BACKGROUND: Coccidioidomycosis (“Valley fever”) is endemic in the southwestern United States, particularly Arizona and California, where its effects on patients have been relatively well-characterized. However, features of coccidioidomycosis in residents of non-highly-endemic states have not been described in detail. Coccidioidomycosis is nationally notifiable, but the National Notifiable Diseases Surveillance System only captures basic coccidioidomycosis patient demographic information. We conducted enhanced surveillance in states where coccidioidomycosis is reportable to better describe the epidemiology, diagnosis, and outcomes of these patients to help inform surveillance and guide awareness and educational efforts.
METHODS: In 14 states (Louisiana, Michigan, Minnesota, Missouri, Montana, Nevada, New Mexico, North Dakota, Ohio, Oregon, Pennsylvania, Utah, Wisconsin, and Wyoming), state and local health department personnel identified coccidioidomycosis cases according to the CSTE case definition through routine surveillance during 2016 and interviewed consenting patients. Patients were asked about symptoms, healthcare use, treatment, outcomes, underlying medical conditions, and travel history using a standardized questionnaire. Coccidioidomycosis diagnostic test information was extracted from health departments’ surveillance databases. Data were compiled at CDC.
RESULTS: As of November 15, 2016, 140 coccidioidomycosis patients were interviewed. Seventy-nine (56%) were male, 113 (82%) were white, and the median age was 66 years (range, 7–90). Fatigue (n=97, 69%), cough (n=92, 66%), and fever (n=68, 49%) were commonly reported symptoms. Median time from symptom onset to seeking healthcare was 7 days (range, 0–488), and median time from seeking healthcare to diagnosis was 38 days (range, 0–295). Eighty-nine patients (66%) reported having been diagnosed with another condition before being tested for coccidioidomycosis; of those, 61 (74%) were prescribed antibiotics. Fifty-seven (42%) were hospitalized, 88 (64%) were treated with antifungal medications, and 88 (66%) said that their illness interfered with daily activities (for a median of 32.5 days [range 2–1,080]). In the 4 months before symptom onset, 69 (49%) traveled to Arizona and 16 (11%) traveled to California. Sixty-five (47%) patients knew about coccidioidomycosis before being diagnosed with it. Forty-one patients (29%) had culture-positive coccidioidomycosis.
CONCLUSIONS: Coccidioidomycosis causes substantial morbidity in residents of non-highly-endemic states, similar to previous studies of Arizona residents. The high proportion of patients diagnosed by culture (compared with <10% in Arizona surveillance) suggest that less severe cases likely go undiagnosed or unreported. Even among recognized cases, delays in diagnosis and unnecessary antibiotic use were common. Improved healthcare provider and public awareness of coccidioidomycosis outside highly-endemic areas is needed.