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Investigation and Results
Preconstruction preparations at the approximately 3,000-acre solar farm in Monterey County began in February 2016, and construction started in June 2016 in two phases; the first was completed in August 2017, and the second is expected to continue through the end of 2018. A confirmed case of coccidioidomycosis was defined by the Council of State and Territorial Epidemiologists as a diagnosed illness that met clinical criteria for coccidioidomycosis and was laboratory confirmed (4); CDPH further required that illness occurred in a solar farm construction employee, with symptom onset ≥1 week after beginning work and <1 month after the final workday at the solar farm. Employee rosters for February 2016–April 2017 provided by the solar farm owner were matched with the statewide CDPH coccidioidomycosis surveillance database to aid in case-finding. Patients identified through this matching process were interviewed using a structured questionnaire to obtain information on clinical signs and symptoms, occupational exposures, and use of dust control measures at the workplace. Medical records were requested from health care providers, and data were abstracted to confirm that patients met clinical and laboratory criteria. Employee rosters and interviews were used to confirm timing of illness onset associated with solar farm employment. The incidence rate among solar farm workers was calculated by dividing the number of confirmed cases by total person-years spent on the worksite among all employees during the period covered by owner-provided rosters. To calculate person-years, the total number of days between first and last day onsite for each employee was obtained from rosters; total person-days was then converted to person-years by dividing by 365. The annualized incidence among employees at this worksite was compared with background 2016 rates for Monterey and other counties surrounding the worksite by calculating a rate ratio with 95{0b7da518931e2dc7f5435818fa9adcc81ac764ac1dff918ce2cdfc05099e9974} confidence interval (CI) for each comparison county.
Among 2,410 employees who had worked at the solar farm for ≥1 day, 16 matches between employee rosters and the CDPH coccidioidomycosis surveillance database were identified; medical records were obtained for all 16, and 11 persons were interviewed by telephone. Overall, nine confirmed cases of coccidioidomycosis were identified among the 16 patients; three persons did not meet clinical criteria, and four did not meet work-related illness onset criteria. Eight of nine patients with confirmed coccidioidomycosis were interviewed; one could not be reached after multiple attempts and was confirmed by review of medical records and employment rosters only. Among the nine confirmed cases, median patient age was 42 years (interquartile range = 31–46 years), and seven were male (Table 1). Patients resided in four California counties (Fresno, Madera, Monterey, and San Luis Obispo). Six received diagnoses of coccidioidomycosis pneumonia; five had visited emergency departments from one to four times; one was hospitalized; and none died. Among the eight interviewed patients, seven reported missing work because of illness (median: 14 days; range = 1–320 days).
Illness onset for the nine patients occurred during August–December 2016 (Figure). Seasonal rains, which suppressed dust, began in late December 2016 and continued through mid-April 2017; most of the first phase of construction was completed by May 2017. All patients reported working outdoors at the solar farm and had job titles that included biologist, paleontologist, electrician, truck driver, iron worker, and general laborer. All eight patients interviewed reported high dust levels frequently (every day or once a week); seven reported that water trucks were frequently unable to control dust levels; five reported frequently working in or near a ditch or trench; no patient was assigned to another work location or sent home because of high dust levels. Seven reported both infrequent (sometimes, rarely, or never) use of respiratory protection and no respirator fit-testing. Although seven reported receiving safety training about Valley fever, only three patients knew what to do if they had symptoms; subsequent review of training materials identified deficiencies (e.g., not emphasizing the potential for Valley fever to be a severe illness, not describing prevention strategies, and not indicating where employees should seek clinical care). No patients reported exposure to a dust cloud or other source of dust or dirt outside of work during the 4 weeks before illness onset.
The annualized coccidioidomycosis incidence among solar farm workers at this worksite was 1,095 per 100,000 persons/year; whereas the 2016 incidence in Monterey County was 17.5 per 100,000 population, corresponding to a rate ratio of 62.6 (95{0b7da518931e2dc7f5435818fa9adcc81ac764ac1dff918ce2cdfc05099e9974} CI = 31.4–124.8). Rate ratios for the five counties surrounding the worksite (Fresno, Kern, Kings, San Benito, and San Luis Obispo) ranged from 4.4 to 210.6 (Table 2). These findings indicate that the coccidioidomycosis incidence among employees was significantly higher than the background incidence rates in surrounding counties.
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