Natural Disaster Sites Breed Serious Infections

NAPA, CALIF. – Although the risk of a serious disease outbreak after natural disasters is rare and often exaggerated by the media, it is important to be prepared to respond to patient infections after such an event, according to Dr. Miriam S. Bettencourt of the University of Nevada in Las Vegas.

Some of the conditions patients may present with after natural disasters include bacterial and fungal infections, leptospirosis, measles, dengue fever, trench foot, arthropod bites, and radiation exposure. Dr. Bettencourt described some of the conditions in detail during her presentation at the Coastal Dermatology Symposisum.

Vibrio

After Hurricane Katrina in 2005, there were 18 reported cases of Vibrio-associated illness because of exposure of patients’ wounds to coastal flood waters. The warm seawater of the Atlantic Ocean that flooded the Gulf Coast was the perfect breeding ground for V. vulnificus and V. parahaemolyticus.

Marty Bahamonde/FEMA

Following the rapid onset of illness, V. vulnificus was identified in 82% of the reported cases, and V. parahaemolyticus in the other 18%, said Dr. Bettencourt. The patients were aged 31-89, with the majority being male (83%); five of the patients died. Comorbidities that may have made people more susceptible to infection, such as heart disease and diabetes, were identified in 72% of the patients.

Vibrio infection starts as edema, erythema, and pain, and, if left untreated, can progress to hemorrhagic blisters, necrotizing fasciitis, and sepsis.

If patients must work in conditions such as those present after Hurricane Katrina, they should wear protective clothing to prevent wound exposure to contaminated water. They should also wash all wounds with soap and water after water exposure to reduce the risk of infection.

"Clinicians should be vigilant for Vibrio infection in hurricane evacuee populations, particularly in patients with infected wounds and especially if the patients are in a high-risk group. If V. vulnificus is suspected, antimicrobial therapy should be initiated immediately; prompt treatment can improve survival," noted the Centers for Disease Control and Prevention (MMWR 2005;54;928-31).

Recommended treatments include doxycycline, third-generation cephalosporins (such as intravenous ceftazidime), fluoroquinolones (such as levofloxacin or cyclosporine), and aminoglycosides. Limb amputation is sometimes necessary, according to Dr. Bettencourt.

MRSA

Wounds are at a particular risk of becoming infected with methicillin-resistant Staphylococcus aureus (MRSA) because of conditions that are likely to occur after a natural disaster, such as close skin-to-skin contact with other individuals, use of contaminated items to treat wounds, a lack of cleanliness, and crowded living conditions.

Dr. Bettencourt recommended looking for signs of MRSA in cuts and abrasions and in areas of a patient that are covered by hair, which could easily be missed.

She noted that new Infectious Diseases Society of America treatment guidelines recommend incision and drainage of mature MRSA infections. Antibiotic treatment should be started if the patient is very young, very old, or immunocompromised; if there are signs of severe or extensive disease; if there is a rapid progression to cellulitis; if symptoms of systemic disease are present; if areas for treatment are difficult to drain (face, hands, genitalia); or if patients are unresponsive to drainage.

Recommended antibiotics include clindamycin, trimethoprim/sulfamethoxazole, tetracycline, doxycycline, minocycline, and linezolid. She pointed out that the presence of pus suggests S. aureus infection, while cellulitis without puss suggests group A streptococcus.

For patients with recurrent MRSA, consider nasal decolonization with mupirocin twice a day for 5 days or body decolonization with bleach baths or chlorhexidine. Oral antibiotics can be started if the patient has active lesions, Dr. Bettencourt said. Family members and close contacts of the patient may need to be evaluated and treated, as well.

Leptospirosis

The floods and mud slides that devastated Rio de Janeiro in January were described as the worst weather-related natural disaster ever to hit Brazil, Dr. Bettencourt said.

Animals carrying the bacterial pathogen Leptospira urinated in the flood waters, which humans then drank or subjected their wounds to.

The bacteria causing leptospirosis can survive for several months, she noted, and the incubation period is 2-4 weeks. Symptoms in people include fever, headache, muscle ache, vomiting, jaundice, red eyes, abdominal pain, diarrhea, and rash (common on the legs). If left untreated, the infection can cause kidney and liver failure.

Severe infection requires hospitalization, and about 5% of patients die (Cochrane Database Syst. Rev. 2000;CD001306). High doses of antibiotics are used to treat patients.

The Centers for Disease Control and Prevention has estimated that there are 100-200 cases of leptospirosis each year in the United States, transmitted primarily through rats and dogs. The infection is most likely to occur in men (75%) – in Hawaii (50%), the Southern Atlantic, and in the Gulf and Pacific coastal states – in July through October.

"The largest recorded U.S. outbreak occurred in 1998, when 775 people were exposed to the disease. Of these, 110 became infected," according to the CDC. "Although the incidence in the United States is relatively low, leptospirosis is considered to be the most widespread zoonotic disease in the world."

Mycobacteria

After the tsunami in Thailand in 2004, 15 people who had crush traumatic injuries developed rapid-growing mycobacterial infections 20-105 days after the tsunami in undamaged skin near sutured wounds. Seven of the infections were from the organism Mycobacterium abscessus, six were from M. fortuitum, one was from M. peregrinum, and the last was from M. mageritense.

All of the patients were treated and free of infection after 12 months.

Mucormycosis

Mucormycosis (also known as zygomycosis) is a rare fungal infection that results from the fungi group Mucoromycotina found in the soil of decaying organic matter. In hospitals, infection is associated with the use of contaminated materials or organ transplantation and carries a mortality rate of 30%-80%, Dr. Bettencourt noted.

There was an outbreak of the rare infection in May, in Joplin, Mo., 12 days after a tornado plowed through the community causing mass destruction. The infection penetrated the open wounds of hospitalized tornado victims, resulting in five deaths. Contaminated tongue dispensers were the vector of transmission.

The first two patients diagnosed with mucormycosis presented with a necrotizing soft tissue fungal infection. Eighteen cases were suspected, with 13 confirmed. None of the patients with the infection were immunocompromised, but two had diabetes. No additional cases were reported after June 17.

Mucormycosis can take many clinical forms, including rhinocerebral, pulmonary, gastrointestinal, cutaneous, and disseminated (most commonly in the brain). The fungi move aggressively into the bloodstream, causing everything from sinus pain and fever to black pus drainage from the eyes and cutaneous necrosis, she reported.

Coccidiomycosis

Coccidiomycosis, also known as valley fever, is a fungus found in the soil of arid areas. Inhalation of conidia from dust stirred up by human activity or a natural disaster can cause infection, said Dr. Bettencourt.

California, Arizona, Nevada, New Mexico, Texas, and Utah are U.S. endemic areas, where 10%-50% of the population will have evidence of exposure to Coccidioides species, according to the CDC.

An earthquake was the cause of the 1994 outbreak of coccidiomycosis in Northridge, Calif., where 203 cases of infection and 3 deaths were reported (JAMA 1997;277:904-8).

Symptoms of acute infection are flulike, occurring 1-3 weeks after exposure, with fever, cough, headache, rash, and muscle ache being the most common events. However, 60% of infected individuals will have no symptoms. Severe infection can cause lung problems, meningitis, skin ulcers, and bone and joint infection, but most patients make a full recovery, Dr. Bettencourt noted. Chronic pulmonary coccidioidomycosis may develop 20 years or more after infection.

Disseminated infection can spread to the skin, brain, bones, and heart. Some of the symptoms of disseminated skin infection are nodules, papules, plaques, furuncles, abscesses, and ulcers. Erythema nodosum is the most common skin presentation, she said.

Other natural disaster–related disease outbreaks include measles. Thirty-five cases were reported after the 2004 tsunami in Indonesia, and 400 cases were reported after the 2005 earthquake in Pakistan. "Malaria outbreaks are directly associated with flooding, while dengue transmission is influenced by rainfall and humidity, but is not directly associated with flooding," reported Dr. Bettencourt. Tetanus, hepatitis, and diarrhea from cholera and salmonella also can affect people after natural disasters.

Dr. Bettencourt reported being on the speakers bureaus of PharmaDerm and Graceway and conducting clinical trials for 3M Pharmaceuticals.

NAPA, CALIF. – Although the risk of a serious disease outbreak after natural disasters is rare and often exaggerated by the media, it is important to be prepared to respond to patient infections after such an event, according to Dr. Miriam S. Bettencourt of the University of Nevada in Las Vegas.

Some of the conditions patients may present with after natural disasters include bacterial and fungal infections, leptospirosis, measles, dengue fever, trench foot, arthropod bites, and radiation exposure. Dr. Bettencourt described some of the conditions in detail during her presentation at the Coastal Dermatology Symposisum.

Vibrio

After Hurricane Katrina in 2005, there were 18 reported cases of Vibrio-associated illness because of exposure of patients’ wounds to coastal flood waters. The warm seawater of the Atlantic Ocean that flooded the Gulf Coast was the perfect breeding ground for V. vulnificus and V. parahaemolyticus.

Marty Bahamonde/FEMA

Following the rapid onset of illness, V. vulnificus was identified in 82% of the reported cases, and V. parahaemolyticus in the other 18%, said Dr. Bettencourt. The patients were aged 31-89, with the majority being male (83%); five of the patients died. Comorbidities that may have made people more susceptible to infection, such as heart disease and diabetes, were identified in 72% of the patients.

Vibrio infection starts as edema, erythema, and pain, and, if left untreated, can progress to hemorrhagic blisters, necrotizing fasciitis, and sepsis.

If patients must work in conditions such as those present after Hurricane Katrina, they should wear protective clothing to prevent wound exposure to contaminated water. They should also wash all wounds with soap and water after water exposure to reduce the risk of infection.

"Clinicians should be vigilant for Vibrio infection in hurricane evacuee populations, particularly in patients with infected wounds and especially if the patients are in a high-risk group. If V. vulnificus is suspected, antimicrobial therapy should be initiated immediately; prompt treatment can improve survival," noted the Centers for Disease Control and Prevention (MMWR 2005;54;928-31).

Recommended treatments include doxycycline, third-generation cephalosporins (such as intravenous ceftazidime), fluoroquinolones (such as levofloxacin or cyclosporine), and aminoglycosides. Limb amputation is sometimes necessary, according to Dr. Bettencourt.

MRSA

Wounds are at a particular risk of becoming infected with methicillin-resistant Staphylococcus aureus (MRSA) because of conditions that are likely to occur after a natural disaster, such as close skin-to-skin contact with other individuals, use of contaminated items to treat wounds, a lack of cleanliness, and crowded living conditions.

Dr. Bettencourt recommended looking for signs of MRSA in cuts and abrasions and in areas of a patient that are covered by hair, which could easily be missed.

She noted that new Infectious Diseases Society of America treatment guidelines recommend incision and drainage of mature MRSA infections. Antibiotic treatment should be started if the patient is very young, very old, or immunocompromised; if there are signs of severe or extensive disease; if there is a rapid progression to cellulitis; if symptoms of systemic disease are present; if areas for treatment are difficult to drain (face, hands, genitalia); or if patients are unresponsive to drainage.

Recommended antibiotics include clindamycin, trimethoprim/sulfamethoxazole, tetracycline, doxycycline, minocycline, and linezolid. She pointed out that the presence of pus suggests S. aureus infection, while cellulitis without puss suggests group A streptococcus.

For patients with recurrent MRSA, consider nasal decolonization with mupirocin twice a day for 5 days or body decolonization with bleach baths or chlorhexidine. Oral antibiotics can be started if the patient has active lesions, Dr. Bettencourt said. Family members and close contacts of the patient may need to be evaluated and treated, as well.

Leptospirosis

The floods and mud slides that devastated Rio de Janeiro in January were described as the worst weather-related natural disaster ever to hit Brazil, Dr. Bettencourt said.

Animals carrying the bacterial pathogen Leptospira urinated in the flood waters, which humans then drank or subjected their wounds to.

The bacteria causing leptospirosis can survive for several months, she noted, and the incubation period is 2-4 weeks. Symptoms in people include fever, headache, muscle ache, vomiting, jaundice, red eyes, abdominal pain, diarrhea, and rash (common on the legs). If left untreated, the infection can cause kidney and liver failure.

Severe infection requires hospitalization, and about 5% of patients die (Cochrane Database Syst. Rev. 2000;CD001306). High doses of antibiotics are used to treat patients.

The Centers for Disease Control and Prevention has estimated that there are 100-200 cases of leptospirosis each year in the United States, transmitted primarily through rats and dogs. The infection is most likely to occur in men (75%) – in Hawaii (50%), the Southern Atlantic, and in the Gulf and Pacific coastal states – in July through October.

"The largest recorded U.S. outbreak occurred in 1998, when 775 people were exposed to the disease. Of these, 110 became infected," according to the CDC. "Although the incidence in the United States is relatively low, leptospirosis is considered to be the most widespread zoonotic disease in the world."

Mycobacteria

After the tsunami in Thailand in 2004, 15 people who had crush traumatic injuries developed rapid-growing mycobacterial infections 20-105 days after the tsunami in undamaged skin near sutured wounds. Seven of the infections were from the organism Mycobacterium abscessus, six were from M. fortuitum, one was from M. peregrinum, and the last was from M. mageritense.

All of the patients were treated and free of infection after 12 months.

Mucormycosis

Mucormycosis (also known as zygomycosis) is a rare fungal infection that results from the fungi group Mucoromycotina found in the soil of decaying organic matter. In hospitals, infection is associated with the use of contaminated materials or organ transplantation and carries a mortality rate of 30%-80%, Dr. Bettencourt noted.

There was an outbreak of the rare infection in May, in Joplin, Mo., 12 days after a tornado plowed through the community causing mass destruction. The infection penetrated the open wounds of hospitalized tornado victims, resulting in five deaths. Contaminated tongue dispensers were the vector of transmission.

The first two patients diagnosed with mucormycosis presented with a necrotizing soft tissue fungal infection. Eighteen cases were suspected, with 13 confirmed. None of the patients with the infection were immunocompromised, but two had diabetes. No additional cases were reported after June 17.

Mucormycosis can take many clinical forms, including rhinocerebral, pulmonary, gastrointestinal, cutaneous, and disseminated (most commonly in the brain). The fungi move aggressively into the bloodstream, causing everything from sinus pain and fever to black pus drainage from the eyes and cutaneous necrosis, she reported.

Coccidiomycosis

Coccidiomycosis, also known as valley fever, is a fungus found in the soil of arid areas. Inhalation of conidia from dust stirred up by human activity or a natural disaster can cause infection, said Dr. Bettencourt.

California, Arizona, Nevada, New Mexico, Texas, and Utah are U.S. endemic areas, where 10%-50% of the population will have evidence of exposure to Coccidioides species, according to the CDC.

An earthquake was the cause of the 1994 outbreak of coccidiomycosis in Northridge, Calif., where 203 cases of infection and 3 deaths were reported (JAMA 1997;277:904-8).

Symptoms of acute infection are flulike, occurring 1-3 weeks after exposure, with fever, cough, headache, rash, and muscle ache being the most common events. However, 60% of infected individuals will have no symptoms. Severe infection can cause lung problems, meningitis, skin ulcers, and bone and joint infection, but most patients make a full recovery, Dr. Bettencourt noted. Chronic pulmonary coccidioidomycosis may develop 20 years or more after infection.

Disseminated infection can spread to the skin, brain, bones, and heart. Some of the symptoms of disseminated skin infection are nodules, papules, plaques, furuncles, abscesses, and ulcers. Erythema nodosum is the most common skin presentation, she said.

Other natural disaster–related disease outbreaks include measles. Thirty-five cases were reported after the 2004 tsunami in Indonesia, and 400 cases were reported after the 2005 earthquake in Pakistan. "Malaria outbreaks are directly associated with flooding, while dengue transmission is influenced by rainfall and humidity, but is not directly associated with flooding," reported Dr. Bettencourt. Tetanus, hepatitis, and diarrhea from cholera and salmonella also can affect people after natural disasters.

Dr. Bettencourt reported being on the speakers bureaus of PharmaDerm and Graceway and conducting clinical trials for 3M Pharmaceuticals.

NAPA, CALIF. – Although the risk of a serious disease outbreak after natural disasters is rare and often exaggerated by the media, it is important to be prepared to respond to patient infections after such an event, according to Dr. Miriam S. Bettencourt of the University of Nevada in Las Vegas.

Some of the conditions patients may present with after natural disasters include bacterial and fungal infections, leptospirosis, measles, dengue fever, trench foot, arthropod bites, and radiation exposure. Dr. Bettencourt described some of the conditions in detail during her presentation at the Coastal Dermatology Symposisum.

Vibrio

After Hurricane Katrina in 2005, there were 18 reported cases of Vibrio-associated illness because of exposure of patients’ wounds to coastal flood waters. The warm seawater of the Atlantic Ocean that flooded the Gulf Coast was the perfect breeding ground for V. vulnificus and V. parahaemolyticus.

Marty Bahamonde/FEMA

Following the rapid onset of illness, V. vulnificus was identified in 82% of the reported cases, and V. parahaemolyticus in the other 18%, said Dr. Bettencourt. The patients were aged 31-89, with the majority being male (83%); five of the patients died. Comorbidities that may have made people more susceptible to infection, such as heart disease and diabetes, were identified in 72% of the patients.

Vibrio infection starts as edema, erythema, and pain, and, if left untreated, can progress to hemorrhagic blisters, necrotizing fasciitis, and sepsis.

If patients must work in conditions such as those present after Hurricane Katrina, they should wear protective clothing to prevent wound exposure to contaminated water. They should also wash all wounds with soap and water after water exposure to reduce the risk of infection.

"Clinicians should be vigilant for Vibrio infection in hurricane evacuee populations, particularly in patients with infected wounds and especially if the patients are in a high-risk group. If V. vulnificus is suspected, antimicrobial therapy should be initiated immediately; prompt treatment can improve survival," noted the Centers for Disease Control and Prevention (MMWR 2005;54;928-31).

Recommended treatments include doxycycline, third-generation cephalosporins (such as intravenous ceftazidime), fluoroquinolones (such as levofloxacin or cyclosporine), and aminoglycosides. Limb amputation is sometimes necessary, according to Dr. Bettencourt.

MRSA

Wounds are at a particular risk of becoming infected with methicillin-resistant Staphylococcus aureus (MRSA) because of conditions that are likely to occur after a natural disaster, such as close skin-to-skin contact with other individuals, use of contaminated items to treat wounds, a lack of cleanliness, and crowded living conditions.

Dr. Bettencourt recommended looking for signs of MRSA in cuts and abrasions and in areas of a patient that are covered by hair, which could easily be missed.

She noted that new Infectious Diseases Society of America treatment guidelines recommend incision and drainage of mature MRSA infections. Antibiotic treatment should be started if the patient is very young, very old, or immunocompromised; if there are signs of severe or extensive disease; if there is a rapid progression to cellulitis; if symptoms of systemic disease are present; if areas for treatment are difficult to drain (face, hands, genitalia); or if patients are unresponsive to drainage.

Recommended antibiotics include clindamycin, trimethoprim/sulfamethoxazole, tetracycline, doxycycline, minocycline, and linezolid. She pointed out that the presence of pus suggests S. aureus infection, while cellulitis without puss suggests group A streptococcus.

For patients with recurrent MRSA, consider nasal decolonization with mupirocin twice a day for 5 days or body decolonization with bleach baths or chlorhexidine. Oral antibiotics can be started if the patient has active lesions, Dr. Bettencourt said. Family members and close contacts of the patient may need to be evaluated and treated, as well.

Leptospirosis

The floods and mud slides that devastated Rio de Janeiro in January were described as the worst weather-related natural disaster ever to hit Brazil, Dr. Bettencourt said.

Animals carrying the bacterial pathogen Leptospira urinated in the flood waters, which humans then drank or subjected their wounds to.

The bacteria causing leptospirosis can survive for several months, she noted, and the incubation period is 2-4 weeks. Symptoms in people include fever, headache, muscle ache, vomiting, jaundice, red eyes, abdominal pain, diarrhea, and rash (common on the legs). If left untreated, the infection can cause kidney and liver failure.

Severe infection requires hospitalization, and about 5% of patients die (Cochrane Database Syst. Rev. 2000;CD001306). High doses of antibiotics are used to treat patients.

The Centers for Disease Control and Prevention has estimated that there are 100-200 cases of leptospirosis each year in the United States, transmitted primarily through rats and dogs. The infection is most likely to occur in men (75%) – in Hawaii (50%), the Southern Atlantic, and in the Gulf and Pacific coastal states – in July through October.

"The largest recorded U.S. outbreak occurred in 1998, when 775 people were exposed to the disease. Of these, 110 became infected," according to the CDC. "Although the incidence in the United States is relatively low, leptospirosis is considered to be the most widespread zoonotic disease in the world."

Mycobacteria

After the tsunami in Thailand in 2004, 15 people who had crush traumatic injuries developed rapid-growing mycobacterial infections 20-105 days after the tsunami in undamaged skin near sutured wounds. Seven of the infections were from the organism Mycobacterium abscessus, six were from M. fortuitum, one was from M. peregrinum, and the last was from M. mageritense.

All of the patients were treated and free of infection after 12 months.

Mucormycosis

Mucormycosis (also known as zygomycosis) is a rare fungal infection that results from the fungi group Mucoromycotina found in the soil of decaying organic matter. In hospitals, infection is associated with the use of contaminated materials or organ transplantation and carries a mortality rate of 30%-80%, Dr. Bettencourt noted.

There was an outbreak of the rare infection in May, in Joplin, Mo., 12 days after a tornado plowed through the community causing mass destruction. The infection penetrated the open wounds of hospitalized tornado victims, resulting in five deaths. Contaminated tongue dispensers were the vector of transmission.

The first two patients diagnosed with mucormycosis presented with a necrotizing soft tissue fungal infection. Eighteen cases were suspected, with 13 confirmed. None of the patients with the infection were immunocompromised, but two had diabetes. No additional cases were reported after June 17.

Mucormycosis can take many clinical forms, including rhinocerebral, pulmonary, gastrointestinal, cutaneous, and disseminated (most commonly in the brain). The fungi move aggressively into the bloodstream, causing everything from sinus pain and fever to black pus drainage from the eyes and cutaneous necrosis, she reported.

Coccidiomycosis

Coccidiomycosis, also known as valley fever, is a fungus found in the soil of arid areas. Inhalation of conidia from dust stirred up by human activity or a natural disaster can cause infection, said Dr. Bettencourt.

California, Arizona, Nevada, New Mexico, Texas, and Utah are U.S. endemic areas, where 10%-50% of the population will have evidence of exposure to Coccidioides species, according to the CDC.

An earthquake was the cause of the 1994 outbreak of coccidiomycosis in Northridge, Calif., where 203 cases of infection and 3 deaths were reported (JAMA 1997;277:904-8).

Symptoms of acute infection are flulike, occurring 1-3 weeks after exposure, with fever, cough, headache, rash, and muscle ache being the most common events. However, 60% of infected individuals will have no symptoms. Severe infection can cause lung problems, meningitis, skin ulcers, and bone and joint infection, but most patients make a full recovery, Dr. Bettencourt noted. Chronic pulmonary coccidioidomycosis may develop 20 years or more after infection.

Disseminated infection can spread to the skin, brain, bones, and heart. Some of the symptoms of disseminated skin infection are nodules, papules, plaques, furuncles, abscesses, and ulcers. Erythema nodosum is the most common skin presentation, she said.

Other natural disaster–related disease outbreaks include measles. Thirty-five cases were reported after the 2004 tsunami in Indonesia, and 400 cases were reported after the 2005 earthquake in Pakistan. "Malaria outbreaks are directly associated with flooding, while dengue transmission is influenced by rainfall and humidity, but is not directly associated with flooding," reported Dr. Bettencourt. Tetanus, hepatitis, and diarrhea from cholera and salmonella also can affect people after natural disasters.

Dr. Bettencourt reported being on the speakers bureaus of PharmaDerm and Graceway and conducting clinical trials for 3M Pharmaceuticals.