Valley fever is considered, by most people in the health industry, a silent epidemic because the spread of the disease is not clearly detected. Most people who might have the disease show no symptoms or display symptoms that are identical to other diseases like the flu, pneumonia, and sometimes even as cancer. Valley fever has become an increasing problem in the US, but namely in the Central Valley. The main behaviors contributing to the rising valley fever problem in the Central Valley include not enough groups raising awareness in the community about the disease and misdiagnosis from health care professionals.
So what is valley fever? Valley fever is a fungal disease caused by the soil-dwelling fungus called Coccidioides immitis. The fungus prefers to reside within hot, dry, and dusty regions and is therefore prominent in the Central Valley. It is saprobic in soil, meaning that it will eat dead matter, and it becomes parasitic once it enters the body. The fungus tends to be located in rodent burrows. It is not known why exactly but it is theorized that this is because desert rodents are resistant carriers of the pathogen and are able to spread the spores of the fungus throughout the burrows and the fungus is able to live off the rodents’ excrements. When the rodents die, the fungus can then colonize in their body, use it as food, and also utilize the body as a source for the spreading of spores. Normally, these fungal spores can be inhaled through dust when soil is disturbed and will settle within the lungs where they then transform into larger, multicellular structures called spherules. Spherules leech off the nutrients in the lungs and grow until they burst, releasing more spores. These spores repeat the process, causing the fungus to vastly multiply within the lungs. This multiplication may lead to spreading of the spores outside of the lungs and throughout the skin, bones and the membranes surrounding the brain, causing meningitis. When the fungus spreads outside of the lungs, it is known as disseminated valley fever.
There are certain groups of people in the Central Valley who are more severely afflicted by valley fever. This includes individuals 23 to 55 years of age, people who work outside in the fields or at construction sites and definitely field workers who speak little English. Hispanic farm workers are greatly affected due to lack of awareness and resources. This is a grand problem because the Central Valley has a vast population of field workers who are Hispanic with limited English capability. This dilemma causes structural violence because the poor immigrant field workers lack awareness of the disease and their employers do not provide them with the proper protective gear and information, putting the field workers in high risk conditions. Employers themselves may not know or are simply trying to save money. However, the groups of people most likely to develop disseminated valley fever are African Americans and Asian/Pacific Islanders. Studies on lab mice has shown that overexpression of the cytokine IL-10, a cytokine responsible in suppressing hyperactive immune responses in the body, led to mice who got injected the disease to acquire disseminated valley fever. Humans also express IL-10 so it is speculated that African Americans and Asian/Pacific Islanders may produce a lot of IL-10, allowing the fungus to proliferate in their bodies while remaining undetected by the immune system.
Research evidence shows 111,717 reported cases in the US between 1998 – 2011. The Centers for Disease Control and Prevention (CDC) estimates about 150,000 cases of valley fever go unreported each year due to lack of awareness. California Department of Public Health reported 4,094 valley fever cases in California in 2012. Over 75% of valley fever cases from California come from the people who live in the Central Valley. Just recently, 3,000 prisoners in San Joaquin Valley had to be transferred due to risk of valley fever after some other inmates contracted the disease, indicating the possibility of the fungus harboring close to the jail.
There are certain current behaviors in the Central Valley that have led to the valley fever becoming such a big problem. At the individual level, workers find it easy and a convenience to not use proper masks when working outside in areas with coccidioidomycosis (scientific name of valley fever) spores. At the organizational level, organizations like the United Farm Workers have not been able to fight hard enough to come to agreement with farmers to provide proper protection for their workers. The San Joaquin Valley Air Pollution Control District also does not have enough restrictions established on how much farmers are allowed to disrupt soil, which does not set a limit to the amount of coccidioidomycosis spores released. Regulating this would help prevent and lower cases of Valley Fever. A major behavioral problem is that healthcare providers are not knowledgeable about the disease thus leading to many misdiagnoses.
Consequences that can be used to ensure that workers use protection when working outside is to have a system put in place where they can be fired or punished by their employer if they are caught not wearing a mask. In order to get organizations like United Farm Workers to petition for more change on protection against coccidioidomycosis spores is to have all the workers in the union stop funding them if they do not represent their worries of valley fever. The consequence that could be given to The San Joaquin Valley Air Pollution Control District would be to cut their funding by a certain percentage if they do not reduce valley fever in the Central Valley. Healthcare providers will be given a positive consequence like a bonus for correct diagnosis or a subtraction from their pay if they misdiagnose.
A solution to dealing with valley fever would be to modify clinician behavior to make mandatory blood tests for patients who display one or more valley fever symptoms. Diagnosis of valley fever is difficult based on symptoms alone due to vague characteristics. Symptoms of valley fever include fever, cough, chest pain, chills, night sweats, headache, fatigue, joint aches, and red-spotty rashes. This often leads to valley fever being mistaken for the flu due to the flu-like symptoms associated with it. In light of this dilemma, valley fever should be diagnosed through mandatory blood tests to check if the patients has valley ever by looking for antibodies present in their blood that fight against the fungus. The goal of this solution is to perform a proper and timely diagnosis that will get rid of the faulty behavior of valley fever misdiagnosis. This will allow for collaboration between patients, health care providers, and insurance companies. The consequence will result in an annual bonus incentive program for clinics where compliance will be reported through attestation from the patient. This will include a 10% bonus to health care providers for proper procedures and a 1% penalty for improper procedures. The funding source will be provided by insurance companies.
This solution will be effective and observable because doctors will get the incentive to properly diagnose valley fever every year. No other incentive program for valley fever has been tried before. The incentive program would be rather inexpensive because the money for the incentive will be reciprocated from the money saved by insurance company. It will also be decentralized since the program can definitely be applied to smaller scales communities such as those in Central Valley where insurance companies usually pay for all the medical bills. The program is flexible because incentives can be adjusted according to area it is being implemented in. The solution will remain sustainable because the funding comes from the money saved from all the misdiagnosis on a yearly basis. The solution is simple to implement since insurance companies already have all the records of all the procedures done on the patients and it is definitely compatible with the value of the target users because doctors value their reputation in giving the correct diagnosis and the incentive programs will give them the push they need.
Other possible solutions are to have people in endemic areas to wear powered air-purifying respirators (PAPRs) with high-efficiency particulate air (HEPA) filters. These masks reduce the average spore concentration to 1/1000 of the ambient air concentration, reducing risk of valley fever infection to around 0.17% due to a battery-powered blower that pulls air in through filters to clean it before delivering it to the wearer’s breathing zone. People living in the central valley can also limit outdoor activity in dusty areas and water down construction sites before disrupting the soil in order to avoid the spreading of spore-containing dust. Dusty clothing should also be removed prior to entering home environment. Research has shown that the drug nikkomycin Z inhibits the enzyme responsible for the formation of chitin, the building block of the fungal cell wall. So far this drug has tested successful in mice inoculated with valley fever in which the disease was halted and mice survived. These results have made nikkomycin Z a favorable candidate for battling the valley fever epidemic in the Central Valley.