In the Aftermath: Post-Hurricane Infections

According to the National Hurricane Center, September 10 marks the peak of the Atlantic hurricane season, with the peak of the Pacific season occurring in late August.¹ These tropical cyclones have made a significant impact on the United States, with an average of 22.8 billion dollars per event. September 28 marks 1 year since Hurricane Ian made landfall in the southwest coast of Florida, and was ranked as the costliest disaster in the US in 2022, with costs estimated over 100 billion dollars.²

The economic impact, however, is only the tip of the iceberg (or the eye of the hurricane, if you will). There are numerous immediate and downstream impacts of natural disasters, especially those that involve significant exposures to contaminated food and water.³

An increase in infectious diseases such as gastrointestinal illness, skin and soft tissue infections, and respiratory illnesses (bacterial and fungal) have been reported after major hurricanes. Vector-borne diseases such as West Nile virus and Dengue fever can be transmitted through mosquitos, which thrive in the post hurricane environment due to standing flood waters and warm climates. Significant rain and flood waters will alter the microbial make up of the environment, and can come into direct contact with individuals affected by the disaster. Additionally, lack of access to clean and running water and lack of electricity contribute to the risk of exposure to contaminated food and water.⁴

Figure 1. Hurricanes can create environments where bacterial infections thrive, so people living in these areas need to take precautions to be aware of such circumstances. ⁴

Skin and soft tissue infections arise through direct exposures to bacteria through flood waters, which often contain ocean runoff, soil microbes, and sewage overflow.⁴ Microorganisms isolated in post-hurricane reports include common species such as Staphylococcus aureus (clusters of MRSA reported after Hurricane Katrina) and Streptococcus pyogenes (reported after Hurricane Harvey in 2017), as well as water associated pathogens such as Vibrio species and Aeromonas species.^5,6

Clusters of Vibrio vulnificus infections have been reported after Hurricane Katrina, Hurricane Irma (2017) and more recently after Hurricane Ian (2022). After Hurricane Ian, there were a total of 38 reported vibriosis cases with the most common isolated pathogen being V vulnificus. V vulnificus can cause life threatening, necrotizing skin infections that warrant urgent surgical debridement. Presentation typically occurs after an open wound is directly exposed to flood waters. Patients often present with systemic signs of illness, including fever, hypotension, sepsis, and bullous skin lesions.^7-9

Figure 2. Hurricane Ian-associated vibriosis cases, (N = 38), and deaths (N = 11), by illness onset and Vibrio species—Florida, September 28-October 9 2022.⁹

Treatment recommendations include third generation cephalosporins, tetracyclines, and fluoroquinolones. Initial treatment of Vibrio species necrotizing skin infections include combination therapy with a third generation cephalosporin such as ceftriaxone in combination with doxycycline.¹⁰ In one 2006 retrospective analysis of 93 patients with V vulnificus necrotizing skin infections, a third generation cephalosporin in combination with a tetracycline was an independent factor for lower mortality ((OR, 0.037; 95% CI, 0.007-0.192; P<.001)).¹¹ Furthermore, combination therapy is supported by a 2012 cohort that demonstrated lower mortality in patients who received a fluoroquinolone +/- minocycline or a 3rd generation cephalosporin + fluroquinolone.¹² Once surgical debridement has been completed and source control is achieved, in vitro susceptibilities have been demonstrated, and a patient is hemodynamically stable, step-down to monotherapy is reasonable.

Acute rises in infectious diarrheal illnesses have been reported after major hurricanes. After hurricane Katrina, norovirus outbreaks were reported in clusters in Louisiana and in the Reliant Park mega shelter in Texas.¹³ Similarly, Hurricane Sandy (2012), Matthew (2016) and Florence (2018) led to reported rises in viral gastroenteritis cases and ED visits due to GI illnesses following the disasters.^14,15 In addition to viral gastroenteritis, an increase in diarrheal illnesses due to bacterial organisms may occur. Though routine diagnostics are not recommended in the mild or moderate setting, they may be considered in patients with severe presentation or sepsis. Bacterial pathogens such as E coli, Salmonella, Campylobacter, Vibrio, and Aeromonas may be associated with exposures to contaminated food and water.¹⁶

Supportive care is the mainstay of treatment for acute infectious diarrhea. Prevention of severe dehydration with fluid repletion utilizing oral rehydration solutions is recommended. In mild or moderate presentations, antimotility agents such as loperamide can be considered, however these should be avoided in patients with features of dysentery (fever, bloody or mucoid stools) due to the risk of prolonging or worsening the disease course. Bismuth salicylate may also be considered but is less efficacious for symptomatic management. If indicated, antiemetics may be administered.¹⁷

Antibiotics are not recommended for most cases of mild or moderate diarrhea. For severe presentations, signs of sepsis or invasive bacterial infections, or high risk patients, antibiotics may be considered. If indicated, empiric antibiotic recommendations include flouroquinolones (ciprofloxacin or levofloxacin) or azithromycin, though antibiotics should be tailored to the isolated pathogen.¹⁷

Though we cannot prevent natural disasters like hurricanes from occurring, we can however protect ourselves from vaccine preventable illnesses like tetanus. Clostridium tetani is found in the environment and the soil and the post hurricane environment may increase the risk for contaminated deep or puncture wounds. There are approximately 30 cases reported in the US annually, with those that develop typically found in unvaccinated individuals or those not updated with the 10 year booster.¹⁸

Hurricane season is upon us and preparation is key. Are you ready?

References

1. Tropical cyclone climatology. National Oceanic and Atmospheric Administration. Accessed September 4,2023. https://www.nhc.noaa.gov/climo/#stca.
2. Hurricane costs. NOAA Office for Coastal Management. Updated August 31st 2023. Accessed September 4, 2023. https://coast.noaa.gov/states/fast-facts/hurricane-costs.html.
3. Prevent Illness After a Disaster. Centers for Disease Control and Prevention. Updated January 29, 2019. Accessed September 4, 2023. https://www.cdc.gov/disasters/disease/facts.html.
4. Smith DFQ, Casadevall A. Disaster microbiology-a new field of study. American Society for Microbiology. mBio. 2022;13(4):e0168022. doi.org/10.1128/mbio.01680-22.
5. Infectious Disease and Dermatologic Conditions in Evacuees and Rescue Workers After Hurricane Katrina—Multiple States, August—September, 2005. September 30, 2005. Accessed September 4, 2023. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5438a6.htm.
6. Liang SY, Messenger N. Infectious diseases after hydrologic disasters. Emerg Med Clin North Am. 2018;36(4):835-851. doi: 10.1016/j.emc.2018.07.002.
7. Dechet AM, Yu PA, Koram N, Painter J. Nonfoodborne Vibrio infections: an important cause of morbidity and mortality in the United States, 1997-2006. Clin Infect Dis. 2008;46(7):970-976. doi: 10.1086/529148.
8. Vibrio vulnificus & Wounds. Centers for Disease Control and Prevention. Updated October 7, 2019. Accessed September 4, 2023. https://www.cdc.gov/vibrio/wounds.html.
9. Sodders N, Stockdale K, Baker K, Ghanem A, Vieth B, Harder T. Notes from the Field: Vibriosis Cases Associated with Flood Waters During and After Hurricane Ian — Florida, September–October 2022. MMWR Morb Mortal Wkly Rep 2023;72:497–498. DOI: http://dx.doi.org/10.15585/mmwr.mm7218a5.
10. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59(2):e10-52. doi: 10.1093/cid/ciu444.
11. Liu JW, Lee IK, Tang HJ, et al. Prognostic factors and antibiotics in Vibrio vulnificus septicemia. Arch Intern Med. 2006;166(19):2117-2123. doi: 10.1001/archinte.166.19.2117.
12. Chen SC, Lee YT, Tsai SJ, et al. Antibiotic therapy for necrotizing fasciitis caused by Vibrio vulnificus: retrospective analysis of an 8 year period. J Antimicrob Chemother. 2012;67(2):488-493. doi: 10.1093/jac/dkr476.
13. Yee EL, Palacio H, Atmar RL, et al. Widespread outbreak of norovirus gastroenteritis among evacuees of Hurricane Katrina residing in a large “megashelter” in Houston, Texas: lessons learned for prevention. Clin Infect Dis. 2007;44(8):1032-1039. doi: 10.1086/512195.
14. Gaither JB, Page R, Prather C, Paavola F, Garrett AL. Impact of a hurricane shelter viral gastroenteritis outbreak on a responding medical team. Prehosp Disaster Med. 2015;30(4):355-358. doi: 10.1017/S1049023X15004872.
15. Quist AJL, Fliss MD, Wade TJ, Delamater PL, Richardson DB, Engel LS. Hurricane flooding and acute gastrointestinal illness in North Carolina. Sci Total Environ. 2022;809:151108. doi: 10.1016/j.scitotenv.2021.151108.
16. Guidelines for the Management of Acute Diarrhea After a Disaster. Centers for Disease Control and Prevention. Updated January 29, 2019. Accessed September 4, 2023. https://www.cdc.gov/disasters/disease/diarrheaguidelines.html.
17. Shane AL, Mody RK, Crump JA, et al. 2017 infectious diseases society of america clinical practice guidelines for the diagnosis and management of infectious diarrhea. Clin Infect Dis. 2017;65(12):e45-e80. doi: 10.1093/cid/cix669.
18. Tetanus in Areas Affected by a Hurricane: Risk, Prevention, and Management Guidelines for Clinicians. Infectious Diseases Society of America. Accessed September 4, 2023. https://www.idsociety.org/public-health/hurricane-resources/hurricane-resources/tetanus-in-areas/.