Title: INFECTIOUS DISEASE AFTER NATURAL DISASTERS
1INFECTIOUS DISEASE AFTER NATURAL DISASTERS
- California Preparedness Education Network
- A program of the Area Health Education Centers
- Presented by
- Funded by ASPR Grant T01HP01405
2CALIFORNIA PREPAREDNESS EDUCATION NETWORK
A program of the California Area Health
Education Centers
3calPEN 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
4HOUSEKEEPING
- 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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6OVERVIEW
- 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
7BACKGROUND
- 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?
8IS 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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10PHASES 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
11VARIABLES 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
12ENVIRONMENTAL 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
13ENDEMIC 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
14ENDEMIC 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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17POPULATION CHARACTERISTICS
- Density
- Displaced populations
- Refugee camps
- Age
- Increased elderly or children
- Chronic Disease
- Malnutrition
- DM, heart disease
- Transplantation
18POPULATION 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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21PRE-EVENT RESOURCES
- Sanitation
- Primary health care and nutrition
- Disaster preparedness
- Disease surveillance
- Equipment and medications
- Transportation
- Roads
- Medical infrastructure
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26TYPE 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
27EPIDEMICS AFTER DISASTERS
28EPIDEMICS AFTER DISASTERS
29FLOODING
- 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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31DOMINICAN 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
32WHAT EPIDEMICS COULD WE SEE TODAY?
- Endemic organisms
- Post-impact phase
- Recovery Phase
33POST-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
34POST-IMPACT PHASE INFECTIONS
- Vectorborne
- Malaria
- WNV, other viral encephalitis
- Dengue and Yellow fever
- Typhus
- Respiratory
- Viral
- CAP
- Rare disease
- Other
- Blood transfusions
35RECOVERY PHASE INFECTIONS
- These agents need a longer incubation period
- TB
- Schistosomiasis
- Lieshmaniasis
- Leptospirosis
- Nosocomial infections of chronic disease
36SKIN 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
37SKIN 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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41CELLULITIS
- 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
42CELLULITIS
- 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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45CELLULITIS
- Treatment
- Antibiotics (MRSA)
- TMP/SMX
- Clindamycin
- Linezolid
- Vancomycin
- Limb elevation
- Systemic support
- Surgical consultation
- Abscess
- Occular
- Necrotizing fasciitis evaluation
46CELLULITIS
- Special situations
- Water exposure
- Aeromonas
- Vibrio vulnificus (Gulf States, chronic disease)
- DM
- Other gram negative rods
- Animal bites
- Pasteurella multocida
47NECROTIZING 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
48NECROTIZING 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
49DIAGNOSIS
- 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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56TREATMENT
- Surgical Debridement!!!!!!!!
- aggressive and explorative
- Wide tissue excision
- Antibiotics
- B- lactam antibiotics
- Clindamycin for toxin production
- Gram negative/anaerobic coverage
- Hyperbaric O2
- Supportive care
57TOXIN DISEASES
- Tetanus
- Rare due to vaccination
- 1 Million die per year in developing world
- 4 clinical patterns
- Generalized
- Local
- Cephalic
- Neonatal
58TETANUS
- 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
59TETANUS
- Needs the right factors to produce
- Penetrating injury with spore delivery
- Co-infection with other bacteria
- Devitalized tissue
- Localized ischemia
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61TETANUS 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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63WATERBORNE 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
64CHOLERA 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
65CHOLERA 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)
66CHOLERA 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
67NON-CHOLERA DYSENTERY
- Giardia
- E. Coli
- Toxin Mediate food poisoning
- Salmonella
- Shigella
- Campylobacter
- Yersinia
- Viral hepatitis
- Viral Gastroenteritis
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72RESPIRATORY 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
73VECTORBORNE DISEASE
- Malaria
- Common after flooding
- Well controlled with mosquito abatement
- Encephalitis
- No documented increase in US but heavy abatement
programs - West Nile?
74DISASTER 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
75DISASTER 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
76CONCLUSIONS
- 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
77CONCLUSIONS
- 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
78QUESTIONS?
- 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)
79calPEN 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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