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
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