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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


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    1. INFECTIOUS DISEASE AFTER NATURAL DISASTERS California Preparedness Education Network A program of the Area Health Education Centers Presented by: Funded by ASPR Grant T01HP01405

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

    3. 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

    4. 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

    5. 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

    6. 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?

    7. 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

    8. 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

    9. 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

    10. 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

    11. 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

    12. 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

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

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

    15. PRE-EVENT RESOURCES • Sanitation • Primary health care and nutrition • Disaster preparedness • Disease surveillance • Equipment and medications • Transportation • Roads • Medical infrastructure

    16. 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

    17. EPIDEMICS AFTER DISASTERS

    18. EPIDEMICS AFTER DISASTERS

    19. 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)

    20. 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

    21. WHAT EPIDEMICS COULD WE SEE TODAY? Endemic organisms Post-impact phase Recovery Phase

    22. 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

    23. POST-IMPACT PHASE INFECTIONS • Vectorborne • Malaria • WNV, other viral encephalitis • Dengue and Yellow fever • Typhus • Respiratory • Viral • CAP • Rare disease • Other • Blood transfusions

    24. RECOVERY PHASE INFECTIONS • These agents need a longer incubation period • TB • Schistosomiasis • Lieshmaniasis • Leptospirosis • Nosocomial infections of chronic disease

    25. 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

    26. 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

    27. 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

    28. 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

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

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

    31. 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

    32. 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

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