Case study 1
On June 24, 2013, a US District Court in northern California issued an unusual court
order: no African-American inmates and no inmates with diabetes mellitus could be sent
to Prisons X and Y. Instead, any inmate fitting either criterion must be sent to one of the
other six prisons in the state.
To some, this in itself is a riddle: why such strange exclusions?
But the truth is, this court mandate was a response to the solving of a looming medical
mystery.
Beginning in 2005, medical officers for the eight-prison system for male inmates in the
San Joaquin Valley, California, reported an unusual phenomenon: over the past 5 years,
two of the eight prisons, which were less than 15 miles apart, had produced an unusual
number of cases of coccidioidomycosis among their inmate population. Stranger still,
those same two prisons consistently reported more than 80% of California’s cases
among inmates. Although it’s true that the arid environment of the San Joaquin Valley is
an excellent environment for the fungus Coccidioides immitis, this alone did not explain
the phenomenon, and here’s why: An initial study confirmed that rates of disease at one
prison was more than 400× higher than those of the surrounding county. In addition, a
cohort study revealed an increased risk for three groups of patients: African American
inmates, inmates 40 years of age or older, and inmates who resided on a particular yard
within the prison.
First responses to this initial study resulted in (1) patient prevention education sessions
for inmates and staff and (2) exclusion of immunocompromised inmates or inmates with
severe chronic obstructive pulmonary disease who were coming from three
coccidioidomycosis-endemic counties. Prisons X and Y also planted native grasses and
shrubs on areas of bare ground to control ambient dust and spores.
Unfortunately, the problem continued at prisons X and Y.
As a result, a second case-control study was done in 2011 to reassess inmate risk
factors for primary, severe, and disseminated coccidioidomycosis, especially its most
debilitating forms. Results indicated that African American inmates who were 40 years
or older were at significantly higher risk and that diabetes was a risk factor for severe
cases. Finally, being African American was a risk factor for disseminated disease.
Because early prevention measures from the 2005 studies had not made a difference,
the decision was to exclude these categories of inmates from prisons X and Y.

Source

Wheeler C, Lucas KD, Mohle-Boetani JC. Rates and risk factors for coccidioidomycosis
among prison inmates, California, USA, 2011. Emerging Infectious Diseases.
2015;21(1):70-75. http://wwwnc.cdc.gov/eid/article/21/1/pdfs/14-0836.pdf. Accessed
January 5, 2015.
Questions:
1. Discuss (a) factors that contribute to a group’s vulnerability and (b) identify the
specific category of limitations that these two prison inmate groups held in common
that increased their susceptibility to this particular pathogen.
2. Both the World Health Organization (WHO) and Healthy People 2020 describe three
overall determinants of health. What are these?
3. Why do you think the prevalence of this disease was 400 times higher among the
prison population than the general population?
4. Identify a interprofessional collaborative practice core competency that applies to
this case study with a rationale on how this pertains to this topic.