Public and Medical Misinformation
on 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 locally
KOB 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.
Do infected people have a lifelong
immunity?
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 vaccine
It is the reason much of the Southwest's population is
not debilitated
Based 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.
Do infected people have a lifelong
immunity?
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.
Do infected people have a lifelong
immunity?
“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.
Do infected people have a lifelong
immunity?
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.
Do infected people have a lifelong
immunity?
"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.
Do infected people have a lifelong
immunity?
“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. p357371.
Do infected people have a lifelong
immunity?
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>
Do infected people have a lifelong
immunity?
“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.
Do infected people have a lifelong
immunity?
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.
Do infected people have a lifelong
immunity?
“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.
Do infected people have a lifelong
immunity?
There are no major long term studies specifically
following 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.
A Severe Reactivation
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.
Do infected people have a lifelong
immunity?
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. Protection
of mice against Coccidioides immitis intranasal infection by vaccination with
recombinant antigen 2/PRA. Infect Immun. 2002 Jun;70(6):3287-9.
Do infected people have a lifelong
immunity?
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
Do infected people have a lifelong
immunity?
Reinfections and Reactivations
Do infected people have a lifelong
immunity?
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.
Reactivations and
Locus Minoris Resistentiae (LMR)
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.
Reactivations and
Locus Minoris Resistentiae (LMR)
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.”
Reactivations and
Locus Minoris Resistentiae (LMR)
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.
Reactivations and
Locus Minoris Resistentiae (LMR)
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.
Reactivations and
Locus Minoris Resistentiae (LMR)
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.
Reactivations and
Locus Minoris Resistentiae (LMR)
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 and
Locus Minoris Resistentiae (LMR)
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.
Do infected people have a lifelong
immunity?
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.
Do infected people have a lifelong
immunity?
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 time
Immunodiffusion tests: 71% of the time
Complement 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 communityacquired 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 uneducated
2) It sets a standard of communication
3) Professionals familiar with the topic can point to
holes in a theory
4) Peer pressure for accuracy
"Valley Fever is not a small problem"
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.
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."
Peer Review's Benefits Vs. Reality
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.
Peer Review's Benefits Vs. Reality
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.
Peer Review's Benefits Vs. Reality
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.
Year
State
County (City)
1970
1990
2010
Totals
2.5
4.5
6.7
Arizona
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
0.4
California
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
0.4
Texas
El Paso (El Paso)
0.4
0.6
0.7
Sources: 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 Diagnoses
1998 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 % Increase
Arizona
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
Risk Factors
Race: Native American, African-American, Asian
(particularly Filipinos)
Age: Children under five and the elderly
Environmental/occupational: Working outdoors and
In dusty environments
Immunocompromised conditions
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, 2427 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.
Considerations About
Racial Risk Factors
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 otherwisehealthy 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.
Considerations About
Racial Risk Factors
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, 19011936. In: Annual Report of the Kern County Department of Public Health, 1936-37, p39-54.
Considerations About
Racial Risk Factors
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.
Considerations About
Racial Risk Factors
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 about
Age Related Risk Factors
Extremes of age are said to be a risk factor
Considerations about
Age 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 frequently
infected 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 20-39
7,684 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."
Considerations About
Risk Factor Warnings
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."
Masks and Protective Measures
Only a miner's mask will provide a seal
that 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
Masks and Protective Measures
“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
windstorms
Close 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.
Valley Fever is not just a local problem
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 13
Lee 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

Valley Fever is not just a local problem
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 airconditioning 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.
MacLean M. The Epidemiology of Coccidioidomycosis – 15 California Counties, 20072011. Produced for the California Coccidioidomycosis Collaborative. Jan 2014
Sondermeyer G, Lee L, Gilliss D, Tabnak F, Vugia D. Coccidioidomycosis-associated
hospitalizations, California, USA, 2000-2011. Emerg Infect Dis. 2013 Oct;19(10):15907. 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.
MacLean M. The Epidemiology of Coccidioidomycosis – 15 California Counties, 20072011. Produced for the California Coccidioidomycosis Collaborative. Jan 2014
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?
Dealing with Flashpoints
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.
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 immunity
Most people won't know they have the disease
It's a small problem
It is important to focus on specific risk factors
Masks can protect people from Valley Fever
It'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 to
[email protected]
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