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Acknowledgments Acknowledgments

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Acknowledgments - PPT Presentation

We acknowledge the Departments of Infectious Diseases and Tropical Medicine Intensive Care Medicine and Microβiology of PointeàPitre University Hospital LInstitut de Recherche Biomédical ID: 940635

test 150 patients skin 150 test skin patients coccidioidomycosis testing x0066006c code data health burkholderia coccidioides population diseases clinical

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Acknowledgments We acknowledge the Departments of Infectious Diseases and Tropical Medicine, Intensive Care Medicine, and Microβiology of Pointe-à-Pitre University Hospital; L’Institut de Recherche Biomédicale des Armées, Brétigny-sur-Orge, France; and Cellule d’Intervention Biologique d’Urgence, Paris, France, for their valuaβle collaβoration in the medical care, investigation, and participation for each case report. About the Author Dr. Melot is a medical doctor in infectious and tropical and epidemiology. Her primary research interests include the study of tropical endemic infections. References of Burkholderia pseudomallei and burden of melioidosis. nmicrobiol.2015.8 a call to action for diagnosing and treating the disease. Am ajtmh.18-0418 4.Sanchez-Villamil JI, Torres AG. Melioidosis in Mexico, Central America, and the Caribbean. Trop Med Infect Dis. discrimination of Burkholderia pseudomallei , B. mallei , and B. thailandensis of Burkholderia pseudomallei and B. mallei . J Clin Microbiol. 483.2005 evolutionary relationships among the causative agents of melioidosis and glanders, Burkholderia pseudomallei and Burkholderia mallei 9 . Hall CM , Jaramillo S , Jimenez , Stone NE , Centner H , JD , et al. Burkholderia pseudomallei , the causative agent of melioidosis, is rare but ecologically established and widely dispersed in the environment in Puerto Rico. PLoS Negl Trop journal.pntd.0007727 03630242.2017.1282396 Coccidioidomycosis Skin Testing in a Commercially Insured Population, United States, 2014–2017 1 Kaitlin Benedict, Orion Z. McCotter, C occidioidal skin testing has been a valuable epi - demiologic and clinical tool for estimating the prevalence of previous Coccidioides spp. exposure and monitoring treatment response ( 1 – 3 ). Such testing could also be useful for evaluating healthy persons’ risk of developing coccidioidomycosis ( 3 ). The skin test became commercially available again in 2014 af - ter more than a decade; it is approved for adults 18–64 of age who have a history of pulmonary coccidioido - mycosis ( 3 , 4 ). However, little is known about its use Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 26, No. 3, March 2020 mon, βased on US health insurance claims data. Patient demographic features were consistent with the approval of the test for adults, βut few patients had previous coc cidioidomycosis diagnosis codes supporting its use for detecting delayed-type hypersensitivity in those with a This work was presented in part at the 63rd Annual California, USA, April 5–6, 2019. in the general population with unknown exposure to Coccidioides . We describe features of patients who have employer-sponsored insurance who received a Coccidioides skin test. We used the IBM MarketScan Research Dataβases - search-databases) to identify patients with a Current Procedural Terminology (CPT; https://www.ama- assn.org/amaone/cpt-current-procedural-terminol - ogy) code for a coccidioidomycosis skin test during 2014–2017. MarketScan health insurance claims data include outpatient visits and prescriptions and hos - pitalizations for employees, dependents, and retirees, �representing 25% of all employer-sponsored ben - e�ciaries throughout the United States. This analysis was not subject to review by the Centers for Disease Control and Prevention institutional review βoard We accessed the data through MarketScan Treat - ment Pathways, a weβ-βased platform that includes data from persons with health insurance plans that contribute prescription drug data to MarketScan. We limited the analysis to patients continuously enrolled during the 3 months before and after the skin test. We examined periods up to 3 years before and 1 year af - ter; because the primary features of interest did not change substantially, we focused on the smaller pe - riod to retain a larger study population. We analyzed patient demographics; visits within 3 days to estimate the proportion who returned to have their test results read after 48 hours (compared with patients with a CPT code for tuβerculosis skin testing); coccidioidomycosis diagnoses (International Classi�cation of Diseases [ICD], 9th Revision, Clini - cal Modi�cation, codes 115.00–115.99; ICD, 10th Revi - sion, Clinical Modi�cation, code B38); laβoratory test - ing; and �uconazole prescriptions. We also examined certain underlying medical conditions and assessed the cost of skin test claims to patients and insurers among patients with noncapitated health plans. Among 57 million MarketScan enrollees, 505 had a coccidioidomycosis skin test; 407 of those were con - tinuously enrolled. Of those 407, most (n = 391, 89%) were 18–64 years of age, female (n = 243, 60%), and in California (n = 367, 90%) (Taβle). Thirty-�ve percent had a code for a subsequent visit within 3 days, com - pared with 24% of 1,061,118 patients who had a tuber - culosis skin test. Test results were not available. Emerging Infectious Diseases • www.cdc.gov/eid •Vol. 26, No. 3, March 2020 Table . �&�K�D�U�D�F�W�H�U�L�V�W�L�F�V �R�I��S�D�W�L�H�Q�W�V��Z�K�R��U�H�F�H�L�Y�H�G��D��F�R�F�F�L�G�L�R�L�G�R�P�\�F�R�V�L�V��V�N�L�Q��W�H�V�W������ – ���� ���8 �6�$ �&�K�D�U�D�F�W�H�U�L�V�W�L�F �9�D�O�X�H �'�L�D�J�Q�R�V�L�V��R�U��S�U�R�F�H�G�X�U�H��F�R�G�H�V �$�J�H���P�H�G�L�D�Q ���\ � �U�D�Q�J�H�\f ���� � – ���\f � – �� ���� ��\f �� – �� ���� ���\f �� – �� ���� ���\f �� – �� ����� ���\f �� – �� ����� �

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#0;R�U�\��W�H�V�W�L�Q�J��R�Q��W�K�H��G�D�\��R�I��R�U��L�Q��W�K�H����P�R��D�I�W�H�U��V�N�L�Q��W�H�V�W �&�R�F�F�L�G�L�R�L�G�R�P�\�F�R�V�L�V��V�H�U�R�O�R�J�L�F��W�H�V�W ���� ���\f �&�3�7��F�R�G�H�V�������������������� �)�X�Q�J�D�O��F�X�O�W�X�U�H ���� ��\f �&�3�7��F�R�G�H�V���������������������������������� �)�X�Q�J�D�O��V�P�H�D�U ���� ���\f �&�3�7��F�R�G�H�V� ������������������� �\r�9�D�O�X�H�V��D�U�H��Q�R��� �\b�\f��H�[�F�H�S�W��D�V��L�Q�G�L�F�D�W�H�G���&�3�7���&�X�U�U�H�Q�W��3�U�R�F�H�G�X�U�D�O��7�H�U�P�L�Q�R�O�R�J�\���,�&�' � � � �&�0���,�Q�W�H�U�Q�D�W�L�R�Q�D�O��&�O�D�V�V�L�I�L�F�D�W�L�R�Q��R�I��'�L�V�H�D�V�H�V����W�K��5�H�Y�L�V�L�R�Q���&�O�L�Q�L�F�D�O� �0�R�G�L�I�L�F�D�W�L�R�Q���,�&�' � �� � �&�0���,�Q�W�H�U�Q�D�W�L�R�Q�D�O��&�O�D�V�V�L�I�L�F�D�W�L�R�Q��R�I��'�L�V�H�D�V�H�V�� �� �W�K��5�H�Y�L�V�L�R�Q���&�O�L�Q�L�F�D�O��0�R�G�L�I�L�F�D�W�L�R�Q � In the 3 months before the skin test, 5% had a coc - cidioidomycosis diagnosis code, 5% had a coccidioi - domycosis serologic test code, and 5% had a �ucon - azole prescription. On the skin test date and in the 3 months after, 7% had a coccidioidomycosis diagnosis code, 15% had a serologic test, and 9% had a �uco - nazole prescription. Forty-four patients (11%) had noncapitated health plans; among those, the mean cost of skin test claims was $43.66 (range $0–$264). Mean costs were $31.57 (range $0–$184) to insurers and $12.09 (range $0–$264) to patients. In the context of the large at-risk population in Coccidioides -endemic areas, coccidioidomycosis skin testing appears to be uncommon in this privately in - sured population. Real-world data on the test’s use and performance in the general population are lack - ing, although it performs well for risk-stratifying prison inmates ( 5 ). Reasons for its low use could βe its limited approved clinical indication to detect de - layed-type hypersensitivity to Coccidioides in persons with a known history of disease or that the clinical implications of such testing may be unclear. Cost may also play a role, although it is unclear why most pa - tients had capitated health plans. Reasons why most tests were performed in California rather than in Ari - zona (states where most coccidioidomycosis cases oc - cur) are unknown. Patient age was consistent with the test’s approv - al for use in adults. However, few patients had coc - cidioidomycosis diagnosis codes, suggesting possible use of this test to screen for immunity in those with unknown exposure to Coccidioides , which has not been evaluated. Another explanation for the low fre - quency of coccidioidomycosis diagnosis codes in the 3 months before testing is a more distant coccidioido - mycosis history. We observed laboratory testing and �uconazole prescription patterns that suggest that the test might be occasionally used as a supplemental diagnostic tool. Patient return visit rate (35%) was comparaβle to that of tuberculosis skin testing. This proportion could appear falsely low if providers chose not to bill for reading the test results. In addition to lack of test results, limitations of this analysis include potential In summary, skin testing could be useful for eval - uating healthy persons’ risk of developing coccidioi - domycosis but appears to be rare, even in endemic areas. Determining features of patients who receive a coccidioidomycosis skin test and assessing clinicians’ knowledge and attitudes could provide insight into the test’s clinical and epidemiologic value. About the Author and Environmental Diseases, National Center for Her research interests include the epidemiology and prevention of fungal infections. References 1.Edwards PQ, Palmer CE. Prevalence of sensitivity to coccidioidin, with special reference to speci�c and nonspeci�c reactions to coccidioidin and to histoplasmin. Dis Chest. 2.Smith CE, Whiting EG, Baker EE, Rosenβerger HG, Beard RR, return of delayed-type hypersensitivity skin testing for 4.Johnson R, Kernerman SM, Sawtelle BG, Rastogi SC, Nielsen HS, Ampel NM. A reformulated spherule-derived coccidioidin (Spherusol) to detect delayed-type hypersensitivity in coccidioidomycosis. Mycopathologia. 2012;174:353–8. to prevent Valley fever among inmates, California, 2015. 10.1177/1078345818792679 Geographic Expansion of Sporotrichosis, Brazil Sandro Antonio Pereira Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 26, No. 3, March 2020