Health Concerns in the Wake of Disaster

After the disastrous hurricanes along America's Gulf Coast, many questions arose about the continuing threats posed by devastating aftereffects. Some of the hazards still uppermost in people's minds are related to the distressing images that we all witnessed via media outlets, such as the bodies of deceased victims floating in the flooded streets of New Orleans - a situation that actually posed very little risk. More realistic are the worrisome effects of common infectious diseases and skin lesions due to untreated open wounds, especially those exposed to toxic wastewater.

In the longer term, worries center on both the chronic and emerging medical problems faced by thousands of people in overcrowded shelters with the potential for inadequate resources for health care.

The following information details the preliminary and ongoing concerns relating to the storm and its aftermath, and responses from the Centers for Disease Control and Prevention (CDC), the US Department of Health and Human Services (DHSS) and the Environmental Protection Agency (EPA) regarding the actions being taken to resolve the problems.

Threat Exists in Common, Not Exotic, Infectious Diseases
Although infectious diseases are a frightening prospect, rare and deadly exotic diseases such as cholera or typhoid do not suddenly break out after hurricanes and floods in areas where such diseases do not naturally occur.

What's more likely are communicable disease outbreaks of diarrhea and respiratory illness that can occur when water and sewage systems are not working and personal hygiene is hard to maintain as a result of a disaster.

"In a city like New Orleans, cholera has not been present for many years," said Dr. Julie Gerberding, Director of the Centers for Disease Control and Prevention (CDC). "What we are concerned about are the things that could more likely persist in water in this society. That would include E coli, diarrhea, and potentially some other infectious diseases." Dr. Gerberding also mentioned Noroviruses as a potential hazard. "These are the same viruses that have caused the widespread outbreaks on cruise ships," she said. "They're so easily transmitted…once these viruses get established in a population, you can expect some vomiting and diarrhea to occur."

An additional concern is the presence of tuberculosis (TB) in some members of the shelter population. Re-establishing the appropriate drug routines for these people has become a priority health concern. "TB obviously is an issue because it's transmitted person to person, but it does take fairly prolonged contact with a highly infectious patient for that to be a major threat," said Dr. Gerberding.

As the urgent needs of shelter inhabitants are met, taking care of pre-existing medical conditions will become the main issue faced by medical teams. "There are the problems that emerge because of the hurricane and the flooding, the injuries and the trauma, the problems that emerge as people go in and try to recover and have injuries and difficulties during the recovery phase," said Dr. Gerberding. "But the biggest challenge of all of this is going to be maintaining the chronic care services to the people who had them before the hurricane ever hit."

Decaying Bodies Create Little Risk for Disease Outbreaks
"Let me just say this," said Dr. Gerberding: "Dead bodies are horrifying and I think the risks they pose to people in this environment is just that humanitarian perspective of how awful to have anybody experience something like the sight of a body floating in water or multiple dead bodies in the water, and I'm sorry that anyone, whether they're a rescue worker, a citizen or a child ever has to see something like that in this country or anywhere.

"But from a health standpoint, bodies in the water do not pose an infectious disease threat. The only conceivable concern would be if someone had direct contact with the blood of one of these victims and that person happened to be carrying a blood-borne infection in which case it's like any body fluid exposure in a health or mortuary situation, it's something that we require personal protection to prevent."

Toxins in Water an Ongoing Problem
Environmental Protection Agency testing has revealed that E. coli levels in the New Orleans area remain greatly elevated and are much higher than the recommended levels for contact. Based on sampling results, emergency responders and the public should avoid direct contact with standing water when possible. In the event contact occurs, EPA and CDC strongly advise the use of soap and water to clean exposed areas if available.

Flood water should not be swallowed and all mouth contact should be minimized and avoided where possible. People should immediately report any symptoms to health professionals. The most likely symptoms of ingestion of flood water contaminated with bacteria are stomach-ache, fever, vomiting and diarrhea. Also, people can become ill if they have an open cut, wound, or abrasion that comes into contact with water contaminated with certain organisms. One may experience fever, redness, and swelling at the site of an open wound, and should see a doctor right away if possible.

EPA is mapping the facilities and sites affected by Hurricane Rita. These maps will be used to conduct a Rapid Needs Assessment. Chemical products stored at the larger facilities to assist responders are also being identified. EPA is mapping Superfund hazardous waste sites impacted by Hurricane Rita. Sites will be inspected in priority order, with all sites inspected within seven to ten days.

Vaccines a Priority for Shelters, Rescue Workers
According to Dr. Gerberding, the immediate focus of health care teams is ensuring that the children living in shelters are up-to-date on their standard vaccinations. Adult vaccination programs will initially focus on tetanus and influenza.

For people offering help in the disaster area or to work with evacuees, the recommended vaccinations vary depending on the expected activities of the volunteer.

According to the website of the EPA, people who will be assisting with search and rescue or clean-up activities should receive a dose of tetanus-diphtheria toxoid if they have not had a booster dose within the previous 10 years. If contact with blood or other body fluids is anticipated the person should receive hepatitis B vaccine. Hepatitis A and typhoid vaccines are not recommended.

People who will be working with displaced persons in a large, crowded evacuation center should receive the same vaccines as recommended for persons living in these centers:

• one dose of MMR vaccine for those born after 1956 without documentation of previous vaccination
• one dose of varicella vaccine for persons born after 1965 who have not had chickenpox or shingles, and have not previously received varicella vaccine
• hepatitis A vaccine for those without a clear history of hepatitis A and who have not previously received the vaccine
• influenza vaccine
• people working in evacuation centers who anticipate contact with blood or other body fluids should also have received hepatitis B vaccine

The Work to Come: Advice for Those Who Return to Disaster Areas
The CDC has provided the following safety recommendations for people who re-enter areas affected by hurricanes:

To Prevent Illness from Food

• Identify and throw away food that may not be safe to eat. Throw away food that may have come in contact with flood or storm water. Throw away canned foods that are bulging, opened, or damaged. Throw away food that has an unusual odor, color, or texture. Throw away perishable foods (including meat, poultry, fish, eggs and leftovers) that have been above 40 degrees Fahrenheit for 2 hours or more. If cans have come in contact with floodwater or storm water, remove the labels, wash the cans, and dip them in a solution of 1 cup of bleach in 5 gallons of water. Relabel the cans with a marker.
• Store food safely. While the power is out, keep the refrigerator and freezer doors closed as much as possible. Add block ice or dry ice to your refrigerator if the electricity is expected to be off longer than 4 hours. Wear heavy gloves when handling ice.

To Prevent Illness from Water

• Listen to and follow public announcements. Local authorities will tell you if tap water is safe to drink or to use for cooking or bathing. If the water is not safe to use, follow local instructions to use bottled water or to boil or disinfect water for cooking, cleaning, or bathing.
• Correctly boil or disinfect water. Hold water at a rolling boil for 1 minute to kill bacteria. If you can't boil water, add 1/8 teaspoon (~0.75 mL) of newly purchased, unscented liquid household bleach per gallon of water. Stir the water well, and let it stand for 30 minutes before you use it. You can use water-purifying tablets instead of boiling water or using bleach. For infants, use only pre-prepared canned baby formula. Do not use powdered formulas prepared with treated water. Clean children's toys that have come in contact with water. Use a solution of 1 cup of bleach in 5 gallons of water to clean the toys. Let toys air dry after cleaning.

To Prevent and Treat Illness and Injuries

• Prevent carbon monoxide poisoning. Carbon monoxide is an odorless, colorless gas that is produced by many types of equipment and is poisonous to breathe. Don't use a generator, charcoal grill, camp stove, or other gasoline- or charcoal-burning device inside your home, basement, or garage or near a window, door, or vent. Don't run a car or truck inside a garage attached to your house, even if you leave the door open. Don't heat your house with a gas oven. If your carbon monoxide detector sounds, leave your home immediately and call 911. Seek prompt medical attention if you suspect carbon monoxide poisoning and are feeling dizzy, light-headed, or nauseated.
• Avoid floodwater and mosquitoes. Follow all warnings about water on roadways. Do not drive vehicles or heavy equipment through water. If you have to work in or near floodwater, wear a life jacket. If you are caught in an area where floodwater is rising, wear a life jacket, or wear or keep some other type of flotation device at hand. Prevent mosquito bites by wearing long pants, socks, and long-sleeved shirts and using insect repellents that contain DEET or Picaridin.
• Avoid unstable buildings and structures. Stay away from damaged buildings or structures until they have been examined and certified as safe by a building inspector or other government authority. Leave immediately if you hear shifting or unusual noises that signal that the structure is about to fall.
• Beware of wild or stray animals. Avoid wild or stray animals. Call local authorities to handle animals. Get rid of dead animals according to local guidelines.
• Beware of electrical and fire hazards. NEVER touch a fallen power line. Call the power company to report fallen power lines. Avoid contact with overhead power lines during cleanup and other activities. If electrical circuits and electrical equipment have gotten wet or are in or near water, turn off the power at the main breaker or fuse on the service panel. Do not turn the power back on until electrical equipment has been inspected by a qualified electrician. Do not burn candles near flammable items or leave the candle unattended. If possible, use flashlights or other battery-operated lights instead of candles.
• Beware of hazardous materials. Wear protective clothing and gear (for example, a respirator if needed) when handling hazardous materials. Wash skin that may have come in contact with hazardous chemicals. Contact local authorities if you are not sure about how to handle or get rid of hazardous materials.
• Clean up and prevent mold growth. Clean up and dry out the building quickly (within 24 to 48 hours). Open doors and windows. Use fans to dry out the building. To prevent mold growth, clean wet items and surfaces with detergent and water. To remove mold growth, wear impervious gloves, open windows and doors, and clean with a bleach solution of 1 cup of bleach in 1 gallon of water. Throw away porous items (for example, carpet and upholstered furniture) that cannot be dried quickly. Fix any leaks in roofs, walls, or plumbing.
• Pace yourself and get support. Be alert to physical and emotional exhaustion or strain. Set priorities for cleanup tasks, and pace the work. Try not to work alone. Don't get exhausted. Ask your family members, friends, or professionals for support. If needed, seek professional help.
• Prevent musculoskeletal injuries. Use teams of two or more people to move bulky objects. Avoid lifting any material that weighs more than 50 pounds (per person).
• Stay cool. When it's hot, stay in air-conditioned buildings; take breaks in shaded areas or in cool rooms; drink water and nonalcoholic fluids often; wear lightweight, light-colored, loose-fitting clothing; and do outdoor activities during cooler hours.
• Treat wounds. Clean out all open wounds and cuts with soap and clean water. Apply an antibiotic ointment. Contact a doctor to find out whether more treatment is needed (such as a tetanus shot). If a wound gets red, swells, or drains, seek immediate medical attention.
• Wash your hands. Use soap and water to wash your hands. If water isn't available, you can use alcohol-based products made for washing hands.
• Wear protective gear for cleanup work. Wear hard hats, goggles, heavy work gloves, and watertight boots with steel toe and insole (not just steel shank). Wear earplugs or protective headphones to reduce risk from equipment noise.

There is a great deal of current and regularly updated information available on the Internet for those who want to keep up with the ongoing issues of response and recovery. Some of the sources used in this article are listed below.

Eileen Early, RN, BSN
HealthLink Editor

State websites:
The State of Louisiana's Hurricane Katrina website
The Official State Web Site of Mississippi
The Hurricane Katrina website of the Governor of Alabama

US Environmental Protection Agency (EPA) websites:
The website of the US Environmental Protection Agency
Hurricane Katrina Response
Water issues: Test results
Hurricane Katrina Response/Current activities
Environmental Health Needs and Habitability Assessment

US Centers for Disease Control and Prevention (CDC) websites:
Key Facts About Hurricane Recovery
Questions and Answers about Immunization Recommendations following Hurricane Katrina
After a Hurricane: Key Facts About Infectious Disease

US Department of Health and Human Services websites:
Hurricane Katrina
Department of Health and Human Services Press Briefing

Each year, Medical College of Wisconsin physicians care for more than 180,000 patients, representing nearly 500,000 patient visits. Medical College physicians practice at Children's Hospital of Wisconsin, Froedtert Memorial Lutheran Hospital, the Milwaukee VA Medical Center, and many other hospitals and clinics in Milwaukee and southeastern Wisconsin.