A Storm of Disease

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A Storm of Disease

• Robert A Thornton, Jr.
• District Epidemiologist
• Coastal Health District

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Coastal Health District
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Why should we worry?

• During the past 2 decades natural disasters have
  killed millions of people and adversely affected
  the lives of at least 1 billion additional
  persons.
• Katrina

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Why should we worry?

• After a natural disaster, negative impact can
  unveil either rapidly or slowly.
• Health effects
• Social effects
• Economic effects

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Disaster related interruption of service

• Power cuts can result in disruption of water
  treatment and sewage service.
• Vaccine preservation issues (private providers)
• After the New York blackout in 2003 there was an
  increase in the amount of diarrheal illness
  noted, meat and seafood causative agentpower was
  out several hours to 2 days

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Rapid impact

• Sudden abundance of dead bodies
• Blunt trauma
• Crush related injuries
• Drowning
• Death from communicable diseases (at least
  initially) are less common

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Displacement and risk of communicable disease

• Size of displaced community (Chatham County
  241,411 and District 524,032)
• Characteristics of population displaced
• Availability of safe water and latrines
• Vaccination status of population

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Risk factors for communicable disease transmission

• Endemic and epidemic diseases that are common in
  the affected area.
• Geographic density of population
• Immunization status
• Degree of access to healthcare

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Water related communicable disease

• Diarrheal illness (especially after flooding)
• Vibrio cholerae
• E. coli
• Salmonella
• Shigella
• Cryptosporidium
• Giardia
• Norovirus

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After Hurricanes Allison and Katrina

• Norovirus
• Vibrio cholerae (non toxigenic and toxigenic)
• Salmonella

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Nasty bugs after a nasty storm

• Hurricane Katrina made landfall on August 29,
  2005, with major impact on the U.S. Gulf Coast.
  During August 29--September 11, surveillance
  identified 22 new cases of Vibrio illness with
  five deaths in persons who had resided in two
  states. These illnesses were caused by V.
  vulnificus, V. parahaemolyticus, and V. cholerae.
  These organisms are acquired from the environment
  and are unlikely to cause outbreaks from
  person-to-person transmission.

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Vibrio cholerae after Rita

• The two cases of toxigenic V. cholerae O1
  infection were identified in a Louisiana couple
  approximately 3 weeks after Hurricane Rita. On
  October 15, 2005, in southeastern Louisiana, a
  man aged 43 years and his wife aged 46 years had
  onset of diarrhea. The husband had a history of
  high blood pressure, alcoholism, diabetes, brain
  tumor, and chronic renal failure that required
  dialysis three times a week. On October 16, 2005,
  he was hospitalized for fever, muscle pains,
  nausea, vomiting, abdominal cramps, and severe
  diarrhea and dehydration subsequently he
  experienced complete loss of renal function and
  respiratory and cardiac failure. However, after
  treatment with ciprofloxacin and aggressive
  rehydration therapy, the man recovered to his
  previous state of health. His wife had mild
  diarrhea and was treated as an outpatient with
  ciprofloxacin and extra fluids.
• Because the couple's residence had been severely
  damaged and flooded by Hurricane Rita, both
  patients had waded in coastal flood waters in
  late September, 2--3 weeks before their illness
  onset. Five days before onset of illness, both
  had eaten locally caught crabs. On October 14,
  the day preceding illness onset, both had eaten
  shrimp purchased from a local fisherman. The
  shrimp were boiled for 5 minutes however, at
  least some of the boiled shrimp were returned to
  a cooler containing raw shrimp and were eaten
  later. Two other persons who ate the shrimp
  reported mild diarrhea and abdominal discomfort
  they did not seek medical attention, and no stool
  or serum specimens were collected from them for
  testing.

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Prevent illness from water

• Listen to and follow public announcements. Local
  authorities will tell you if tap water is safe to
  drink or to use for cooking or bathing. If the
  water is not safe to use, follow local
  instructions to use bottled water or to boil or
  disinfect water for cooking, cleaning, or
  bathing.
• Correctly boil or disinfect water. Hold water at
  a rolling boil for 1 minute to kill bacteria. If
  you can't boil water, add 1/8 teaspoon
  (approximately 0.75 mL) of newly purchased,
  unscented liquid household bleach per gallon of
  water. Stir the water well, and let it stand for
  30 minutes before you use it. You can use
  water-purifying tablets instead of boiling water
  or using bleach. For infants, use only
  pre-prepared canned baby formula. Do not use
  powdered formulas prepared with treated water.
  Disinfect children's toys that have come in
  contact with water. Use a solution of 1 cup of
  bleach in 5 gallons of water to disinfect the
  toys. Let toys air dry after cleaning. Some toys,
  such as stuffed animals and baby toys, cannot be
  disinfected they should be discarded.

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Prevent illness from food

• Identify and throw away food that may not be safe
  to eat. Throw away food that may have come in
  contact with flood or storm water. Throw away
  canned foods that are bulging, opened, or
  damaged. Throw away food that has an unusual
  odor, color, or texture. Throw away perishable
  foods (including meat, poultry, fish, eggs and
  leftovers) that have been above 40F for 2 hours
  or more. Thawed food that contains ice crystals
  or is 40F or below can be refrozen or cooked. If
  cans have come in contact with floodwater or
  storm water, remove the labels, wash the cans,
  and dip them in a solution of 1 cup of bleach in
  5 gallons of water. Relabel the cans with a
  marker.
• Store food safely. While the power is out, keep
  the refrigerator and freezer doors closed as much
  as possible. Add block ice or dry ice to your
  refrigerator if the electricity is expected to be
  off longer than 4 hours. Wear heavy gloves when
  handling ice.

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Vectorborne Diseases

• Initial flooding may actually wash away existing
  mosquito breeding sites (weeks delay)
• New areas of standing water create new breeding
  sites
• West Nile virus
• EEE

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West Nile after Katrina
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5 Ds for insects

• Dawn
• Dusk
• Drain
• Dress
• DEET

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Repellants that can be used on skin and clothing

• DEET (Chemical Name N,N-diethyl-m-toluamide or
  N,N-diethly-3-methyl-benzamide)
• Picaridin (KBR 3023, Chemical Name
  2-(2-hydroxyethyl)-1-piperidinecarboxylic acid
  1-methylpropyl ester )
• Oil of Lemon Eucalyptus or PMD (Chemical Name
  para-Menthane-3,8-diol) the synthesized version
  of oil of lemon eucalyptus
• IR3535 (Chemical Name 3-N-Butyl-N-acetyl-aminop
  ropionic acid, ethyl ester)
• Permethrin can be used on clothing only

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Diseases Associated with Overcrowding

• Rashes
• Neisseria meningitidis meningitis
• Acute respiratory infections (especially those
  younger than 5 years of age)

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Fungal Infections

• Warm, humid climate promotes fungal growth
• Clean up and prevent mold growth. Clean up and
  dry out the building quickly (within 24 to 48
  hours). Open doors and windows. Use fans to dry
  out the building. To prevent mold growth, clean
  wet items and surfaces with detergent and water.
  To remove mold growth, wear rubber gloves, open
  windows and doors, and clean with a bleach
  solution of 1 cup of bleach in 1 gallon of water.
  Throw away porous items (for example, carpet and
  upholstered furniture) that cannot be dried
  quickly. Fix any leaks in roofs, walls, or
  plumbing.

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Other injuries and concerns

• Chain saw
• Cuts
• Musculoskeletal strains
• Heat exhaustion
• Dehydration
• Falls
• Electrical injuries
• Carbon monoxide poisoning (over 50 cases after
  Katrina)
• Animal bites (mammals, reptiles and insects)

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Figure 2
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Summary of Illness after Katrina

• During September 1--22, chronic illness (e.g.,
  diabetes, asthma, emphysema, and cardiovascular
  disease) was the most commonly reported category
  in ECs, peaking at 651 visits on September 9 (in
  all four states combined) and accounting for 33
  (4,786) of the 14,531 total visits included in
  these analyses. GI illness, the second most
  commonly reported category, accounted for 27
  (3,892) of total visits and peaked in ECs during
  September 5--10. Visits for respiratory illness
  increased during September 1--22, accounting for
  20 (2,896) of total visits and 52 (1,003) of
  visits during September 17--22. The percentage of
  visits for rash illnesses accounted for 16 (320)
  of visits during September 1--4, decreased
  somewhat, and then increased again to 20 (376)
  of visits during September 17--22. Visits for
  injury and mental illness accounted for less than
  6 each of the total visits during September
  1--22.
• In HCFs, during September 5--22, injury was the
  most commonly reported category, with
  approximately 135 visits reported daily, peaking
  at 532 on September 8, and accounting for 58
  (5,716) of 9,772 total HCF visits for the six
  categories. Respiratory illness was the second
  most commonly reported condition, accounting for
  16 (1,550) of total HCF visits. During September
  5--22, GI, rash, and chronic and mental illnesses
  each accounted for less than 10 of the total HCF
  visits.

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Emergency Response Illness After Katrina

• Upper respiratory and skin rash symptoms were the
  most common physical symptoms reported by police
  officers and firefighters and lacerations and
  sprains were the most common injuries. In
  addition, approximately one third reported either
  depressive symptoms or symptoms of posttraumatic
  stress disorder (PTSD), or both.
• Floodwater contact with the nose, mouth, or eye
  was reported by 51 of firefighters (254 of 500)
  and 30 of police officers (258 of 864) 52 of
  police officers (473 of 910) and 63 of
  firefighters (330 of 524) reported rescuing
  citizens from flooded areas.

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Emergency Response Illness After Katrina

• Police officers and firefighters reported similar
  prevalences of physical health symptoms.
  Approximately 28 of police officers (236 of 848)
  and 31 of firefighters (162 of 525) reported
  upper respiratory symptoms (i.e., head/sinus
  congestion or nose/throat irritation). Cough was
  reported by 21 of police officers (176 of 845)
  and 23 of firefighters (124 of 525). Skin rash
  was reported by 54 of police officers (493 of
  909) and 49 of firefighters (258 of 525).
  Injuries most commonly reported by police
  officers and firefighters were lacerations
  (police officers 20 184 of 912 and
  firefighters 24 127 of 525), sprains/strains
  (13 120 of 912 and 25 130 of 525), falls
  (9 84 of 912 and 10 54 of 525) and animal
  bites/stings (11 104 of 911 and 8 41 of
  525). Of 525 firefighters, 114 (22) reported
  symptoms consistent with PTSD, and 133 of 494
  (27) reported major depressive symptoms. Of 912
  police officers, 19 (170) reported PTSD symptoms
  and 26 (227 of 888) reported major depressive
  symptoms. Among all police officers, 31 (279)
  reported seeing a health-care provider for
  post-hurricane illnesses and injuries
  health-care utilization among firefighters was
  not assessed.

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Immunizations

• Tetanus and diphtheria toxoid (receipt of primary
  series, and Td booster within 10 years). Not
  transmitted person to person, toxin released by
  the anaerobic tetanus bacillus Clostridium tetani
• Hepatitis B vaccine series for persons who will
  be performing direct patient care or otherwise
  expected to have contact with bodily fluids

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Immunizations

• hepatitis A vaccine (low probability of exposure,
  even under these conditions, in U.S. ) No
  transmission from contaminated water has been
  identified in the U.S. since the 1980s. Hepatitis
  A outbreaks have not occurred following other
  hurricanes or floods in other parts of the
  country, including the devastating hurricanes in
  Florida last year, and the Midwestern floods of
  the late 1990's. The Gulf Region has had few
  hepatitis A cases in recent years, with less than
  10 in the past 3 months reported from the New
  Orleans area. Thus, even though the water and
  sewage systems are damaged or out of operation in
  many areas along the Gulf Coast , the risk of a
  hepatitis A epidemic is extremely low. Vaccine
  will take at least one to two weeks to provide
  substantial immunity.
• typhoid vaccine (low probability of exposure,
  even under these conditions, in U.S. ).
• cholera vaccine (low probability of exposure,
  even under these conditions, in U.S. , plus no
  licensed cholera vaccine available in the U.S. ).
  
• meningococcal vaccine (no expectation of
  increased risk of meningococcal disease among
  emergency responders).
• rabies vaccine series (the full series is
  required for protection). Persons who are exposed
  to potentially rabid animals should be evaluated
  and receive standard post-exposure prophylaxis,
  as clinically appropriate.

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Handwashing

• Handwashing or hand sanitizing is one of the most
  important actions that persons can take that will
  limit the spread of infection.

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Benefits of Surveillance

• Identify the number of illnesses and
  deaths-related to disasters and provide basic
  morbidity and mortality information.
• Identify high risk groups that could benefit from
  immediate public health interventions.
• Evaluate and assess the direct and indirect
  impact of the disaster and human toll in affected
  communities on high vulnerable groups.
• Provide information on disaster-related morbidity
  and mortality for emergency officials and public
  health officers to assist in future planning and
  mitigation efforts.

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Steps that CHD department of Epidemiology will
take in order to conduct post storm surveillance

• Pre-event communication with State Epidemiology
  will take place.
• Alternate operations site will be established,
  phone numbers and fax numbers provided to
  community partners and establishment of web
  capabilities (satellite).
• Inform healthcare community how to contact CHD
  Epidemiology staff (hospitals, healthcare
  providers, infection control practitioners,
  emergency departments, urgent care centers and
  laboratory directors)

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• Provide alternate instructions for disease
  reporting to aforementioned healthcare partners.
• Make sure that extra specimen collection forms
  and supplies are available for bacterial, viral,
  ova and parasite testing.
• Communication with Environmental Health staff to
  resolve health issues such as animal bites
  (displaced animals both wild and domestic),
  investigation of shelter outbreaks, foodborne and
  waterborne illnesses.
• Work closely with immunization staff in the event
  vaccine preventable diseases become a threat to
  the health of the community (tetanus).

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• Establish and maintain communication with
  mosquito control staff.
• Post hurricane surveillance for injury/illness
  will take place (hospitals, nursing homes, acute
  care centers, shelters, correctional facilities)
• Establish communication with newly opening storm
  shelters via the local Incident Command
  System/EOC (Emergency Operations Center). Review
  disease reporting procedures and determine who
  will discuss infection control procedures with
  shelter staff following the storm. Coordinate
  with Environmental Health Specialists who will be
  conducting sanitation inspections of shelters and
  feeding stations. Continue to communicate with
  shelters (in person or over the phone). Daily
  communication and monitoring is best for ensuring
  any community health issues or outbreaks can be
  addressed as soon as possible.

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• Summary of Disease/Illness
• Outbreak management

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