INFECTIOUS DISEASE AFTER NATURAL DISASTERS

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INFECTIOUS DISEASE AFTER NATURAL DISASTERS

• California Preparedness Education Network
• A program of the Area Health Education Centers
• Presented by
• Funded by ASPR Grant T01HP01405

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CALIFORNIA PREPAREDNESS EDUCATION NETWORK
A program of the California Area Health
Education Centers
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calPEN at COMMUNITY HEALTH PARTNERSHIP

• calPEN covers the 9 San Francisco Bay Area
  counties
• It is a program of the Health Education and
  Training Center (South Bay AHEC), a division of
  the Community Health Partnership
• Community Health Partnership is the community
  clinic consortium for Santa Clara County with one
  clinic in San Mateo County

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HOUSEKEEPING

• Folder contents
• Sign-in sheet with degree/job function and
  license number (if applicable)
• Please FILL OUT the participant data form and the
  evaluation form and TURN IN by the end of the
  presentation

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OVERVIEW

• The role of infectious diseases in natural
  disasters
• Factors leading to a disease outbreak after a
  disaster
• Review some of the common diseases and their
  treatment after a natural disaster

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BACKGROUND

• Historically, infectious disease epidemics have
  high mortality
• Disasters have potential for social disruption
  and death
• Epidemics compounded when infrastructure breaks
  down
• But, can a natural disaster lead to an epidemic
  of an infectious disease?

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IS THERE A LINK BETWEEN A NATURAL DISASTER AN
OUTBREAK?

• Some studies relate direct link (Dominican
  Republic-hurricane)
• Experts conflicted about the extent and
  infectious agent
• Many theories but no link
• Many factors influence outbreak

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PHASES OF A DISASTER

• Impact Phase (0-4 days)
• Extrication
• Immediate soft tissue infections
• Post impact Phase (4 days- 4 weeks)
• Airborne, foodborne, waterborne and vector
  diseases
• Recovery phase (after 4 weeks)
• Those with long incubation and of chronic
  disease, vectorborne

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VARIABLES FOR DEVELOPMENT OF AN EPIDEMIC AFTER A
DISASTER

• Environmental considerations
• Endemic organisms
• Population characteristics
• Pre-event structure and public health
• Type and magnitude of the disaster

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ENVIRONMENTAL CONSIDERATIONS

• Climate
• Cold- airborne
• Warm- waterborne
• Season (USA)
• Winter- influenza
• Summer- enterovirus
• Rainfall
• El Nino years increase malaria
• Drought-malnutrition-disease
• Geography
• Isolation from resources

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ENDEMIC ORGANIZMS

• Infectious organisms endemic to a region will be
  present after the disaster
• Agents not endemic before the event are UNLIKELY
  to be present after
• Deliberate introduction could change this factor

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ENDEMIC ORGANIZMS

• Northridge Earthquake
• Ninefold increase in coccidiomycosis (Valley
  fever) from January- March 1994
• Mount St. Helens
• Giardiasis outbreak in 1980 after increased
  runoff in Red Lodge, Montana from increased ash

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POPULATION CHARACTERISTICS

• Density
• Displaced populations
• Refugee camps
• Age
• Increased elderly or children
• Chronic Disease
• Malnutrition
• DM, heart disease
• Transplantation

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POPULATION CHARACTERISTICS

• Education
• Less responsive to disaster teams
• Religion
• Polio in Nigeria, 2004
• Hygiene
• Underlying health education of public
• Trauma
• Penetrating, blunt, burns
• Stress

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PRE-EVENT RESOURCES

• Sanitation
• Primary health care and nutrition
• Disaster preparedness
• Disease surveillance
• Equipment and medications
• Transportation
• Roads
• Medical infrastructure

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TYPE OF DISASTER

• Earthquake
• Crush and penetrating injuries
• Hurricane (Monsoon, Typhoon) and Flooding
• Water contamination, vectorborne diseases
• Tornado
• Crush
• Volcano
• Water contamination, airway diseases
• Magnitude
• Bigger can mean more likelihood for epidemics

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EPIDEMICS AFTER DISASTERS
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EPIDEMICS AFTER DISASTERS
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FLOODING

• Missouri 1993
• Increase reports if E.D. visits due to illness
• 20 respiratory,17 GI
• Iowa 1993
• No reports of GI or respiratory increase due to
  sanitation measures
• Florida Hurricane Andrew
• Heavy mosquito spraying lead to no change in
  encephalitis rates

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DOMINICAN REPUBLIC 1979

• Hurricane David and Fredrick on Aug 31 and Sept
  5th 1979
• gt2,300 dead immediately
• Marked increase in all diseases measured 6 months
  after the hurricane
• Thyphoid fever
• Gastroenteritis
• Measles
• Viral hepatitis

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WHAT EPIDEMICS COULD WE SEE TODAY?

• Endemic organisms
• Post-impact phase
• Recovery Phase

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POST-IMPACT PHASE INFECTIONS

• Crush and penetrating trauma
• Skin and soft tissue disruption (MRSA)
• Muscle/tissue necrosis
• Toxin production disease
• Burns
• Waterborne
• Gastroenteritis
• Cholera
• Non-cholera dysentery
• Hepatitis
• Rare diseases

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POST-IMPACT PHASE INFECTIONS

• Vectorborne
• Malaria
• WNV, other viral encephalitis
• Dengue and Yellow fever
• Typhus
• Respiratory
• Viral
• CAP
• Rare disease
• Other
• Blood transfusions

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RECOVERY PHASE INFECTIONS

• These agents need a longer incubation period
• TB
• Schistosomiasis
• Lieshmaniasis
• Leptospirosis
• Nosocomial infections of chronic disease

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SKIN AND SOFT TISSUE DISEASE

• Crush and penetrating injuries
• ABCs
• Establish airway
• Circulation
• Stabilize
• BP support
• Respiratory support
• Diagnose extent of injuries
• Radiology
• Diagnostic procedures
• Corrective action
• CT, fracture stabilization, transfusion
• Surgery if necessary

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SKIN AND SOFT TISSUE DISEASE

• Post-traumatic Care
• Hypoxia from pulmonary contusion, ARDS, VAP
• Coagulopathy
• Renal failure
• DVT/PE
• Ulcer disease
• Soft tissue infections
• Cellulitis
• Necrotizing fasciitis
• Post op wound infection
• Burn care

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CELLULITIS

• Skin infection involving the subcutaneous tissue
• Predisposing factors
• Lymphatic compromise
• Site of entry
• Obesity
• DM
• Microbiology
• Streptococci, Groups A, B, C, G
• Staphylococcus aureus
• Others

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CELLULITIS

• Pathogenicity
• Not well understood
• Venous and lymphatic compromise
• Bacterial invasion with endo/exotoxin release
• Cytokine release
• Symptoms
• Systemic- F/C/M
• Redness, swelling
• Tenderness, edema
• May have ulcer or abscess

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CELLULITIS

• Treatment
• Antibiotics (MRSA)
• TMP/SMX
• Clindamycin
• Linezolid
• Vancomycin
• Limb elevation
• Systemic support
• Surgical consultation
• Abscess
• Occular
• Necrotizing fasciitis evaluation

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CELLULITIS

• Special situations
• Water exposure
• Aeromonas
• Vibrio vulnificus (Gulf States, chronic disease)
• DM
• Other gram negative rods
• Animal bites
• Pasteurella multocida

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NECROTIZING FASCIITIS

• Fulminant destruction of tissue
• Systemic toxicity
• Very high mortality
• Much larger bacterial load than cellulitis
• Travels through fascial plain
• Much less inflammation from necrosis, vessel
  thrombosis, and bacterial factors

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NECROTIZING FASCIITIS

• Two types
• Type I
• Largely mixed aerobic and anaerobic infection
• Seen in post surgical patients
• DM, PVD big risk factors
• Examples
• Cervical necrotizing fasciitis (Ludwigs angina)
• Fourniers gangrene
• Type II
• Group A strep
• Large exotoxin production or M protein
• Any age group or without portal of entry

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DIAGNOSIS

• Pain
• May mimic post surgical changes
• Skin changes
• Thick or woody in nature
• Minimal erythema
• Bullae
• Systemic symptoms
• Fevers, chills
• Rapid sepsis

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TREATMENT

• Surgical Debridement!!!!!!!!
• aggressive and explorative
• Wide tissue excision
• Antibiotics
• B- lactam antibiotics
• Clindamycin for toxin production
• Gram negative/anaerobic coverage
• Hyperbaric O2
• Supportive care

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TOXIN DISEASES

• Tetanus
• Rare due to vaccination
• 1 Million die per year in developing world
• 4 clinical patterns
• Generalized
• Local
• Cephalic
• Neonatal

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TETANUS

• Spores of C. tetani enter the tissue
• Produce metalloprotease, tetanospasmin
• Retrograde movement into CNS
• Blocks neurotransmission by cleaving protein
  responsible for neuroexocytosis
• Disinhibition of motor cortex
• Extensive spasm

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TETANUS

• Needs the right factors to produce
• Penetrating injury with spore delivery
• Co-infection with other bacteria
• Devitalized tissue
• Localized ischemia

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TETANUS TREATMENT

• Wound management
• Halts toxin production
• Tetanus antitoxin and vaccine
• Neutralized unbound toxin
• Benzodiazepines and paralytics
• Treats spasms
• B-blockers
• Treats autonomic dysfunction of late disease
• Supportive care

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WATERBORNE DISEASE

• Cholera
• Gram negative bacterium Vibrio cholerae
• Severe water diarrhea with 50 mortality if
  untreated
• 190 serrotypes but only O1 and O139 cause human
  epidemics
• Bacterial model for toxin mediated disease

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CHOLERA PATHOPHYSIOLOGY

• Enter the small bowel and colonize
• Pilus required
• Hemagglutanins
• Acessory colonizing factor
• Porin like proteins
• Produces toxin
• A with 5 B subunits
• A cleaves to A1, activates adenylate cyclase
• Leads to increase Cl secreation and decreased Na
  absorption

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CHOLERA SYMPTOMS

• Majority are asymptomatic
• Some with develop rapid diarrhea
• Diarrhea most severe days 1-2, stops by day 6
• May loose 100 body weight in 2 days
• Children, elderly at risk
• Death in 2 -48 hours (18 average)

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CHOLERA TREATMENT

• Oral rehydration- per liter
• 3.5g NaCl
• 2.9g NaHCO3
• 1.5g KCl
• 20g glucose
• IV rehydration
• Antibiotics- not necessary
• Lessens diarrhea by one day
• Vaccine- no evidence
• Public health prevention

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NON-CHOLERA DYSENTERY

• Giardia
• E. Coli
• Toxin Mediate food poisoning
• Salmonella
• Shigella
• Campylobacter
• Yersinia
• Viral hepatitis
• Viral Gastroenteritis

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RESPIRATORY ILLNESS

• Viral
• Most common cause of infectious illness after
  Midwest floods over past 20 years
• More common is shelter setting (unpublished)
• TB
• 25 mortality in camps in Africa and Asia
• Worsened by drought
• Community acquired bacterial pneumonia
• Mainly theoretical, no data

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VECTORBORNE DISEASE

• Malaria
• Common after flooding
• Well controlled with mosquito abatement
• Encephalitis
• No documented increase in US but heavy abatement
  programs
• West Nile?

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DISASTER RESPONSE

• Endemic diseases of the area
• CDC or WHO for health alert outbreaks
• Intense disease surveillance
• Working with public health
• Field laboratory for early diagnosis
• Antibiotics, equipment, and supplies

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DISASTER RESPONSE

• Record Keeping
• Restore basic medical care quickly
• Reduces disease susceptibility
• Vaccinations
• May be very costly and not effective (cholera)
• Uses only proven vaccines after disease starts
  (measles, meningococcal)
• May be chance to vaccinate chronically ill when
  compared to baseline

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CONCLUSIONS

• Infectious disease epidemics may play a role in
  the post disaster period
• These diseases will vary depending on many
  factors
• If the disease if not present before the
  disaster, it will not be there after

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CONCLUSIONS

• Early recognition of certain diseases in disaster
  setting important
• Infrastructure and response is key and
  important!
• If deployed, know where you are going and what is
  endemic

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QUESTIONS?

• Please remember to complete and turn in
• Personal data sheet
• Evaluation
• Sign-in sheet (include your degree or job
  function AND your license number if applicable to
  receive CEUs)

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calPEN INFORMATION

• calpen_at_chpscc.org
• Module 1 General Preparedness
• Module 2 Bioterrorism
• Module 3 Chemical Radiation Hazards
• Module 4 Emerging Infectious Diseases
• Module 5 Infectious Disease After a Natural
  Disaster
• Module 6 Pandemic Influenza

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