Coccidioidomycosis among Visitors to a Coccidioides immitis-Endemic Area: An Outbreak in a Military Reserve Unit

Standaert, Steven M.; Schaffner, William; Galgiani, John N.; Pinner, Robert W.; Kaufman, Leo; Durry, Elias; Hutcheson, Robert H.

doi:10.1093/infdis/171.6.1672

Cited by 53 publications

(23 citation statements)

References 7 publications

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“…Military members are at particular risk for this infection due to their training activities in desert locations (16); we have recently reported an outbreak among U.S. Navy SEALS training in a similar desert terrain (2). In addition, Standaert et al reported an outbreak of coccidioidomycosis in a Marine Corps reserve unit training in southern California (17). With over 350,000 personnel stationed in areas of endemicity and thousands more training in these areas, we sought to determine the disease incidence to assess whether preventative measures, including the potential use of prophylactic antifungals, were warranted during military maneuvers in regions of coccidioidomycosis endemicity (7).…”

Section: Discussionmentioning

confidence: 99%

Seroincidence of Coccidioidomycosis during Military Desert Training Exercises

2004

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Coccidioidomycosis is a common fungal infection acquired in the southwestern United States. This is the first study in over 2 decades to determine the seroincidence of Coccidioides immitis infections among U.S. military members performing training exercises in an area of endemicity. Only 8% of participants were aware of coccidioidomycosis, despite the majority having visited or lived previously in an area of endemicity. One (0.6%) of the 178 participants developed "definite" serologic evidence of infection over a 5-week training period; four (2.3%) additional patients developed "possible" coccidioidomycosis infections. None had complicated disease. The calculated annual incidence ranged from 6 to 32%. This study suggests that the risk of serious coccidioidomycosis is low among military personnel during desert training exercises; however, disease incidence may vary depending on specific activities and geographic factors. Due to the potential morbidity and mortality of this infection, preventative strategies, including vaccine development, are advocated.

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Section: Discussionmentioning

confidence: 99%

Seroincidence of Coccidioidomycosis during Military Desert Training Exercises

2004

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“…Coccidioidomycosis is considered to be a reemerging disease because of the dramatic increase in the number of cases during the early part of the past decade (47,52,105,157,207,219,260,282). Between 1991 and 1994, there was a notable increase of new cases in California, in particular in Kern and Tulare counties in the southern part of the San Joaquin Valley (219).…”

Section: Clinical Manifestations Epidemiologymentioning

confidence: 99%

“…Since the early epidemiological studies by Smith et al (274,277,279), it has become almost axiomatic that fully 60% of primary infections with Coccidioides are asymptomatic, being evident only by conversion of skin test reactivity. Notable exceptions have occurred during outbreaks during archeological excavations, construction projects, and military exercises (83,180,260,282,302,307), where symptomatic infections have been documented in 90% or more of persons. This increased incidence of symptomatic infection following primary exposure to arthroconidia is probably attributable to exposure to an unusually high dose of arthroconidia (37).…”

Section: Categories Of Diseasementioning

confidence: 99%

Coccidioidomycosis: Host Response and Vaccine Development

2004

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Coccidioidomycosis is caused by the dimorphic fungi in the genus Coccidioides. These fungi live as mycelia in the soil of desert areas of the American Southwest, and when the infectious spores, the arthroconidia, are inhaled, they convert into the parasitic spherule/endospore phase. Most infections are mild, but these organisms are frank pathogens and can cause severe lethal disease in fully immunocompetent individuals. While there is increased risk of disseminated disease in certain racial groups and immunocompromised persons, the fact that there are hosts who contain the initial infection and exhibit long-term immunity to reinfection supports the hypothesis that a vaccine against these pathogens is feasible. Multiple studies have shown that protective immunity against primary disease is associated with T-helper 1 (Th-1)-associated immune responses. The single best vaccine in animal models, formalin-killed spherules (FKS), was tested in a human trial but was not found to be significantly protective. This result has prompted studies to better define immunodominant Coccidioides antigen with the thought that a subunit vaccine would be protective. These efforts have defined multiple candidates, but the single best individual immunogen is the protein termed antigen 2/proline-rich antigen (Ag2/PRA). Studies in multiple laboratories have shown that Ag2/PRA as both protein and genetic vaccines provides significant protection against mice challenged systemically with Coccidioides. Unfortunately, compared to the FKS vaccine, it is significantly less protective as measured by both assays of reduction in fungal CFU and assays of survival. The capacity of Ag2/PRA to induce only partial protection was emphasized when animals were challenged intranasally. Thus, there is a need to define new candidates to create a multivalent vaccine to increase the effectiveness of Ag2/PRA. Efforts of genomic screening using expression library immunization or bioinformatic approaches to identify new candidates have revealed at least two new protective proteins, expression library immunization antigen 1 (ELI-Ag1) and a β-1,3-glucanosyltransferase (GEL-1). In addition, previously discovered antigens such as Coccidioides-specific antigen (CSA) should be evaluated in assays of protection. While studies have yet to be completed with combinations of the current candidates, the hypothesis is that with increased numbers of candidates in a multivalent vaccine, there will be increased protection. As the genome sequences of the two Coccidioides strains which are under way are completed and annotated, the effort to find new candidates can increase to provide a complete genomic scan for immunodominant proteins. Thus, much progress has been made in the discovery of subunit vaccine candidates against Coccidioides and there are several candidates showing modest levels of protection, but for complete protection against pulmonary challenge we need to continue the search for additional candidates

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“…2,3 Risk factors for coccidioidomycosis include living in or traveling in endemic areas, advanced age, occupations that involve handling laboratory specimens infected with C immitis and immunosuppressed states. 4 serve duty stationed or trained at bases in endemic areas are also at risk, 2,6 as was the case for the patients described above. Rare cases of coccidioidomycosis have been encountered in nonendemic areas, but most of these patients had traveled in endemic areas or were immunocompromised.…”

Section: Discussionmentioning

confidence: 97%