Picture this scenario: a 62-year-old backhoe operator working in one of the many residential construction developments in Bakersfield, Calif., has been suffering from recurring fever, cough, tiredness, shortness of breath, headaches, chills, night sweats, joint aches, leg rashes, and muscle soreness for the past week.
With symptoms such as these, one could easily surmise that it might be the flu. Perhaps the common cold. Possibly even Covid-19 or tuberculosis.
Three weeks pass by but the initial symptoms have not completely resolved. Additional symptoms may include weight loss, chest pain, blood-tinged coughs, and skin lesions in the skull and spine. The worker has become extremely weak and unable to work so he reports it to his boss. His boss then tells him to see the designated healthcare facility to be evaluated and hopefully treated.
The doctor’s initial diagnosis was pneumonia but eventually recommends further diagnostic testing due to the presence of skin rashes. After a positive skin test, blood test, and routine chest x-ray, the results come in. The worker is informed that he has contracted coccidioidomycosis, which is more commonly referred to as the Valley Fever.
But what is Valley Fever? How does one contract this disease? And from a California workers’ compensation perspective, how does one prove or disprove that Valley Fever was contracted at the job?
WHAT IS VALLEY FEVER?
Valley Fever, or coccidioidomycosis, is a fungal infection triggered by coccidioides (pronounced kok-sid-e-OY-deze) organisms.1 Coccidioides was named after the San Joaquin Valley in Central California where a substantial number of cases have been reported historically. The other areas in California with the highest rates include the Central Valley comprising the counties of Fresno, Kern, Kings, Madera, San Joaquin, and Merced and along the Central Coast including the counties of Monterey, San Luis Obispo, Santa Barbara, Tulare, and Ventura. Other regions where the fungus can be found are parts of Arizona, Nevada, Utah, New Mexico, Texas, Washington, northern Mexico, Central America, and South America.
Coccidioides organisms are fungi with elongated threads found in the soil. These threads eventually separate from the stem and become airborne spores once soil is disturbed by human activities like farming or construction or even by natural forces such as strong winds. The spores are so small and light that they can be carried by the wind. An individual can then inhale these spores and become infected.2 It is important to note that it is not contagious and cannot spread from one person to another.3 Other uncommon ways to contract Valley Fever are by inhalation of spores from a wound infected with coccidioides, contact with contaminated objects, such as rocks or shoes, or by receiving an organ transplant if the organ donor had Valley fever.4
It can take weeks to completely recover – or even months in very severe cases. Severity depends on a number of factors but mainly are attributed to one’s general health and the quantity of fungus spores inhaled.
There are three kinds of severity from coccidioidomycosis with corresponding symptoms.
The first kind is the most common called Acute Coccidioidomycosis. Symptoms are similar to other diseases such as influenza or tuberculosis so misdiagnosis is not uncommon among healthcare professionals. Symptoms may include cough, fever, chest pain, persistent headaches, muscle aches, body rashes, knee joint pain, ankle joint pain, and fatigue.5
If the initial infection is not fully cured, it may progress to a chronic form called Chronic Coccidioidomycosis. This is more common with individuals who suffer from preexisting medical conditions that cause weakened immune systems.6 Symptoms of chronic coccidioidomycosis include low-grade fever, weight loss, cough, chest pain, blood-tinged coughs, and ruptured lung nodules.7
The worst kind of Valley Fever is called Disseminated Coccidioidomycosis. This is rare form of Valley Fever. The infection spreads past the lungs and may creep to other parts of the body, such as the skin, bones, liver, brain, heart, brain membranes, and spinal cord membranes. Additional symptoms may include painful skin lesions in the skull or spine, swollen knee or ankle joints, nodules, ulcers, and meningitis.8
Individuals with increased risk of contracting Valley Fever include those with weakened immune systems; individuals living with acquired immunodeficiency syndrome (AIDS); those undergoing chemotherapy; those who are taking anti-rejection drugs after transplant surgery; those with rheumatoid arthritis; Crohn’s Disease; diabetes; older individuals; and pregnant women. For reasons not yet fully understood, Filipinos and African-Americans are also more vulnerable to severe forms of Valley Fever. The vulnerability for disseminated coccidioidomycosis is 175 times higher for Filipinos and 10 times greater for African-Americans than in non-Hispanic Whites.9
Valley Fever usually lasts anywhere from one week to six months. Many do not require treatment but more severe cases can only be diagnosed through a blood test or laboratory test. Patients with severe Valley Fever are administered with antifungal medication.10
INCREASING CASES OF VALLEY FEVER
In California, the number of reported cases of Valley Fever for 2024 (as of August 2024) is 7,340. This number has already surpassed the number of reported cases as of August 2023 with 4,421 cases. In Kern County alone, the total number of reported cases as of August 2024, is already at 2,583. This is an increase from Kern County’s previously reported cases of 1,433 as of August 2023.11
For the past 60 years, 10,000 to 20,000 cases are reported yearly to the Centers for Disease Control and Prevention on a nationwide-basis, with most cases found in the States of California and Arizona. From 1999 to 2021, the average death rate is nearly 200 each year.12
Needless to say, the number of cases of Valley Fever are growing yearly. A person may contract Valley Fever in the most unexpected places. In May 2024, California Department of Public Health reported that five individuals contracted Valley Fever when they attended a musical festival called “Lightning in a Bottle” in Bakersfield, Kern County. The musical festival was attended by more than 20,000 concertgoers. Three of the individuals were hospitalized but health officials noted that more individuals could have contracted Valley Fever without seeking medical intervention.13
REGULATIONS RELATED TO VALLEY FEVER PROTECTION
Regulations that relate to Valley Fever protection of workers can be found in California Code of Regulations, Title 8, namely: Section 342 (Reporting Work-Connected Fatalities and Serious Injuries), Section 3203 (Injury and Illness Prevention), Section 5141 (Control of Harmful Exposures), Section 5144 (Respiratory Protection), and Section 14300 (Employer Records Log 300).14
For workers in the construction industry, California AB 203 requires construction employers to provide Valley Fever training to workers if a project is located in one of the counties with high number cases of Valley fever.15
PROTECTION AGAINST VALLEY FEVER
There is yet no vaccine to prevent Valley Fever but there are present initiatives from the government to create a vaccine. The California Legislature proposed the Valley Fever Awareness and Vaccine Development and Manufacturing Act of 2024 that seeks to create a vaccine especially for workers in the industries of construction, agriculture, and other marginalized workers in Valley Fever hotspots.16 The Valley Fever Institute, located in Bakersfield, is at the forefront of Valley Fever vaccine research and it is currently developing at least three vaccines that potentially could be tested on people soon to determine their efficacy.17
But as long as there is no available vaccine for Valley Fever, employers and workers can only trust the old adage that “prevention is better than cure.” To avoid incurring huge expenses in workers compensation insurance premiums, medical expenses, legal services, lost productivity, and accident investigation – an employer would be wise to establish protocols so employees are well-protected from Valley Fever.
Workers should be aware of the recommended practices to avoid Valley Fever:18
- Use a mask: Wear a fitted N95 respirator if you can.
- Avoid dusty locations: Steer clear of places like construction sites if at all possible.
- Stay indoors during dust storms: Limit your exposure to outside dust.
- Moisten the soil before digging: If you’re at higher risk, consider avoiding digging altogether.
- Seal your home: Keep windows and doors tightly shut.
- Clean wounds properly: Use soap and water to clean any skin injuries.
- Stay away from dusty places: Avoid areas with high dust, such as construction sites.
- Practice precautions in high-risk areas: If you live in or visit places where Valley Fever is prevalent, especially during dry seasons after rain, take sensible measures.
- Remain indoors during dust storms: Close your windows to keep dust out.
- Limit soil contact: Avoid activities that involve digging in the ground.
- Implement air filtration indoors: Use air filters to help reduce indoor dust.
- Thoroughly clean injuries: Wash skin injuries well with soap and water to prevent infection.
- Cover bare soil: Plant grass or other ground cover around homes to minimize exposed dirt.
- Keep car windows closed while driving: Use recirculated air in vehicles if possible.
- Steer clear of dusty spots: Avoid construction or excavation sites.
- Stay upwind of disturbed dirt: Position yourself so that you’re not downwind from areas being excavated.
- Change clothes after being outdoors: Remove any dirt-covered clothing inside before washing, and inform anyone else handling them to avoid dust exposure.
- Wash dirt off before leaving work: Clean tools, vehicles, and equipment with water to remove soil before transporting them.
- Keep work and casual clothes separate: Use different storage areas for work clothes and everyday clothes, ideally keeping work boots at the job site.
- Shower after work: Take a shower and wash your hair as soon as you can after your shift or when you get home.
For employers, the California Department of Industrial Relations recommends that employers implement the following practices in the workplace:19
- Assess the worksite’s Valley Fever risk: Identify whether the worksite is located in an area with known Valley Fever cases. For instance, the Central Valley has a greater propensity for Valley Fever.
- Reduce outdoor dust exposure: Limit workers’ contact with outdoor dust in areas prone to Valley Fever. Minimize soil disturbance and halt work during strong winds or dust storms. Stabilize soil piles using tarps or similar methods, and provide enclosed, air-conditioned vehicle cabs while ensuring windows and air vents remain closed.
- Position workers strategically: Keep workers upwind of activities that generate dust, such as digging, grading, driving, soil dumping, drilling, or blasting.
- Use appropriate cleaning methods: Clean equipment, tools, and surfaces with vacuums equipped with HEPA filters, water, or wet cloths. Avoid using compressed air or dry sweeping, as these methods can create dust.
- Maintain soil moisture: Keep soil wet before, during, and after it is disturbed. Moisten the soil before heavy equipment or vehicles operate on it and continue to wet it while digging to minimize dust.
- Ensure respiratory protection: If dust exposure is unavoidable, supply NIOSH-approved respirators with particulate filters rated N95, N99, N100, P100, or HEPA.
- Identify a knowledgeable healthcare provider: Find a healthcare professional experienced in diagnosing and treating occupational injuries and illnesses related to Valley Fever.
- Educate workers about symptoms and exposure: Train workers to recognize Valley Fever symptoms and reduce exposure. Encourage them to report symptoms lasting more than a week to a supervisor. Provide them with an informational fact sheet and ensure they receive a medical evaluation.
If a worker has symptoms of Valley Fever, an employer is recommended to do the following: (1) Send the worker to the company’s workers’ compensation health care provider or occupational medicine clinic. Choose a provider who is knowledgeable about work-related Valley Fever. (2) Provide the health care provider with details about the location of the worksite and dust or soil exposure, and (3) Employers must immediately report cases where workers are hospitalized to Cal/ OSHA within 24 hours.20
ESTABLISHING WORK-RELATED EXPOSURE FOR VALLEY FEVER CASES
So how does one, within the context of California workers’ compensation prove (or disprove) that Valley Fever was contracted arising out of and occurring in the course of employment (AOE/COE)?
There are two notable Workers’ Compensation Appeals Board panel decisions that expound on the elements needed to demonstrate industrial causation in cases of claimed Valley Fever in the work place.21 The two cases are Shuere v. State of California, Department of Youth Authority (ADJ11413863, December 20, 2021) and Dieball v. State of California, Department of Corrections—Men’s Colony (ADJ11330624, January 13, 2022).
First and foremost, both cases laid out that the worker has the burden of proving reasonable probability of industrial causation but does not need evidence of causation to rise to the level of scientific certainty. It is sufficient that employment is a contributing cause of the injury.22
Second, the test for determining AOE/COE must be met. The claimed infection must be proven to have occurred in the course of employment, specifically proving the time, place, and circumstances that the alleged injury occurred.23 Next, it should be demonstrated that the injury occurred in the course of employment meaning a worker was doing reasonable work activities, which the employment contract requires to be done.24 In addition, the infection must be proven to arise out of employment meaning the alleged injury and employment must be linked in some casual manner.25
Third, like in many Workers’ Compensation cases, industrial causation is often determined or bolstered by expert medical opinion that is substantial medical evidence. To clarify, substantial medical evidence should be based on reasonable medical probability, be in accordance with correct medical history and examination, and based on a medical framework supporting the expert’s opinions.26
In Shuere and Dieball, the Appeals Board laid out that a worker can establish industrial causation by proving that it is “more probable than not” that they contracted the infection at work, OR that the job exposed the employee to a special risk of exposure in excess of that of the general public.27
In Shuere, the plaintiff, a vocational instructor for the California Department of Youth Authority, claimed that he contracted Valley Fever as he was required to spend a considerable amount of time outside in the employer’s parking lot which he had to traverse on the way to his specific work area. His employer was located in an area where Valley Fever was prevalent.
The employer countered by saying that the source of infection could have been elsewhere outside of work and that his work did not expose him at a greater risk to Valley Fever than the general public. The WCAB found the applicant to have met his burden of proof despite the Panel Qualified Medical Examiner opining that it is impossible to isolate the exact site of exposure by taking samples of dirt from locations that the worker had been to. The commissioners accepted the Panel Qualified Medical Examiner’s opinion as substantial medical evidence when he opined that the proportion of time the plaintiff spent his work hours indoors and outdoors exposed him to Valley Fever at work.
The majority agreed that this “more probable than not” test of proving exposure to Valley Fever was sufficient to prove AOE/COE.
In Dieball, the plaintiff, a correctional officer patrolling the prison yard for two-hour shifts, claimed that he contracted Valley Fever when he was exposed to open areas of dry dirt, some of which were disturbed due to ongoing construction.
The defendant opposed this claim by saying that the plaintiff likely contracted Valley Fever in his home or somewhere outside of work. The appointed medical expert opined that the risk of contracting Valley Fever at home was low and that Dieball likely contracted Valley Fever at work where wind gusts would scatter aerosolized coccidioides spores in the air raising the risk of the applicant inhaling the spores. The workers’ compensation judge agreed with the medical expert’s opinion that the plaintiff was exposed to a greater risk of exposure to aerosolized Coccidioides, establishing the “more probable than not” theory that Valley Fever was contracted at his job.
CONCLUSION
Valley Fever cases are silently rising by the hundreds, if not thousands, annually in California. With drought conditions in California being ever present. The risk of contracting Valley Fever for workers who spend considerable time outdoors in arid and dry regions is very high. The ever-present threat of drought conditions in California will likely exacerbate the spread of the Coccidioides spores even more.
Thus, employers and workers should take a holistic approach in preventing Valley Fever. As there is yet no viable vaccine in preventing Valley Fever, it is recommended that employers and employees work together in acknowledging the threat Valley Fever presents and by observing recommended best practices in the workplace to avoid individuals from acquiring Valley Fever.
Mikhail N. Gomez is an associate attorney at Bradford and Barthel’s Bakersfield location. If you have questions about workers’ compensation defense issues, feel free to contact Mikhail at mgomez@bradfordbarthel.com or by calling 661.347.4500.
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1 https://www.mayoclinic.org/diseases-conditions/valley-fever/symptoms-causes/syc-20378761
2 Ibid.
3 https://www.cdph.ca.gov/Programs/OPA/Pages/NR24-018.aspx
4 https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/ValleyFeverFactSheet.pdf
5 https://www.dir.ca.gov/dosh/valley-fever-home.html
6 See supra note 1.
7 Id.
8 Id.
9 (https://emedicine.medscape.com/article/215978-overview#a5?form=fpf)
10 https://www.cdph.ca.gov/Programs/CCDPHP/DEODC/OHB/CDPH%20Document%20Library/VfEmployerFactSheet.pdf
11 https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/CocciinCAProvisionalMonthlyReport.pdf
12 Id.
13 See supra note 3.
14 https://www.dir.ca.gov/dosh/valley-fever-home.html
15 Id.
16 https://www.turnto23.com/news/in-your-neighborhood/bakersfield/congressmen-pushes-for-valley-fever-vaccine-development-with-new-legislation
17 Id.
18 https://www.dir.ca.gov/dosh/valley-fever-home.html
19 Id.
20 Id.
21 https://www.lexisnexis.com/community/insights/legal/workers-compensation/b/recent-cases-news-trends-developments/posts/california-occupational-infections-and-workers-compensation-proving-industrial-exposure-in-valley-fever-cases?srsltid=AfmBOoqFR7mM_Us1WaI5JoAtTmn9GIvamTM7xpfFGiXs1rtOdeuFYBj1
22 McAllister v. Workmen’s Comp. Appeals Bd. (1968) 69 Cal. 2d 408 [33 Cal. Comp. Cases 660; South Coast Framing, Inc. v. Workers’ Comp. Appeals Bd. (2015) 61 Cal. 4th 291, 298 [80 Cal. Comp. Cases 489].
23 La Tourette v. Workers’ Comp. Appeals Bd. (1998) 17 Cal. 4th 644 [63 Cal. Comp. Cases 253]
24 Employers Mutual Liability Ins. Co. of Wisconsin v. Industrial Acc. Com. (1953) 41 Cal. 2d 676 [18 Cal. Comp. Cases 286]; Maher v. Workers’ Comp. Appeals Bd. (1983) 33 Cal. 3d 729 [48 Cal. Comp. Cases 326, 329]
25 Id.
26 E.L. Yeager v. Workers’ Comp. Appeals Bd. (Gatten) (2006) 145 Cal. App. 4th 922, 928 [71 Cal. Comp. Cases 1687]
27 Bethlehem Steel Co. v. Industrial Acci. Com. (1943) 21 Cal. 2d 742 [8 Cal. Comp. Cases 61]