After Hurricane Florence, Significant Worry Over Infectious Diseases

Troy Brown, RN

September 21, 2018

Infectious diseases and injuries are significant concerns after Hurricane Florence, and experts also remain vigilant about the disease threat resulting from destruction of the numerous hog farms in the Carolinas and the runoff from hog waste lagoons.

Although everyone agrees that infectious diseases pose a significant risk in the aftermath of Hurricane Florence, these aren't the only threats to residents in the hardest hit areas in North and South Carolina and parts of Virginia.

Many residents were — at least initially — unable to access healthcare as a result of flooded and damaged roads and nonfunctioning communications systems. Many also had no access to necessary medications or were unable to properly store them, E. Anne Peterson, MD, MPH, senior vice president of the global poverty and disaster relief organization Americares, told Medscape Medical News.

Emotional trauma has also affected residents and healthcare providers alike and will continue to do so for the foreseeable future, she said. Healthcare workers are particularly vulnerable to vicarious trauma as they relive their own distress while caring for patients in similar situations, Peterson explained.

She said even though the immediate hurricane event is over, flash flooding continues to be a problem.

Infectious Diseases of Most Concern

"Infectious disease outbreaks of diarrheal and respiratory illnesses can occur after a natural disaster when access to safe water and sewage systems are disrupted and personal hygiene is difficult to maintain. Infections of concern include leptospirosis, hepatitis A, vibriosis, and influenza," Satish K. Pillai, MD, MPH, deputy director, Division of Preparedness and Emerging Infections, Centers for Disease Control and Prevention (CDC), told Medscape Medical News.

"In [the] short term, one worries about infectious diseases contracted after contact with contaminated water — so diarrheal disease from enteric bacterial infections, but also norovirus outbreaks. Another major short-term issue is among displaced populations living under stress in shelters leading to respiratory virus transmission. We're also in the middle of enterovirus season, so that would also be a concern in crowded settings," Peter Hotez, MD, PhD, FASTMH, FAAP, dean of the National School of Tropical Medicine at Baylor College of Medicine and director of the Texas Children's Hospital Center for Vaccine Development, both in Houston, told Medscape Medical News.

"Infectious disease outbreaks of diarrheal and respiratory illnesses can occur after any natural disaster and are always an issue after hurricanes.... Still another concern are wound infections," Hotez said.

"Then as the flood waters recede, I also worry about increases in mosquito-borne viruses, especially West Nile virus infection, as we saw following Katrina," he said.

Clinicians need to be especially vigilant about making sure that all of their patients' tetanus immunizations are current and educating them on safe cleanup of their homes, Peterson said. Patients will "need continued hygiene kinds of items and cleanup items; we see a lot of infection as people are exposed to that murky, contaminated water and get skin infections," she explained.

Even small cuts to the skin can rapidly escalate to life-threatening infections and sepsis, Peterson said.

Injury Risk Will Continue

The potential for injuries will continue for some time, Peterson said. There will be those who are trapped in water, and some may be electrocuted as they seek shelter. Residents returning to their homes are likely to find wild animals, including snakes, that have sought refuge in unoccupied homes.

People attempting to clean up their homes and properties are also at risk for injury as they pull trees off their houses and remove junk from inside their homes.

Residents in affected areas will have to contend with mold growth in their homes, and asthma rates are likely to rise in the coming weeks and months, Peterson continued.

Hog Farms

As of September 19, 3.4 million chickens and 5500 hogs had perished as a result of Hurricane Florence, according to multiple news reports.

But, "the infectious disease risk to humans from animal carcasses is low if proper precautions are taken. These precautions include proper handwashing to prevent infection with pathogens that may be transmitted from animal feces, such as Salmonella and E coli, as well as removal of animal carcasses. Most states have their own guidelines on disposal of dead animals. People with questions about the specific situation in their state are highly encouraged to contact local or state health and agricultural officials for clarification," Pillai told Medscape Medical News. For more information about animal disposal, he recommended a CDC website specific to the problem.

"Pathogen-specific infectious disease risks from contamination of floodwaters with animal carcasses or animal waste are not well documented. Clinicians suspecting cases of gastrointestinal, respiratory, dermatologic, or other conditions following contact with animal carcasses or animal waste are encouraged to contact their state or local health department," Pillai continued.

The CDC also has information on pathogens transmitted between animals and people, including Salmonella, Campylobacter, E coli, and Cryptosporidium, Pillai said.

Hotez, from Baylor College of Medicine, mentioned another concern. "I would worry about wound infections from antibiotic-resistant bacteria, as well as Balantidium colitis," he said.

"In terms of potential health threats due to floodwaters contaminated with hog waste and feces, due to all the hog farming in the Carolinas, I would be more concerned with antibiotic-resistant bacteria — because of antibiotics sometimes used in hog feed — resulting in diarrheal disease or as opportunistic pathogens of wound infections, which can be very common during hurricane cleanup and rescue efforts," Hotez explained.

He also again emphasized the risk for "a severe intestinal parasitic infection known as balantidiasis, caused by the protozoan parasite Balantidium coli," which can "cause severe and even life-threatening colitis."

Vigilant for Common Disease – and Uncommon

It's not just the hog carcasses and the runoff from their farms that cause worry. After Hurricane Maria in Puerto Rico, there was a spike in cases of the rare disease leptospirosis, which can occur because of bacteria carried by animals from rodents to cattle infecting the standing water. So far, so good, though, for the Carolinas.

"Cases of leptospirosis can increase after hurricanes or floods, when people may have to wade through urine-contaminated water (flood water or natural fresh water sources) or use it for drinking or bathing. While human leptospirosis cases are not commonly reported from the states in the path of Hurricane Florence, it is important to avoid touching or drinking water that may be contaminated after hurricanes or flooding. To date, no cases of leptospirosis have been reported to CDC from the hurricane-affected areas, but public health authorities remain vigilant," Pillai explained.

"Leptospirosis is a major problem in Asia and elsewhere and is a potentially significant problem after Pacific typhoons and cyclones, but it is less of a problem in the US, with the exception of Puerto Rico. The CDC estimates there are approximately 100-plus cases of leptospirosis annually in the US, with about half in Puerto Rico. After Hurricane Maria, leptospirosis is believed to have caused deaths," Hotez said.

"In humans, leptospirosis can cause a wide range of symptoms, many of which can be mistaken for other diseases. Symptoms can include high fever, headache, chills, muscle aches, vomiting, jaundice (yellow skin and eyes), red eyes, abdominal pain, diarrhea, and rash. Early treatment may decrease the severity and duration of disease. In patients with a high clinical suspicion of leptospirosis, initiating antibiotic treatment as soon as possible without waiting for laboratory results is recommended," the CDC's Pillai added.

A CDC Checklist

According to a CDC website, healthcare providers should be watchful for community and healthcare-associated infections, including influenza and the aforementioned, as well as less common infections, such as leptospirosis, hepatitis A, and vibriosis. Clinicians should consider some of those less common infectious diseases when caring for patients with acute respiratory symptoms, gastroenteritis, renal or hepatic fever, wound infection, or fever.

The CDC urges local healthcare providers to report to their local health authorities cases in which they suspect leptospirosis, hepatitis A, and vibriosis, even before laboratory confirmation. Clinicians should immediately report confirmed cases of leptospirosis, hepatitis A, and vibriosis to the territorial or state health department. Although not all states require reporting of these conditions, "they are conditions of public health importance and should be reported," according to the CDC.

"Any febrile illness should be taken seriously, especially if it's accompanied by chills, headache, or rash, and any wounds should receive prompt medical attention," Hotez said.

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