Just One Breath: Valley fever lurks inside and outside prison walls

Last year, the state of California was forced to move thousands of prisoners out of facilities in the Central Valley because they were infected or might become infected with valley fever.

The fungus that causes valley fever lives in the dirt throughout the Central Valley. The dirt gets into the air, and people are infected when they breathe in the fungal spores. Prisons in the Central Valley have a highly concentrated population in facilities that apparently don’t circulate the air very well. The rates of valley fever in prisons in the Bakersfield and Fresno areas has been found to be many times higher than the rates of the surrounding population.

But the rates in the surrounding population are so high – many times higher than the rest of the state – that a recent report by a federal agency found that prison workers who live in the community are suffering from the disease in large numbers. In their case, the prisons themselves cannot easily be blamed.

Here’s what happened.

The National Institute for Occupational Safety and Health (NIOSH), which is part of the CDC, “received a request from managers on behalf of a state correctional and rehabilitation agency and a state correctional health care services agency,” according to the report released last month, Evaluation of Coccidioides Exposures and Coccidioidomycosis Infections among Prison Employees. “They were concerned about potential employee exposure to the fungus Coccidioides at two state prisons (prison A and prison B) in the Central Valley of California.”

Oddly, the report never actually names the prisons that were studied. But Don Thompson from the Associated Press in Sacramento did obtain the names and reported:

Pleasant Valley State Prison in Coalinga had 3,358 inmates and more than 1,300 guards and other employees last May. The institute confirmed 65 Valley fever cases among the prison's employees over the 3 1/2-year period of its study, including two employee deaths. That equates to an average rate of 1,039 cases per 100,000 individuals, higher than the general rate of infection of 40 cases per 100,000 among the non-inmate adult population in Fresno County, the report says, though it cautions that there can be no direct comparison because of differences in the populations and the reporting of the illness. Avenal State Prison in Kings County had 4,538 inmates and more than 1,500 employees last May. The institute confirmed 38 Valley fever cases there, with one death. It had an average rate of 511 cases per 100,000, higher than the average of 110 cases per 100,000 adults in Kings County.

How did the agency do its study? It linked databases in a way that reporters across the country try to do every day. Usually reporters are denied access to the types of databases the agency used, though. This following paragraph from the report will likely make trainees from the National Institute for Computer Assisted Reporting salivate:

We obtained annual employee rosters for each prison from 2009–2013 from the correctional agency and the prisons. With assistance of the California Department of Public Health (CDPH) Infectious Diseases Branch, we matched the names on these rosters to the CDPH database that contains confidential morbidity report data on reported confirmed coccidioidomycosis cases in California. CDPH uses the Council of State and Territorial Epidemiologists (CSTE) case definition for coccidioidomycosis, which includes clinical and laboratory criteria. … We identified 276 possible matches at prison A and 216 possible matches at prison B. We then obtained more information from agency headquarters and the prisons on the possible employee matches, including sex, dates of birth, last four digits of social security numbers, home addresses, and dates of employment, to confirm that these coccidioidomycosis cases reported to CDPH occurred in individuals employed at either prison. We considered a match to be a coccidioidomycosis case reported to CDPH with the same name and same date of birth and/or same last four digits of social security numbers. For cases reported to CDPH that were missing date of birth or social security numbers, we considered a confirmed match if the employee was listed as a correctional facility employee in the confidential morbidity report. We excluded coccidioidomycosis cases among employees that were reported to CDPH prior to their date of hire.

To me, the key fact in the report is that the agency could not identify where the prison staff contracted the disease.

It was not possible to determine if each confirmed case of coccidioidomycosis among prison employees was due to an exposure at work or outside of work. The vast majority of prison employees with confirmed cases of coccidioidomycosis resided in a hyperendemic area, and our interview findings revealed that employees are likely exposed to Coccidioides both at work and outside of work. At work, almost all interviewed employees at each prison reported spending some time outdoors. Even walking from building to building could pose a risk for exposure to Coccidioides.

If “spending time outdoors” puts someone at risk for valley fever, then any job that requires an employee to spend time outside becomes a risky job. Police officers. Mail carriers. Those people who wave the signs telling you that you can get a deal on a pizza in the nearby strip mall.

The report adds a few more risk factors, too.

Almost one-third of interviewed employees reported having a job that involved disruption of soil. Activities included grid searches and digging for contraband in the soil by custody employees and drilling/digging for maintenance and repairs by plant operations employees. These activities could increase the risk of exposure to Coccidioides.

Home construction crews. Road building crews. People laying gas, electrical, phone, or cable lines. All of these workers are at risk. Not to mention your average teen-ager. I don’t think I had a single job between the ages of 16 and 19 -- outside of delivering balloons for a brief period – that did not involve digging into the ground at some point. And then there are the acts of nature that can hit anyone who just happens to be in the wrong place at the wrong time.

About 80%–85% of interviewed employees reported being outside in dust storms during their job. This could increase their risk of exposure to Coccidioides. According to the supplemental operations manual we reviewed, there are no written procedures for ending yard exercise and outdoor programs for dust storms or for unusually dusty or windy days.

Similarly, should every home in the Central Valley have an operations manual that tells people not to go get groceries if the wind speed hits a certain point, not to go pick up their children from school, not to go outside and turn off the sprinkler.

Why is it so important that the prisons could not be pinpointed as the source for valley fever in prison staff? Because valley fever is not a prison problem. It’s a population problem. And, as the Just One Breath series showed, it should not be thought of as just a Central Valley problem. It has been found to have an ever widening footprint, and there are fears that climate change could make it worse. The number of cases and deaths has been climbing, and yet we still are very far from a vaccine or effective treatments.