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Infectious Disease Issues in Natural Disasters

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Infectious Disease Issues in Natural Disasters Christian Sandrock, M.D. UC Davis School of Medicine Overview Discuss the role of infectious diseases in natural ... – PowerPoint PPT presentation

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Title: Infectious Disease Issues in Natural Disasters


1
Infectious Disease Issues in Natural Disasters
  • Christian Sandrock, M.D.
  • UC Davis School of Medicine

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Overview
  • Discuss the role of infectious diseases in
    natural disasters (flood, earthquake, hurricane,
    etc)
  • Look at the factors effecting the development of
    disease outbreak after a disaster
  • Discuss specific diseases seen after various
    disasters
  • Review efficacy of various treatment options

4
Is there a link?
  • Conflicting belief among experts as to rise in
    disease after disaster
  • Some studies relate direct link between disaster
    and disease outbreak (Dominican Republic-
    hurricane)
  • Others offer theory but no link
  • All depends on variable factors

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Background
  • Historically, infectious disease epidemics have
    accounted for large number of deaths
  • Disasters have potential for large number of
    deaths
  • Epidemics are still viable and feared
  • Can a natural disaster lead to an epidemic?

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

14
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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Endemic organisms
  • The organisms are endemic to the region before
    the disaster
  • If not present before the event, it will not be
    there after regardless of ecological conditions
  • Deliberate introduction could change this factor

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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 Organisms
  • 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, vector borne 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
  • 17 GI, 20 respiratory
  • Iowa 1993
  • No reports of GI increase due to
    sanitationmeasure
  • 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 would predominate 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
  • Muscle/tissue necrosis
  • Toxin production disease
  • Burns
  • Waterborne
  • Cholera
  • Non-cholera dysentery
  • Hepatitis
  • Rare diseases

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Post-Impact Phase Infections
  • Vector borne
  • Malaria
  • 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 long 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
  • B-lactam atnibiotics
  • Clindamycin
  • Vancomycin
  • Other
  • Limb elevation
  • Systemic support
  • Surgical consultation
  • Abscess
  • Occular
  • Necrotizing fasciitis evaluation

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Cellulitis
  • Special situations
  • MRSA possibility
  • Water exposure
  • Aeromonas
  • Vibrio in liver failure
  • DM
  • Other gram negative rods
  • Animal bites
  • Pasteurella multocida

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Necrotizing Fasciitis
  • Fulminant destruction of tissue with systemic
    signs of toxicity
  • Overlaps with necrotizing myositis or gangranous
    myositis
  • 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 explarative
  • 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
  • Tetnus
  • Rare due to vaccination
  • 1 Milliion die per year in developing world
  • 4 clinical patterns
  • Generalized
  • Local
  • Cephalic
  • Neonatal

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Tetnus
  • Spores of C. tetani enter the tissue
  • Produce metalloprotease, tetanospasmin
  • Retrograde movement into CNS
  • Blocks neurotransmission by cleaving protein
    responsible for neuroexocytosis
  • Leads to disinhibition of motor cortex and
    extensive spasm

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

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Tetnus Treatment
  • Wound management
  • Halts toxin production
  • Tetnus 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, with some
    emesis
  • 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
  • others

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Respiratory Illness
  • Viral
  • Most common cause of infectious illness after
    Midwest floods over past 20 years
  • TB
  • 25 mortality in camps in Africa and Asia
  • Worsened by drought
  • Community acquired bacterial pneumonia
  • Mainly theoretical, no data

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Vector borne disease
  • Malaria
  • 2nd most documented increase in disease 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 Teams
  • 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 and equipment supplies
  • IVF
  • Multiple range of antibiotics for all people

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Disaster Response Teams
  • Record Keeping
  • Therapies and syndromes known
  • Restore basic medical care quickly
  • Reduces disease susceptability
  • Vaccinations
  • May be very costly, misdirected in acute phase
    (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 type of
    disaster, population characteristics, endemic
    diseases, and climate and geography of the region
  • 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
    particular disaster settings may improve outcome
  • Public health infrastructure, equipment,
    antibiotics, and medical infrastructure is key to
    a communitys survival and well being
  • If deployed, know where you are going
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