MAUREEN L ICHTVELD, MD, MPHP R O F E S S O R A N D C H A I R , D I R E C T O R ,

C E N T E R F O R G U L F C O A S T E N V I R O N M E N T A L H E A L T H R E S E A R C H , L E A D E R S H I P , A N D S T R A T E G I C I N I T I A T I V E S

D E P A R T M E N T O F G L O B A L E N V I R O N M E N T A L H E A L T H S C I E N C E S

T U L A N E U N I V E R S I T Y S C H O O L O F P U B L I C H E A L T H A N D T R O P I C A L M E D I C I N E

ENVIRONMENTAL STRESSORS, DISASTERS, AND INFECTIOUS DISEASE:

IMPLICATIONS FOR VULNERABLE COMMUNITIES

OBJECTIVES

• Discuss the cumulative impact of environmental disruptions on transmission of

and exposure to infectious disease using four case studies:

• New Orleans, LA and Hurricane Katrina (2005)

• Nepal and the 2015 Earthquakes

• Puerto Rico and Hurricane Maria (2017)

• Suriname and the 2006 Floods

• Examine the consequences at the community level on the key social capitals

• Highlight opportunities and challenges for strengthening the science base of

cumulative risk domains

LINKAGES BETWEEN DISASTERS AND INFECTIOUS DISEASE

Kouadio et al., 2012

EXAMPLE: VECTOR BORNE DISEASE

• Determinants of vector- borne

disease transmission include:

• Vector survival and

reproduction

• The vector’s biting rate

• The pathogen’s incubation

rate within the vector

organism

• The WHO estimates that one-

sixth of the illness and

disability suffered worldwide is linked to vector-borne diseases, with more than half

of the world’s population

currently at risk.Lendrum et al., 2015

ENVIRONMENT AND INFECTIOUS DISEASE: TRANSMISSION OF DENGUE

• Influencing Factors

Density

Breeding Sites

Competitors

Aedes

aegypti

VirulenceSerotype

Virus

Human

Age

Gender

Ethnicity

Immune status

Climate

UrbanizationSanitation

Environment

Hamer et al., 2015

Historic Disparities

Persistent Environmental Health Threats

Residence in Disaster-prone

Areas

TRIPLE HEALTH BURDEN

unique

vulnerability

Lichtveld et al., 2016

CASE STUDY #1: NEW ORLEANS AND HURRICANE KATRINA

• Hurricane Katrina devastated the Gulf Coast on August 29, 2005

• Category 3 storm with winds near 127 mph

• Made landfall near Grand Isle, Louisiana

• Fatalities:• Alabama: 2

• Florida: 14

• Georgia: 2

• Louisiana: 1577

• Mississippi: 238

• Total damage from Katrina is estimated to be $125 billion.

(Dodla et al., 2011)

NEW ORLEANS AND HURRICANE KATRINA

• Fragile health-Historic health disparities:

• high uninsured rates in the country; NCDs, adverse birth outcomes

• Fragile health system:

• Charity Hospital closure

• The University Medical Center opened August 2015

• Fragile governance:

• Lack of disaster preparedness prior to 2005

• Delayed and infective aid

WEST NILE NEUROINVASIVE DISEASE AFTER HURRICANE KATRINA

• Louisiana:

• No cases of WNND were reported

3 weeks before Hurricane Katrina

(CDC weeks 32 – 34)

• 3 weeks post storm (CDC weeks 35

-37), 11 cases were reported

• Mississippi:

• 3 weeks after the landfall, the

affected region showed an

increase from 0 to 10 WNND cases

• Unaffected regions showed only a

minor increase in cases during the

same periods

Small increase in WNND cases signals

larger increase in WNV transmission

Caillouet et al., 2008

WEST NILE NEUROINVASIVE DISEASE AFTER HURRICANE KATRINA

Caillouet et al., 2008

POSSIBLE EFFECTS OF HURRICANE KATRINA AND AFTERMATH ON WEST NILE TRANSMISSION

Courtesy of Kevin A. Caillouet

CHAGAS DISEASE AND HURRICANE KATRINA

• Chagas disease

• Causative agent: Protozoan parasite

Trypanosoma cruzi

• Endemic in Latin America

• Autochthonous transmission of Trypanosoma

cruzi, in a patient in rural New Orleans,

• 5 autochthonous cases of infection with the

Chagas disease parasite have been reported

in the US:

• 3 in infants in Texas

• 1 in infants in Tennessee

• 1 in 56 year old woman in California

AUTOCHTHONOUS TRANSMISSION OF TRYPANOSOMONA CRUZI IN LOUISIANA

• 9 months post Hurricane Katrina increases in domestic infestation with triatomines were reported

• The armadillo population increased substantially months after Hurricane Katrina

• Likely that these hosts supported a larger pest population, that later sought other bloodmeal sources as the armadillo population returned to pre-storm levels

• Patient background

• 74 year old woman residing in a house in rural New Orleans.

• Considerable number (>50) of insect bites (triatomines)

CASE STUDY #2: NEPAL AND THE 2015 EARTHQUAKES

• Nepal had a decade-long civil war,

followed by a “restless peace”

• Recent political transition to federal

system with seven provinces

• Delayed constitutional process

• Protests and riots

• Gorkha earthquake (magnitude 7.8)

occurred about 80km east of Kathmandu

on April 25, 2015

• Followed by aftershocks, including a

magnitude 7.3 earthquake on May 12,

2015 about 40km west of Kathmandu

IMPACTS OF THE 2015 EARTHQUAKES

• 9,000 deaths

• 22,000 injuries

• 10% of the population (3.5

million) became homeless

• 400 health facilities, 9,000

classrooms and more than

800,000 homes damaged

RESPONSE TO THE 2015 EARTHQUAKES IN NEPAL

• Nepali government, army, civil society, and

international aid mobilized to assist survivors

• Fragile response:

• Disaster response was assigned to Ministry

of Home Affairs (MoHA)-limited authority,

under-resourced

• Weak linkage of national and subnational

disaster management structures

IMPACT ON HEALTH: MIXED FINDINGS

• Acute gastroenteritis among children from families substantially affected by the earthquakes (Giri et al,. 2018)

• Pre-existing health disparities played a role

• Hepatitis E (Shrestha et al., 2016)

• Pre-disaster outbreaks in Nepal

• Earthquake created “perfect storm” of risk factors after the earthquake

• Study examined previous and current HEV infection in Nepalese blood donors after 2015 earthquakes (June –September 2015)

• No significant increase detected

Thorne-Lyman et al., 2018

IMPLICATIONS FOR VULNERABLE GROUPS

• Earthquakes occurred in most remote and rural areas of Nepal

• Fragile infrastructure• Many villages were unable to receive aid due to

road infrastructure and severe weather conditions

• Pre-existing disparities (e.g., health, financial, social, educational, political representation)

• Housing post-disaster still not restored

• Variability in subnational disaster response structure

• Some areas were nearly inoperative, while others were taken over by parochial interests

• High reliance on international aid organizations, NGOs and national government, which often lacked contextual information and local partners

• Political instability is hampering aid from China and Japan to put in place drinking water pipes

CASE STUDY #3:PUERTO RICO AND HURRICANE MARIA

• Hurricane Maria devastated

several islands in the Caribbean on

September 20, 2017

• Category 4 storm hit Puerto Rico

with winds near 155 mph

• Affected the island’s 3.7 million

inhabitants

• Fatalities: 2,975

• Caused an estimated $90 billion in

damage

NYTimes, 2017

PUERTO RICO AND HURRICANE MARIA

• Devastating impacts

on fundamental needs

• Food and water

• Electricity

• Full power only

restored to the last

homes one year

after the hurricane

• Communications

• Medical care

RESTORATION OF LABORATORY SERVICES AFTER HURRICANE MARIA IN SAN JUAN, PUERTO RICO

Concepción-Acevedo et al., 2018

LEPTOSPIROSIS AND HURRICANE MARIA

• Leptospirosis

• Caused by a spiral- shaped bacterium Leptospira, which can infect animals and people

• Transmission via contact with animal urine or environmental contamination (water, soil)

• 26 deaths in Puerto Rico in the six months after Hurricane Maria were attributed to leptospirosis

CASE STUDY#4:SURINAME 2006 FLOODING

• May 2006 floods aka “the big flood”

• Affected 13,000 households in the eastern

interior of Suriname

• The population living in the interior

(approx. 50,000) primarily consist of tribal

peoples (85%) and indigenous (15%)

• Damage estimated at SRD$111 million

• Many agricultural plots were destroyed

• Women and the elderly were

disproportionately vulnerable to flood

impacts – no alternate source of income

HEALTH IMPACTS OF 2006 FLOODS: DIARRHEAL DISEASE (0-5 YRS)

Medical Mission Primary Health Care, Suriname

HEALTH IMPACTS OF 2006 FLOODS: MALARIA

Medical Mission Primary Health Care, Suriname

INSIGHTS FROM THE 2006 FLOODS IN SURINAME

• Diarrheal disease had only a small increase and

malaria decreased following the 2006 floods

• Effective surveillance and active primary care

services countered infectious disease post

environmental disruption

• Anopheles Darlingi breeding places destroyed

• Other short- and long-term coping strategies:

Reliance on traditional social networks

• Moving agricultural plots to higher ground

• Diversification of income sources (employment

in large- and small-scale goldmining)Flooding episodes have increased since 2006

DISCUSSION

• Environmental disruption includes slow moving shocks and stressors

• Infectious disease control post disruption must be an integral component of disaster preparedness, response, and recovery

• Coping strategies may lead to environmental exposures posing cumulative health threats

• Triple fragility – health disparities, health infrastructure, governance- influence impact of infectious disease post environmental disruptions

• MCH as “sentinel” vulnerable conditions/populations

• Build data collection capacity on frontline to strengthen data availability during and after disaster

• Limitations of cross-sectional approach; invest in longitudinal “baseline assessments” during inter-disaster periods beyond surveillance

THANK YOU

Acknowledgements: Mya Sherman; Cecilia Alcala