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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. CALIFORNIA PREPAREDNESS EDUCATION NETWORK. A program of the California Area Health Education Centers.

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Infectious disease after natural disasters l.jpg

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

Western K Tropical Public Health, London School of Hygiene and Tropical Public Health


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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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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

Howard et al, Emergency Medicine Clinics in North America 1996 14 (2)


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DOMINICAN REPUBLIC 1979

  • Hurricane David and Fredrick on Aug 31 and Sept 5th 1979

  • >2,300 dead immediately

  • Marked increase in all diseases measured 6 months after the hurricane

    • Thyphoid fever

    • Gastroenteritis

    • Measles

    • Viral hepatitis

Bissell, RA J Emerg Med 1983 1 (1):59-66


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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

    • ABC’s

      • 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 (Ludwig’s angina)

        • Fournier’s 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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cal·PEN INFORMATION

[email protected]

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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