The infection is tough to diagnose, leading to an undercount of cases and delayed treatment
By Kaitlin Washburn @kwashy12
CENTRAL VALLEY – Dr. Royce Johnson is one of the go-to doctors for valley fever. He has been treating people with the infection, which can be fatal and is endemic to the Central Valley, for decades.
As the medical director of the Valley Fever Institute, he sees thousands of patients infected with valley fever, and he feels it should be a lot less.
“There is a lesser knowledge and misunderstanding of how big and severe the problem is and the impact on the population where you and I live,” Johnson said. “This is a major national health problem.”
While Johnson said the Institute recently received more attention and funding from the state and federal levels, he said lawmakers should have been taking valley fever seriously long ago.
“We’ve been doing research steadily over the years. But it’s always been on a shoestring,” Johnson said. “We never really had any support on this. I’ve had to do other research that paid me money so that I could do the research on valley fever.”
While valley fever is nothing new for the San Joaquin Valley, infection cases continue to rise. Health care professionals and activists say the care and resources for those afflicted fall short. This shortcoming acutely impacts farm workers, who risk contracting valley fever on the job and often don’t have access to health care.
Valley fever, also called coccidioidomycosis, or cocci, is an infection from a fungus that lives in soil, primarily in the southwestern parts of the United States, Mexico and Central and South America, according to the Centers for Disease Control and Prevention.
People contract the infection from inhaling the fungal spores, which usually enter the air when soil or dust is kicked up, like from agriculture or construction work. The spores prefer to live in undisturbed and dry natural soil. Once they’ve entered the air, valley fever spores can travel up to 75 miles.
People who work outside, like farm workers, tend to be at a greater risk of contracting the infection, said Dr. George Thompson, an associate professor of clinical medicine at UC Davis.
Thompson, who specializes in fungal infections and researches valley fever, said farm workers are more likely to inhale the spores while working outside.
Even though the fungus doesn’t like fertilized soil, it can still travel to fields where people are working. Some fields, even some parts of the same field, are more likely to have cocci spores than others, Thompson said.
However, that doesn’t mean a person with a desk job is safe from valley fever. Johnson, from the Valley Fever Institute, said roughly 50 percent of people who work indoors tested positive for the infection, as did 50 percent of farm workers, according to skin test surveys.
If someone tests positive for valley fever, that doesn’t mean they’ll experience symptoms, Johnson said. The fungus can remain dormant for someone’s entire life. Researchers have been trying to determine why the infection behaves this way, and Johnson said one explanation could be immunogenetics, the relationship between genes and the immune system.
Symptoms of valley fever are wide ranging, Thompson said. Most people who have inhaled the fungus never present symptoms, around two-thirds of people who test positive for the infection.
For the remaining one-third, most deal with flu-like symptoms for weeks, and in some cases, months.
The remaining three percent of people infected with valley fever deal with some aversion to the infection that requires life-long treatment. For less than one percent of patients, the infection travels to other parts of their body, like their bones, spine, skin and brain, Thompson said.
When patients are properly diagnosed, treatment for valley fever is effective and people can recover. The antifungals used to treat the infection continue to improve, Thompson added.
Johnson says only five to 10% of people who contract valley fever are diagnosed. If there were 3,000 diagnosed cases in a year, Johnson said he would predict that there were 30,000 infections.
The main limitation when diagnosing valley fever, Thompson said, is that doctors often don’t think to test for it and patients don’t think to ask.
“Some people think it’s this niche, rare infection. But that’s not the case,” Thompson said.
California, especially in the Central Valley, is in the midst of a doctor shortage, and doctors are coming from out of state to fill the health care gaps.
The Council on Graduate Medical Education recommends 60 to 80 primary care doctors per 100,000 people. But in the San Joaquin Valley, there are only 39, according to a report from The Future Health Workforce Commission.
Even though valley fever has been in California for over a century, doctors who weren’t trained here aren’t familiar with the infection. Those doctors don’t think to test for valley fever and will misdiagnose patients with diseases like pneumonia or the flu, Thompson said.
If someone with valley fever goes undiagnosed for months, it’s often too late for treatment to eradicate the infection. The patient is likely to experience lifelong symptoms.
Cases of valley fever in California have steadily increased for nearly 20 years. While that’s partially due to an increase in people contracting the infection, that spike is also thanks to doctors learning to recognize and properly diagnose valley fever, Thompson said.
The state of California did not start collecting data on valley fever cases until 1995, said Johnson, from the Valley Fever Institute.
In 2018 and 2017, California cases were at the highest ever, according to 17 years worth of data from the California Department of Public Health. Cases in 2018 totaled 7,515, slightly down from 7,658 in 2017.
In Tulare County, the numbers follow a similar pattern, 2017 and 2018 were the highest years for valley fever infections since 2001. Tulare County had 248 cases in 2018 and 281 in 2017.
The environment and climate does impact valley fever. It’s widely assumed that while in a drought, cases of valley fever spike. The relationship is not simple, said Johnson from the Valley Fever Institute.
“There almost certainly is a relationship between weather and climate and valley fever,” said Johnson. “Despite the fact that we’ve come out of a drought and had a very rainy year, it appears that this will be a very big year. We changed from very dry to very wet quite quickly, yet the trend line is still going up.”
Isabel Arrollo Toland is the executive director of El Quinto Sol de America, an organization based in Lindsay focused on working with communities to connect them with resources they might otherwise not be able to access or know about.
Health is a major priority for many of the people Toland works with, and valley fever is a particular worry for farm workers.
Toland said her organization teaches farm workers to advocate for themselves at the doctor’s office. She’d also like for doctors to ask questions that are tailored around understanding the work someone does in agriculture.
“Working in the fields, your health is always impacted. Valley fever is just one health threat that people face,” Toland said. “They are more affected by heat, lack of water, pesticide exposure. There are so many different things that could be asked that would improve care for the farm workers.”
Thompson, from UC Davis, said another struggle with linking farm workers with health care is the nature of their work is mobile, their jobs rely on following the harvest.
Toland said her organization connects people to services available for valley fever. Her main recommendation if someone thinks they have valley fever? Don’t get treated in Tulare County, but go to Kern County to see a specialist at the Valley Fever Institute.
That advice comes from personal experience. Toland contracted valley fever twice, and was misdiagnosed both times. The first time, in 2007, her doctor in Tulare County repeatedly diagnosed her with pneumonia.
Months passed and when Toland didn’t get better, she was advised to see a valley fever specialist in Bakersfield. She visited the Valley Fever Institute and tested positive for the infection. She was given proper medications, but it took months for her to recover.
Five years later, she developed a rash on her leg. After visiting a dermatologist for three months and watching the rash progressively worsen, she went back to Bakersfield and was again diagnosed with valley fever.
Toland said her organization isn’t aware of valley fever-specific resources available in Tulare County.
“We would love to encourage and support an organization in Tulare County that focuses on valley fever, it’s a necessity,” Toland said.
Julie Solis founded Valley Fever Awareness and Resources in 2016 when she realized nothing was being done to bring awareness to valley fever. Her organization is based in Kern County, which has — by far — the highest rates of valley fever in the state. Kern County had 2,937 cases in 2018, the highest rate in 17 years for the county.
Since forming her organization, Solis said she focuses on educating people about valley fever and encouraging community organizing.
“One of the biggest challenges is the lack of resources available to people who work outside, like agriculture workers,” Solis said. “We focus on outreach into the fields because nobody is out in the fields explaining what valley fever is.”
Solis, armed with cold water and valley fever pamphlets written in Spanish, ventures out to farms to visit with workers. She said many of the people she meets are undocumented and their fear of deportation prevents them from seeking care.
“There’s a lot of work to be done,” Solis said. “We would love for the county and the state to take more responsibility on this issue.”
Tammie Weyker-Adkins, public information officer for Tulare County Health and Human Services Agency, said her department focuses on educating residents about all health risks they might face, including valley fever.
“Our role is educational base, and we have partnerships with stakeholders that have different roles, like Kaweah Delta,” Weyker-Adkins said. “We do outreach via social media or press releases and recommend people to take simple, preventative measures.”
One preventative measure they recommend, particularly to farm workers, is to wear a mask while working to avoid inhaling the fungal spores.
“We have public health clinics in the county that provide health services, including valley fever treatment,”said Sharon Minnick, an epidemiologist with the health and human services agency.
Aside from those efforts, Weyker Adkins said, “It’s not necessarily our role to specifically provide valley fever help.”
Dr. Dan Boken, an infectious disease physician at Kaweah Delta, said he doesn’t know of any efforts at Kaweah Delta that specifically focus on valley fever.
Boken said, however, there is plenty of access to treatment in Tulare County for people who contract valley fever. He works in clinics throughout the county that treat people for the infection. He sees a diverse group of patients with the infection, some of whom work in agriculture.
Rep. Kevin McCarthy, the House Minority Leader from California’s 23rd District, recently co-sponsored the FORWARD Act, a bill that would address the challenges of detecting, treating, and eventually eradicating valley fever.
The bill, which was sponsored by a bipartisan group of congress members from California and Arizona, would include efforts to increase public awareness of the infection and promote the development of new treatments and a vaccine.
In 2018, former Gov. Jerry Brown approved $8 million in state funding for valley fever. Of that $6 million was dedicated toward research and split between the UC system and the Valley Fever Institute. Two million dollars was allocated for awareness and outreach through the California Department of Public Health.
Johnson, who has been with Kern Medical 44 years, said he’s grateful for the support from lawmakers at both the national and state level, but this is a new phenomenon.
“It’s been a long time coming,” Johnson said. “I think both of those groups should have known this was a problem 50 years ago.”