even after apparently

successful antifungal therapy, is not uncommon.”Pappagianis D. Coccidioides immitis. In Collier L, Balows A, Sussman M,

Ajello L, Hay RJ, eds. 9th ed. Topley and Wilson's microbiology and microbial infections, Vol. 4, Medical Mycology. London: Arnold 1998.

p357-371.


Even in those who are not treated, Valley Fever’s lung lesions are known to expand, sometimes years later.

Coccidioidomycosis. MedlinePlus Medical Encyclopedia. <http://www.nlm.nih.gov/medlineplus/ency/article/001322.htm>

This makes it important for Valley Fever patients to keep track of their x-rays of lung nodules, since they

have frequently been mistaken as cancer. Arizona Respiratory Center. What you Should Know About Valley Fever

(Coccidioidomycosis). University of Arizona Health Sciences Center <http://www.respiratory.arizona.edu/patient-info/adults/valley-fever-a.htm>

http://www.nlm.nih.gov/medlineplus/ency/article/001322.htm

http://www.respiratory.arizona.edu/patient-info/adults/valley-fever-a.htm


“Despite the prevalent belief that primary attack of coccidioidomycosis confers a lasting immunity, there are many cases which do not follow this simple concept. Examples have been presented illustrating that the disease can resolve and then reappear; that residual nodules and cavities can reactivate; that surgery and debilitating conditions can produce reactivations; and that late disseminations can occur. In addition, exogenous reinfection can also occur by both pulmonary

and extrapulmonary routes.”

Salkin D. Clinical examples of reinfection in coccidioidomycosis. Am Rev Respir Dis. 1967 Apr;95(4):603-11.


Testimony about Valley Fever to the Arizona State Senate committee on health "pointed out the

problems with current therapy, noting that less than 70% of patients respond to therapy. However, when

therapy is stopped, relapses occur."

Galgiani, JN. Minutes of the Arizona State Senate Committee on Health. Phoenix, AZ 4 Feb 2002.

http://www.azleg.state.az.us/FormatDocument.asp?inDoc=/legtext/46leg/1R/comm_min/Senate/0213+HEA%2EDOC.htm

Accessed 8/01/2003.


“Unfortunately, the rates of failure and relapse after treatment of chronic pulmonary or disseminated Coccidioidomycosis are disappointingly high.”

Laniado-Laborín R. Cost-benefit analysis of treating acute coccidioidal pneumonia with azole drugs. In: Proceedings of the Forty-Fifth Annual

Coccidioidomycosis Study Group Meeting. March 31, 2001. The University of Arizona. Tucson, Arizona.


There are no major long term studies specificallyfollowing people with dormant Valley Fever to

observe how they are struck by it later in life.

There are many studies and case reports following patients who relapsed severely after seemingly

defeating the disease with medication.

Documentation has also proven that patients’ infections relapsed (or activated for the first time) years after leaving the

endemic zones where they contracted Valley Fever.

Antony SJ, Jurczyk P, Brumble L. Successful use of combination antifungal therapy in the treatment of coccidioides meningitis. J Natl Med Assoc. 2006 Jun;98(6):940-2.Bellin HJ, Bhagavan BS. Coccidioidomycosis of the prostate gland. Report of a case and review of the literature. Arch Pathol. 1973 Aug;96(2):114-7.Catanzaro A, Cloud GA, Stevens DA, Levine BE, Williams PL, Johnson RH, Rendon A, Mirels LF, Lutz JE, Holloway M, Galgiani JN. Safety, tolerance, and efficacy of posaconazole therapy in patients with nonmeningeal disseminated or chronic pulmonary coccidioidomycosis. Clin Infect Dis. 2007 Sep 1;45(5):562-8. Epub 2007 Jul 23.Cole GT, Xue JM, Okeke CN, Tarcha EJ, Basrur V, Schaller RA, Herr RA, Yu JJ, Hung CY. A vaccine against coccidioidomycosis is justified and attainable. Med Mycol. 2004 Jun;42(3):189-216.Crum NF, Lederman ER, Stafford CM, Parrish JS, Wallace MR. Coccidioidomycosis: A Descriptive Survey of a Reemerging Disease. Clinical Characteristics and Current Controversies. Medicine (Baltimore). 2004 May;83(3):149-175.Johnson RH, Einstein HE. Forty-five years of disseminated coccidioidomycosis. In: Proceedings of the Forty-Sixth Annual Coccidioidomycosis Study Group Meeting. March 31, 2001. The University of Arizona. April 6, 2002. Davis, California. VFCE. Oldfield EC 3rd, Bone WD, Martin CR, Gray GC, Olson P, Schillaci RF. Prediction of relapse after treatment of coccidioidomycosis. Clin Infect Dis. 1997 Nov;25(5):1205-10.

When he was infected in 1957 he experienced pneumonia and appeared to recover. In 1958 he had a reactivation of

his Valley Fever that required the removal of a testicle and other parts of his genitourinary tract.

Again the Valley Fever went dormant, until it reactivated over four decades later as meningitis in 2002 to kill him. Even when an infected person does not look or feel sick, reactivation is always a dangerous lingering possibility

with this disease.

Johnson RH, Einstein HE. Forty-five years of disseminated coccidioidomycosis. In: Proceedings of the Forty-Sixth Annual Coccidioidomycosis Study Group Meeting. March 31, 2001. The University of Arizona. April 6, 2002. Davis, California.

A Severe Reactivation


Lab accidents and animal data proving that reinfection is possible

Salkin D. Clinical examples of reinfection in coccidioidomycosis. Ajello L,ed. Coccidioidomycosis. Papers from the second symposium on

coccidioidomycosis. Tucson: University of Arizona Press, 1967: 11-18.

Shubitz LF, Peng T, Perrill R, Simons J, Orsborn K, Galgiani JN. Protectionof mice against Coccidioides immitis intranasal infection by vaccination with

recombinant antigen 2/PRA. Infect Immun. 2002 Jun;70(6):3287-9.


Fifteen trillion Coccidioides arthroconidia can fit into a cubic inch.

Valley Fever Center for Excellence. Frequently Asked Questions.http://www.vfce.arizona.edu/FAQ.htm

It is impossible to predict when any breath of air in an endemic area might contain enough spores to

demolish an infected person’s immune resistance.

Reinfection with Valley Fever may be something commonly regarded by some as impossible, but it is

also a proven fact


Reinfections and Reactivations


Dose dependence:

The question is not whether experimental vaccines are protective, but at what dose are they protective?

Concerns of reinfection and reactivation could follow a similar line of thought.

Reactivations and Locus Minoris Resistentiae (LMR)

It has been shown that dormant Coccidioides in some patients activated as “lesions that occurred after

various forms of trauma, including those ensuing on medical-surgical procedures. What factors may

contribute to such local proliferation of C. immitis are not yet explained.”

Pappagianis D. The phenomenon of locus minoris resistentiae in coccidioidomycosis. In: Einstein HE, Catanzaro A, eds.

Coccidioidomycosis. Proceedings of the 4th International Conference on Coccidioidomycosis. Washington, DC. National Foundation for Infectious

Diseases; 1985: 319-329.


It has also been reported that other active bacterial and viral diseases can lead to the

reactivation of dormant Valley Fever.

Cole GT, Xue JM, Okeke CN, Tarcha EJ, Basrur V, Schaller RA, Herr RA, Yu JJ, Hung CY. A vaccine against coccidioidomycosis is justified and

attainable. Med Mycol. 2004 Jun;42(3):189-216.

Reactivations and Locus Minoris Resistentiae (LMR)Reactivations like these “indicate that relatively silent

dissemination from a primary pulmonary focus does occur. However, many of the present episodes of peripheral

coccidioidal lesions could not be associated with a recent respiratory infection. Thus, C. immitis may have been

present in the blood at the time of injury and settled in the injured site, or it may have previously been deposited via

the circulation in the tissue which was later injured, setting the stage for fungal replication and development of a

lesion.”

Pappagianis D. The phenomenon of locus minoris resistentiae in coccidioidomycosis. In: Einstein HE, Catanzaro A, eds. Coccidioidomycosis. Proceedings of the 4th International Conference on Coccidioidomycosis. Washington, DC. National Foundation for Infectious

Diseases; 1985: 319-329.


Dr. Demosthenes Pappagianis was the first to describe this phenomenon in Valley Fever with the term

“locus minoris resistentiae.” LMR is based on an old laboratory term meaning

“lessened resistance at a local area.”


One example was a man who was struck in the shoulder by a tree branch while riding on a tractor,

and had Valley Fever activate in his shoulder. Another was a dock worker outside the endemic area

who had a heavy weight fall on his foot, and soon had his latent Valley Fever activate in that foot.

Pappagianis, D. Personal Communication.


LMR has also been known to occur in other diseases, like bacterial osteomyelitis and syphilis.

Pappagianis D. The phenomenon of locus minoris resistentiae in coccidioidomycosis. In: Einstein HE, Catanzaro A, eds. Coccidioidomycosis. Proceedings of the 4th International Conference on Coccidioidomycosis. Washington, DC. National

Foundation for Infectious Diseases; 1985: 319-329.


More Valley Fever examples include an infection in the leg,

Pappagianis D, Welland F, Jordan G. Backache and Ulcer of Calf in a human. In: Ajello L, ed. Coccidioidomycosis. Papers from the second symposium on coccidioidomycosis. Tucson:

University of Arizona Press, 1967: 19-22.

a disseminated infection of the epididymis that apparently spread to the testicle after a blunt trauma,

Fiese MJ. Coccidioidomycosis. Springfield, Charles C. Thomas, 1958: Ch8 Pathology and pathogenesis of Coccidioidomycosis. P104-126.

and the upper chest where a man was punched in a Judo class

Caraway NP, Fanning CV, Stewart JM, Tarrand JJ, Weber KL. Coccidioidomycosis osteomyelitis masquerading as a bone tumor. A report of 2 cases. Acta Cytol. 2003 Sep-Oct;47(5):777-82.


LMR may also apply in the cases of children who fell and subsequently developed osteomyelitis from

Valley Fever at the site of their injuries.Iger M. Coccidioidal osteomyelitis. In: Ajello L, ed. Coccidioidomycosis:

Current clinical and diagnostic status. Miami: Symposia Specialists; 1977: 177-190.Bried JM, Speer DP, Shehab ZM. Coccidioides immitis osteomyelitis in a 12-month-old child. J

Pediatr Orthop 1987 May-Jun;7(3):328-30.

“Several anatomical sites have been involved - upper and lower extremities, face, thorax,

and an internal surgical site.”Pappagianis D. The phenomenon of locus minoris resistentiae in coccidioidomycosis.

In: Einstein HE, Catanzaro A, eds. Coccidioidomycosis. Proceedings of the 4th International Conference on Coccidioidomycosis. Washington, DC.

National Foundation for Infectious Diseases; 1985: 319-329.


Reactivations of “surgical cases are of special interest because operative trauma and post-operative

pulmonary mechanical changes form an extraneous force which can upset a tenuous immunity.”

Salkin D. Clinical examples of reinfection in coccidioidomycosis. In: Ajello L, ed. Coccidioidomycosis. Papers from the second symposium on coccidioidomycosis. Tucson:

University of Arizona Press, 1967: 11-18.


Having Valley Fever's symptoms once does NOT guarantee total protection for the future.

For the sake of accuracy and honesty in communications, "immune resistance" is better than

saying "total immunity" because there are many ways that this resistance can be overcome.


Many patients have mentioned their doctor told them once they had a case of Valley Fever that they would never suffer symptoms again, and any sickness they experienced was from something else. This caused years of improper medical care until future doctors

ultimately were willing to listen and work on the real problem.

The difference between "immune resistance" and "total immunity" must be made clearer in the future for the

medical community and lay audience alike.

"Most people won't know they have Valley Fever"

Is this true?

The estimate that 60% of cases would be asymptomatic came from military studies during World War II

Smith CE, Beard RR. Varieties of coccidioidal infection in relation to the epidemiology and control of diseases. Am J Public Health 1946;36:1394-402.

In today's population, the more important question is whether we should assume so many infections

will not have symptoms.

According to the Arthritis Foundation, 50 million Americans have arthritis. This is 1/6th of the

population. How much of this is from fungal disease in general or Valley Fever in particular?

The data is incomplete.

How accurate has Valley Fever testing been? The blood tests are among the most commonly used form

of diagnosis. False positives had been noted under the particular circumstance of an EIA test with positive

IgM antibodies but negative IgG antibodies.

Kuberski T, Herrig J, Pappagianis D. False-positive IgM serology in coccidioidomycosis. J Clin Microbiol. 2010 Jun;48(6):2047-9. doi:

10.1128/JCM.01843-09. Epub 2010 Mar 31.

Blair JE, Currier JT. Significance of isolated positive IgM serologic results by enzyme immunoassay for coccidioidomycosis. Mycopathologia. 2008 Aug;166(2):77-82. doi:

10.1007/s11046-008-9129-9. Epub 2008 Jun 4.

False negatives are a greater concern among the variety of blood tests for valley fever. In a

2006 study that evaluated tests in people already known to have Valley Fever, how often

were blood tests accurate?

EIA tests were positive 82% of the timeImmunodiffusion tests: 71% of the timeComplement fixation: 56% of the time

Pollage CR, et al. Revisiting the sensitivity of serologic testing in culture positive coccidioidomycosis. Presented at the 106th Annual Meeting of the American Society of Microbiology. Orlando, FL. 2006. Cited in: Saubolle MA. Laboratory aspects in the diagnosis of coccidioidomycosis. Ann N Y Acad Sci. 2007 Sep;1111:301-14. Epub 2007 Mar 15.

In a case report, the patient had a lumbar puncture to test for cocci, but it was not found there. However, a blood test had a colossally high titer of 1:512. This

and similar cases illustrate the need for ongoing testing, repeated testing and often more than

one type of testing.

Gibbs BT, Neff RT. A 22-year-old Army private with chest pain and weight loss. Mil Med. 2004 Feb;169(2):157-60.

One study was a specific attempt to find Valley Fever in Arizona by testing hospitalized patients with

community acquired pneumonia. It led to a discovery that 29% were Valley Fever infections and not the expected influenza or bacterial pneumonia cases.

Valdivia L, Nix D, Wright M, Lindberg E, Fagan T, Lieberman D, Stoffer T, Ampel NM, Galgiani JN. Coccidioidomycosis as a common cause of community-acquired

pneumonia. Emerg Infect Dis. 2006 Jun;12(6):958-62.

The rate of testing for Valley Fever ranges from 13% to as little as 2%

of pneumonia cases, so the question of a subclinical case may be up to

the doctors' willingness to consider Valley Fever at all.

Chang DC, Anderson S, Wannemuehler K, Engelthaler DM, Erhart L, Sunenshine RH, Burwell LA, Park BJ. Testing for coccidioidomycosis among patients with community-

acquired pneumonia. Emerg Infect Dis. 2008 Jul;14(7):1053-9. doi: 10.3201/eid1407.070832.

Peer review should be an answer to the release of bad data and bad decisions. It could get every doctor and

epidemiologist on the same page with all the right answers so they can share perfection

with the media...in theory.

Benefits of peer review are...

1) It filters out the generally uneducated2) It sets a standard of communication3) Professionals familiar with the topic can point to holes in a theory4) Peer pressure for accuracy

In the general public, there seems to be a horrible misconception that Valley Fever is just like a cold,

or that if it WERE serious, it would already be under control.

Questionnaire respondents have often said they had no idea how serious the disease was, and point to the

estimates released to the news about the overall scope of the epidemic.

"Valley Fever is not a small problem"

Different journal articles from the 1950's to the 2000's repeatedly estimated 100,000 people in the USA

were infected each year.

Seemingly without regard to circumstances, the numbers stayed the same. In fact, you could follow a chain of citations from one journal article to the next, repeating that same number, and not one ever stated

exactly how it arrived at that conclusion in the journal.

I asked Dr. John Galgiani at the Valley Fever Center for Excellence about his current estimate of 150,000 annual infections, and his previous 100,000 infection

estimate in 1999. His estimates were in-line with some of the final surveys taken before the skin test was

unavailable, accounting for the population in the six most endemic counties of the country.

Larwood TR. Coccidioidin skin testing in Kern County, California: decrease in infection rate over 58 years. Clin Infect Dis. 2000 Mar;30(3):612-3.

A discussion with Dr. Hans Einstein...

With a laugh Dr. Einstein told me about a dust bowl era radiologist in California. Flush with new

respiratory illnesses to diagnose from the Okies entering the San Joaquin Valley for work, he estimated

35,000 lung lesions from Valley Fever were seen in California in a single year.

So how did the estimate go from 35,000 to 100,000 people? Arizona has about twice as many diagnosed cases as California. So there was no peer review. No journal entry. No statistical model. One radiologist with an estimate gave us 100,000 people every year.

That was the established "truth" for decades, even in peer reviewed articles that should have done their

homework, until the new VFCE model matched and later exceeded that number to 150,000.

What changed?

Physicist Max Plank's perspective took hold:

"A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather

because its opponents eventually die, and a new generation grows up that is familiar with it."

1) It filters out the generally uneducated

...but without printing a statistical model or naming the radiologist, was any writer truly educated on the matter?

Peer Review's Benefits Vs. Reality


2) It sets a standard of communication

...but the chain of citations led nowhere and were not checked - can you imagine the time it would take for dozens of citations for each article? Journals don't have enough staff for that level of quality assurance.


3) Professionals familiar with the topic can point to holes in a theory.

...but if the right expert is not a reviewer, only an extensive historical review would show where the data came from.


4) Peer pressure for accuracy

...but if a previous expert put his reputation on an estimate, the assumption is that he did not make a mistake. Is that assumption always fair?

Today's most commonly used estimate of the nation's annual infection rate is 150,000 per year, based on the population of the six most endemic counties and historical skin test infection rates.

Table 1. Populations (in millions of persons) of selected counties within regions highly endemic for coccidioidomycosis.

YearState County (City) 1970 1990 2010Totals 2.5 4.5 6.7Arizona 1.5 2.9 5.2 Maricopa (Phoenix) 1.0 2.1 3.8 Pima (Tucson) 0.4 0.7 1.0 Pinal 0.1 0.1 0.4California 0.6 1.0 1.5 San Louis Obispo 0.1 0.2 0.3 Kern (Bakersfield) 0.3 0.5 0.8 Tulare 0.2 0.3 0.4Texas El Paso (El Paso) 0.4 0.6 0.7Sources: US Bureau of the Census

This also assumes 30% are already infected and a 3% annual infection rate. This estimate model is unpublished data from Dr. John Galgiani, VFCE.

There is also a less famous statistical model in the CDC publication Emerging Infectious Diseases

in 2001.

Cost-effectiveness of a potential vaccine for Coccidioides immitis. Barnato AE, Sanders GD, Owens DK. Emerg Infect Dis. 2001 Sep-Oct;7(5):797-806.

Over time it can be harsher than any of the 100,000 or 150,000 estimates.

Comparative Data:Centers for Disease Control and Prevention (CDC). Increase in reported coccidioidomycosis--United States, 1998-2011. MMWR Morb Mortal Wkly Rep. 2013 Mar 29;62 (12):217-21.

Total Diagnoses1998 2011 % Increase

Arizona 1,474 16,467 +1017%California 719 5,697 +692%NV, NM, UT 72 237 +229%

By case rates per 100,000 population, even accounting for the tremendous population increase in

these states, rates of Valley Fever diagnosis still outstripped population growth.

Diagnosed cases per 100,000 population

1998 2011 % IncreaseArizona 30.5 247.7 +712%California 2.1 14.9 +610%NV, NM, UT 1.4 3.1 +121%

If this CDC report had gone back earlier in Arizona's records to 1990, with only 280 reported cases, the

difference between that and Arizona's 2011 reported caseload of 16,474 would show a cocci diagnosis

increase of 5,784%!

In the past decade and beyond, nearly every year in Arizona and California had been the worst epidemic in

that state's Valley Fever history in total cases or the rate of infection based on population, if not both.

The speed of this epidemic's increase outstrips the statistical models we have. Why?

- The study was based on infection rates in soldiers from WWII. These were young healthy men, but in a general population otherwise, people today would have a greater severity of illness that may not be measured properly.- Our present day has people with more immunocompromised conditions, diabetes, chemical sensitivities, and environmental toxins than ever before.- The population boom has brought in new residents, expansion to new desert areas, and more soil-disturbing construction to those areas.- Man-made drought could affect the life cycle in agricultural areas where this had not previously been a concern.

When diagnoses are occurring thousands of percent higher now than in the past, it may not be outlandish to

see more accurate models that may estimate even a million people newly infected in a year.

Valley Fever is no stranger to large numbers. Dr.

David Stevens' landmark textbook Coccidioidomycosis estimated there were 10 million people living with

Valley Fever in America in 1980.

A simplified underestimate of the 2001 EID model would still lead to hundreds of thousands

of annual infections when applying the equation to the caseload and calculating to find the

number of infected people overall.

Is there a good reason NOT to use higher estimates?

- Politicians might fear economic disaster- Awareness of legal liabilities- Orphan drug research concerns- The increase in case reporting does not match the previous trend of decreasing skin test data from over two decades ago.

The first three do not have a basis in science

Race: Native American, African-American, Asian (particularly Filipinos)

Age: Children under five and the elderly

Environmental/occupational: Working outdoors andIn dusty environments

Immunocompromised conditions

Risk Factors

Risk Factors

A discussion of risk factors, no matter how simple, can make matters unclear for general audiences.

Risk Factors

A discussion about Valley Fever risk factors can be true at face value, but people who are not part of

the risk groups notice the lack of attention the report gives to them and believe they could have an

illusion of safety.

The risk to the immunocompromised should not be overstated to the general population because virtually any disease is worse

when the immune system is not functioning normally. “Mortality rates are 40 to 60 percent for patients without concomitant HIV infection” in Valley Fever patients with

meningitis. (1) This complication is clearly serious even for patients who do not have HIV/AIDS. In a study of Valley

Fever pneumonia autopsies from the San Joaquin Valley, 98% of the victims did not have an immunocompromised condition.

The conclusion is clear: “Fatal coccidioidal pneumonia is certainly not confined to the immunocompromised host.” (2)

(1) Kelly PC. Coccidioidal meningitis. In: Einstein HE, Catanzaro A, eds. Coccidioidomycosis. Proceedings of the 5th International Conference on Coccidioidomycosis. Stanford University, 24-27 August, 1994. Washington, DC. National Foundation for Infectious Diseases; 1996: 373-384.

(2) Stevens DA. Immunology of coccidioidomycosis. In: Stevens DA. Coccidioidomycosis. A Text. New York, London: Plenum Medical Book Company, 1980: 87-95.

Before the increased use of immunosuppressive drug therapy and the appearance of HIV/AIDS, only 2% of Valley Fever cases had an underlying illness. Coccidioides clearly threatens public health regardless of any individual’s immune status. (1) A 2006 study of hospitalization data found that only 12% of hospitalized Valley Fever patients had an underlying immunocompromising condition. (2) From our own questionnaires at www.valleyfeversurvivor.com to date, the vast majority of people had healthy immune systems when they contracted Valley Fever.

(1) Bouza E, Dreyer JS, Hewitt WL, Meyer RD. Coccidioidal meningitis. An analysis of thirty-one cases and review of the literature. Medicine (Baltimore) 1981 May;60(3):139-72 citing Hart PD, Russell E, Remington JS: The compromised host and infection. II. Deep fungal infection. J Infect Dis., 120: 169, 1969.

(2) Chu JH, Feudtner C, Heydon K, Walsh TJ, Zaoutis TE. Hospitalizations for endemic mycoses: a population-based national study. Clin Infect Dis. 2006 Mar 15;42(6):822-5.

Even when immune system problems are ruled out, it is clear from studies that race is a risk factor. Some studies even seem to show that being an otherwise-healthy African-American with Valley Fever can be

as problematic as having AIDS or other immune diseases with Valley Fever.

Seitz AE, Prevots DR, Holland SM. Hospitalizations associated with disseminated coccidioidomycosis, Arizona and California, USA. Emerg Infect Dis. 2012

Sep;18(9):1476-9. doi: 10.3201/eid1809.120151.

Considerations About Racial Risk Factors


Racial risk factors in Valley Fever are not always clear.

No racial differences found in a 30% dissemination rate at Lemoore NAS

Lee R, Crum-Cianflone N. Increasing incidence and severity of coccidioidomycosis at a naval air station. Mil Med. 2008 Aug;173(8):769-75.

45% of a Navy SEAL squad fell ill with Valley Fever in Coalinga, CA, with no risk groups infected.

Crum N, Lamb C, Utz G, Amundson D, Wallace M. Coccidioidomycosis outbreak among United States Navy SEALs training in a Coccidioides immitis-endemic area--Coalinga, California.

J Infect Dis. 2002 Sep 15;186(6):865-8. Epub 2002 Aug 16.


Ironically, for all the race-based risk factors, Caucasians are almost always the most affected by Valley Fever—Even in the classic study that first demonstrated dramatically higher death rates in

other groups, the total number of Caucasians killed by Valley Fever was higher than any other race.

Gifford MA, Buss WC, Douds RJ. Data on coccidioides fungus infection. Kern County, 1901-1936. In: Annual Report of the Kern County Department of Public Health, 1936-37, p39-54.


Considering that whites and Hispanics may not have the same risk factors of other groups, it is interesting to note that from the years 2000-2011, both of these

groups supposedly at lower risk of developing Valley Fever illnesses in fact had 78% of California's

infections overall.Sondermeyer G, Lee L, Gilliss D, Tabnak F, Vugia D. Coccidioidomycosis-associated

hospitalizations, California, USA, 2000-2011. Emerg Infect Dis. 2013 Oct;19(10):1590-7. doi: 10.3201/eid1910.130427.


As racial diversity increases, it may be possible to expect a corresponding increase in the overall

severity and death toll of the Valley Fever epidemic. However, demography shows the people who are least likely to suffer per capita will suffer from the

illness the most by the force of numbers alone.

Considerations aboutAge Related Risk Factors

Extremes of age are said to be a risk factor

Considerations aboutAge Related Risk Factors

One study in California showed children under the age of five to be the least likely age group to

be infected.(1)

In Los Angeles County in 2006, the most frequentlyinfected age group was 15-34 years old, and the second

most infected age group was 45-54 years old. (2)(1) Rosenstein NE, Emery KW, Werner SB, Kao A, Johnson R, Rogers D, Vugia D, Reingold A,

Talbot R, Plikaytis BD, Perkins BA, Hajjeh RA. Risk factors for severe pulmonary and disseminated coccidioidomycosis: Kern County, California, 1995-1996. Clin Infect Dis. 2001 Mar 1;32(5):708-15. Epub 2001 Feb 28.

(2) Los Angeles County. Tables of Notifiable Diseases 2006. http://www.lapublichealth.org/acd/docs/Tablesnotifynew06%5B1%5D.pdf

MacLean M. The Epidemiology of Coccidioidomycosis – 15 California Counties, 2007-2011. Produced for the California Coccidioidomycosis Collaborative. Jan 2014

More data supports this, showing that the increased incidence of reported Valley Fever by age is

mitigated by the sheer numbers of people infected in younger adult risk groups.

In a 1998-2011 of age groups...6,352 infections in ages 20-397,684 infections in ages 40-59

Either of these two groups were higher than any other age group by a margin of over 1300, and together represented

more than half of the study's 22,401 reported cases.

Centers for Disease Control and Prevention (CDC). Increase in reported coccidioidomycosis--United States, 1998-2011. MMWR Morb Mortal Wkly Rep. 2013

Mar 29;62 (12):217-21.

A simple analysis of the numbers shows again that those at the greatest risk per capita are not the ones

being infected the most overall.

If the most important thing is to notify the people at greatest risk, who is that?

Don't bury the lead

Does this bury the lead?Snyder CH. Coccidioidal meningitis presenting as memory loss. J Am Acad Nurse Pract. 2005 May;17(5):181-6.

PURPOSE: This case study is designed to help the nurse practitioner recognize atypical symptoms of coccidioidal meningitis, particularly in high-risk groups that require further diagnostic treatment.

DATA SOURCES: Selected research, clinical articles, and case studies.

CONCLUSIONS: Coccidioidal meningitis is a potentially lethal infection unless recognized and treated. Unlike other infectious meningitides that present with more acute meningeal symptoms, disseminated coccidioidomycosis can present insidiously. When it presents as cognitive dysfunction, it may be mistaken for early dementia and if undiagnosed can result in death. While it is an infectious disease that is endemic to a small number of southwestern states, these areas see a high volume of tourists who can unwittingly become infected. Knowledge of this infectious disease and the many ways it can imitate other diseases is critical to its early recognition and treatment.

IMPLICATIONS FOR PRACTICE: Failure to recognize this reemerging, endemic fungal infection in high-risk groups can result in death.

Compare the two warnings:

1) "Groups that are particularly likely to have dissemination are Native Americans, African Americans, Asians, the elderly, and workers in close contact with soil or dusty conditions."

2) "Groups that are particularly likely to have dissemination are Native Americans, African Americans, Asians, the elderly, and workers in close contact with soil or dusty conditions but Caucasians, Hispanics and any race can suffer a severe or fatal case of Valley Fever. Chronic Valley Fever conditions are not race specific."

Even in a dust storm, people tend not to abandon their daily routine. It may not be realistic or useful to

highlight risk factors at all. Race and age discussions may be a distraction from the

fundamental truth that will protect everyone. It would be simpler and just as true to to highlight only

the behavioral risk:

"Avoid dusty conditions and work in the soil because anyone can suffer a severe or

fatal case of Valley Fever."

Considerations About Risk Factor Warnings

Only a miner's mask will provide a sealthat is tight enough to offer protection

Cocci arthroconidia have blown up to 500 miles outside of endemic areas.

DiSalvo A. Dimorphic Fungi. Microbiology and Immunology On-Line.http://www.med.sc.edu:85/mycology/mycology-6.htm

Masks and Protective Measures


One of our questionnaire respondents had soil testing done and found it right outside her front door. Contrast this with the historical experience of

researchers who had difficulty finding a soil sample but happened to be infected during the search for it.

Egeberg RO. Socioeconomic impact of coccidioidomycosis. In Einstein HE, Catanzaro A, eds. Coccidioidomycosis. In: Einstein HE, Catanzaro A, eds.

Coccidioidomycosis. Proceedings of the 4th International Conference on Coccidioidomycosis. Washington, DC. National Foundation for Infectious

Diseases; 1985


“Roads were paved, air strips were hard-surfaced and swimming pools replaced dusty athletic fields.

Lawns were planted by the acre, and military personnel were ordered, at risk of court martial, to avoid

unprotected areas”

Fiese, MJ: Coccidioidomycosis 1958 Springfield, Ill. Thomas

Protective Measures

Keep kids, pets and yourself indoors during windstormsClose all vents, windows, and doors during times of high wind.Industrial work crews use the wetting of soil as a dust control measure outdoors. During World War II training in the desert even sprays of oil on sand were used to reduce the infection rate. Water can be used as a dust control measure to help with outdoor furniture as well after a storm.

The Biggest Valley Fever Misperception

Valley Fever is not just a local disease!

Valley Fever is not just a local problem

Millions of people visit the endemic areas every year. As in the past, our military are hit hard. With bases comprising approximately 300,000 personnel in the endemic areas, many of them from home cities and

states that are not endemic, they are a large population being exposed to Valley Fever.


A sample of military reviews with different perspectives but similar comments across the decades

are listed in this slide.

Smith CE, Beard RR. Varieties of coccidioidal infection in relation to the epidemiology and control of diseases. Am J Public Health. 1946;36:1394–402.Olivere JW, Meier PA, Fraser SL, Morrison WB, Parsons TW, Drehner DM. Coccidioidomycosis--the airborne assault continues: an unusual presentation with a review of the history, epidemiology, and military relevance. Aviat Space Environ Med. 1999 Aug;70(8):790-6.Crum-Cianflone NF. Coccidioidomycosis in the U.S. Military: a review. Ann N Y Acad Sci. 2007 Sep;1111:112-21. Epub 2007 Apr 13Lee R, Crum-Cianflone N. Increasing incidence and severity of coccidioidomycosis at a naval air station. Mil Med. 2008 Aug;173(8):769-75.Coccidioidomycosis, active component, U.S. Armed Forces, January 2000-June 2012. MSMR. 2012 Sep;19(9):10


Fomites are objects that can harbor spores to infect people at long distances

A mechanic in Oregon was “totally disabled” from Valley Fever after working under a truck that had

driven through endemic areas. Marmor D. “Fungus among us” and Workmen’s Compensation. Med Trial Tech Q.

1976 Spring;22(4):385-402.

Cotton factory workers in Japan and non-endemic parts of the United States were sickened (with some fatalities) in outbreaks of Valley Fever due to

Coccidioides spores brought to them on cotton.

Ogiso A, Ito M, Koyama M, Yamaoka H, Hotchi M, McGinnis MR. 1997. Pulmonary coccidioidomycosis in Japan: case report and review. Clin. Infect. Dis. 25:1260-1261.

Gelhlbach SH, Hamilton JD, Connant NF. Coccidioidomycosis-an occupational disease in cotton mill workers. Arch Intern Med 1973;131:254-5.

Iranian soldiers who had purchased imported American clothing were infected in Iran.

Asgari M, Owrang A. Results of skin test surveys for systemic mycoses in Iran. Mycopathol Mycol Appl 1970;41(1):91-106.

A 23-year-old steam boat crewman who had not been to endemic areas was found with Valley Fever lesions in both lungs and osteomyelitis, ultimately requiring

the amputation of both feet.Rothman PE, Graw RG Jr, Harris JC Jr, Onslow JM. Coccidiodomycosis--possible

fomite transmission. A review and report of a case. Am J Dis Child. 1969 Nov;118(5):792-801.

A woman in Europe became infected with Valley Fever because someone mailed her a cactus from

Arizona as a gift. Coccidioides spores were later found inside its pot.

Brauer RJ, VFCE Executive Director personal communication, Sept 2002.

A European traveler to Africa and Asia was also sickened. His doctors believed his dose of

Coccidioides spores might have been “harboured in the air-conditioning system of an aircraft arriving from an endemic area” since the man had never visited North

or South America, let alone the specific endemic areas.Papadopoulos KI, Castor B, Klingspor L, Dejmek A, Loren I, Bramnert M. Bilateral

isolated adrenal coccidioidomycosis. J Intern Med. 1996 Mar;239(3):275-8.

Valley Fever might have achieved major visibility in the late 1980s from a Department of Transportation report. They knew even in 1989 that commercial

airliner cabin environments could hold and transport infectious organisms and specifically named

coccidioidomycosis as a potential problem. Rather than making this a discussion of fomites and Valley

Fever, this report achieved greater fame by its mention of tobacco smoke in the air cabin. Television and

newspaper reporting focused on health concerns from second hand smoke, leaving major Valley Fever

headlines for a future time.Nagda, Niren Laxmichand, United States Department of Transportation. Airliner cabin

environment : contaminant measurements, health risks, and mitigation options. Germantown, Md. : GEOMET Technologies ; Washington, D.C. : U.S. G.P.O., 1989

Finally, to show its nationwide reach, Medicare is responsible for 23-25% of payment of Valley Fever related hospital costs in recent studies in California.


Sondermeyer G, Lee L, Gilliss D, Tabnak F, Vugia D. Coccidioidomycosis-associated hospitalizations, California, USA, 2000-2011. Emerg Infect Dis. 2013 Oct;19(10):1590-

7. doi: 10.3201/eid1910.130427.

The financial cost of Valley Fever has been borne nationwide and will continue to be.

Flashpoints

Local media and health departments Do not refer to Coccidioides as the

most virulent fungal parasite known to man, even if biological warfare information does.

Dixon DM. Coccidioides immitis as a Select Agent of bioterrorism. J Appl Microbiol. 2001 Oct;91(4):602-5.

Perhaps there is a "seriousness gap" between the common reporting of Valley Fever and the way the military and many peer-reviewed journals handle it.

I have never been able to find the term "fungal parasite" spoken when Valley Fever appears on any media broadcast and reporting unless I have been

quoted. This term helps people understand the seriousness of the disease and may shake people

from their illusion of safety.

The word "fungus" on its own does seem to make people associate it with the severe symptoms.It makes people think of something that gets

killed off when they put powder on their feet. Perhaps the term "systemic fungal infection"

would also be appropriate.

The selective use of words can make people respect the importance of the disease or ignore it.

If someone says most people won't notice they are infected, says the risk group is "someone else" and

claims Valley Fever is only a local problem affecting a small number of people, you can practically guarantee the disease will be swept under the rug – After all, it is

still practically unknown to the general American public for over a century.

This "seriousness gap" will inevitably be bridged by a cold slap of reality as the Valley Fever epidemic continues. With the booming population in the

Southwest, the increasing number of tourists, and attention focused on the disease like never before,

professionals will be faced with flashpoints that will inevitably occur in the epidemic.

Natural disasters have already occurred to focus attention on Valley Fever. With the windstorm over

the Tehachapis in late 1977, the Northridge Earthquake of 1994, and other disasters sharply increasing the

Valley Fever caseload.

While sickness is always devastating, Valley Fever is not often seen as a drain on the economy. Consider what natural disasters might add to the following cost

estimates:

In 2001 the national medical treatment cost of Valley Fever was estimated at $120 million dollars.

Laniado-Laborín R. Cost-benefit analysis of treating acute coccidioidal pneumonia with azole drugs. In: Proceedings of the Forty-Fifth Annual Coccidioidomycosis Study Group Meeting. March 31, 2001. The University of Arizona. Tucson, Arizona.

A 2014 analysis for average annual Valley Fever hospitalization charges in California from 2000 to 2010 averaged over 171 million dollars annually.


Despite the severity of this incredible jump in one state's averages alone, another recent analysis also took

on California's 2011 charges as well. Rather than using the average, it showed the increase in costs that

have occurred over time. Its findings follow...

"During 2000–2011, the total charges for all coccidioidomycosis-associated hospitalizations in

California was US $2.2 billion, and the average annual total was US $186 million. After we adjusted for

inflation, the annual total charges increased from US $73 million in 2000 to US $308 million in 2011."

Sondermeyer G, Lee L, Gilliss D, Tabnak F, Vugia D.Coccidioidomycosis-associated hospitalizations, California, USA, 2000-2011.

Emerg Infect Dis. 2013 Oct;19(10):1590-7. doi: 10.3201/eid1910.130427.

Arizona is known to have twice as many cases as California. There are other endemic states. There are travelers to these

areas who become infected, many of whom must seek medical care elsewhere. There is also the fact that many

would face medical expenses that would be unrelated to the specific hospitalization charges studied, such as those

diagnosed who did not require hospitalization.

Therefore, adding a little more than twice these expenses to the previous total could be reasonable for the country.

That comes to one billion dollars in annual medical costs for Valley Fever, and could be a very conservative estimate of medical expenses when ongoing antifungal drug costs are

considered. The cost of lost productivity could be left to actuaries, and the personal suffering is,

of course, incalculable.

Transmission by fomites would be a different form of disaster. Deaths and illness have occurred from

sending potted plants, sending agricultural products like cotton, and even clothing exported from the

endemic areas. Nurseries do not test whether the soil they export in plants may harbor Valley Fever, cotton farms do not test, and even simple items being sold

from retail outlets may ultimately spread these spores. Tourists who buy from outdoor vendors, automobiles,

and virtually anything imaginable could become a public focus for this. Inevitably, an export of Valley

Fever from the area will become publicized.

Biological Warfare: After events such as the Japanese sarin gas attack, the attack on Oklahoma City,

and the attacks of September 11th, the fungus that causes Valley Fever was federally regulated as a Select

Agent in the Antiterrorism and Effective Death Penalty Act of 1996 and the Public Health Security and Bioterrorism Preparedness and Response Act

of 2002.

Cocci was regulated as a select agent of biological terrorism for 16 years. Then in late 2012 it was

dropped from the list, even though the reasons for its inclusion had never changed: It is still difficult to treat,

it can be chronic or reactivate over time, it causes major economic damage, and it is still an ongoing

problem at our military installations.

Specific outbreaks could also draw attention to the disease. Infections at the Kern Model Airplane

Championship and California's prisons are among the most well known. Archaeologists and missionaries

also have experienced some local outbreaks.

Off-road parks, solar stations, and other construction projects have become areas of specific outbreaks that

draw specific attention – legal attention

Lester Randolph's lawsuit against Arizona...

Explaining their reasons to reject Randolph's case, Judges Krucker, Hathaway, and Howard said that if a

duty to warn about Valley Fever existed, "the stream of cases would be endless,

the financial burden imposed upon such parties in defendant’s position catastrophic;

the workability of the rule impractical; and the availability of means by

which loss may be shifted impractical.”

Randolph v. Arizona Bd. of Regents, 19 Ariz.App. 121, 505 P.2d 559 (1973)

The judges essentially admitted there would be an “endless” stream of people would be so debilitated by

Valley Fever that any attempt to compensate them fairly would be a “catastrophic” pull on the

state’s purse strings.

Then, because the judges recognized the size of the Valley Fever problem, they decided it was

“impractical” to require warnings or to compensate those who suffer. According to these judges, then,

responsibility decreases as damages increase.

The impact of this reasoning inside a courtroom was to dismiss Randolph's case. Outside the courtroom, in today's media climate, even a little media coverage

would guarantee a stunning national outrage.

The recent movement of Californian prisoners seemed like an attempt to avoid this kind of outrage. However,

the story of Arjang Panah explains its urgency.

The $425,000 payout to Panah may have come because there is a unique duty to protect people who are

brought into areas against their will by the state. Panah was a federal prisoner originally from New York.

There must have been a realization that if one federal prisoner were able to sue successfully, an avalanche of other infected prisoners would realize they could sue. Settling out of court was a handy way of avoiding a

precedent-setting ruling.

It is not without precedent to move prisoners. After all, during World War II, captured Germans in

Florence, Arizona were moved because they were contracting Valley Fever, and Nazi Germany invoked the Geneva Convention to have the prisoners moved.

Deresinski SC. History of coccidioidomycosis: Dust to Dust. in Stevens DA, ed. Coccidioidomycosis. A Text. New York, London: Plenum Medical Book Company, 1980: p1-20.

Smith CE. Reminisces of the Flying Chlamydospore and its allies. In Ajello L, ed. Coccidioidomycosis. Papers from the second symposium on coccidioidomycosis. Tucson: University of Arizona Press, 1967: xiii-xxii.

On the subject of human rights, a focus could be moved away from adult prisoners to our most precious asset, our children. I was surprised

to find a medical journal article titled "Focal Endemic Coccidioidomycosis in Los Angeles County."

This title regrettably buries the lead.

Rao S, Biddle M, Balchum OJ, Robinson JL. Focal endemic coccidioidomycosis in Los Angeles County. Am Rev Respir Dis 1972 Mar;105(3):410-6.

A more appropriate title would be "Experimentation on Children in California."

Economic consequences may come from completely unexpected organizations with no specific legal authority.

Consider the SARS epidemic of 2003 in Toronto, Canada.

"On April 23, 2003, the World Health Organization issued an advisory against travel to Toronto. Although it was

withdrawn six days later, the advisory had a costly effect. The tourism industry lost $260 million (Canadian), and 11 percent of businesses related to tourism reported layoffs. In Ontario, provincial government costs of coping with SARS

have been estimated at $1.13 billion (Canadian)."

Svoboda T, Henry B, Shulman L, Kennedy E, Rea E, Ng W, Wallington T, Yaffe B, Gournis E, Vicencio E, Basrur S, Glazier RH. Public health measures to control the spread of the severe acute respiratory syndrome during the outbreak in Toronto. N Engl J Med. 2004 Jun 3;350(23):2352-61.

Now consider any of the Valley Fever disaster scenarios. Publicity can shape public opinion and the need for groups to act. Is it inconceivable that any of

these scenarios might prompt the World Health Organization or another group to react with a travel

advisory against Valley Fever's endemic areas?

When politicians are accused of something bad, it hurts them in polls. Then when they deny it, the denial

hurts them again in public opinion.

Professor Kathleen Fearn-Banks, author of' "Crisis Communication"

In the court of public opinion as well as in any legal proceedings that may occur against government offices, publicity could worsen for those holding

information back.

Dealing with Flashpoints

The clearest political move is to "get out in front" of any issue and create a track record. But to work it can never be a half measure. Half-hearted efforts will not earn full respect, and no amount of public relations can

overcome a history of inaction or misinformation.

Those who shape public policy have to focus on the most severe aspects of the data and the most serious

problems Valley Fever can cause or they will be caught completely unprepared. The states, counties, and cities whose work focuses on information that

could be seen as making the disease look less serious than it truly is would magnify their publicity problem

as the truth gradually trickles out during a crisis.

Churchhill said the truth is so important that it must be protected by a bodyguard of lies, but when so many falsehoods about Valley Fever are so common, using outdated or unclear information in the middle of a

crisis actually creates a panic scenario. When expert commentary can be disproven in a crisis, experts lose control and people will be inclined to believe

the worst thing they can imagine.

No matter how harsh it may sound on its face, truth is an antidote to panic. When your comments can be

independently verified as true you establish a foundation of trust.

The most useful response to a crisis depends on one's job in communications:

Medical doctors – aside from the treatments specific to the individual patient, you can mention the

possibility of reactivation and patient-specific risks as something calmly to watch for. It is neither a death

sentence nor the common cold to a given patient, but there is value in being prepared.

Employers – Everyone has seen a construction site with terrible dust control or an uncovered dump truck,

even when dust control measures require they be covered. Prepare with dust control measures and

education ahead of time so when a crisis hits, your people and the people nearby can be as

protected as possible.

Public Officials and Educators – Telling the whole truth, especially when it is unpleasant and harsher than expected, builds credibility. Aside from the fact that it is the only way to motivate funding for the vaccine and

cure projects, it is the best policy for the long term because it shows a history of honesty.

The positive example set at Kern County's Valley Fever web site:

http://kerncountyvalleyfever.com/

Whatever problems occur from Valley Fever in the future, a major challenge is that few people even know about it, and those who do often believe some of the following statements in full:

Infected people have a lifelong immunityMost people won't know they have the diseaseIt's a small problemIt is important to focus on specific risk factorsMasks can protect people from Valley FeverIt's only a local problem

A flashpoint will inevitably occur. People will demand clear and useful information when Valley Fever is in the spotlight. We need to

present facts that are free from misperceptions of the past, and the time to prepare ourselves is now.

For more information about our work:http://www.valleyfeversurvivor.com

Please send comments about this speech [email protected]

Public and Medical Misinformation on Valley Fever By David Filip Presented 4/23/2014.

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Transcript of Public and Medical Misinformation on Valley Fever By David Filip Presented 4/23/2014.