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HomeMy WebLinkAbout4/27/2005 - STAFF REPORTS (6) Palm Springs Economic Development Corporation N Nonpmll l Publm In[e LQoM,mhon April 27, 2005 City Council City of Palm Springs 3200 E Tahquitz Canyon Palm Springs, CA 92262 Re: Downtown Parking Dear Mayor and City Council: Beginning two years ago, the Palm Springs Economic Development Corporation helped organize and facilitate a coalition of community stakeholders to research and develop an improved parking strategy for downtown to serve the needs of customers, business owners and employees. Participants in this partnership included representatives from a broad base of retail, hotels, restaurants and attractions of various sizes and locations in the downtown/uptown area. Specifically, members from PSEDC, Mainstreet, Palm Springs Chamber of Commerce, Palm Springs Hotel and Hospitality Association, Heritage District and the Desert Roundtable were represented in the discussions. The parking proposal that you are currently considering is the result of many months of study and mutually agreed upon elements that all parties believe will help to drastically improve the parking situation in our downtown area. We believe that the proposal to offer the first two-hours free parking and unlimited parking for $5.00/day is a win-win for locals who want to visit their favorite restaurants and shops and for visitors who want to spend the day enjoying all that downtown has to offer. Regulations governing downtown street parking will not be changed or impacted by this plan. Only city-owned lots, the downtown parking structure and parking at Desert Fashion Plaza will be governed by this new fee arrangement. We whole-heartedly support this plan and urge you to vote in favor of its implementation. Of course, should you have any questions or want further comment, please do not hesitate to contact me. S eerely, Jon Caffery President cc: City Manager's Office Jerry Ogburn, Mainstreet Joy Meredith, President, Mainstreet Board �9 Cathy Van Horn, Economic Development Downtown Partnership )00,54 ELECTroVOTE- COUNCIL CHAMBER VOTING SYSTEM Page 1 of 2 r PT ro rLet-rraaom: E ILECTroVOTETm CollipollelliS trstallavun A 3-year Lease for: An initial payment of 10% of the total ptuchase price" And 36 monthly payments of 3% of the total purchase I r1$[RiC LIo715 price. Pricsng Final Purchase for: $1.00 at end of Lease. 6-knc to f3rder Program not available when purchasing for Resale. Wsrrlslh° ''For California Purchasers the required sales tax will be 7ron,c collected by including it in the original purchase price. Basic Component I( Small Vole Large Vote ry Laree Displ::y Sets of Indivit3uol Set !I Display Panel Display Panel N Name Overlay Vote Display Panel Panels Power Supply 3/4"s41@" �,,¢12" 4"Ilieh-25"wide Clerk's Control name plates for multiple _ name plates s 4'" Module, 10"wide 75"wide vofing 6otlies name plate Voting Modules I II II 1 $1,921.50 J $658.151 $823.5011 $175.0011 $1,317.001 [7 ] $2,066.75 � $699.5011 $885,4511 $187.5011 $1,416.001 J ,, 1 $2,212.00 11 $739.501 $948.001 $200.0011 $1,517.00� a_ $2,357.75 $777.00 $1,010.251 $212.2011 $1,616.001 $2,502.50 11 $814.751 $1,072.501 $225.00� $1,717.001 $2,647.75 $95025� $1,134.75� $237.50�� $1,816.00� 11 $2,791.00 $885.75 $1,197.00� $250.00� $1,917.001 $2,93825 Fsq 18.501 $1,259.25 $263.50� $2,016.00 1 $3,083.50 Fsq5 1.501 $1,321.50 $275.001 $2,117.001 F-1 $1,228.75 11 $981.71 $1,383.751 $287.51 $2,216.00 II IF II n http://vwvw.clectrovote.com/ElectroVote/pricing.htm 4/27/2005 ELECTroVOTE- COUNCIL CHAMBER VOTING SYSTEM Page 2 of 2 ,il :_o,+:; 11 $3,174.00 I$1,012.001 $1,446.0011 $300.0011 $2,317.001 $3,664.5011$1,072.50NNNNNN� $1,570.501 $312,5011 $2,416.00 ILaptop/Printer Cable II $1900.251 For further information contact: Electyovote,L.L.C. 22322 Gilberto Rancho Santa Margarita, CA 92688 email: slies�cr dectrovete.coin ?Nome: (949) 8058-M,20 (949) 85g-0505 http://www.clectrovote.conL/ElectroVote/Pricing.htm 4/27/2005 r -F`ORlill. GPA-4 1 � 4011a COMMERCIAL PROPERTY PURCHASE AGREEMENT,Ak ` C A L f F O P-NIA AND JOINT ESCROW INSTRUCTIONS ASSOCIATION (AND RECEIPT FOR DEPOSIT, •OF REACTORS®'. - (C.A.R,(Form CPA-1D1 Revised 4/01) i )" Date .at ,Califomia. 1. OFFER: - A. THIS IS AN OFFER FROM ("Buyer). ❑ Individual(s), 0 A Corporation, ❑ A Partnership, 0 An LLC, 0 An LLP,or ❑ Other B. THE REAL PROPERTY TO BE ACQUIRED is described as ,Assessors Parcel No. situated in County of_ California,("Proper[). a C. THE PURCHASE PRICE offered is ._ Dollars $ D. CLOSE OF ESCROW shall occur Days After Acceptance(or❑ on. (date)), i 2. FINANCING:Obtaining the bans below is a contingency of this Agreement unless:(I)either 21 or2J is dredked below or(ii)otherwise agreed.Buyershall ad diligently -; and in good faith to obtain the designated loans.Obtaining deposit,down payment and dosing costs is not a contingency. - A. BUYER HAS GIVEN A DEPOSIT TO THE AGENT SUBMITTING THE OFFER . .... . ... ..... . . .... . .... ... . . . .$ 1 (or to ❑_ ), made payable to ,, by Personal Check,or 0- ,which shall be held "$ uncashed until Acceptance and then deposited within 3 business days after Acceptance or ❑ ,❑ with Escrow Holder, ❑ into Broker's 3 trust account or ❑ i j Buyer represents that funds will a good when deposited with Escrow Holder. B. INCREASED DEPOSIT shall be deposited by Buyer with Escrow Holder within Days After Acceptance,......... $ or ! C. FIRSTLOAN INTHEAMOUNTOF .............................................................................. . ! NEW First Deed of Trust in favor of ElLENDER, 0 SELLER, \ - t``" a Wt i 7i44 q,i A, d r - OR 0 ASSUMPTION of(or ❑ "subject to") Existing First Deed of Trust �� �• �;' �� g encumbering the Property, securing a note payable at maximum interest of % fixed rate, or J I �yal' flab" j7 0/6 initial adjustable rate with a maximum interest rate cap of %, balance due in "� years,amortized over years.(If checked: ❑ and with a margin not to exceed %,tied to the ,r d following index: .)Buyer shall pay loan fees/points not to exceed ! rbVf4` I: Additional terms: D. SECOND LOAN INTHE AMOUNT OF ......................................................................... ......$ 1 NEW Second Deed of Trust in favor of ❑ LENDER, ❑ SELLER, OR 0 ASSUMPTION of(or 0 "subject to')Existing Second Deed of Trust encumbering the Property,securing a note payable at maximum interest of %fixed rate,or initial adjustable rate with a maximum interest rate cap of %, balance due in years,amortized over years.(If checked: ❑ and with a margin not to exceed %,tied to the following i index: .) Buyer shall pay loan fees/points not to exceed_ Additional terms: I t E. ADDITIONAL FINANCING TERMS: .. . . . . . .. . ... ... ... . . ... . . ... . ... ... . .... . ... .. ... . . . .... . .....$ I i f F. BALANCE OF PURCHASE PRICE(not including costs of obtaining loans and other closing costs)to be deposited with .........:$ j- Escrow Holder within sulficienttime to dose escrow. G. TOTAL PURCHASE PRICE............................................................................................$ H. LOAN CONTINGENCY shall remain in effect until the designated loans are funded or assumption of existing financing is approved by lender(or❑ Days) After Acceptance,by which time Buyer shall give Seller written notice of Buyers election to cancel this Agreement ff Buyer is unable to obtain the designated loans. If Buyer does not give Seller such notice,the contingency of obtaining the designated bans shall be removed by the method specified in paragraph 15. 1- ❑NO LOAN CONTINGENCY:(If checked)Obtaining any loan in paragraphs 2C,2D,2E or elsewhere in this Agreement is NOT acontingency of this Agreement If Buyer does not obtain the loan(s),and as a result Buyer does not purchase the Property,Seller may be entitled to Buyers deposit or other legal remedies. 1 The copyright laws of the United States (Title 17 U.S. Code) forbid the Buyer and Seller acknowledge receipt of a copy of this page. � unauthorized reproduction of this form, or any portion thereof, by photocopy ^ Buyers Initials machine or any other means, including facsimile or computerized formats. PmwLxousixc I Copyright©1993-2001,CALIFORNIA ASSOCIATION OF REALTORS@,INC Seller's Initials( )( ) OPPORTUNITY ALL RIGHTS RESERVED. CPA-11 (PAGE 1 OF 10) Print Date BDC Al I Reviewed by Broker or Designee Date Property Address: Date: J. ❑ALL CASH OFFER:(If checked)No loan is needed to purchase the Property.Buyer shall,within 5(or❑_�Days Aker Acceptance,provide Seller written verification of sufficient funds to close this transaction.Seller may cancel this Agreement in writing within 5 Days After:(I)time to provide verification expires,If Buyer fails to provide verification,or(ii)receipt of verification,If Seller reasonably disapproves it. K. LOAN APPLICATIONS;PREQUALIFICATION: Willim 5(or ❑ ---J Days After Acceptance,Buyer shall provide Seller a letter from lender or mortgage loan broker stating that,based on a review of Buyers written application and credit report,Buyer is prequallied for the NEW loan(s)indicated above.If Buyer fails to provide such letter within that time,Seller may cancel this Agreement in writing. L ❑APPRAISAL CONTINGENCY.(if ched<ed)This Agreement is contingent upon Property appraising at no less than the specified total purchase price.if there is a loan contingency,the appraisal contingency shall remain in effect until the loan contingency is removed.If there is no loan contingency, the appraisal contingency shall be removed within 10(or ❑ 1 Days After Acceptance M. SELLER FINANCING: For any Seller financing designated above, Buyer is to execute a note secured by a deed of trust in favor of Seller, on the terms and conditions set forth in the attached addendum (C.A.R.Form SFA-11). N. ASSUMED OR"SUBJECT TO"FINANCING: Seller represents that Seller is not delinquent on any payments due on any loans. Seller shall, within the time specified in paragraph 15,provide copies of all applicable notes and deeds of trust, loan balances and current interest rates to Buyer.Buyer shall then,within the time specified in paragraph 15, provide Seller with notice, if any, as specified in paragraph 15.Differences between estimated and actual loan balances shall be adjusted at Close Of Escrow by cash down payment.Impound accounts,if any,shall be assigned and charged to Buyer, and credited to Seller.Seller is advised that Buyer's assumption of an existing loan may not release Seller from liability on that loan.If Property is acquired subject to an existing loan,Buyer and Seller are advised to consult with legal counsel regarding the ability of an existing lender to call the loan due,and the consequences thereof. 3. CLOSING AND OCCUPANCY A. Possession and occupancy,subject to the rights of tenants under existing leases,shall be delivered to Buyer at AM/PM, on the date of Close Of Escrow, ❑ on , or ❑ no later than Days After Close Of Escrow. B. At Close Of Escrow,Seller assigns to Buyer any assignable warranty rights for items included in the sale and shall provide any available copies of such warranties.Brokers cannot and will not determine the assignability of any warranties. C. At Close Of Escrow, unless otherwise agreed in writing, Seller shall provide keys and/or means to operate all locks, mailboxes, security systems,alarms and garage door openers.If Property is a unit in a condominium or other common interest subdivision,Buyer may be required to pay a deposit to the Owners'Association("01 to obtain keys to accessible CA facilities. 4. ALLOCATION OF COSTS(If checked): If any of the inspections or reports in paragraph 4A,B,C and D are checked,then with regard to that item, Buyer shall have approval,removal and cancellation rights,and obligations as specified in paragraph 15. INSPECTIONS AND REPORTS A. ❑ Buyer ❑ Seller shall pay for sewer connection,if required by Law prior to Close Of Escrow. B. ❑ Buyer ❑ Seller shall pay to have septic or private sewage disposal system inspected. C. ❑ Buyer ❑ Seller shall pay to have domestic wells tested for water potability and productivity, . D. ❑ Buyer ❑ Seller shall pay for a natural hazard zone disclosure report prepared by GOVERNMENT REQUIREMENTS AND RETROFIT E. ❑ Buyer ❑ Seller shall pay for smoke detector installation and/or water heater bracing, if required by Law.Prior to Close Of Escrow, Seller shall provide Buyer a written statement of compliance in accordance with state and local Law, unless exempt. F. ❑ Buyer ❑ Seller shall pay the cost of compliance with any other minimum mandatory government retrofit standards, inspections and reports if required as a condition of closing escrow under any Law. ESCROW,TITLE AND OTHER COSTS G. ❑ Buyer ❑ Seller shall pay escrow fee. Escrow Holder shall be H. ❑ Buyer ❑ Seller shall pay for owner's title insurance policy specified in paragraph 14, Owners title policy to be issued by (Buyer shall pay for any title insurance policy insuring Buyer's Lender, unless otherwise agreed.) I. ❑ Buyer ❑ Seller shall pay County transfer tax or transfer fee. J. ❑ Buyer ❑ Seller shall pay City transfer tax or transfer fee. K. ❑ Buyer ❑ Seller shall pay Owners'Association transfer fees. L. ❑ Buyer ❑ Seller shall pay Owners'Association document preparation fees. 5. SELLER DISCLOSURES: Within the time specified in paragraph 15, Seller, shall provide to Buyer, in writing, the following disclosures and information.Buyer shall then,within the time specified in paragraph 15, investigate the disclosures and information,and provide Seller with notice, if any, as specified in paragraph 15. A. NATURAL HAZARD ZONE:Special Flood Hazard Areas;Potential Flooding(Inundation)Areas;Very High Fire Hazard Severity Zones;State Fire Responsibility Areas; Earthquake Fault Zones; Seismic Hazard Zones, or any other federal, state, or locally designated zone for which " disclosure is required by Law. B. PROPERTY DISCLOSURES AND PUBLICATIONS: Earthquake Guide (and disclosures), if required by Law, and Environmental Hazards Booklet. C. STRUCTURAL MODIFICATIONS: Any known structural additions or alterations to, or the installation, alteration, repair or replacement of, significant components of the structure(s) upon the Property. The cops lams of the United States (Title 17 1 Cade) forbid the Buyer and Seller acknowledge receipt of a copy of this page. unauthorized reproduction of this form, or any portion thereof, by photocopy Buyer's Initials( )( ) machine or any other means, including facsimtle or computerized formats Copyright(cD 1993-2001. CALIFORNIA ASSOCIARON OF REALTORS@, INC. Seller's Initials( 1( ) w�w.xous�nc )vaoxruxrry .ALL RIGHTS RESERVED. CPA-11 (PAGE 2 OF 10) I Reviewed by Broker or Designee Date 1 Operational Guidelines (version 1.0) for Geological Fieldwork in Areas Endemic for Coccidioidomycosis (Valley Fever) by Frederick S. Fishers, Mark W. Bultananz and Demosthenes Pappagianis3 U.S. Geological Survey Open-File Report 00-348 Version 1.0 2000 U.S. DEPARTMENT OF THE INTERIOR BRUCE BABBITT, Secretary U.S. GEOLOGICAL SURVEY Charles G. Groat,Director This report is preliminary and has not been reviewed for conformity with U.S. Geological Survey editorial standards (or with the North American Stratigraphic Code). Any use of trade, product, or firm names is for descriptive purposes only and does not imply endorsement by the U.S. Government or the University of California. Guidelines and conclusions presented in this report are the author's opinions and are not, and should not be interpreted as, official policy of the U.S. Geological Survey or the University of California. 1 U.S.Geological Survey contractor,Suite 355, 520 N.Park Avenue,Tucson,AZ 85719 2 U.S.Geological Survey, Suite 355,520 N. Park Avenue,Tucson,AZ 85719 3 School of Medicine,University of California,Davis,CA 95616 o4f Z-I I zoo r, Abstract Coccidioidomycosis (Valley Fever) is a disease caused by the inhalation of the arthroconidia(spores) of Coccidioides immitis, a fungus that lives in the soils of southwestern United States. Although large numbers of people are exposed to the arthroconidia and are consequently infected,very few individuals contract the more serious forms of the disease. Earth scientists working in field areas where Coccidioides immitis is endemic have an increased risk of becoming infected. Because field operations often disturb the upper surface of the ground,they may inhale large numbers of arthroconidia. This also increases their risk of developing more severe forms of the disease. Any other occupations or activities that create dusty conditions in endemic areas also have increased risk of infection. Risk management strategies can lower the incidence of infection and also reduce the numbers of arthroconidia inhaled thereby decreasing the chances of developing more serious disease. Dust control, by utilizing dust masks, and dust prevention, by limiting ground disturbing activities, are the primary weapons against infection. However, infection risk can also be lowered by conducting fields studies in the winter months; avoiding sites favorable for Coccidioides immitis growth; seeking prompt medical treatment if flu-like or respiratory illness occur during, or within a few weeks following, fieldwork; getting a coccidioidin skin test to determine susceptibility to the disease; and by educating all members of the field party about the possibilities and consequences of infection. Introduction The purpose of this report is to present operational guidelines that will lower the risk of contracting coccidioidomycosis for individuals who work outdoors in areas where the disease is endemic. Coccidioidomycosis (or as it is sometimes called, Valley Fever) is an infection usually caused by the inhalation of(rarely by traumatic introduction through the skin) arthroconidia (spores) of the soil inhabiting fungus Coccidioides immitis. The disease may occur in any individual residing, visiting, or even passing through endemic areas. While this report is directed at earth scientists it also applies to other occupations involving outdoor activity in dusty conditions (e.g. farming, ranching, construction, archaeology, soil scientist, etc.). However, specific occupation is not as important in determining infection risk as is the amount of time spent outdoors and involvement in activities that expose an individual to dusty conditions or to intensive contact with soils. This report also applies to many outdoor recreational pursuits (e.g.. gardening, landscaping, equestrian, biking, hiking etc.). The recommendations made here are based on information available to date on the habitat of Coccidioides immitis. This information may change as new data are currently being collected by ongoing studies at the University of Arizona and by the U.S. Geological Survey that are focused specifically on the habitat of C. immitis. This paper does not discuss medical treatments for the disease, however, the authors do utilize knowledge about the ailment to help individuals apply strategies that will lower their risk of becoming infected. Definitive discussions of the medical 2 aspects and treatments of coccidioidomycosis may be found in Einstein and Johnson, (1993) and Galgiani, (1993). Endemic areas Rapid population growth, greater numbers of recreational visits and activities, and continued stationing of military personnel for active training,in the deserts of the southwestern U.S. place an increasingly large unexposed population within endemic areas. These demographic changes, coupled with increasing numbers of individuals with suppressed immune systems due to the ongoing AIDS epidemic, and the growing use of immunosuppressing medical therapies are of concern to public health officials (Galgiani, 1992, 1993, 1999; Rush and others, 1993; Pappagianis and others, 1993). Figure 1. Endemic regions of C immitis in the United States and northern Mexico Courtesy of the Valley Fever Americas Foundation, Bakersfield, California s� r Ll F Known highly endemc area f' Y` Established endemic area ;;,, Suspected endermic arm In the conterminous United States C. immitis is endemic in parts of Arizona, California, New Mexico, Nevada, Texas, and Utah (fig. 1). Outside of the United States it is endemic in parts of Argentina, Brazil, Colombia, Guatemala, Honduras, Mexico, Nicaragua, Paraguay, and Venezuela. With some exceptions endemic areas are generally 3 and to semiarid with low to moderate rainfall (5 to 20 inches), mild winters, and long hot seasons. The Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia declared in 1993 that coccidioidomycosis was epidemic in parts of California (Kern County) and also issued a warning to physicians nationwide to watch for the disease in patients who may have become infected while traveling in endemic areas. The CDC also listed coccidioidomycosis as an example of one of the important emerging disease threats to the Nation and has called for expanded studies of the disease (Bryan, and others, 1994). In endemic areas, recognized cases of coccidioidomycosis are under-reported (Lundergan and others, 1985, p. 53; Galgiani, 1992, p. 100). In 1957 it was shown that, in infected individuals,the disease resulted in an average of 33 to 35 lost work days (Scogins, 1957). Pappagianis (1980) estimated that the overall annual cost to the nation was one million person-days of labor. A review by the CDC (Goodman, 1994) of the medical records in Kern County, California showed that coccidioidomycosis accounted for approximately $66 million in direct costs of hospitalization and outpatient care during the period 1991- 1993. Infection rates for humans vary throughout the endemic areas. In 1966 long-term residents in Arizona(several years) showed the following infection rates by county; Apache 13%, Cochise 37%, Coconino 5%, Gila 48%, Graham 60%, Greenlee 40%, Maricopa 71%, Mohave 57%, Pima 72%, Pinal 76%, Santa Cruz 40%, Yavapai 14%, Yuma 26%(Converse and Reed, 1966, p. 682, fig. 4). Character of the Disease Arthroconidia of C. immitis can be released into the air when soils are disturbed by natural or anthropogenic means. Inhalation of the arthroconidia into the lungs of an appropriate host can cause primary infection. Once in the lung the arthroconidia change into a spherule form and reproduce efficiently by endosporulation causing relatively rapid growth and increased infection (Galgiani, 1993; Einstein and Johnson, 1993). Primary coccidioidomycosis is limited to the lesions in the lungs with symptoms that may include fever, chills, night sweats, chest pains, cough, appetite loss, and muscle and joint aches. Symptoms usually clear within a few weeks. Disseminated coccidioidomycosis occurs when the disease spreads to sites in the body other than the lungs and can involve any organ with the exception of the gastrointestinal tract which is rarely involved (Einstein and Johnson, 1993). Disseminated forms of the disease are more severe and have a variety of symptoms. Involvement of a vital organ can lead to death. Most people who are long-term residents (several years) in areas where C. immitis is present are exposed to the arthroconidia of the fungus and are consequently infected. About 60 percent of the people infected are asymptomatic,their exposure to the infection being reflected only by a positive coccidioidin skin test. Most symptomatic cases result in primary infection with relatively mild cold or influenza-like symptoms for which only about 10 percent of the people seek medical attention; however, in some cases there may be pneumonia. In about 1 percent of those infected, C. immitis disseminates elsewhere in the body beyond the pulmonary system with much more serious, and at times, fatal results (Pappagianis and others, 1993). Early diagnosis and treatment of coccidioidomycosis is 4 of value in managing primary infections and is essential in most cases of disseminated disease (Galgiani, 1999). Pregnant women, African-Americans, Filipinos, and possibly Asians, Hispanics, and Native Americans have higher rates of dissemination of the disease (Pappagianis and others, 1979; Einstein and Johnson, 1993). Coccidioidomycosis is often severe and life threatening in patients whose immune systems have been compromised. The disease is capable of lying dormant in some infected individuals for years, becoming active and opportunistic only when the immune system is weakened by other conditions (Cuellar and others, 1993). In addition to humans the disease affects many species of domestic and wild animals including burros, cattle, dogsl , horses, sheep, swine, bats, coyotes, mountain lions, rodents, sea otters, and reptiles (Reed and others, 1994; Pappagianis, 1988). New infections are frequently seasonal and appear to be related to several factors including humidity, rainfall, sunlight, temperature, and wind conditions (Smith and others, 1946; Egeberg, 1953; Pappagianis, 1988). Rates of infection are highest during hot dry spells that follow cooler rainy seasons and rates often spike following large dust storms (Pappagianis, 1988). Other new infections are related to ground-disturbing activities with consequent exposure to soil and dust, such as construction, mining, agriculture, archaeological excavations, military maneuvers, recreational activities, etc.(Johnson, 1981; Pappagianis, 1983). Laboratory studies have shown that as few as 10 arthroconidia are sufficient to cause an infection in dogs and monkeys (Converse and Reed, 1966) and it has been suggested that even a single arthroconidia could be responsible for infection in humans (Fulmer, 1979; Galgiani, 1993). Many severe infections in animals and humans are related to inhaling aerosols containing high doses of arthroconidia derived from sites where C. immitis is present in the soils (Converse and Reed, 1966; Pappagianis, 1988). Once an individual has been infected by C. immitis, even mild cases, and is skin-tested positive, immunity to additional infection by C. immitis is developed(Fiese, 1958, pp 92-97; Galgiani, 1999). Habitat of C. immitis C. immitis grows in the upper(5 - 20 cm) horizons of soils in endemic areas (fig. 2). This saprophytic phase of the fungus is characterized by branching segmented hyphae that form a network of mycelium. As the fungus matures, arthroconidia, 2 to 5znn in size, are formed as barrel shaped, rectangular segments of the hyphae. Given the right environmental conditions, alternate arthroconidia undergo autolysis leaving the viable arthroconidia which are easily separated by soil disturbance (natural or anthropogenic) and consequently easily dispersed by the wind. Arthroconidia are also very buoyant and may be readily moved by sheet-wash water during rainstorms only to be concentrated in fine sedimentary material some distance from the initial growth site. Under suitable environmental conditions the arthroconidia can germinate to form new hyphae and mycelium, which can repeat the cycle. However, numerous studies suggest that C. I Dogs are very prone to infection because of their habit of sniffing the ground and frequent deep inhalation of air in rodent barrows. Once infected many dogs develop severe forms of the disease which most often necessitates euthanasia(Davidson and Pappagianis, 1994). 5 immitis does not readily colonize outside of existing growth sites. The reasons for this are not completely understood but may be associated with the sensitivity of the fungus to environmental factors and competition from other soil inhabiting organisms (Swatek. 1975; Pappagianis, 1980, 1988). Figure 2. Life cycle of C. immitis ' •t ` �1 t aeptntdoa-aqd �+ s •.. � endospore I4 aegmentatign. � �' taq:�ro"r -^ - thousand of intaa .. �1 ,r a .r* to each spLerule e t rspherole ruptu"s . �� s m '' arthrocmtd�a are tro tyLaledpyfhahos{qnd em SOL SalDr entluspo its ,,,,� - sr �, t � ertdospore�to thslungs °�� yotheaw ,.. R'„ M , , , ), , i 6 If the airborne arthroconidia are inhaled by an appropriate host (humans, animals, even reptiles) the invasive phase of C. immitis is initiated (fig. 2). In tissue the arthroconidia transform into spherules 10 to 80 um in diameter which when mature are internally divided into endospores that are 2 to 5 um in diameter. The mature spherules then rupture and the endospores are released into the surrounding tissue thereby spreading the infection locally, or at times, into other organs by disseminating outside of the respiratory system. The invasive phase may end with the death of the host or by the expulsion of spherules outside of living tissue by sputum, pus, or exudates. If this occ4lrs in an acceptable environment then the spherules (or endospores) will germinate and hyphae and mycelium will be developed and the saprophytic phase will again be initiated (Fiese, 1958). In some cases both mycelia and spherule forms of C. immitis have been observed in tissue and sputum (Fiese, 1958, p. 34-35). The presence of C. immitis in specific areas is determined by direct sampling of soils, identification of positive skin and serologic tests in non-mobile human populations, and recognition of the infection in humans and animals (mostly dogs). Several authors have noted that these occurrences or growth sites are relatively restricted in size, with individual sites ranging from several tens to several hundreds of square meters (Maddy and Crecelius, 1967; Egeberg and others, 1964; Swatek, 1975; Pappagianis, 1980, 1988). Although some growth sites have been identified, their distribution and recognition throughout the entire endemic area of the southwestern U.S. is poorly known. Laboratory and site specific field studies have shown that many physical, chemical. climatic, and biological factors influence the growth of C. immitis in the soil and the consequent development and deployment of arthroconidia(Fiese, 1958; Sorensen, 1964; Swatek, 1975; Pappagianis, 1988). Key factors include, amount and timing of rainfall and available moisture (humidity),temperature, soil texture, alkalinity, salinity and types of water-soluble salts, organic content of soils, and degree of exposure to sunlight and ultraviolet light. Others that may be important are the presence of marine sedimentary rocks, presence of borates, soil chemistry, presence of specific vegetation types, inclusion within the Lower Sonoran Life Zone, competition with other fungal and/or plant species, presence of Indian middens, and presence of rodent burrows and middens (Maddy, 1957; Egeberg, 1962; Pappagianis, 1'988). Many of the above mentioned factors are closely interrelated and the influence on the presence and/or growth of C. immitis by any combination of, or single factor, is an intricate balance that varies both in time (season) and in response to changes in the physical, chemical, and biological environment at any given location. Risk Management Strategies Because ambient airborne C. immitis arthroconidia may be present anywhere within endemic areas, absolute prevention of infection is virtually impossible, and, as no effective vaccine for coccidioidomycosis is currently available, consideration of risk management strategies seems prudent. Some of these methods may not be practical for individuals who are not involved closely with soils, aerosols, or other materials derived directly from C. immitis growth sites; however, earth scientists doing fieldwork in 7 endemic areas can lower their risk of infection by following strategies appropriate for their own particular activities. Education of individuals and institutions about the disease is the first step in developing risk management strategies and it is to that end this report is directed. General information brochures on coccidioidomycosis may be obtained from the American Lung Association of Arizona (2819 E. Broadway Blvd., Tucson,AZ, 85716), the California Department of Health Services (2151 Berkeley Way, Berkeley, CA, 94704), and The Valley Fever Center for Excellence (Mail Stop 111, 3601 S. 6th Ave., Tucson, AZ, 85723). The factors listed below, all of which increase the chance of infection, are associated with the probability of inhaling C. immitis arthroconidia and must be considered in a risk management strategy. 1) Residence within endemic areas; longer times increases risk 2) Travel within endemic areas; again longer time increases risk 3)No previous history of infection as shown by a negative coccidioidin skin test; (successful recovery from coccidioidomycosis, even mild cases, imparts immunity to further infection) 4) Exposure to dust containing arthroconidia, as a result of incidental circumstances, occupation, recreation, or life style 5) Duration of time spent outdoors 6) Duration of time spent in dusty conditions (inhalation of larger numbers of arthroconidia has been associated with more severe cases of coccidioidomycosis) 7) Activities (and duration of time)that involve intensive contact with soils in endemic areas 8) Exposure to fomites derived from endemic areas In addition to the above it is also important to consider the risk factors associated with development of the more serious disseminated forms of the disease as listed below: 1)A compromised immune system (HIV/AIDS, organ transplants, diabetes, chemotherapy, etc.) 2) African-American, Filipino, or other Asian heritage (possibly also Hispanic and native American) 3) second and third trimester of pregnancy 4) male gender For those earth scientists living in or assigned to work in endemic areas several strategies should be considered to lower the risk and severity of infection by C. immitis arthroconidia. A coccidioidin skin test should be done to determine prior exposure to the disease. Those who test negative indicating no prior exposure should be more diligent in adopting risk reducing strategies and should seek medical treatment early in the course of flu-like illnesses that may develop a few weeks following fieldwork in endemic areas. Those who test positive are unlikely to become reinfected and probably only need to use extra precautions when exposed to intensive contact with soils in highly infective areas 8 (i.e. rodent burrows in known C. immitis growth sites). Individuals who are at a higher risk of developing disseminated disease, especially the immunosuppressed, may be wise to a) limit fieldwork in endemic areas, b) completely avoid locations containing favorable C. immitis growth sites and, c) avoid dust producing activities. Infections by C. immitis frequently have a seasonal pattern with infection rates that generally spike in the first few weeks of hot dry weather that follow extended milder rainy periods. In California infection rates are generally higher during the hot summer months especially if weather patterns bring the usual winter rains between November and April. The normal weather pattern in Arizona is a winter rainy season in December, January, and February followed by hot dry weather and also a summer monsoon season in July and August again followed by hot dry weather. Thus in Arizona infection rates are often higher in spring,then decrease during the summer monsoons and increase again in autumn, with highest rates often occurring in November, and finally decreasing to the lowest rates during the winter rainy season. Numerous studies have suggested the connection between above average rainfall during the winter and spring and higher infection rates the following summer(Smith and others, 1946; Maddy, 1965, Pappagianis, 1988). Increased moisture is believed to provide a longer period for growth of C. immitis and consequently greater production of arthroconidia which, with the onset of dry, hot, windy weather creates infective conditions for susceptible hosts (Maddy, 1965). During rainfall, dust and arthroconidia are washed from the air and wetting of the soil decreases the opportunity for spores to become airborne thereby creating less infective conditions. The seasonal character of infections should be considered in risk management strategies and earth scientists should whenever possible schedule fieldwork in endemic areas during the winter rainy periods when infection rates are generally lowest. Clearly, dust-control measures are the main defense against infection. However it is important to note that dust itself is only an indicator that C. immitis arthroconidia may be airborne in a given area and that some dust clouds may be completely free of arthroconidia. Arthroconidia of C. immitis have slow settling rates in air due to their small (gum - 5um) size, low terminal velocity (0.003 cm/sec), and possibly also due to their buoyancy, barrel shape and commonly attached empty hyphae cell fragments (Gregory, 1973; Dimmick, 1965; Lacey, 1981). Thus arthroconidia, whose size is well below the limits of human vision, may be present in air that appears relatively clear and dust free. Such ambient, airborne arthroconidia with their low settling rates can remain aloft for exceedingly long periods and be carried hundreds of kilometers from their point of origin (Table 1). 9 Table 1 Time of flight and range of distances of particles moving in moderately strong winds (15 m/sec.). Modified from Chorley and others, 1984 Particle Diameter Fall Velocity Flight time Transportation type (mm) (cm/sec) (maximum) distance (max.) clay 0.001 0.00824 9-90 years 4-40 x I Ob km C. immitis 0.002-0.005 0.003 ? ? arthroconidia silt 0.01 0.824 8-80 years 4-40 x 102km very fine sand 0.10 82.4 0.3-3 sec. 46-460 meters Arthroconidia may also become airborne by hitchhiking rides on larger dust or sand sized particles. Large dust storms, at times carrying arthroconidia of C. immitis, in California and Arizona have long been noted for creating epidemic conditions (Smith and others, 1946). More recently dust clouds resulting from the January 17, 1994, earthquake in California are believed to be responsible for outbreaks of coccidioidomycosis from eastern Ventura County to the western San Fernando Valley (Pappagianis and others, 1994; Schneider and others, 1997; Jibson and others, 1998). Viability of fungi spores in the atmosphere depends on several factors including temperature, desiccation, radiation (especially in the ultraviolet wave lengths), and how robust individual types of spores are when placed in different environments (Gregory, 1973; Lacey, 1981). How long airborne C. immitis arthroconidia remain infective for humans is unknown but laboratory experiments suggest that C. immitis arthroconidia are hardy (Friedman and others, 1956; Pappagianis, 1988) and thus may be viable in the atmosphere for extended periods. Weather patterns with associated strong winds can carry arthroconidia great distances and coupled with their robust viability can spread infection well outside of recognized endemic areas. For example, in 1977 strong winds (gusts to 160 km/hr) centered in Kern County, California (located in the southern San Joaquin Valley) scoured topsoil to depths of 15 cm creating a dust cloud that reached elevations of approximately 1500 meters. The storm carried C. immitis arthroconidia 500 km north to the vicinity of Sacramento, California(an area not considered endemic for C. immitis) (Flynn and others, 1979). The dust spread over an area of about 87,000 km2 reaching Sacramento about 20 hours after the start of the storm in Kern County and infecting as many as 7,000 people in Sacramento County (Pappagianis and Einstein, 1978; Flynn and others, 1979, p. 360). There are many ways to avoid and control dusty conditions during field operations, although some may not be practical for certain operations. Few methods (perhaps none) 10 are 100 percent effective. Following are suggestions for reducing infection risk by limiting exposure to dust in endemic areas: 1) Avoid working outdoors during windy conditions 2) If possible use machinery with enclosed cabs and utilize air conditioning 3) Use air conditioning in field vehicles 4) Avoid unnecessary digging or soil disturbance 5) Use dust masks; Although the use of dust masks for protection against the inhalation of C. immitis arthroconidia has not been scientifically evaluated, their application.by workers in dusty conditions is strongly recommended. Several types of masks are available that have been proven to be very effective against dust particles as small as 0.4 microns in size, which is several times smaller than C. immitis arthroconidia. Masks capable of filtering particles as small as 0.4 microns should provide nearly total protection if fitted properly and conscientiously utilized during dusty operations. Manufactures instructions must be followed and it should be noted that mustaches or beards may prevent a mask from making an airtight seal against the face and thus may allow unfiltered dust to be inhaled. 6) Wet soils before digging or collecting samples ( a small backpack weed sprayer containing water may be useful) 7) camp and sleep upwind of known or suspected C. immitis growth sites or dusty areas 8) avoid sandy campsites; camp on vegetated areas as much as possible 9) sterilize soil or rock samples by heating them to 600C for thirty minutes which will kill C. immitis 10) Use fungicides to kill C. immitis (Elconin and others, 1967) but be aware that they are only effective on the soil surface and possibly to a depth of 0.5 cm Don't take C. immitis arthroconidia home with you or unwittingly expose other individuals to infection by fomites from endemic areas. Many cases of coccidioidomycosis have occurred as a result of exposure to contaminated materials derived from endemic areas (Albert and Sellers, 1963). 1)wash and sterilize rocks, soils, fossils, vegetation, or other sampled material before removing it from the field to the laboratory 2) keep field vehicles washed, and clean interiors by using water(do not create dust by sweeping or vacuuming interiors) 3) remove dusty clothing after fieldwork and store in closed plastic bags until washed 4) clean field equipment before returning to the home, office or laboratory The distribution of C. immitis within endemic areas is not uniform and growth sites are commonly small (a few tens of meters) and widely scattered. Known sites appear to have some ecological factors in common suggesting that certain physical, chemical, and biological conditions are more favorable for C. immitis growth. Avoidance, when possible, of sites favorable for the occurrence of C. immitis is a prudent risk management strategy. Listed below are ecologic factors and sites favorable for the occurrence of C. immitis: 11 1) Rodent burrows (often a favorable site for C. immitis, perhaps because temperatures are more moderate and humidity higher than on the ground surface) 2) Old (prehistoric) Indian campsites near fire pits 3) Areas with sparse vegetation and alkaline soils 4) Areas with high salinity soils 5) Areas adjacent to arroyos (where residual moisture may be available) 6) Packrat middens 7) Upper 30 cm of the soil horizon, especially in virgin undisturbed soils 8) Sandy well aerated soil with relatively high water holding capacities Sites within endemic areas less favorable for the occurrence of C. immitis include: 1) Cultivated fields 2) Heavily vegetated areas (e.g. grassy lawns) 3) Higher elevations (above 7,000') 4) Areas where commercial fertilizers (e.g. ammonium sulfate) have been applied 5) Areas that are continually wet 6) Paved (asphalt or concrete) or oiled areas 7) Soils containing abundant microorganisms 8) Heavily urbanized areas where there is little undisturbed virgin soil In summary, because arthroconidia of C. immitis can occur anywhere within endemic areas, or even possibly a few hundred kilometers outside of endemic areas, (given windy, dusty conditions as documented above) 100 percent protection against infection is impossible. However earth scientists conducting field studies within endemic areas can limit their risk of becoming infected and most likely, reduce the severity of the disease in those that do become infected by; 1) scheduling fieldwork during winter months; 2) avoiding activities (if possible) in areas most favorable for C. immitis occurrences; 3) utilizing dust control methods when appropriate; 4) having a coccidioidin skin test and, if test is negative, exerting additional caution while working in dusty conditions: 5) seeking prompt treatment of flu like or respiratory illness that occur during, or a few weeks following, fieldwork and also informing their physician about possible exposure to C. immitis arthroconidia; and 6) educating all members of the field party about the disease. Those individuals at high risk of developing severe disseminated disease should carefully evaluate the necessity of conducting field studies within endemic areas, however, it should be remembered that the large majority of individuals infected suffer no or very minor symptoms and that the severe disseminated form of the disease occurs in less than one percent of those exposed. 12 References Albert, B.L. and Sellers, Jr., T.F., 1963, Coccidioidomycosis from fomites: Archives of Internal Medicine, Aug. 1963, v. 112, p. 253-261 Bryan, R.T., Pinner, R.W., Gaynes, R.P., Peters, C.J., Aguilar, J.R., and Berkelman, R.L., 1994,Addressing emerging infectious disease threats: a prevention strategy for the United States executive summary: Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, v. 43, n. RR-5, p. 1-18. Buhner, G.S., 1979, Introduction of medical mycology: Year Book Medical Publishers, Inc., Chicago, 195 p. Charley, R.J., Schumm, S.A., and Sugden, D.E,, 1984, Geomorphology: Methuen & Co., New York, 605 p. Converse, J. L. and Reed, R. E., 1966, Experimental epidemiology of coccidioidomycosis: Bacteriological Reviews, v. 30, n. 3, p.678 - 695. Cuellar, M. L., Silveira, L. H., Citera, Gustavo, Cabrera, G. E., and Valle, Rafael, 1993, Other fungal arthritides: Rheumatic disease clinic of North America, v. 19, n. 2, p. 439 - 455. Davidson, A.P. and Pappagianis, D.,1994, Canine coccidioidomycosis 1970-1993: in Conference Program and Abstracts, 5th Centennial Conference on Coccidioidomycosis, Stanford, CA, Aug. 24-27, P. 21. Dimmick, R.L., 1969, Mechanics of Aerosols, in An introduction to experimental aerobiology, by Dimmick, R.L. and Akers, A.B., John Wiley and Sons, Inc. Egeberg, R. 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Thomas, Springfield, IL, 253 p. Flynn,N. M., Hoeprich, P. D., Kawachi, M. M., Lee, K. K., Lawrence, R. M., Goldstein, Elliot, Jordan, G. W., Kundargi, M. B., and Wong, G. A., 1979, An unusual outbreak of windbome coccidioidomycosis: The New England Journal of Medicine, v. 301, n. 7, p. 358 - 361. Friedman, Lorraine, Smith, C.E., Pappagianis, Demosthenes., and Berman, R.J., 1956, Survival of Coccidioides immitis under controlled conditions of temperature and humidity: Airier. Journal Public Health, v. 46, p 1317-1324. Galgiani, J.N., 1992, Coccidioidomycosis: Changes in clinical expression, srological diagnosis, and therapeutic options: Clinical Infectious Diseases, v. 14, supplement 1, p. 100 -105. 1993, Coccidioidomycosis: Western Journal of Medicine, v. 159, p. 153 - 171. 1999, Coccidioidomycosis: A regional disease of National importance, rethinking approaches for control: Annals of Internal Medicine, v. 130, n. 4 (part 1), p. 293-300. 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Lacey, J., 1981, The aerobiology of conidial fungi, in Cole, Garry T., and Kendrick, Bryce, eds., Biology of conidial fungi, v. I, Academic Press,New York, 1981, p. 400. Lundergan, L. L., Kerrick, S. S., and Galgiani, J.N., 1985, Coccidioidomycosis at a university outpatient clinic: A Clinical description: in Einstein, H. E., and Catanzaro, Antonin eds., Coccidioidomycosis, Proceedings of the 4th International Conference on 14 coccidioidomycosis, San Diego, The National Foundation for Infectious Diseases, Washington, D. C., p. 47 - 53. Maddy, K.T., 1957, Ecological factors of the geographic distribution of Coccidioides immitis: Journal American Veterinarians Association, v. 130, n. 11, p. 475 - 476. Maddy, K. T., 1965, Observations on Coccidioides bnmitis found growing naturally in soil: Arizona Medicine, v. 22, p. 281-288. Maddy, K.T. and Crecelius, G.T., 1967, Establishment of Coccidioides immitis in negative soil following burial of infected animals and animal tissues, in Ajello, Libero, Coccidioidomycosis, Tucson, University of Arizona Press, p. 309-312. Pappagianis, Demosthenes and Einstein, Hans, 1978, Tempest from Tehachapi takes toll or coccidiodes conveyed aloft and afar: The Western Journal of Medicine, v. 129, p.527- 530. Pappagianis, Demosthenes, Lindsay, Suzanne, Beall, Sharen, and Williams, Paul, 1979, Ethnic background and the clinical course of coccidioidomycosis: American Review of respiratory disease, v. 120, p.959-961. Pappagianis, Demosthenes, 1980, Epidemiology of coccidioidomycosis: in Stevens, D. A., Coccidioidomycosis, Plenum Medical Book Company,New York, p. 63 - 85. 1983, Coccidioidomycosis (San Joaquin or Valley Fever) in DiSalvo, A. F., (ed), Occupational Mycoses, Lea and Febiger, Philadelphia, p. 13 - 28. 1988, Epidemiology of Coccidioidomycosis: Current Topics Medical Mycology, v. 2, p. 199 - 238. Pappagianis, Demosthenes, Sun, R.K., Werner, S.B., Rutherford, G.W., Elsea, R.W., Miller, G.B., Jr., Egleston, M.D., and Hopkins, R.S., 1993, Coccidioidomycosis--United States, 1991-1992: Journal America Medical Association, v. 269, n. 9, p. 1098. Pappagianis, Demosthenes, Feldman, G., Billimek, M., Mascola, L., Werner, S. B., and Rutherford, G. W., 1994, Coccidioidomycosis following the Northridge earthquake-- California, 1994: Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, v. 43, n. 10, p. 194- 195. Reed, R., Reggiardo, C., Shupe, M., and Ingram, K., 1994, Coccidioidomycosis in domestic and wild animals: in Conference Program and Abstracts, 5th Centennial Conference on Coccidioidomycosis, Stanford, California, Aug. 24-27, p. 20. Rush, W.L., Dooley, D. P., Blatt, S. P., Drehner, D. O., 1993, Coccidioidomycosis: a persistent threat to deployed populations: Aviation, Space, and Environmental Medicine, v. 64, p. 653 - 657. 15 Schneider, Eileen, Hajjeh, R.A., Spiegel, R.A., Jibson, R.W.,Harp, E.L., Marshall, G.A., Gunn, R.A., McNeil, M.M., Pinner, R.W., Baron, R.C., Burger, R.C., Hutwanger, L.S., Crump, Casey, Kaufman, Leo, Reef, S.E., Feldman, G.M., Pappagianis, Demosthenes, and Werner, S.B., 1997: A coccidioidomycosis outbreak following the Northridge earthquake, Ventura County, California, January-March 1994: Journal of the American Medical Association, v. 277, no. 11, p. 904-908. Scogins, J. T., 1957, Comparative study of time loss in coccidioidomycosis and other respiratory diseases: in Proceeding Symposia on coccidioidomycosis, Public Health Service Publication, n. 575,p. 132 - 135. Smith, C. E., Beard, R. R., Rosenberger, H. G., and Whiting, E. G., 1946, Effect of season and dust control on coccidioidomycosis: Journal American Medical Association, v. 132, n. 14, p. 833 - 838. Sorensen, R. H., 1964, Survival characteristics of mycelia and spherules of Coccidioides immitis in a simulated natural environment: American Journal of Hygiene, v. 80, n. 3, p. 275 - 285. Swatek, F. E., 1975, The epidemiology of coccidioidomycosis: in Al-Doory, Yousef, ed., The epidemiology of human mycotic diseases, Charles C.Thomas, Springfield, 1L, p. 75 - 102. 16 IF STRIKIES AMIL ,� . �� , J '000" 1� �1� / / '-- � r .r - J IIII q1 , �I , pill IF r�� ® ;� , , 1I �J J � .w 2�_ Tor, s;w �Iw 414-j,� p 41i i uppose terrorists were to release rough guide. Methods that eradicated The networks that support everyday life PI plague in Chicago, and health smallpox in African villages in the and provide employment,transportation officials,faced with limited re- 1970s, for example, might not be the infrastructure,necessities and luxuries sources and personnel, had to most effective tactics against smallpox are the same ones that infectious diseases quickly choose the most effective re- released in a U.S.city in the 21st century. exploit to spread among human hosts.By spouse.Would mass administration of To identify the best responses under a modeling this social network in fine de- antibiotics be the best way to halt an variety of conditions in advance ofdisas- tail,we can understand its structure and outbreak? Or mass quarantines?What ters, health officials need a laboratory how to alter it to disrupt the spread of if a chance to nip a global influenza pan- where"what if"scenarios can be tested disease while inflicting the least damage demic in the bud meant sending nation- as realistically as possible.That is why to the social fabric. al stockpiles of antiviral drugs to Asia our group at Los Alamos National Lab- where a deadly new flu strain was said oratory (LANL) set out to build Epi- Virtual Epidemiology to be emerging?If the strategy succeed- Sims,the largest individual-basedepide- LONG BEFoxr the germ theory of dis- ed,a worldwide crisis would be averted; miology simulation model ever created. ease,London physician John Snow at- if it failed,the donor countries would be Modeling the interactions of each in- gued that cholera,which had lulled tens left with less protection. dividual in a population allows us to go of thousands of people in England dur- Public health officials have to make beyond estimating the number of people ing the preceding 20 years, spread via choices that could mean life or death for likely to be infected;it lets us simulate the the water supply.In the summer of 1854 thousands,even millions,of people,as paths a disease would take through the he tested that theory during an outbreak well as massive economic and social dis- population and thus where the outbreak in the Soho district.On a map,he marked ruption.And history offers them only a could be intercepted most effectively. the location of the homes of each of the f �h * 3 \WM +y I r,� M` I ".j i w. 500 victims who had died in the preced- her is a best guess based on historical high-performance supercomputing clos- ing 10 days and noted where each victim situations, even though the culture, ters and by building on an existing mod- had gotten water.He discovered that ev- physical conditions and health status of el called TRANSIMS developed over ery one of them drank water from the people in those events may differ greatly more than a decade at Los Alamos for Broad Street pump,so Snow convinced from the present situation. urban planning[see"UnjammingTraffic officials to remove the pump handle.His In real epidemics,these details mat- with Computers," by Kenneth R.How- action limited the death toll to 616. ter.The rate at which susceptible people ard; SciENTrEic AMERICAN, October Tracing the activities and contacts of become infected depends on their indi- 19971.The TRANSIMS project started individual disease victims,as Snow did, vidual state of health,the duration and as a means of better understanding the remains an important tool for modern nature of their interactions with conta- potential effects of creating or rerouting epidemiologists.And it is nothing new gious people,and specific properties of roads and other transportation infra- for health authorities to rely on models the disease pathogen itself.Truer models structure.By giving us a way to simulate the movements of a large population Truer models must capture the through a realistic urban environment, p TRANSIMS provided the foundation we probability of disease transmission ` I needed tomodeltheirEpiSims. fmil- lions of individuals for EpiSims. Although EpiSims can now be adapt- from one person to another. ed to different cities,the original TRAN- SIMS model was based on Portland,Ore. when developing policies to protect the of outbreaks must capture the probabil- The TRANSIMS virtual version of Port- ipublic. Yet most mathematical models ity of disease transmission from one per- land incorporates detailed digital maps for understanding and predicting the son to another,which means simulating of the city,including representations of course of disease outbreaks describe not only the properties of the disease and its rail lines,roads,signs,traffic signals only the interactions of large numbers of the health of each individual but also de- and other transportation infrastructure, people in aggregate. One reason is that tailed interactions between every pair of and produces information about traffic modelers have often lacked detailed individuals in the group. patterns and travel times.Publicly avail- knowledge of how specific contagious Attempts to introduce such epide- able data were used to generate 180,000 {„ diseases spread. Another is that they etiological models have,until recently, specific locations,a synthetic population have not had realistic models of the so- considered only very small groups of of 1.6 million residents,and realistic dai- cial interactions in which people have 100 to 1,000 people.Their size has been ly activities for those people[see box on contact with one another.And a third is limited because they are based on actual opposite page]. that they have not had the computation- populations,such as the residents,visi- Integrating all this information into al and methodological means to build tors and staff of a nursing home,so they a computer model provides the best esti- models of diseases interacting with dy- require detailed data about individuals mate of physical contact patterns for namic human populations. and their contacts over days or weeks. large human populations ever created. As a result, epidemiology models Computing such a large number of inter- With EpiSims,we can release a virtual typically rely on estimates of particular actions also presents substantial techni- pathogen into these populations,watch disease's "reproductive number"—the cal difficulties. it spread and test the effects of different number of people likely to be infected by Our group was able to construct this interventions.But even without simulat- one contagious person or contaminated kind of individual-based epidemic model ing a disease outbreak,the model pro- location. Often this reproductive num- on a scale of millions of people by using vides intriguing insights into human so- cial networks, with potentially impor- tant implications for epidemic response. Social Networks 01-1,f7l; r mr ii 14,,-I, i ind TO UNDERSTAND what asocial net- work really is and how it can be used for 01 „ � II ,_ Nip" ,r - 9i ail l.�,�d In 1�iin ��r, o o:,lo,,ri ,0I,��.IJ C ai epidemiology,imagine the daily activi- iflII „ r cmirP L" ol', of raw�� �_:.�,I ties and contacts of a single hypothetical _a .',1 11 '1I w1lu" .. I n "-ID I n p., n1c,i adult,Ann.She has short brushes with " mn„ 'JJli ou..,Zli L.IIL1116 .Jl , 1rl Nw;, ,�,_ua I n:,IkVL l'!lw:,i family members during breakfast and I o I.gnI "� 11, l u _iirii, :n"1 then with other commuters orcarpool- "�'4:� W I a',,n . vri.nil ers on her way to work.Depending on 1 her job,she might meet dozens of people 56 SCIENTIFIC AMERICAN MARCH 2O05 i 500 victims who had died in the preced- her is a best guess based on historical high-performance supercomputing clus- ing 10 days and noted where each victim situations, even though the culture, ters and by building on an existing mod- had gotten water.He discovered that ev- physical conditions and health status of el called TRANSIMS developed over ery one of them drank water from the people in those events may differ greatly more than a decade at Los Alamos for Broad Street pump,so Snow convinced from the present situation. urban planning[see"Unjammhng Traffic officials to remove the pump handle.His In real epidemics,these details mat- with Computers," by Kenneth R.How- action limited the death toll to 616. ter.The rate at which susceptible people ard; SCIENTIrIC AMERICAN, October Tracing the activities and contacts of become infected depends on their indi- 19971.The TRANSIMS project started individual disease victims,as Snow did, vidual state of health,the duration and as a means of better understanding the remains an important tool for modern nature of their interactions with conta- potential effects of creating or rerouting epidemiologists.And it is nothing new gious people,and specific properties of roads and other transportation infra- for health authorities to rely on models the disease pathogen itself.Truer models structure.By giving us a way to simulate the movements of a large population Truer models must capture the through a realistic urban environment, p TRANSIMS provided the foundation we probability of disease transmission "endedt°m°dualsforEpel the iSmcis°�ml" lions of individuals for EpiSims. Although EpiSims can now be adapt- from one person to another. ed to different cities,the original TRAN- SIMS model was based on Portland,Ore. when developing policies to protect the of outbreaks must capture the probabil- The TRANSIMS virtual version of Port- public. Yet most mathematical models ity of disease transmission from one per- land incorporates detailed digital maps for understanding and predicting the son to another,which means simulating of the city,including representations of course of disease outbreaks describe not only the properties of the disease and its rail lines,roads,signs,traffic signals only the interactions of large numbers of the health of each individual but also de- and other transportation infrastructure, j people in aggregate. One reason is that tailed interactions between every pair of and produces information about traffic modelers have often lacked detailed individuals in the group. patterns and travel times.Publicly avail- knowledge of how specific contagious Attempts to introduce such epide- able data were used to generate 180,000 ' diseases spread. Another is that they miological models have, until recently, specific locations,a synthetic population have not had realistic models of the so- considered only very small groups of of 1.6 million residents,and realistic dai- cial interactions in which people have 100 to 1,000 people.Their size has been ly activities for those people[see box on contact with one another.And a third is limited because they are based on actual opposite page]. that they have not had the computation- populations,such as the residents,visi- Integrating all this information into at and methodological means to build tors and staff of a nursing home,so they a computer model provides the best esti- models of diseases interacting with dy- require detailed data about individuals mate of physical contact patterns for namic human populations. and their contacts over days or weeks. large human populations ever created. As a result, epidemiology models Computing such a large number of inter- With EpiSims,we can release a virtual typically rely on estimates of articular actions also resents substantial techni- pathogen into these populations,watch YP Y Y P P P g P P disease's "reproductive number"—the cal difficulties. it spread and test the effects of different number of people likely to be infected by Our group was able to construct this interventions.But even without simulat- one contagious person or contaminated kind of individual-based epidemic model ing a disease outbreak, the model pro- location. Often this reproductive num- on a scale of millions of people by using vides intriguing insights into human so- cial networks, with potentially impor- eview/ Iw+ V tant implications for epidemic response. i.rvI,k, oT �I1 I t i _� u Social Networks lw�yW'�ii,i•,yy`-1r+w+u+o-iw w!WwuWPI+MwMiwlYw++4wr«w..yi:u - c�ini -i .... � ylyyyry.uyy,�yr wi -.,.rNW'W°YYY�+w�„aw✓r •w�^"r' �'"""^"'� ��^"^' � TO UNDERSTAND what asocial Ret- m 0 „ � �, - - - »„ " •' work really is and how it can be used for a a WUYbiltil4vi•a+r6::.ne.r Aei MnnJn Rrzl tiY'eV V�MI 'l1Y�tl'iNE"�+j y '� "�f_'T "'1 ni'"" o, .w,uw , epidemiology,imagine the daily activi- It �, "Wf.,z .j ���i� ties and contacts of a single hypothetical _ adult,Ann.She has short brushes with t i µ i � d� _ family members during breakfast and w i .,Yww.a h':��.J11, 11 + I — I 11L. i � :oi rhea with other commuters or carpool- r��: r ,I„�yW,�i,l aarurrauur undo + ; >,ar, ,r '4xwilwn,: ,:: q,�� .•....,� „� ers on her way to work.Depending on ...,... ..W.. ...... .,...."..mow.".��.....„....... -..,_ . her job,she might meet dozens of people 56 SCIENTIFIC AMERICAN MARCH 2005 The original EpiSims model was based on Portland,Ore.,but intrusive.Asynthetic population,statistically indistinguishable gathering sufficiently detailed information about 1.G million from the real one,could nonetheless be constructed and real people and their activitieswould have been difficult and given realistic daily lives using publicly available data. SYNTHETIC HOUSEHOLDS HODSEHOLD#2376 The LI.S.Census Bureauprovided - _- jli _J-I_ 1 _ demographic information,such as age, household composition and income, forthe entire city as well as S percent of Luhch - -- -I its complete records for smaller study - c, �1-1 areas ofa fews uare blocks. 1 1 Through a statistical technique called iterative proportional fitting,these two Age: 28 27 7 3 �x data sets were combined to create y'` ,y- ! ',,.-lNjorl, households and individuals with Income: $37K $28K $0 $0t;-__,_: -,�!_ statistical) correct demographics - ✓ _' - i� yStatus: worker worker student daycare � and geographic distribution. �HH2375 h �l / I ��� - � J s`eppl L - �n -4 LE 8 rNH2375 DAILYACTIVITIE$ Ar 3:00A M. 4.4s F.c = ✓ --'� -!' r -- 2 p Leave home Leave dentist '1- Hone i yy�H 8:40A.M 530F.nf. -, � - 1 ry 2: Arrive atwork Goshopping -- — 3 H. li l G, 2�9OFM. Goo F.M, 3: Havelunch Leave shoppingHellttls - T -- Gr — 320FM 7:20 PM. —j-� Gotothedentist Arrive home � v LOCATIONS ACTIVITIES Setting the population in motion requires assigning locations to every Most metropolitan planning offices conduct detailed traveler household's activities.Land-use data for buildings,parking lots, jl activity surveys for small population samples of a few thousand. parks and other places were associated with 180,000 locations in the These logs track the movements of each household member over the model,providing estimates of the number of people performing course of one or more days,noting the time of each activity.By various types of activities there.Activities were anchored to matching the demographics of survey respondents to the entire individuals'work or school locations,and then places were chosen for p synthetic population,realistic daily activities can be generated for additional activities,such as grocery shopping or recreation,taking every synthetic household member. into accounttheir distance and other measures oftherr appeal. r1 I: t at work,with each encounter having a The popular idea that everyone on been found to displaythis same tendency different duration,proximity and pur- the earth is connected to everyone else toward having"hubs":certain locations, pose. During lunch or a shopping trip by at most six degrees of separation people or even molecules with anunusu- ul after work,Ann might have additional means that if we continued building our ally high number of connections to the short contacts with strangers in public social network until it included everyone rest of the network.The shortest path be- places before returning home. on the planet,no two people would be tween any two nodes in the network is We can visually represent Ann's con- more than six hops from one another. typically through one of these hubs, tacts as a network with Ann in the center The idea is not strictly true,but it makes much as in a commercial airline's route and a line connecting Ann to each of for a good story and has even led to the system.Technically,such networks are them[see box on next page].All Ann's well-known game involving the social called "scale-free"when the number of contacts engage in various activities and network of actors who have appeared in hubs with exactly k connections,N(k),is meet other people as well.We can repre- films with Kevin Bacon. In academic proportional to a power of [see"Scale- sent these "contacts of contacts" by circles, another such social network Free Networks," by Albert-Laszlo drawing lines from each—for example, traces mathematicians' co-authorship Barabasi and Eric Bonabeau;SCIENTIFIC Ann's colleague named Bob—to all his connections, with one's "Erdos num- AMERICAN,May 2003]. contacts.Unless they are also contacts of ber"defined by graph distance from the Because a scale-free network can be Ann,Bob's contacts are two"hops"away late,brilliant and prolific Paul Erdos. severely damaged if one or more of its from Ann. The number of hops on the Other types of networks,including hubs are disabled, some researchers shortest path between people is some- the Internet,the links among scientific have extrapolated this observation to times called the graph distance or degree article citations and even the interactions disease transmission.If infected "hub" of separation between those people. among proteins within living cells,have individuals,such as the most gregarious www.sciam.com SCIENTIFIC AMERICAN 57 I TYPICAL HOUSEHOLD'S CONTACTS Constructing asocial network for a household oftwo adults and This diagram shows where the household members go and what they two children starts by identifying their contacts with otherpeople do all day but reveals little about how their individual contacts might throughout a typical day. be interconnecteddoor,''.connected to others. �/Work Work V ICI Lunch I'-- —( Carpool -__---_._Car pool Shopping Home Home Car Car Day care Ll Schoolbus School Schoolbus i LOCAL SOCIAL NETWORK EXPANDER GRAPH a Asocial network emerges by drawing lines to represent The shape ofthis small connections within the household(a)and from the network expands with each household members to their direct contacts(b). !'.'\ generation ofcontacts. Connectingthose individuals to their own circle ofcontacts ' Adisease movingthrough b (c)andthosetothe nextgeneration ofcontacts(d) 'I, such a population therefore enlargesthe network.Long-distance connections show infects risingnumbers i contactswho also know each other.Yet no onein this : ' of eoP lem each ("ill network has morethan lS direct contacts, i,i�, P generation oftransmission. meaning none is a highly connected"hub" ofsociety.One insight from this work is that so many alternative paths can connect any vair ofC \ ndiiduaIspweuld dolttle to only hub ���(��f•{ �� i4flr ��� ��� \ �y. the spread of infectious disease -1 _ through this population r f,ai r I I r. Long-distance i' e connections t1,, \1 A ` 1 i' r $S SCIENTIFIC AMERICAN MARCH 2005 t people in a population,could somehow Small pox Attack pox from developing.We assumed in all be identified and treated or removed AFTER WE BEGAN developungEpiSims our simulations that health workers and from the network,the reasoning goes, in 2000, smallpox was among the first people charged with tracking down the then an epidemic could be halted with- diseases we chose to model because gov- contacts of infected people had already ;1 out having to isolate or treat everyone in ernment officials charged with bioterror- been vaccinated and thus were immune. the population.But our analyses of the ism planning and response were faced Unlike many epidemiological models, social networks used by EpiSims sug- with several questions and sometimes our realistic simulation also ensures that gest that society is not so easily disabled conflicting recommendations. In the the chronology of contacts will be con- as physical infrastructure. event that smallpox was released into a sidered. If Ann contracted the disease, The network of physical locations in U.S.population,would mass vaccination she could not infect her co-worker Bob a our virtual Portland,defined by people be necessary to prevent an epidemic?Or week earlier.Or,if Ann does infect Bob traveling between them,does indeed ex- would targeting only exposed indivtdu- after she herself becomes infected and if hibit the typical scale-free structure, als and their contacts for vaccination be Bob in turn infects his family member with certain locations acting as impor- enough?How effective is mass quaran- Cathy, the infection cannot pass from tant hubs.As a result, these locations, tine? How feasible are any of these op- Ann to Cathy in less than twice the min- such as schools and shopping malls, would be good spots for disease surveil- Our analyses suggest that lance or for placing sensors to detect the i presence of biological agents. The urban social networks in the city society is not so easily also have human hubs with higher than average contacts, many because they disabled as infrastructure. work in the physical hub locations,such as teachers or sales clerks. Yet we have tions with the existing numbers of health imum incubation period between disease also found an unexpectedly high number workers,police and other responders? exposure and becoming contagious. 1+ of"short paths" in the social networks To answer such questions, we con- With our disease model established that do not go through hubs,so a policy strutted a model of smallpox that we and everyone in our synthetic population of targeting only hub individuals would could release into our synthetic popula- assigned an immune status,we simulated probably do little to slow the spread of a tion.Smallpox transmission was particu- the release of smallpox in several hub lo- disease through the city, larly difficult to model because the virus cations around the city,including a um- In fact,another unexpected property has not infected humans since its eradica- versity campus. Initially, 1,200 peopled we have found in realistic social networks non in the 1970s. Most experts agree, were unwittingly infected, and within is that everyone but the most devoted re- though,that the virus normally requires hours they had moved throughout the cluse is effectively a small hub.That is to significant physical contactwith an infer- city,going about their normal activities. j say,when we look at the contacts of any tious person or contaminated object.The We then simulated several types of j small group, such as four students,we disease has an average incubation period official responses,including mass vacci- i fund that they are always connected by of approximately 10 days before finlike nation of the city's population or contact one hop to a much larger group.Depict- symptoms begin appearing,followed by tracing of exposed individuals and their ing this social network structure results skin rash.Victims are contagious once contacts who could then be targeted for in what is known as an expander graph symptoms have appeared and possibly vaccination and quarantine.Finally,we [see box on opposite page],which has a for a short time before they develop fever. simulated no response at all for the put- cone shape that widens with each hop.Its Untreated,some 30 percent of those in- pose of comparison. most important implication for epidemi- fected would die,but the rest would re- In each of these circumstances,we ology is that diseases can disseminate ex- cover and be immune to reinfection. also simulated delays of four,seven and ponentially fast because the number of Vaccination before exposure or with- 10 days in implementing the response people exposed in each new generation of in four days of infection can stop small- after the first victims became known.In transmission is always larger than the number in the current generation. F CHRIS L.BARRETT,STEPHEN G.£UBANK and JAMES P.SMITH worked for five years to- ' Theoretically,this should mean that 4 gether at Los Alamos National Laboratory(LAN L)to develop the EpiSims simulation. whatever health officials do to intervene Q Barrett,who oversaw a predecessor proj act,TRANSIMS,is a bioinformatics speci alist in a disease outbreak,speed will be one 3" who now directs the Simulation Science Laboratory at the Virginia Bioinformatics Insti- of the most important factors determin- tute(VBI)in Blacksburg.Eubank,aphysicist,is deputy director of the VBl simulation lab ing their success.Simulating disease out- Q and was EpiSims team leader at Los Alamos.Smith,a Ise a physicist,continues to work breaks with EpiSims allows us to see with simulations related to TRANS]MS as the project office leader for Discrete Simulation 's', whether that theory holds true. Science in the LANL Computer and Computational Sciences Division. www.sciam.com SCIENTIFIC AMERICAN 59 EpiSims animations depict simulated outbreaks andthe effects show no public health response as a baseline.In the right-hand of official interventions.In the still frames below,vertical lines images,infected and exposed individuals are targeted for indicate the number of infected people present at a location,and vaccination and quarantine.Results from a series of such color shows the percentage of them who are contagious.In both simulations(bottom)show that people withdrawing to their scenarios shown,smallpox is released at a university in central homes early in an outbreak makes the biggest difference in Portland,but the attack is not detected until victims start death toll.The speed of official response,regardless of the experiencing symptoms 10 days later.The left-hand images strategy chosen,proved to be the second most important factor. DAY 1: UNDETECTED SMALLPDX RELEASE NO CSi OG�SE TAIRGETED 'ULCCiMATGON AND RIJARANTlNE STARTVNC DAY a,4, INFECTED:S,E81 r QUARANTINED:0 INFECTED:1,281 ContagiousperepstaVACCINATED:O DEAD:O - DEAD:O DAY 35:SMALLPDX EPIDEMIC .I INFECTED:2,564 .M QUARANTINED:29,910 �i INFECTED:23,919 - VACCINATED:30,560 1 OEAO:551 �� ��� =7�• DEAD:312 DAY?0:EPIDEMIC UNCONTAINED OR CONTAINED :w Jaw+a«-ram r ,~' ^^+'•^�' INFECTED:2,564 — "' QUARANTINED:36,725 INFECTED:3801,582 "' ''1 VACCINATED:37,207 DEAD:12,499 DEAD:435 WITHDRAWAL TO HOME 10,OD0 Earl Late Never a a o INTERVENTION KEY RESPONSE EFFECTIVENESS F " Simulations allowed people to withdraWto their e ao1,000— 0No vaccine homes because they felt ill orwere following wr � 10-day delay officials'instructions.Withdrawal could be"early,' viz 100— • 7-day delay before anyone became contagious,at"never," a� 04.day delay meaning people continued moving about unless they oa 10— died."Late"withdrawal,24 hours after becoming w o contagious,was less effective than early >w withdrawal,which prevented an e idemicwithout �w . ---------'-�'�-i"-""""� other intervention.Official responses included doing 1____,_. �= O O O U u U nothing,ortargeted vaccination and quarantinewith o 03 rJ unlimited personnel,or targeted vaccination limited m y d N m y a N v v by only halfthe necessary personnel being :E on E available,or mass vaccination ofthe entire ! z g z z r population.The interventions began four,seven or OFFICIAL RESPONSE 10 days afterthe first victims became symptomatic. addition,we allowed infected individu- Flu and the Future neuraminidase.In our simulations,we I als to isolate themselves by withdrawing OVER THE PAST YEAR, a highly vir- will be able to use neuraminidaseinhib- 4 to their homes. ulent strain of influenza has raged itors as both treatment and prophylaxis. Each simulation ran for a virtual100 through bird populations in Asia and (A vaccine against H5N1 has been de- days[see box on opposite page],and the has infected more than 40 human be- veloped and recently began clinical tri- precise casualty figures resulting from ings in Japan,Thailand and Vietnam, als but because the vaccine is not yet each scenario were less important than killing more than 30 of those people. proven or available,we will focus our the relative effect different responses had The World Health Organization has simulations on seeing whether the anti- on the death tolls.The results upheld our warned that it is only a matter of time viral drugs together with traditional theoretical prediction based on the ex- before this lethal flu strain,designated public health measures might stop an pander-graph structure of the social net- H5N1, more easily infects people and epidemic.) work:time was by far the most impor- spreads between them. That develop- Preliminary results announced in late tant factor in limiting deaths.The speed ment could spark a global flu pandemic February are reported at www.sciam. with which people withdrew to their with a death toll reaching tens of mil- com.In April,we will complete similar homes or were isolated by health officials lions [see SA Perspectives, SCIENTIFIC flu pandemic simulations in the EpiSims was the strongest determinant of the out- AMERICAN,January]. Portland model. break's extent.The second most influen- MIDAS collaborators will be study- Our hope is that the ability to realisti- tial factor was the length of the delay in ing the possibility that an HSN1 virus tally model populations and disease out- officials'response.The actual response capable of spreading in humans might breaks can help health officials make dif- strategy chosen made little difference be contained or even eradicated by rap- ficult decisions based on the best possible compared with the time element. id intervention while it is still confined answers to"what if" questions. In the case of a smallpox outbreak, these simulations indicate that mass vac- The actual response chosen cination of the population,which carries its own risks,would be unnecessary.Tar- �I made little difference compared geted vaccination would be just as effec- tive so long as it was combined with rapid detection of the outbreak and rapid re- With the time element. sponse.Our results also support the im- portance of measures such as quarantine to a small population.To simulate the The creation of models such as and making sure that health officials give appropriate conditions in which the TRANSIMS that simulate human move- enforcement adequate priority during strain would likely emerge among hu- merits through urban environments was highly infectious disease outbreaks. mans,we are constructing a model rep- the computational breakthrough that Of course,appropriate public health resenting a hypothetical Southeast made EpiSims possible, and epidemiol- responses will always depend on the dis- Asian community of some 500,000 ogy is only one potential application for ease,the types of interventions available people living on farms and in neighbor- this kind of individual-based modeling. and the setting. For example, we have ing small towns.Our model of the influ- We are also in the process of creating and simulated the intentional release of an in- enza virus itself will be based both on linking simulations of other sociotechni- halable form of plague in the city of Chi- historical data about pandemic flu cal systems, including environmental cago to evaluate the costs and effects of strains and information about the and atmospheric pollution,telecommu- different responses.In those simulations H5N1 virus,whose biology is currently nications, transportation, commodity we found that contact tracing,school clo- a subject of intense investigation. markets,water supplies and power grids, sures and city closures each incurred eco- We know,for example,that HSN1 to provide virtual laboratories for ex- nomic losses of billions of dollars but did is sensitive to antiviral drugs that inhib- ploring solutions to a wide variety of not afford many health benefits over vol- it one of its important enzymes,called real-world problems. m notary mass use of rapidly available anti- biotics at a much lower economic cost. �ubL'hil�■�l'IJ1rl: Most recently, as part of a research Scalable,Efficient Epidemiological Simulation.Stephen Eubank in Proceedings of the 2002 network organized by the National In- ACM Symposium on Applied Computing,pages 139-145;2002. stitute of General Medical Sciences Six Degrees:The Science of a Connected Age.Duncan J.Watts.W.W.Norton,2004. called the Models of Infectious Disease Containing Pandemic Influenza with Antiviral Agents.Ira M.Longini,Jr.,at al.inAmerican Jo urn of of Epidemiology,VoL 1S%No.?,pages 623-633;April 1,2004. Agent Study (MIDAS), we have been Modelling Disease Outbreaks in Realistic Urban Social Networks.Stephen Eubank et al,in adapting EpiSims to model a naturally Nature,Vol.429,pages 180-184;May 13,2004. occurring disease that may threaten the A sample EpiSims animation and additional data from the Portland smallpox simulations can be entire planet:pandemic influenza. viewed at http://episims.lani.gov www.sciam.com SCIENTIFIC AMERICAN 61 COCcidioidomyco sis A Fungus Among U s Eligia M. Herrera, RN Program , MSNY PHN Coordinator Communicable Diseases COCdd|Oidesimm$S � : - \ ^k ( { © - \ �- ! - - � ® 12 qj - �� • � � � . . . . � £, � / � � _ . } ° $ \ • . . . . \ - � - � / 1�0m a off , all Coccidioidomycosis Also Known as •: Cocci ❖Valley fever •3San Joaquin fever ❖ Desert fever :• Desert rheumatism Cocci • A fungal infection that generally begins as a respiratory infection • May be asymptomatic or resemble aviral-like illness • Primary infection may. heal without residuals • May progress to a disseminated form of the disease • 1 /1000 of symptomatic cases become disseminated M Coccidioides immitis L J, AV V f, A_ z Y of L. Ajollo-� 2M Doctorfun �;Wporatlon '.0000gh,t 0 - Genus/Species: Coccidioides immitis - Title: Spherules . Image Type: MicroInfection - Diseases): Coccidioidomycosis - Legend: Spherules in lung tissue. KOH, 400X. • Infectious agent: Coccidioides immitis • Occurrence : Soil dwelling organism that likes arid and semi-arid areas of the Western Hemisphere like: ➢ California ➢ All the way to southern Texas ➢ Northern Argentina ➢ Paraguay ➢ Columbia ➢ Venezuela ➢ Mexico ➢ Central America • The disease affects all ages, both genders and all races • More than half of the patients with symptoms are between the ages of 15 and 25 • Males are more affected than females probably because of occupational exposures • Infections are more frequent in the Summers after a rainy winter or spring and especially after wind and dust storms • It is a special concern among migrant workers , archeologists and military personnel who move to endemic areas • Since 1991 there has been a marked increase in California • Reservoirs = the soil • Infects : humans , cattle , cats , dogs , horses , burros , sheep , swine , wild desert rodents , coyotes , chinchillas , llamas and other animal species • Mode of transmission : inhalation of the spore from the soil and in the laboratory • Incubation period : 1 -4 weeks . Sometimes goes unrecognized for years after primary infection • Communicability: not directly transmitted from human or animals to humans Coccidioides i a � Nib t Y y y. 'aF -6 •�� -S. t -fR,k { {. r � � 1 Image Courtesy of D_ Grayhill .A Copyright Q 2000 Doctorfungus Corporation • Genus/Species: Coccidioides immitis • Title: Skin lesion • Disease : Coccidioidom• Image Type: MacroInfection (s cosis1 Y • Legend: Skin lesion resulting from dissemination of the fungus from the lungs. " I feel the earth move under my feet= _m-ail over a I I over" The Fall 2003 California fires burned many miles and acres of land exposing the soil. So windy days are good transporters of the spores �a o � ➢ In March 2004 Ventura County reported increases in reported cases. More than 70 cases had been reported since October 2003. 2/3 of the cases reported were from the eastern portion of the county where the Simi fires scorched more than 108,000 acres. This ■ ■ compared to the typical occurrence of ■ ■ 2 cases per month ■ ➢ The last outbreak in Ventura County ` � ■ ■ was after the 1994 Northridge earthquake with 203 cases compared with 50 cases the year before • The saga continues San Bernardino County ➢ Where more than 60 , 000 acres were burned , had seen 14 cases by March 2004 . The county had only 13 cases for the entire previous year And the boat goes on : San Diego County ➢ 280,000 acres were burned last October ➢ As of November 1 , 2003 the county recorded 34 cases which was more than double the number in an almost 5 month period the previous year • There's a lot of building going on in Riverside County as people migrate from other locations for affordable housing . If the ground is not /0000 watered down the 2x dust from moving the dirt could disperse the spores ❑ Occupational hazards ➢ Laboratory personnel : Specimens need to f be handled carefully and under lab hoods _ ➢ Construction workers especially earth movers ➢ Migrant farm workers t ➢ Military personnel Risk for disseminated disease • People with weakened immune systems ( HIV, cancer patients (chemo) • Pregnant women • People who are diabetics • People of African American , Filipino and of Latino descent are believed to be of greater risk Reported Cases : Riverside County , 1999 =2004* 35 30 rA 25 c 20 15 E z 10 5 0 1999 2000 2001 2002 2003 2004* *Data through 6/30/04 Compiled By: Riverside County Department of Public Health,Health Statistics Branch, July 23,2004 Reported Cases Diagnosed Jan -June : Riverside County, 1999=2004 18 16 14 v 12 c 10 8 a 6 z 4 2 0 1999 2000 2001 2002 2003 2004 *Data through 6/30/04 Compiled By:Riverside County Department of Public Health, Health Statistics Branch,July 23,2004 Reported Cases by Region : Riverside County, 1999=2004* 25 rA 20 15 0 ... z 5 0 1999 2000 2001 2002 2003 2004* ■ Western ❑ Mid ■ Eastern � *Data through 6/30/04 Compiled By: Riverside County Department of Public Health,Health Statistics Branch, July 23,2004 Reported Cases by Race/Ethnicity : Riverside County, 1999 =2004* 18 16 14 12 0 10 a 8 5 6 z 4 2 0 1999 2000 2001 2002 2003 2004* ■ White ❑ Hispanic i Other/Unknown *Data through 6/30/04 Compiled By:Riverside County Department of Public Health, Health Statistics Branch,July 23,2004 Reported Cases by Age Group : Riverside County, 1999 =2004* 18 16 14 U 12 0 10 8 8 6 z 4 2 0 1999 2000 2001 2002 2003 2004* i e 25 years-old ❑ 25-50 years-old ® > 50 years old *Data through 6/30/04 Compiled By: Riverside County Department of Public Health, Health Statistics Branch,July 23,2004 Reported Cases by Sex : Riverside County, 1999 =2004* 25 20 � 15 0 .� 10 z 5 0 1999 2000 2001 2002 2003 2004* ■ Male ❑ Female *Data through 6/30/04 Compiled By:Riverside County Department of Public Health,Health Statistics Branch,July 23,2004 Reported Cocci' . Riverside County, 1999 =2004* Legend Total Coccl Coccl by Year [_ ] 0 200&2003 1 -2 • 2004 3-10 11 - 15 _ 1E- 22 Reported Cases -by Diagnosis Date : Riverside County, 1999=2004* 16 14 12 rA U 10 w 8 a> A 6 z 4 2 0 4j e�w�4 '� ��c' A S O S`� 1999 2000 2001 2002 2003 2004 *Data through 6/30/04 Compiled By:Riverside County Department of Public Health,Health Statistics Branch, July 23,2004 Coccidioides immitis Courtesy of The Geraldine Kaminski Medical Mycology Library Produced by: David Ellis and Roland Hermanis Copyright o 2003 Doctorfungus Corporation 4 t f 11 1y P r •� �_., : :, _- .T#•e [i Qrri/dina `r=E--GrYm,fci,:�M.4dFC5F�/-�'4�nA/q$S".1.i4s�f�Fy ny- ior -/-/!V'-x•;/RR!?••.:/i.�F. 3+:.OBvidE//is and-RoxFtrarJparlt�lyis -... _ ,•' ;Gypyr,lp:kxt �3_.R'Oa3 Oioctorl/a•n.9us..Ci4-![iioragi. xn S • Genus/Species:Coccidioides immitis • Slide Reference #: GK 109 �=s-3 " ` • Image Type: Clinical Presentation • Disease(s): Coccidioidomycosis - a - t h t a rA`rf� —a_H 3 i � last --'�'. yap �• t tt •t • Genus/Species: Coccidioides immitis • Title: Erythema nodosum • Image Type: Macrolnfection • Disease(s): Coccidioidomycosis • Legend: The rash is a immunologic response to the fungus. It is most commonly seen in caucasion women. Treatment ➢ Antifungal agents such as : ❖Amphotericin •SDiflucan ➢ No vaccine developed yet Precautions • Wear a mask • Work under a hood (lab personnel ) • Water down the dirt • Follow up with PMD That' s all Folks Eligia M. Herrera, RN, MSN, PHN Program Coordinator � Y I Communicable Diseases Unit Disease Control Branch ;v Special Acknowledgement to : F y Wendy Betancourt, MPH 4_ £ M_ Health Statistics Branch Reported Coccidioidomycosis (Valley Fever) by Place of Residence: Riverside County, 2000-2004 TF - � . • k�.ly t _ 2 I C, Reported Coccidioidomycosis by Zip Code(all cases) u 0 Cases 1 -2 Cases 3-10 Cases 11 - 15 Cases - 16+Cases • Reported Coccidioidomycosis Case(only cases with addresses.able to be geocoded) Swcad gy RloCoun ty IVDeparof z,i Meats,a Ima PLo—Igy .urinle0 2y RlrrsWe Lounly OepeMmnioi'rconc FXmm tpi�mwhgVaM Pc�om Evalutlun 9nrcM1,MemM1 2005 Reported Coccidioldomycosis (Valley Fever) by Place of Residence: Riverside County, 2000-2004 Ink k W ', % �Ad Coccidloidomycosis Case Rate per 100,000 Population by Zip Code = 0.0 MO.1 -15.0 = 15.1 -30.0 30.1 -70.0 70.1 + • Reported Coccidioldomycosis Case(only cases with addresses able to be geocoded) do County D up artunum of FjdJd Ho-Wh,D—a a Control Branch C., d B,R—rp,d.County OeparMeNol Nbrz hualLp,Epoemoogy ard P,E.I..U—B..h,MdpIf Mo