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Rates and Risk Factors for Coccidioidomycosis among Prison Inmates, California, USA, 2011 - Volume 21, Number 1—January 2015 - Emerging Infectious Disease journal - CDC

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Rates and Risk Factors for Coccidioidomycosis among Prison Inmates, California, USA, 2011 - Volume 21, Number 1—January 2015 - Emerging Infectious Disease journal - CDC


Volume 21, Number 1—January 2015


Rates and Risk Factors for Coccidioidomycosis among Prison Inmates, California, USA, 2011

Charlotte WheelerComments to Author , Kimberley D. Lucas, and Janet C. Mohle-Boetani
Author affiliations: California Correctional Health Care Services, Elk Grove, California, USA


In California, coccidioidomycosis is a disease acquired by inhaling spores of Coccidioides immitis, a fungus found in certain arid regions, including the San Joaquin Valley, California, USA, where 8 state prisons are located. During 2011, we reviewed coccidioidomycosis rates at 2 of the prisons that consistently report >80% of California’s inmate cases and determined inmate risk factors for primary, severe (defined as pulmonary coccidioidomycosis requiring >10 hospital days), and disseminated coccidioidomycosis (defined by hospital discharge International Classification of Disease, Ninth Revision code). Inmates of African American ethnicity who were >40 years of age were at significantly higher risk for primary coccidioidomycosis than their white counterparts (odds ratio = 2.0, 95% CI 1.5–2.8). Diabetes was a risk factor for severe pulmonary coccidioidomycosis, and black race a risk factor for disseminated disease. These findings contributed to a court decision mandating exclusion of black inmates and inmates with diabetes from the 2 California prisons with the highest rates of coccidioidomycosis.
Coccidioidomycosis, commonly called “cocci” or “valley fever,” is an illness caused by Coccidioides immitis and C. posadasii, soil-dwelling fungi found in certain arid regions of the southwestern United States, northern Mexico, and Central and South America. Infection is acquired by inhaling airborne fungal spores and is not spread person-to-person. Sixty percent of Coccidioides infections are asymptomatic, and most symptomatic infections consist of self-limited, flu-like illnesses. A small proportion of cases result in prolonged illness that may require lifelong treatment and can be life-threatening, particularly the 3%–5% in which the disease disseminates outside of the lungs. Infection, except in very rare cases, confers lifelong immunity.
In 2005, the medical executive team of the California Department of Corrections and Rehabilitation (CDCR) informed the California Department of Public Health (CDPH) that physicians at 2 prisons for adult men (prison X and prison Y) reported an increase in the number of inmates with coccidioidomycosis. The prisons are located <15 miles apart from one another in a Coccidioides-endemic area of California’s San Joaquin Valley. In response to the call, CDPH investigated the cases at prison X and confirmed rates of disease >400× higher than those of the surrounding county. Additionally, CDPH performed a cohort study at prison X and identified an increased risk for coccidioidomycosis among African-American inmates, inmates >40 years of age, and inmates who resided on a particular yard (J. Yuan, unpub. data).
In 2006, CDPH made recommendations concerning coccidioidomycosis. In response, the California Correctional Health Care Services (CCHCS) (the medical arm for California inmates) instituted policies for educating inmates and staff about coccidioidomycosis and for excluding inmates with immunocompromising conditions or severe chronic obstructive pulmonary disease from California prisons in 3 coccidioidomycosis-endemic counties. In addition, the agency mandated the cancellation of planned construction to expand prison X. During subsequent years, prisons X and Y took measures to control ambient dust (and presumably spores) by planting native grasses and shrubs on bare grounds. In December 2011, prison X applied a soil-stabilizing emulsion to most of the grounds within the prison’s perimeter. Despite these efforts, high coccidioidomycosis attack rates continued to be reported from these institutions (CCHCS coccidioidomycosis surveillance system, unpub. data).
The purpose of this study was to review rates of coccidioidomycosis at prisons X and Y, to reevaluate the population for risk factors for development of primary disease, as well as to evaluate inmate risk factors for development of the most debilitating forms of coccidioidomycosis. We used the study results to improve the policies and practices for protecting California inmates from coccidioidomycosis and its most serious sequelae.

Dr. Wheeler is a public health physician with the California Correctional Health Care Services in Elk Grove, California. Her interests include the investigation of outbreaks of infectious diseases and the prevention and control of infectious diseases in correctional settings.


We thank Renee Kanan, Annette Lambert, and the Quality Management team for helping us to characterize the inmates in this study. We also thank Faisal Aranki and Michael MacLean for providing information for the cities in which prisons X and Y are located. Finally, we thank the public health nurses at CCHCS headquarters and in the field for their assiduous reporting of coccidioidomycosis in inmates at California prisons.
Preliminary results from this study were presented at the 7th Academic and Health Policy Conference on Correctional Health, March 20–21, 2014, Houston, Texas, USA.


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Suggested citation for this article: Wheeler C, Lucas KD, Mohle-Boetani JC. Rates and risk factors for coccidioidomycosis among prison inmates, California, USA, 2011. Emerg Infect Dis. 2015 Jan [date cited]. http://dx.doi.org/10.3201/eid2101.140836
DOI: 10.3201/eid2101.140836

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