DMR
Feature Article
The Threat of Communicable Diseases Following
Natural Disasters: A Public Health Response
Stephen C. Waring, DVM, PhD, and Bruce J. Brown, MPH
Natural disasters, such as the recent Indian Ocean
tsunami, can have a rapid onset, broad impact,
and produce many factors that work synergistically to increase the risk of morbidity and
mortality caused by communicable diseases. The
primary goal of emergency health interventions is
to prevent epidemics and improve deteriorating
health conditions among the population affected.
Morbidity and mortality due to infectious diseases
can be minimized providing these intervention
efforts are implemented in a timely and coordinated fashion. This article presents a review
of some of the major issues relevant to preparedness and response for natural disasters.
O
n December 26, 2004, an earthquake off the
coast of Sumatra in the Indian Ocean triggered a widespread tsunami that resulted in
one of the worst natural disasters in modern history
(see Web site http://www.usaid.gov). Massive casualties that occurred were the result of the direct impact
of the tsunami and were mostly a result of drowning
or severe trauma from debris. Numerous people were
injured and in need of medical or surgical attention,
and many survivors were displaced because of damage or destruction of dwellings and massive disruption
of infrastructure throughout the affected region.)
Stephen C. Waring, DVM, PhD, is Associate Director, Center
for Biosecurity and Public Health Preparedness, University
of Texas School of Public Health at Houston. Bruce
J. Brown, MPH, is Director, Environmental Health and
Safety, Center for Biosecurity and Public Health
Preparedness, University of Texas School of Public Health
at Houston.
Reprint requests: Dr Stephen Waring, DVM, PhD, University
of Texas School of Public Health, 1200 Hermann Pressler,
RAS-E1019, Houston, TX 77030, E-mail: stephen.c.waring@
uth.tmc.edu.
)
According to the WHO report of February 1, 2005, there
were 148,724 confirmed deaths, 142,123 missing, 34,410
injured (requiring immediate medical attention), and more
than 1.5 million displaced (see Web site www.who.int.en).
Disaster Manage Response 2005;3:41-7.
1540-2487/$30.00
Copyright Ó 2005 by the Emergency Nurses Association.
doi:10.1016/j.dmr.2005.02.003
April-June 2005
In the days and weeks following such a devastating
disaster, the threat of infectious disease outbreaks is
high. The goal of emergency health is to prevent
epidemics and improve deteriorating health conditions among the population affected. The highest
priority is directed toward diseases that could potentially cause excess mortality and morbidity as a result
of the disaster.1 Immediately following the tsunami
disaster, the World Health Organization (WHO) Health
Action in Crisis Network was activated to support
disease surveillance, advise on outbreak situations,
support needs assessments and restoration of public
health infrastructure, and mobilize resources and
supplies such as drugs and water purification tablets
(see Web site http://www.who.int). Because public
In the days and weeks following such
a devastating disaster, the threat of infectious
disease outbreaks is high.
health provides critical services to support clinical care
activities, this article provides a timely review of issues
relevant to preparation, response, and successful
completion of the challenging missions associated
with public health disaster relief.
Risk for Communicable Diseases
Natural disasters that have a rapid onset and broad
impact can produce many factors that work synergistically to increase the risk of morbidity and mortality
resulting from communicable diseases.2 Large numbers of people are forced to seek temporary shelter in
crowded conditions with inadequate sanitation and
waste management, compromised sources of water,
potential food shortages, malnutrition, and a low level
of immunity, all factors that play a key role in compounding the devastation.3,4
The social environment can add further compromise for relief and recovery efforts. Although disease
outbreaks are more likely to occur when disasters hit
poor and developing regions,2 an outbreak may occur
any time conditions and circumstances favor such an
event regardless of where the disaster strikes. Areas
Disaster Management & Response/Waring and Brown 41
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that are affected by armed conflicts may experience
significant outbreaks.
Providing Emergency Responses
Pre-Event Preparation
The morbidity and mortality resulting from infectious diseases can be minimized if public health
intervention efforts are implemented in a timely and
coordinated fashion. Disaster response is a complex
process that requires continual review and revision
of preparedness missions at the local, national, and
international level. Such efforts are greatly facilitated
by ongoing government, academic, and private organizations that have programs designed to provide upto-date training and education. The public health
workforce can take advantage of these services to
ensure preparedness planning and responding to
complex emergencies and disasters (Tables 1 and 2).
Table 1: Education and training
Association of Schools of Public Health, Centers for
Public Health Preparedness
http://www.asph.org/acphp/index.cfm
Centers for Disease Control and Prevention, Public
Health Training Network
http://www.phppo.cdc.gov/phtn/default.asp
World Health Organization Health Action in Crisis
http://www.who.int/hac/techguidance/training/en/
Federal Emergency Management Agency, Education
and Training
http://www.fema.gov/tab_education.shtm
American Red Cross Community Disaster Education
Materials
http://www.redcross.org/pubs/dspubs/cde.html#target
National Disaster Medical System, Response Team
Training Program
http://ndms.umbc.edu/information.asp
United Nations Disaster Management Training Program
http://www.undmtp.org/
American Medical Association, National Disaster
Life Support
http://www.ama-assn.org/ama/pub/category/
12606.html
Post-Event Epidemiology and Surveillance
Baseline information. A crucial initial step for
a public health emergency response is to establish
adequate disease surveillance systems that take into
account the inherent disruption of the public health
infrastructure. Outbreaks are prevented when public
health can detect increases in diarrheal, respiratory,
and other communicable diseases early and rapidly.
Therefore, responders will need to use pre-impact
Outbreaks are prevented when public health
can detect increases in diarrheal, respiratory,
and other communicable diseases early and
rapidly.
epidemiologic information, such as baseline (expected) frequencies and distributions of disease (ie,
incidence, prevalence, and mortality), known risks,
immunization coverage for vaccine preventable diseases, and awareness (education) among the community to plan and implement the response.5-7
Rapid assessments. Responders should conduct
a health assessment of the community as soon as
possible within the first week following a disaster. The
primary purpose is to identify the immediate impact
and health needs in order to enhance timely decision
making and direct planning. Rapid health assessments
use all available pre-impact information on baseline
health, as well as other characteristics of the region
(eg, demographic, geographic, environmental, health
facilities and services, transportation routes, and
security), information from key informants, and visual
inspection of the affected area.8
42 Disaster Management & Response/Waring and Brown
Rapid epidemiologic assessments can provide more
detailed analysis of ongoing threats and facilitate
monitoring of response and recovery. These assessments should be planned and completed as soon as
possible following the initial health assessments and
build on the information already acquired. While
rapid epidemiologic assessments require additional
resources and multiple skills and expertise, they have
been used in a number of postdisaster settings to
assess immediate health needs and facilitate ongoing
response efforts.9-15
Surveillance and assessment systems need to be
tailored to whatever means are available during the
immediate period after the impact. In a disaster
setting with widespread disruption and displacement,
information networks could include a variety of
sources, ranging from rumors from untrained observers to communications with local health care
providers. The goal is to have the capacity to initiate
field investigations immediately to verify all potential
outbreaks.
Details such as laboratory protocols, case definitions, and case management protocols for all catchment areas need to be addressed during the initial
phase of the response. The frequency and method of
reporting (usually a telephone alert system) also
should be established as a matter of protocol at the
outset with the necessary resources and personnel in
place to ensure effective monitoring. Thresholds for
every disease with epidemic potential should be
established, and it should be determined at what
point above that level that a response must be initiated
(ie, epidemic threshold).8
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DMR
Table 2: Sources for a more in-depth review on
emergency preparedness and response
Centers for Disease Control and Prevention
http://www.bt.cdc.gov/
World Health Organization
General Information: http://www.who.int/en/
Communicable Disease Control Field Manual:
http://www.who.int/csr/don/en/
Federal Emergency Management Agency
http://www.fema.gov/
American Red Cross
http://www.redcross.org/index.html
Sphere Organization
http://www.sphereproject.org/
The actual implementation of surveillance and
rapid needs assessments under field conditions is not
without substantial challenges. The goal is timely and
accurate delivery of information on the health status of
an affected population, which needs to be adequately
understood and communicated to ensure the effort
will meet expectations. Issues such as compromises
between what is collected and how it is to be
analyzed, competing priorities for the same information, limitations of resources, lack of available information required to produce meaningful estimates,
and lack of standardization of collection and reporting
protocols are all considerations for planning and
implementing such an endeavor.16
rapidly recognized and treated in the acute postdisaster phase to prevent an epidemic (see Table 3).
The emergence of antibiotic-resistant strains of Vibrio
cholera complicate control efforts in some regions and
also should be taken into consideration when treating
patients who do not respond to conventional therapy.
Other causes of diarrheal disease are also capable of
contributing to a high incidence of morbidity and
mortality following a disaster (Table 3). More than
350,000 cases of diarrhea resulted from the July 2004
flood in Bangladesh, many resulting from Escherichia
coli, particularly in children; dysentery (Shigella); and
cholera.19 Cholera and dysentery warrant particular
concern because of their ease of transmission, rapid
spread in crowded conditions, and immediate lifethreatening conditions. Guidelines on managing an
outbreak of acute diarrhea in emergency settings are
Cholera and dysentery warrant particular
concern
available from the WHO (see Web site http://w3.
whosea.org). Other foodborne and waterborne diseases such as typhoid fever, hepatitis, and leptospirosis also are capable of producing severe illness and
high case fatalities.
Acute Respiratory Infections
Anticipated Diseases Following Disasters
Diarrheal Diseases
Diarrheal diseases may be a major contributor to
overall morbidity and mortality rates following a disaster. After a disaster there is a large scale disruption
of infrastructure, water quality becomes compromised, there is poor sanitation, and massive numbers
of the population are displaced into temporary
crowded shelters. Common sources of infection are
contaminated water supplies and contaminated foods.
Diarrheal diseases may be a major contributor
to overall morbidity and mortality rates
following a disaster.
One of the leading causes of diarrhea in such crowded
conditions is cholera, which can spread rapidly and
lead to very high mortality rates across all age groups.
According to the WHO, cholera continues to be
a major global threat in many developing regions of
the world, and the threat of an epidemic is constant
throughout any given year.17,18 Cholera must be
April-June 2005
Acute respiratory infections can be a major cause of
morbidity and mortality in emergency settings. The
combination of overcrowding, susceptibility, malnourishment, and poor ventilation in temporary shelters
increase the risk for pneumonia. Many acute infections
involve only the upper respiratory system and may be
mild and self-limiting. Lower respiratory infections,
such as bronchitis and pneumonia, generally are more
severe and require medical attention and even
hospitalization. According to the WHO, acute respiratory infections account for up to 20% of all deaths in
children younger than 5 years, with the majority of
deaths resulting from pneumonia. Therefore, depending on the region affected and the characteristics of
the displaced population and temporary dwellings,
acute respiratory infections may account for a major
portion of the overall morbidity.3 Acute-care clinicians
should be aware of the potential for exposure
resulting from aspiration of contaminated flood water.
Early recognition and management are keys to
avoiding an outbreak.
Measles
While measles epidemics are an expected threat in
some complex emergency settings, few outbreaks
have been associated with acute natural disasters.2,3
Disaster Management & Response/Waring and Brown 43
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Table 3: Communicable diseases with epidemic potential (all except tetanus) in natural disasters
Disease
Waterborne
Cholera
Transmission
Agent
Clinical features
Incubation
period
Fecal/oral, contaminated
water or food
Vibrio cholerae
serogroups
O1 or O139
Leptospira spp
Profuse watery diarrhea,
vomiting
2 hours
to 5 days
Lepto-spirosis
Fecal/oral, contaminated
water
Hepatitis
Fecal/oral, contaminated
water or food
Hepatitis A, E
virus
Bacillary dysentery
Fecal/oral, contaminated
water or food
Typhoid fever
Fecal/oral, contaminated
water or food
Shigella
dysenteriae
type 1
Salmonella typhi
Acute respiratory
Pneumonia
Sudden onset fever,
2-28 days
headache, chills, vomiting,
severe myalgia
Jaundice, abdominal pain,
15-50 days
nausea, diarrhea, fever,
fatigue and loss of appetite
Malaise, fever, vomiting, blood 12-96 hours
and mucous in stool
Sustained fever, headache,
constipation
3-14 days
Person to person by
airborne respiratory
droplets
Streptococcus
pneumoniae,
Haemophilus
influenzae,
or viral
Cough, difficulty breathing, fast 1-3 days
breathing, chest indrawing
Person to person by
airborne respiratory
droplets
Measles virus
(Morbillivirus)
Neisseria
meningitidesd
serogroups
A, C, W135
Rash, high fever, cough, runny 10-12 days
nose, red and watery eyes;
serious postmeasles
complications (5%-10% of
cases)ddiarrhea,
pneumonia, croup
Sudden onset fever, rash, neck 2-10 days
stiffness; altered
consciousness; bulging
fontanelle in !1 year of age
Clostridium
tetani
Difficulty swallowing, lockjaw,
muscle rigidity, spasms
3-21 days
Mosquito (Anopheles spp) Plasmodium
falciparum,
P vivax
Mosquito (Aedes aegypti) Dengue virus-1,
-2, -3, -4
(Flavivirus)
7-30 days
Japanese
encephalitis
Mosquito (Culex spp)
5-15 days
Yellow fever
Mosquito (Aedes,
Haemogogus)
Fever, chills, sweats, head and
body aches, nausea and
vomiting
Sudden onset severe flu-like
illness, high fever, severe
headache, pain behind the
eyes, and rash
Japanese encephalitis Quick onset, headache, high
virus (Flavivirus)
fever, neck stiffness, stupor,
disorientation, tremors
Yellow fever virus
Fever, backache, headache,
(Flavivirus)
nausea, vomiting; toxic
phase-jaundice, abdominal
pain, kidney failure
Direct contact
Measles
Bacterial Meningitis Person to person by
(meningococcal
airborne respiratory
meningitis)
droplets
Wound-related
Tetanus
Vectorborne
Malaria
Dengue fever
Soil
4-7 days
3-6 days
CSF, Cerebrospinal fluid; ELISA, enzyme-linked immunosorbent assay; HAV, Hepatitis A virus; HEV, hepato-encephalomyelitis virus;
JE, Japanese encephalitis; WCC, white blood cell count.
Global awareness and rapid implementation of postemergency immunization campaigns have contributed
to a trend of decreasing frequency of reports of
measles epidemics during the past couple of decades.20 However, following the eruption of Mount
Pinatubo in the Philippines in 1991, measles accounted for 25% of the cases of morbidity and 22%
44 Disaster Management & Response/Waring and Brown
of the cases of mortality among the more than 100,000
people displaced. The high morbidity and mortality
rates were attributed to the indigenous tribe who were
the majority of the displaced population and who had
a very low immunization coverage and cultural
barriers to care.21 Therefore, the possibility of a measles
epidemic following a natural disaster remains high and
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Table 3: (Continued)
Diagnosis
Treatment
Prevention/control
Direct microscopic observation of
V cholerae in stool
Intensive rehydration therapy;
antimicrobials based on sensitivity
testing
Leptospira-specific IgM serologic assay Penicillin, amoxicillin, doxycycline,
erythromycin, cephalosporins
Hand washing, proper handling of
water/food and sewage disposal
Avoid entering contaminated water;
safe water source
Serologic assay detecting anti-HAV of
anti-HEV IgM antibodies
Supportive care; hospitalization and
Hand washing, proper handling of
barrier nursing for severe cases; close
water/food and sewage disposal;
monitoring of pregnant women
Hepatitis A vaccine
Hand washing, proper handling of
Suspect if bloody diarrhea; confirmation Nalidixic acid, ampicillin;
water/food and sewage disposal
hospitalization of seriously ill or
requires isolation of organism from
malnourished; rehydration
stool
Culture from blood, bone marrow,
Ampicillin, trimethoprimHand washing, proper handling of
bowel fluids; rapid antibody tests
sulfamethoxazole, ciprofloxacin
water/food and sewage disposal;
mass vaccination in some settings
Clinical presentation; culture respiratory Co-trimoxazole, chloramphenicol,
secretions
ampicillin,
Isolation; proper nutrition; if cause is
Streptococcus, polyvalent vaccine to
high-risk populations
Rapid mass vaccination within 72 hours
of initial case report (priority to high
risk groups if limited supply); Vitamin
A in children 6 mo to 5 years of age to
prevent complications and reduce
mortality
Penicillin, chloramphenicol, ampicillin, Rapid mass vaccination
ceftriaxone, cefotaxime, cotrimoxazole; supportive therapy;
diazepam for seizures
Generally made by clinical observation Supportive care; proper nutrition and
hydration; vitamin A; control fever;
antimicrobials in complicated cases
with pneumonia, dysentery; treat
conjunctivitis, keratitis
Examination of CSFdelevated WCC,
protein; gram-negative diplococci
Entirely clinical
Tetanus immune globulin
Thorough wound cleaning, tetanus
vaccine
Parasites on blood smear observed
Chloroquine, sulfadoxineusing a microscope; rapid diagnostic
pyrimethamine
assays if available
Serum antibody testing with ELISA or Intensive supportive therapy
rapid dot-blot technique
Mosquito control, insecticide-treated
nets, bedding, clothing
Mosquito control. isolation of cases,
mass vaccination
Serologic assay for JE virus IgM specific Intensive supportive therapy
antibodies in CSF or blood (acute
phase)
Serologic assay for yellow fever virus Intensive supportive therapy
antibodies
can only be prevented through an effective early
warning system and rapid response to suspicious
reports. Indeed, in the ongoing post-tsunami relief
efforts throughout Indonesia and other regions, the
WHO early warning system has been integral in
preventing a measles epidemic (see Web site http://
www.who/int/en).
April-June 2005
Mosquito control. isolation of cases,
mass vaccination
Mosquito control. isolation of cases,
mass vaccination
Tetanus
The likelihood of tetanus also should be a consideration in any disaster situations, such as a tsunami.
The inherent chaos from collapsing structures and
swirling debris inflicts numerous crush injuries,
fractures, and serious contaminated wounds. Tetanus
is an expected complication when disasters strike in
Disaster Management & Response/Waring and Brown 45
DMR
regions where tetanus immunization coverage is low
or nonexistent. It is essential that injured people
receive prompt surgical and medical care of contaminated open wounds as well as appropriate tetanus
The likelihood of tetanus also should be
a consideration in any disaster situations
immunization and immunoglobulin, depending on
vaccination history and seriousness of the wound
infection (see Web site http://www.who/int/en).
Vectorborne Diseases
The risk of acquiring a vectorborne disease, such as
malaria and dengue fever, is usually higher following
a disaster such as a hurricane (typhoon), flood, or
tsunami because of an increase in the number and
range of vector habitats. Whereas the initial force may
actually flush out mosquito breeding sites, the insects
return shortly after waters begin to recede. The
changing dynamics of vector breeding, coupled with
the displacement of large numbers of people into
temporary crowded shelters, favor vectorborne outbreaks even in areas where normal transmission risk is
low. There generally is a lag time of up to 8 weeks
before the onset of vectorborne diseases.22
Malaria. Malaria epidemics represent serious public health emergencies that occur with little warning.
When disasters occur in malaria-endemic areas where
the public health infrastructure is disrupted and highly
vulnerable populations exist, the likelihood of an
epidemic is high. An epidemic of malaria in a disaster
setting usually occurs 4 to 8 weeks after initial impact
and is characterized by several weeks duration before
it peaks.
It is possible to control malaria in the early stages
when cases are diagnosed early and treated. If
laboratory diagnosis is limited or delayed, treatment
can be based solely on clinical history without
Malaria is becoming more difficult to control
demonstration of parasites.23 Vectors of malaria are
exclusively from the mosquito genus Anopheles,
which breed in stagnant fresh or brackish water.
Transmission efficiency depends on species of mosquito, preferred breeding habitats, and prevalence of
the parasite. In some endemic areas, the disruptions
caused by flooding may change what would otherwise
be poor breeding conditions, such as primarily salt
water, into those more favorable for increased
breeding. This can occur when water is diluted by
rain or other sources of fresh water. Malaria is
becoming more difficult to control because of an
emergence of antimalarial resistance to medications
46 Disaster Management & Response/Waring and Brown
over the years and an increased transmission potential. The vector habitats may have an expanding range
as a result of climatic changes associated with global
warming.24 Malaria control is important for diverse
regions like that affected with the Indian Ocean
tsunami.
Dengue. Dengue spreads rapidly and may affect
large numbers of people during an epidemic. Dengue
Hemorrhagic Fever is associated with high mortality,
particularly in children. There has been a dramatic
increase in the incidence of disease during the past
20 years, with up to an estimated 100 million cases
occurring annually.25 The virus is endemic throughout
all tropical regions of the world and is transmitted
by Aedes mosquitoes, primarily Ae aegypti. The
vector is particularly suited for an urban cycle of
transmission because it breeds primarily in containers
and other sources of standing water in and around
human dwellings rather than groundwater pools and
swamps.
Similar to malaria, conditions following a disaster
increase the likelihood of a dengue epidemic, and
only through adequate early warning and rapid
response can outbreaks be contained. Effective prevention and control for both diseases requires vector
control, which may prove challenging during recovery
periods depending on availability of adequate resources and appropriate access to breeding habitats.
Closing Comments
Emergency health relief workers are concerned
with the rapid detection and response to immediate
health needs. The role of public health is to prevent
epidemics with interventions such as proper placement of shelters, adequate sanitation and personal
hygiene, provision of clean water and adequate
nutrition, vaccinations, vector control, and health
education.8 Any emergency response designed to
mitigate adverse health effects resulting from natural
disasters requires a multidisciplinary approach that
employs a broad range of expertise to help minimize
exposure to known health threats while identifying
and attending to those in need of immediate
treatment. This multidisciplinary effort also forms the
framework for postdisaster recovery, which will
require extensive ongoing preparedness planning,
education, and training efforts.
We are hopeful for continued progress toward
complete recovery from the Indian Ocean tsunami
disaster and other disasters that occurred before or
since December 26, 2004. The ultimate goal is to
translate lessons learned from these devastating events
into better preparedness and response for another
natural disaster or other complex emergency certain to
follow, if not already here.
Volume 3, Number 2
DMR
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Disaster Management & Response/Waring and Brown 47