Using massive, multi-regional EHR data to estimate the impacts of environmental and other risk factors on fungal disease epidemiology in the U.S. - In the past 40 years, fungal diseases have emerged as a pressing health concern, as incidence rates have increased markedly, novel pathogens have emerged, resistance to antifungal drugs has risen and prevalence of immunosuppressive conditions has increased. Environmental conditions may exacerbate fungal disease risks by shifting the suitable habitat for pathogenic environmental fungi, lengthening the transmission season of spores, and dispersing spores via extreme weather events. An understanding of the effects of environmental conditions (wind, soil composition and moisture, floods, temperature extremes) and patient risk factors (rural residence, limited insurance coverage, low-income) on the distribution and severity of fungal diseases is critical to protecting the health of high-risk groups. To date, epidemiologic studies of fungal diseases in the U.S. have been limited in spatiotemporal scope and sample size, precluding robust characterization of risk factors and outcomes among patient subpopulations. While largely untapped as a resource for investigating fungal disease, electronic health record (EHR) and infectious disease surveillance systems generate massive health datasets that can be used to estimate risk factors for fungal infections, including candidiasis, cryptococcosis, aspergillosis, blastomycosis, histoplasmosis, coccidioidomycosis and dermatomycosis. Via partnership with Oracle/Cerner (Austin, TX), we will analyze deidentified EHR data for over 96 million patients, 1.4 billion visits, and 4.7 billion clinical events. A subset of the databases is available with geographic locations of patient 3-digit zip codes. We will also analyze surveillance data on all reported cases (>95,000) of coccidioidomycosis in California since 2000, geolocated to patient address. After addressing misclassification, selection, and missing data biases in the EHR, our team will estimate regional trends in incidence, hospitalization and mortality rates for fungal diseases in the U.S. We will apply modern time series approaches to understand the role of environmental conditions in fungal disease epidemiology, estimating the association between temperature, precipitation, soil moisture, and other factors on fungal disease incidence and emergence. We will investigate the impacts of extreme events such as heat waves, dust storms, tropical cyclones and flooding on incidence, and will determine whether exposure-response relationships are modified by patient risk factors. We will examine the role of individual- and community-level factors—such as preexisting comorbidities and housing quality—on fungal disease outcomes, and will forecast near-term trends in incidence. The project will yield robust understanding of the environmental epidemiology of major mycoses in the U.S., and the role of environmental conditions, patient risk factors and community-level factors in exacerbating disease risks.
