Depending on the scale of devastation, a hurricane can leave those in its path reeling long after dangerous, damaging high winds and driving rains pound an area. Often it can take years to rebuild. Some places hardest hit are never quite the same.
Nearly two months since Hurricane Maria swept through Puerto Rico and turned out the lights, much of the island is still without power, and residents face many other issues ranging from a lack of access to clean drinking water to impassable roads. Beyond the immediate danger of the storm itself — and the long arc of its impact thereafter — another danger can sometimes lurk following a hurricane: the spread of disease. That’s particularly a concern when damage to infrastructure is severe and floodwaters don’t recede quickly — as in Puerto Rico.
“The need is particularly acute in Puerto Rico and the U.S. Virgin Islands,” wrote Infectious Diseases Society of America President Dr. Paul Auwaerter and HIV Medicine Association Chair Melanie Thompson. “Key infectious disease considerations in the aftermath of a hurricane include access to clean water, medicines and medical supplies; vaccination and hand hygiene, particularly in crowded shelters; vector-borne diseases such as Zika; and mold-related illnesses.”
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Auwaerter and Thompson penned their concerns in a letter to the Congressional Subcommittee on Oversight and Investigations in October, after hurricanes Maria and Irma upended life for so many. The letter was in response to the U.S. Health and Human Services’ “Public Health Preparedness for and Response to the 2017 Hurricane Season” hearing.
Vector-borne diseases, which are transmitted through the bite of an infected arthropod — frequently a mosquito — are of special concern, since standing water is a perfect breeding ground for the insect. But standing, contaminated water itself is also a major source of disease spread, as well. “The big risks are waterborne diseases like typhoid, cholera … leptospirosis and hepatitis” as well as vector-borne diseases, like dengue fever and Zika virus, says Dr. Rajeev Fernando, chief of infectious diseases at Stony Brook Southampton Hospital in Long Island, New York. Working with the Federal Emergency Management Agency and the government of Puerto Rico, he’s been to Puerto Rico twice since Maria hit to assess damage and health risks there.
Residents with open wounds, including injuries sustained in Maria, are also at risk, especially with infrastructure that carries away stormwater run-off and sewage still disrupted and water contaminated. People who have open wounds and who are exposed to this sewage water can sustain very severe skin infections that can get into the bloodstream and be very life-threatening, Fernando says.
But of all the disease threats, the one that seems to have the most significant potential for spread in Puerto Rico is leptospirosis, he says. The bacterial disease, which affects animals and people, can spread in floodwaters contaminated by the urine of an infected animal; it causes fever and liver disease and can be fatal. And a person needn’t have an open wound to contract the disease. “It can actually penetrate intact skin,” Fernando says, noting that rats — which have proliferated in flooded conditions — are spreading it in Puerto Rico. “The rats actually urinate into these contaminated waters.”
Dozens of leptospirosis cases have been confirmed in Puerto Rico since Maria, including at least a couple deaths, as of last month, with other deaths suspected to have been caused by the disease. “The risk of acquiring leptospirosis can be greatly reduced by not swimming or wading in water that might be contaminated with animal urine, or eliminating contact with potentially infected animals,” the Centers for Disease Control and Prevention says on its website. For officials like public health care workers in flooded areas who must do so to reach people in need, Fernando recommends the drug doxycycline as a preventive measure against leptospirosis. The drug may also be used to treat mild cases, though Fernando says the treatment of choice is penicillin.
“Certainly we’ve seen problems with prior hurricanes with leptospirosis,” adds Auwaerter, a professor of medicine at the Johns Hopkins University School of Medicine in Baltimore.
Experts say with so many factors out of residents’ control, the governmental response to disaster — which has been a source of significant criticism — is critical. Restoring infrastructure lays the groundwork for improving access to clean drinking water, turning power on to keep food cold and safe and improving people’s ability to get care and access to medicines to treat and manage routine or ongoing health issues.
“So much of what you see in the aftermath of these crises is very similar to the aftermath you see in a setting like war,” in terms of infrastructure destruction, says Dr. Nahid Bhadelia, infectious diseases physician at Boston Medical Center and director of medical response and infection control at the National Emerging Infectious Diseases Laboratories at Boston University. “All of the sudden, you don’t have access to clean water or electricity. You have a lot of public service institutions that may not be functioning at their full capacity.”
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So advising people to access clean drinking water, isn’t always so simple. “If you don’t have access to clean water, you are now getting water from sources such as streams or standing water that may not be clean,” Bhadelia says. “If people had access to clean drinking water, of course they would drink it.”
For people who don’t have ready access to clean drinking water, experts advise taking other measures like boiling water first. Of course that, too, can be a tall order, Bhadelia points out, when a person needs electricity to power a stove and the power is out.
Similarly, to avoid foodborne illness, like hepatitis A, getting rid of spoiled food and only eating or drinking what’s been properly stored — refrigerated, if recommended — is advised. But for those who are without power and particularly low-income individuals hesitant to throw out food, that can be difficult to follow.
But even and especially amidst these difficult circumstances, public health officials say it’s important for people to take all the steps they can to protect against disease spread. That includes one mainstay in preventing infections everywhere: hand-washing. “Hand hygiene should be stressed,” Fernando says.
What’s more, guarding against seemingly mundane diseases like flu — by getting a flu shot (again, if available and accessible) — is recommended, particularly since many who are displaced come into closer contact with relatives, friends and strangers. Experts say this should be a priority among people who are more vulnerable — like older adults, or those with serious conditions that compromise their health. Getting the vaccine, if possible, is a good idea, especially if that person is living in crowded conditions, Auwaerter says.
People are also advised to use bug spray to keep away mosquitoes that may carry disease. “For protection, especially in homes that may no longer be air conditioned … people can sleep under mosquito nets and/or use insect repellents to reduce the chances of acquiring a mosquito-borne infection,” he says.
Of course, the plethora of potential problems post-Maria is overwhelming in Puerto Rico. “Because Puerto Rico locally manufactures many medications, we are deeply concerned that the severe impact of Hurricane Maria could lead to drug shortages for critical medicines, including for HIV and cancer, exacerbating already troubling antimicrobial drug shortages throughout the country,” Auwaerter and Thompson wrote to the congressional subcommittee. “For people living with HIV, maintaining continuous access to medications is critical to prevent treatment disruptions that could lead to disease progression, life-threatening illness and treatment resistance. When people with HIV have ‘undetectable virus’ while on effective HIV treatments, HIV is not transmitted to others, but access must be continuous to be effective. Therefore interruptions in drug access also are likely to be associated with outbreaks of new HIV infections.”
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That’s something governmental agencies and health providers are trying to avoid. Still, following Maria, many people in Puerto Rico with HIV and other conditions are finding it difficult to get the medicines they need — yet one more storm many are contending with in the aftermath of the hurricane.
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Preventing the Spread of Disease After a Hurricane originally appeared on usnews.com
