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DISASTER
RECOVERY

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related Vibrio vulnificus and V. parahemolyticus wound infections, in December 2016 presented in San Antonio shelters with cough,
including six deaths (MMWR Sept 30, 2005. Vol 54(38);961-964) V. with or without fever, pharyngitis, or rhinorrhea (personal obser-
vulnificus is a gram negative rod-shaped bacillus present in marine vation, personal communication Barbara Taylor, MD, Andrew
environments including brackish ponds and flood waters in coastal Muck, MD). The first responder challenges were to distinguish pa-
areas. Vibrio infection must be considered in any patient with blis- tients with signs and symptoms of serious infection such as pneu-
tering dermatitis after exposure of broken skin to contaminated ma- monia or tuberculosis from those who merely needed symptomatic
rine water (Epidemiol Infect. 2005 Jun; 133(3): 383–391). care. In more than one instance, patients reported that they had a
Recognition of a blistering skin infection, and awareness of life- positive PPD skin test, but had been placed on transport buses with-
threatening complications such as necrotizing fasciitis and sepsis out medications. Isoniazid sometimes arrived at San Antonio shel-
from Vibrio infections is critical in patients with underlying chronic ters one or two days after the asylum seekers; in certain instances,
liver disease, iron overload, or diabetes; these individuals are at high the immigration process prevented the pills from catching up with
risk of septicemia and may have mortality rates greater than 50 per- the patients. The ability of a clinician to take a careful history in
cent. Treatment of V. vulnificus includes aggressive wound debride- Spanish, about duration of cough, presence or absence of hemop-
ment as well as combination antibiotic therapy with ceftazidime and tysis, fevers, and night sweats, was one of the more important skills
doxycycline. required for medical response to this international displacement in-
Rescue workers with skin conditions after Hurricane Katrina were cident. The importance of tracking potentially infectious patients
found to have Tinea corporis, prickly heat, mite and insect bites, with respiratory illness cannot be overstated, and our experience
highlighting the effects of working in hot, wet environments with with this precipitous, unforeseen episode involving foreign nationals
restricted access to clean water. made evident the need for practical solutions like providing transi-
There were about 1,000 reported cases of diarrhea and vomiting tory patients with their own hand-held records summarizing PPD,
in Katrina evacuation centers, but only one documented outbreak vaccine, and chest X-ray status, as well as prescriptions. Such records
of Norovirus. Some sporadic non-typhoidal Salmonella cases were could be digitized and given to patients on a microchip.
documented. The CDC offers guidelines for the acute management In contrast to our dilemmas with displaced, coughing, interna-
of diarrhea after disasters, including whom to refer for medical eval- tional asylum seekers, a recent issue of Morbidity and Mortality
uation, at www.cdc.gov/disasters/disease/diarrheaguidelines.html. Weekly Report (MMWR, December 2017) notes that after Hurri-
Of note, no Shigella, typhoid or cholera cases were reported after cane Harvey, most Texan tuberculosis patients stayed in Texas, re-
Hurricane Katrina, and by three weeks after the population displace- ceiving uninterrupted directly observed therapy (DOT). “…
ment began, there were no further significant outbreaks of gastroin- video-enabled DOT using electronic devices, such as smart
testinal disease (MMWR Sept 30, 2005. Vol 54(38);961-964). phones”, became “a useful tool for patients who cannot visit, or be
In contrast, first responders to post-earthquake Haiti came vac- visited by, a health care provider.” In fact, after Harvey, there were
cinated against typhoid and Hepatitis A, and well-supplied with 61 patients on video-enabled DOT. MMWR continues: “Immedi-
medications to treat anticipated outbreaks of typhoid or shigellosis. ately after Hurricane Harvey, the DSHS TB program directly con-
However, with rapid deployment of potable water by rescue work- tacted all affected regional and local health departments to
ers, minimal diarrheal illness was observed in makeshift relief cen- determine the status of high-priority TB patients (persons with new
ters during the first two weeks of earthquake relief (personal TB diagnoses, infectious patients, and children), and relayed status
observation). Many patients who had suffered crush injuries actually of patient care, health care worker safety, and needs of local and
developed constipation from prescribed narcotics, and startled vol- regional health departments to CDC. In addition, surveillance ques-
unteers were dispatched to purchase stool softeners from local out- tionnaires were distributed to temporary shelters to identify resi-
lets (Tyler Curiel, MD, personal communication). It was months dents or volunteers exhibiting signs and symptoms of TB. Although
later, as Haiti’s already fragile health infrastructure unraveled, that TB control personnel in Texas were personally affected by the
the cholera epidemic, inadvertently introduced by U.N. peacekeep- storm’s damage, they remained on duty, with some staff members
ers, gained its momentum (N Engl J Med 2011; 364:33-42). traveling into flooded communities to follow up patients.”

Medium Term Challenges: 2. Vector-borne disease.
1. Respiratory disease management and prevention: At the time of Harvey’s landfall, South Texas health care profes-
Crowded shelter conditions inevitably result in transmission of sionals were on alert for cases of fever suggesting vector-borne dis-
viral respiratory illness. The majority of mothers and children pre- ease such as Zika virus, in the wake of ongoing outbreaks of zika,
cipitously discharged from ICE facilities in Dilley and Karnes City dengue and chikungunya infections in Central America; all trans-
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16 San Antonio Medicine • February 2018