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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

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
CALIFORNIA PREPAREDNESS EDUCATION NETWORK

A program of the California Area Health Education Centers

calpen at community health partnership
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
housekeeping
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
overview
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
background
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?
is there a link between a natural disaster an outbreak
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
phases of a disaster
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

variables for development of an epidemic after a disaster
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
environmental considerations
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
endemic organizms
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
endemic organizms14
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
population characteristics
POPULATION CHARACTERISTICS
  • Density
    • Displaced populations
    • Refugee camps
  • Age
    • Increased elderly or children
  • Chronic Disease
    • Malnutrition
    • DM, heart disease
    • Transplantation
population characteristics18
POPULATION CHARACTERISTICS
  • Education
    • Less responsive to disaster teams
  • Religion
    • Polio in Nigeria, 2004
  • Hygiene
    • Underlying health education of public
  • Trauma
    • Penetrating, blunt, burns
  • Stress
pre event resources
PRE-EVENT RESOURCES
  • Sanitation
  • Primary health care and nutrition
  • Disaster preparedness
  • Disease surveillance
  • Equipment and medications
  • Transportation
  • Roads
  • Medical infrastructure
type of disaster
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
flooding
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)

dominican republic 1979
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

what epidemics could we see today

WHAT EPIDEMICS COULD WE SEE TODAY?

Endemic organisms

Post-impact phase

Recovery Phase

post impact phase infections
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
post impact phase infections34
POST-IMPACT PHASE INFECTIONS
  • Vectorborne
    • Malaria
    • WNV, other viral encephalitis
    • Dengue and Yellow fever
    • Typhus
  • Respiratory
    • Viral
    • CAP
    • Rare disease
  • Other
    • Blood transfusions
recovery phase infections
RECOVERY PHASE INFECTIONS
  • These agents need a longer incubation period
    • TB
    • Schistosomiasis
    • Lieshmaniasis
    • Leptospirosis
    • Nosocomial infections of chronic disease
skin and soft tissue disease
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
skin and soft tissue disease37
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
cellulitis
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
cellulitis42
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
cellulitis45
CELLULITIS
  • Treatment
    • Antibiotics (MRSA)
      • TMP/SMX
      • Clindamycin
      • Linezolid
      • Vancomycin
    • Limb elevation
    • Systemic support
    • Surgical consultation
      • Abscess
      • Occular
      • Necrotizing fasciitis evaluation
cellulitis46
CELLULITIS
  • Special situations
    • Water exposure
      • Aeromonas
      • Vibrio vulnificus (Gulf States, chronic disease)
    • DM
      • Other gram negative rods
    • Animal bites
      • Pasteurella multocida
necrotizing fasciitis
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
necrotizing fasciitis48
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
diagnosis
DIAGNOSIS
  • Pain
    • May mimic post surgical changes
  • Skin changes
    • Thick or “woody” in nature
    • Minimal erythema
    • Bullae
  • Systemic symptoms
    • Fevers, chills
    • Rapid sepsis
treatment
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
toxin diseases
TOXIN DISEASES
  • Tetanus
    • Rare due to vaccination
    • 1 Million die per year in developing world
    • 4 clinical patterns
      • Generalized
      • Local
      • Cephalic
      • Neonatal
tetanus
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
tetanus59
TETANUS
  • Needs the right factors to produce
    • Penetrating injury with spore delivery
    • Co-infection with other bacteria
    • Devitalized tissue
    • Localized ischemia
tetanus treatment
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
waterborne disease
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
cholera pathophysiology
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
cholera symptoms
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)
cholera treatment
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
non cholera dysentery
NON-CHOLERA DYSENTERY
  • Giardia
  • E. Coli
  • Toxin Mediate food poisoning
  • Salmonella
  • Shigella
  • Campylobacter
  • Yersinia
  • Viral hepatitis
  • Viral Gastroenteritis
respiratory illness
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
vectorborne disease
VECTORBORNE DISEASE
  • Malaria
    • Common after flooding
    • Well controlled with mosquito abatement
  • Encephalitis
    • No documented increase in US but heavy abatement programs
    • West Nile?
disaster response
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
disaster response75
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
conclusions
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
conclusions77
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
questions
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)
cal pen information
cal·PEN INFORMATION

calpen@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