Clinical Microbiology Newsletter 29:8,2007 2007 Elsevier 0196-4399/00 (see frontmatter) 57

Hurricanes, flooding, earthquakes,tornados, tsunamis, and drought aretypes of natural disasters that can con-tribute to the transmission of someinfectious agents. The World HealthOrganization (WHO) lists diarrhea,acute respiratory infection, measles,malnutrition, and malaria in areas ofendemicity as the most common causesof death in a disaster (1). Because infec-tious disease accounts for four of thefive listed causes, the possibility of anoutbreak or disaster-related infection ishighest in the days and weeks followinga natural disaster (2). The impact ofsuch infectious diseases is dependent on the type of disaster and the publichealth infrastructure and disease sur-veillance available (3). It should benoted that an infectious agent can betransmitted only if that agent is presentin the environment where the naturaldisaster occurred.

Several factors can facilitate thespread of microorganisms during anatural disaster. One such factor is

the disruption of the public water andsewage systems. In some instances, thepublic water may become contaminatedwith sewage, resulting in water-borneand food-borne illnesses. Crowdedliving conditions as a result of largenumbers of evacuees being placed intemporary shelters also contribute to thespread of infectious diseases. Althoughpreventive measures, such as cot place-ment, can be used to reduce the risk of airborne transmission of certain dis-eases, it is often difficult to keep theevacuees from congregating, whichallows airborne transmission to occur.The presence of nave populations orlack of adequate immunizations maycontribute to the spread of disease. Per-sonal hygiene may become compromisedas a result of crowded living conditionsand/or contamination of the publicwater supply. There may also be a risein injury-related infections as a result ofexposure to storm debris. Public healthmeasures, like tuberculosis control,immunization programs, and prenatalcare, may be disturbed in the aftermathof a disaster. These factors allow naturaldisasters to serve as a microbes paradisein which there can be an increased rateof infectious diseases.

This article will focus on reportableinfectious diseases associated withnatural disaster and on preventive

measures and laboratory diagnostictests for detection of less commonlyisolated infectious agents. Strategies for hospital evacuations and operationof a laboratory and/or hospital during a natural disaster are topics too broad to address here.

DroughtsThere have been a few instances of

drought-induced amplification of SaintLouis encephalitis virus and West Nilevirus, which occurred in Florida (4,5).During drought conditions, the mos-quito vectors and avian population areforced to an area where limited watersupplies can be found. Thus, an ampli-fication of the virus occurs as a result of the number of mosquito vectors andavian hosts available in a small con-fined area. Once the drought conditionsare over, both the infected mosquitovectors and avian hosts migrate to other

Natural Disasters a Microbes ParadiseAndrea J. Linscott, Ph.D., D(ABMM), Louisiana State University Health Science Center Shreveport, Department of Pathology,Shreveport, Louisiana

AbstractNatural disasters can serve as a microbes paradise. Various infectious diseases have been reported as a result of flooding,

hurricanes, earthquakes, tsunamis, tornadoes, and droughts. Crowded living conditions, disruption in water supplies, and downedelectrical services due to disasters can contribute to the spread of infectious agents. This article will focus on the occurrence ofinfectious diseases associated with natural disasters.

Vol. 29, No. 8 www.cmnewsletter.com April 15, 2007

Mailing address: Andrea J. Linscott, Ph.D.,D(ABMM), Louisiana State UniversityHealth Science Center Shreveport,Department of Pathology, 1501 KingsHighway, Shreveport, LA 73110. Tel.: 318-675-8662. Fax: 318-675-7662. E-mail: alinsc@lsuhsc.edu

ClinicalMicrobiologyNewsletter

regions, where the viruses can be spreadto other avian hosts or accidental hosts,such as horses or humans.

Drought conditions related to an El Nio phenomenon resulted in morethan 550 deaths due to malaria in IrianJaya, Indonesia (6). The drought condi-tions caused numerous transient poolsof standing water in streams that nor-mally held fast-moving water. Thestanding water facilitated an increase in the infected-mosquito population,providing an increased opportunity for transmission of Plasmodium spp.to humans.

EarthquakesInfections related to earthquakes can

occur from a variety of events, such asfalling debris, trauma inoculation bydebris, or from the disruption of soil asa result of the earthquake. In 1994, therewas a coccidioidomycosis outbreak fol-lowing the Northridge, California, mag-nitude 6.7 earthquake (7). The infectiousarthroconidia of Coccidioides immitiswere dispersed via large dust cloudsgenerated by landslides triggered by the earthquake. Cases of C. immitisinfection in the Simi Valley peaked 2weeks after the earthquake. Schneideret. al (7) reported that contact with adust cloud and the duration of exposureto a dust cloud significantly increasedthe likelihood of developing acute coc-cidioidomycosis (7).

In the Marmara region of Turkey, amagnitude 7.4 earthquake occurred in1997. An account of the medical experi-ence of a university hospital reportedthat an infection rate of 25.8% (76patients of the 295 screened) was seenin earthquake-related hospitalizations(8). The most common types of infec-tion were deep surgical wound infec-tions and bacteremia, at 33% and 20%,respectively (8). Pseudomonas aerugi-nosa, Acinetobacter baumanii, methi-

cillin-resistant Staphylococcus aureus,and Candida spp. were the organismsmost often recovered (8). The authorsnoted that the frequency of infectiouscomplications was highest followingthe first week after the earthquake (8).

Kazancioglu et al. (9) characterizedthe infections their institution investi-gated in the Marmara earthquake. Atotal of 112 bacteriological sampleswere collected, with 45.5% (51/112) of isolates recovered from wounds (9).The most common wound organismswere Acinetobacter spp. and P. aerugi-nosa, at 45% and 22%, respectively (9).

In another article related to theMarmara earthquake and a subsequentearthquake 3 months later, also in thenorthwest region of Turkey, the authorslooked at the parasitic infection ratesassociated with post-earthquake livingconditions. ztrk et al. (10), reportedthat the rates of Giardia lamblia andEnterobius vermicularis infections weresignificantly higher in children whowere living and attending school intemporary housing in the aftermath ofthe earthquake. Risk factors associatedwith the transmission of these parasiticagents included the number of commu-nal toilets per child at school, socioeco-nomic level, size of the classroom, andthe frequency of hand washing (10).

An infectious-disease surveillancestudy conducted after the 1999 earth-quake in Kocaeli, Turkey, which killedmore than 16,000 people and left500,000 homeless, saw an increase indiarrheal illness. Only 8% of the stoolsamples were culture positive for bacte-rial pathogens, with Shigella spp. beingthe most frequently isolated organisms at 4.9% (11). No cultures or assays forviral detection were performed. An inter-esting aspect was that multiple clonesof Shigella were seen in different areasof the region.

FloodingFlooding is the most common cause

of natural disaster and is estimated toaccount for 40% of all natural disasters(12). Water-borne diseases (typhoidfever, cholera, leptospirosis, and hep-atitis A) and vector-borne diseases(malaria, yellow fever, West Nile fever,dengue and dengue hemorrhagic fever)are communicable diseases that can allbe transmitted during flooding (13).There is an increased risk of infectionwhen an individual has direct contactwith contaminated water. Often theseindividuals will present with diarrhealillness, dermatitis, conjunctivitis, orwound, ear, or throat infections. Depend-ing on the type, infections may show up immediately or during the clean-upphase of the disaster.

Leptospirosis, a zoonotic disease,has frequently been reported duringfloods. A few of the reported outbreaksof leptospirosis related to flooding were located in Hawaii, Puerto Rico,Nicaragua, and India (14-17). Lepto-spira is shed in the urine of wild anddomestic animals, and leptospirosis isconsidered the most common zoonoticdisease worldwide (14). The animalsmost frequently infected with the orga-nism include rodents, dogs, pigs, andcattle. As a result of flooding, there isoften an increase in the rodent popula-tion, which shed large amounts of lep-tospires in their urine. The organismcan then be transmitted to humans whenskin or mucous membranes come incontact with water contaminated withanimal urine. These individuals maypresent with fever, chills, myalgia,nausea, diarrhea, cough, and/or con-junctivitis. Jaundice, renal failure,hemorrhage, and pneumonia can beseen in severe cases. An unusual find-ing in the Nicaragua outbreak was theclinical presentation of hemorrhagic

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pneumonia, causing 15 deaths (16).During periods of flooding, leptospiro-sis should be part of the differentialdiagnosis of patients presenting withfebrile illness when the organism isendemic to the flood area.

The laboratory gold standard fordiagnosis is the microagglutination testfor antibody conversion, which is onlyavailable through a reference laboratoryor public health laboratory. Dark-fieldexamination of urine for leptospires andIgM enzyme-linked immunoassays areused 14 to 21 days after symptoms pre-sent. These tests are most useful duringsuspected outbreak situations in coun-tries where leptospirosis is endemic (17).

A sewer pipe was damaged andcontaminated the public water supplyduring a flood related to Utahs springthaw, which resulted in an upsurge ofgiardia infection cases (18). Similarly,an outbreak of giardiasis was associatedwith heavy water runoff due to warmweather and volcanic ashfall in Montana(19). In both reports, Giardia lambliawas the pathogen identified from theindividuals presenting with diarrhealillness, cramping, abdominal pain,nausea, fever, and vomiting.

Vibrio cholerae infection is the mostfrequent flood-related diarrheal illnessseen in Bangladesh (20,21). The O1 sero-group and El Tor biotype of V. choleraewere the most frequent isolates in astudy of diarrheal epidemics during theDhaka, Bangladesh, floods of 1988,1998, and 2004 (20). Qadri et al. (21)reported the occurrence of both entero-toxigenic Escherichia coli (ETEC) andV. cholerae diarrhea in the Bangladeshflood of 2004. ETEC was noted to bethe most common bacterial pathogenisolated from pediatric patients

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required surgical management. Threepatients developed a sepsis syndromeduring the first four post-trauma days.The organisms isolated from blood,wound, and respiratory samples wereSerratia marcescens, P. aeruginosa,Alcaligenes spp., and/or Enterococcusspp.

TsunamisTsunamis were not a natural disaster

that readily came to mind, until a mag-nitude 9.0 quake occurred near theIndonesian island of Sumatra in 2004.With the disruption of the ocean floor, a massive tsunami, or tidal wave, sweptover the costal regions of Indonesia,Thailand, Sri Lanka, India, Bangladesh,Myanmar, and Malaysia, killing morethan 100,000 people and injuring count-less more. Infections associated withthe tidal wave included traumatic woundinfections and aspiration pneumonia dueto the inhalation of soil-contaminatedsaltwater.

A report on skin and soft tissueinfections among tsunami survivors inSouthern Thailand stated that 70% ofwound infections were polymicrobic(39). In 41% of the cases, two organ-isms were recovered per specimen, and24% of the specimens had three organ-isms recovered (39). Only 28% of thewound infections grew a single organism(39). Of the 641 organisms identified,the most prominent were Aeromonasspp. (23%), Escherichia coli (18%),Klebsiella pneumoniae (15%) and P.aeruginosa (12%) (39). Kallman et al.(40) reported that their clinical micro-biology laboratory observed moregram-negative isolates from the secre-tions of tsunami survivors returning toStockholm than what was typically seenin their general population. The authorsalso noted that some of these organismswere resistant to all licensed antibiotics.Gram-negative organisms, often morethan one type, were recovered fromsecretions in 98 of 209 patients, with P. aeruginosa, Proteus spp., E. coli,Klebsiella spp., and Aeromonas spp.being the most commonly isolated (40).

Burkholderia pseudomallei, anorganism endemic in Southeast Asia,Central and South America, and north-ern Australia, was also reported in asso-ciation with the tsunami. The clinicalpresentation with B. pseudomallei mayrange from skin infections to melioido-

sis, in which sepsis, pneumonia, andsecondary abscesses may be present. B.pseudomallei was recovered from threeFinnish tourists visiting the southwestcoast of Thailand, two of which wererecovered from wound cultures collectedupon their return to Finland (41). Thethird tourist, a 47-year-old male whowas treated for superficial wounds whilein Thailand, was febrile upon arrivalhome and was admitted for suspectedaspiration pneumonia. B. pseudomalleiwas isolated from blood and woundcultures. Six other cases of melioidosiswere reported in tsunami survivorsreturning to Southern Thailand, an areawhere B. pseudomallei is not endemic(42). All six patients presented withpneumonia, and three of the six hadwound infections (42). A serologic studywas performed in which an increasedincidence of B. pseudomallei antibodyin tsunami survivors and residents wasshown (43). The authors concluded thatclinical vigilance for new cases wouldbe necessary to detect cases of melioi-dosis that occur later due to a prolongedincubation period associated with thatdisease (43).

Other unusual infections werereported in tourists returning home afterthe tsunami. Apophysomyces eleganswas recovered from the chest wall anddeltoid abrasion of a previously healthy56-year-old Australian man, who had abeach hut collapse on him and had topush through the debris to escape (44).Aeromonas hydrophila, P. aeruginosa,Achromobacter spp., and methicillin-resistant S. aureus were also recoveredfrom the mans wounds (44). Two Swisstourists were treated for severe atypicalinfections upon their return home. OneSwiss tourist presented with polymicro-bial aspiration pneumonia; the patientlater grew Scedosporium apiospermumfrom paravertebral specimens (45). Thesecond Swiss tourist presented withdeep cutaneous wounds on the legs andmultiple pelvic fractures. The woundswere characterized as polymicrobial.Nocardia africanum was recoveredfrom a thigh abscess 2 weeks afteradmission. Eight weeks later, S. apio-spermum was isolated from an intrac-erebral abscess, and 3 months later,Mycobacterium chelonae was isolatedfrom an open wound of the leg (45).Cladophialophora bantiana and Myco-bacterium abscessus isolates were

recovered from soft tissue infections in two additional Swedish tourists (46).Clearly, the effects of tsunamis providethe best, or perhaps worst, that naturaldisasters have to offer in terms of a sec-ond wave of destruction due to infec-tious disease. Rapid response and activedisease surveillance are critical parts ofevery diaster recovery effort and havethe potential to significantly decreasemortality rates. The remainder of thisarticle is dedicated to a discussion ofprevention and interventional measuresessential to the revitalization of commu-nities and countries following a naturaldisaster.

Preventive MeasuresPreventive measures against the

transmission of infectious agents relatedto natural disasters most often involvepreventing waterborne or food-borneinfections. The WHO has listed five keypoints to improve the safety of food inregions hit by disasters (47): (i) Keepclean by washing your hands with soapand water, avoid preparing food directlyin areas surrounded by flood water, cleansurfaces before food preparation, keeppersons with gastrointestinal symptomsaway from food preparation areas, keepkitchen and toilet areas separate, andavoid eating food raw; (ii) separate raw and cooked food; (iii) cook foodthoroughly; (iv) keep food at safe tem-peratures by eating cooked food imme-diately and not leaving cooked food out at room temperature for more than 2 hours, keeping food hot (more than60C), and throwing away cooked andperishable foods that cannot be refrig-erated; and (v) use safe water.

Appropriate protective clothingshould be worn during the rescue and/or clean-up phase. Gloves, boots, long-sleeve shirts, and pants should be worn.Wounds should be cleaned with soapand water. Medical attention should be sought for serious wounds. Personsinvolved with rescue efforts or those living in evacuee shelters may requireimmunizations. An excellent source ofinformation on interim health recom-mendations for relief workers can befound on the CDC website (48).

Mosquito abatement may be neededin order to prevent the spread of variousdiseases as a result of an increasedpopulation of mosquitoes following anatural disaster. This action will be

Clinical Microbiology Newsletter 29:8,2007 2007 Elsevier 0196-4399/00 (see frontmatter) 61

dependent on the disaster location andthe public health infrastructure available.

Authors Note. I presented a talk onNatural disasters a microbes par-adise at the Hyatt in New Orleans 4days before Hurricane Katrina hit. Myhusband, who is in law enforcement,was sent to New Orleans the day afterHurricane Katrina struck to aid in res-cue effects and to provide police pro-tection. I didnt realize how timely this talk would be when I gave it.

The transmission of an infectiousagent can occur only if that organism is endemic to the area in which the disaster occurred. However, clinicalmicrobiology laboratories may recoverorganisms rarely or never encounteredin their patient population as disastervictims or relief/rescue workers seekmedical attention once they have returnedto their home country. Clinicians willneed to obtain an adequate travel his-tory and ensure that the patients travelinformation reaches the clinical micro-biology laboratory. It is important thatclinical laboratory scientists rememberthat many of the patients specimenswill have multiple organisms recovered.An open dialogue with the disaster vic-tims clinician is necessary to properlyevaluate patient specimens.

It is essential to detect any water-borne or food-borne diseases as early as possible to prompt an investigationand determine the cause and infectiousagent, as well as to coordinate efforts tostop the spread of that infectious agent.Surveillance of persons visiting clinicsor medical facilities, reports from phar-macists of increased demand for anti-diarrheal agents, or higher incidence of absenteeism from work or school are factors which may indicate anoutbreak of some infectious agent.

Hurricane Katrina should serve toremind us that natural disasters can takeplace anywhere and infectious diseasescan occur following a natural disastereven in industrialized countries. As clin-ical microbiologists, we should educatethe general public regarding the mecha-nisms by which infections occur andwhat should be done to prevent andprotect ourselves from the wide varietyof infectious diseases that may presentthemselves following a natural disaster.

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Natural Disasters a Microbes ParadiseDroughtsEarthquakesFloodingHurricanesTornadoesTsunamisPreventive MeasuresReferences