Physicians: Valley fever underreported

New protocol intended to increase screenings

Phoenix-based Banner Health has a new protocol for physicians that the company suspects will increase screenings for valley fever, a potentially deadly and often misdiagnosed upper-respiratory infection.

“From looking at the data, it’s obvious that many physicians almost never or never order valley fever tests,” said Dr. John Galgiani, who is director of the University of Arizona’s Valley Fever Center for Excellence and helped develop Banner protocol.

“They are not looking for valley fever.”

If the Banner program works as intended in its primary care offices, urgent care centers and emergency departments, Valley fever screening in Arizona will increase. And researchers such as Galgiani should be able to more accurately gauge the disease’s impact and patients will get more accurate diagnoses and timely treatment.

As many as 25 percent of Arizonans diagnosed with community-acquired pneumonia actually have Valley fever, Galgian said, citing published research.

“We know there’s a discrepancy between the number of folks that get tested for valley fever versus the number of folks that likely have valley fever,” said Dr. William W. Holland, who is vice president of care management for Banner Health, Arizona’s largest health system.

“When folks are trained in other states where valley fever is not endemic, it’s not always the first thing on their mind . ... I think this will help bring a significant amount of awareness in helping to identify those patients early.”

Though it’s one of the most commonly reported infectious diseases in Arizona, awareness of valley fever is lagging and Galgiani estimates the fungal disease, which goes by the clinical name coccidioidomycosis, is severely underreported.

That’s important for health providers because an estimated two-thirds of all valley fever cases nationwide occur in Arizona.

It’s also important for Arizona residents because the main risk factor for getting valley fever is impossible to avoid — breathing air in one of the areas in the Southwest and West where the disease is endemic, primarily Arizona

and California’s San Joaquin Valley.

Valley fever has also been found in Nevada, New Mexico, Texas, Utah, parts of southeastern Washington, Mexico, and in parts of Central and South America.

One need inhale just a single coccidioides fungal spore to get Valley fever. The good news is that most people who get Valley fever will recover on their own, and may not even know they had it. Once you’ve had Valley fever, experts say, you can’t get it again.

But approximately one-third of people who inhale a coccidioides fungal spore gets sick enough to go to a doctor. In one of every 200 people who get infected, the Valley fever disease goes to the bloodstream.

Earlier detection ideally will cut down on unneeded treatment, biopsies and in some cases, severe illness and death, Galgiani said.

One of the reasons for the underreporting is that symptoms of the disease, which was blamed for the deaths of 48 people in Arizona last year, can easily be mistaken for pneumonia or even the flu.

Those symptoms often include fatigue, cough, fever, shortness of breath, headache, night sweats, muscle aches or joint pain and rash on upper body or legs. The bone and joint pain can be so bad that valley fever has also been known as “desert rheumatism.”

Doctors in Arizona often have trained outside the state and do not always consider vballey fever as a possibility, Galgiani said.

Galgiani spearheaded the valley fever protocol change through a Bannerwide process called Clinical Consensus Groups, in which system changes in protocol happen through consensusbuilding.

Banner has done similar processes with groups of medical experts to develop best practices for, among others, sepsis detection and specific surgical procedures.

The idea is to then “hardwire” the practice across the organization, Holland said.

Patients who show up at any Banner facility with symptoms of pneumonia, particularly if they return after not getting better, should now expect valley fever to be considered as a diagnosis.

Ideally, with the new protocol primary care doctors will be able to both diagnose and manage valley fever cases themselves, officials said. The idea is to create systemic change by forming new treatment habits, which should work better than handing out educational materials, Galgiani said.

Galgiani, an internationally known expert in valley fever, said the protocol is for front-line physicians, including those who work in primary care, urgent care and emergency departments. Banner in 2015 formed an academic affiliation with the UA as part of a merger with the University of Arizona Health Network.

The valley fever protocol is a product of that partnership, said Galgiani, who, along with his valley fever colleague Dr. Fariba Donovan, is doing statewide, inperson trainings with Banner doctors.

Banner operates 28 hospitals in six states but will be implementing its new protocol solely in Arizona, where the private, non-profit company is based.

That’s because the fungal coccidioidomycosis spores that cause valley fever grow in a “Valley fever corridor” that runs through Maricopa, Pima and Pinal counties.

From January to October this year, nearly 6,500 cases of valley fever were reported to the Arizona Department of Health Services. The total is 32.7 percent higher than the five-year average for that same time period.

“Folks typically have symptoms for one to three weeks after exposure, but they look and feel very similar to the symptoms for community-acquired pneumonia,” Holland said,

“Some data out there suggests there’s a large number of folks who are diagnosed with community-acquired pneumonia who are treated with antibiotics for bacteria rather than anti-fungals and may actually have Valley fever.”

Last December nearly 1,200 cases were reported to the state marking the highest monthly number of valley fever cases reported to the state in five years, a recent report from the U.S. Centers for Disease Control and Prevention says.

The CDC found an overall spike in Arizona cases reported from October 2017 to March 2018 may have been caused by several factors, including precipitation, which can promote coccidioides growth, followed by high temperatures and drought, which can cause the spores to spread through dust.

Other contributing factors may have included dust disturbance from increased residential construction, the CDC report said.

The UA is working on a vaccine against valley fever in dogs that may end up working for humans, too. But, at the moment, there is no proven way to prevent the disease.