Treatment of survivors after the tsunami

The Impact of Earthquakes on Public Health: A Narrative Review of Infectious Diseases in the Post-Disaster Period Aiming to Disaster Risk Reduction

Earthquakes are among the most impressive natural phenomena with very high potential to set off a chain of effects that significantly affects public health through casualties and injuries. Related disasters are attributed not only to the strong ground motion and coseismic phenomena but also to secondary effects, comprising mainly landslides and tsunamis, among others. All these can create harsh conditions favorable for the emergence of infectious diseases that are capable of causing additional human and economic losses and disruption of the emergency and recovery process. The present study comprises an extensive narrative review of the existing literature on the earthquake-triggered infectious diseases recorded worldwide, along with their symptoms, causative pathogens, associated risk factors, most vulnerable population groups, and prevention strategies. Respiratory, gastrointestinal, and vector-borne diseases, as well as wound and skin infections, are mainly recorded among the earthquake-affected population. Measures for effectively preventing earthquake-triggered infectious diseases are also proposed. One of the widely proposed measures is the establishment of a proper disease surveillance system in order to immediately and effectively identify the pre- and post-disaster occurrence of infectious diseases. This approach significantly contributes to disease trends monitoring, validation of early warning, and support of the emergency response and recovery actions.

Respiratory Infections Following Earthquake-Induced Tsunamis: Transmission Risk Factors and Lessons Learned for Disaster Risk Management

Earthquake-induced tsunamis have the potential to cause extensive damage to natural and built environments and are often associated with fatalities, injuries, and infectious disease outbreaks. This review aims to examine the occurrence of respiratory infections (RIs) and to elucidate the risk factors of RI transmission following tsunamis which were induced by earthquakes in the last 20 years. Forty-seven articles were included in this review and referred to the RIs emergence following the 2004 Sumatra-Andaman, the 2009 Samoa, and the 2011 Japan earthquakes. Polymicrobial RIs were commonly detected among near-drowned tsunami survivors. Influenza outbreaks were commonly detected during the influenza transmission period. Overcrowded conditions in evacuation centers contributed to increased acute RI incidence rate, measles transmission, and tuberculosis detection. Destruction of health care infrastructures, overcrowded evacuation shelters, exposure to high pathogen densities, aggravating weather conditions, regional disease endemicity, and low vaccination coverage were the major triggering factors of RI occurrence in post-tsunami disaster settings. Knowledge of risk factors underlying RIs emergence following earthquake-induced tsunami can contribute to the implementation of appropriate disaster prevention and preparedness plans characterized by sufficient environmental planning, resistant infrastructures, resilient health care facilities, and well-established evacuation centers. Global and local disease surveillance is a key prerequisite for early warning and protection against RIs’ emergence and transmission in tsunami-prone areas.

Emergency Anesthesia in Resource-Limited Areas

Anesthesia providers play a critical role in the gap between unmet surgical need and access to safe surgical care. Providers from high-income countries can help fill this gap, particularly during crises, but it is critical to provide care responsibly and ethically. Most unmet surgical need is in low-income and middle-income countries where limited infrastructural, human, and material resources pose significant challenges. Anesthesia providers must recognize these difficulties as they apply to the local context and plan accordingly. This article outlines some of the unique issues and provides a framework of considerations for safe and responsible anesthesia delivery in resource-limited areas.

Emergency Anesthesia in Resource-Limited Areas

Anesthesia providers play a critical role in the gap between unmet surgical need and access to safe surgical care. Providers from high-income countries can help fill this gap, particularly during crises, but it is critical to provide care responsibly and ethically. Most unmet surgical need is in low-income and middle-income countries where limited infrastructural, human, and material resources pose significant challenges. Anesthesia providers must recognize these difficulties as they apply to the local context and plan accordingly. This article outlines some of the unique issues and provides a framework of considerations for safe and responsible anesthesia delivery in resource-limited areas.

Managing anaesthetic provision for global disasters

The numbers of people affected by large-scale disasters has increased in recent decades. Disasters produce a huge burden of surgical morbidity at a time when the affected country is least able to respond. For this reason an international disaster response is often required. For many years this disaster response was not coordinated. The response consisted of what was available not what was needed and standards of care varied widely producing a healthcare lottery for the affected population. In recent years the World Health organisation has initiated the Emergency Medical Team programme to coordinate the response to disasters and set minimum standards for responding teams. Anaesthetists have a key role to play in Level 2 Surgical Field Hospitals. The disaster context produces a number of logistical challenges that directly impact on the anaesthetist requiring adaptation of anaesthetic techniques from their everyday practice. The context in which they will be working and the wider scope of practice that will be expected from them in the field mandates that deploying anaesthetists should be trained for disaster response. There have been significant improvements in recent years in the speed of response, equipment availability, coordination and training for disasters. Future challenges include increasing local disaster response capacity, agreeing international standards for training and improving data collection to allow for future research and improvement in disaster response. The goal of this review article is to provide an understanding of the disaster context and what logistical challenges it provides. There has been a move during the last decade from a globally uncoordinated, unregulated response, with no consensus on standards, to a globally coordinated response through the World Health Organisation (WHO). A classification system for responding Emergency Medical Teams (EMTs) and a set of agreed minimum standards has been defined. This review outlines the scope of the role of the anaesthetist in a Level 2 field hospital and some of the challenges that this scope and context present. It focuses mainly on natural disasters, but also outline some of the differences encountered in responding to other global disasters such as conflict and infectious outbreaks, and concludes with some of the challenges for the future.

Characteristics of pneumonia deaths after an earthquake and tsunami: an ecological study of 5.7 million participants in 131 municipalities, Japan

OBJECTIVE

On 11 March 2011, the Great East Japan Earthquake struck off Japan. Although some studies showed that the earthquake increased the risk of pneumonia death, no study reported whether and how much a tsunami increased the risk. We examined the risk for pneumonia death after the earthquake/tsunami.

DESIGN

This is an ecological study.

SETTING

Data on population and pneumonia deaths obtained from the Vital Statistics 2010 and 2012, National Census 2010 and Basic Resident Register 2010 and 2012 in Japan.

PARTICIPANTS

About 5.7 million participants residing in Miyagi, Iwate and Fukushima Prefectures during 1 year after the disaster were targeted. All municipalities (n=131) were categorised into inland (n=93), that is, the earthquake-impacted area, and coastal types (n=38), that is, the earthquake-impacted and tsunami-impacted area.

OUTCOME MEASURES

The number of pneumonia deaths per week was totalled from 12 March 2010 to 9 March 2012. The number of observed pneumonia deaths (O) and the sum of the sex and age classes in the observed population multiplied by the sex and age classes of expected pneumonia mortality (E) were calculated. Expected pneumonia mortality was the pneumonia mortality during the year before. Standardised mortality ratios (SMRs) were calculated for pneumonia deaths (O/E), adjusting for sex and age using the indirect method. SMRs were then calculated by coastal and inland municipalities.

RESULTS

6603 participants died of pneumonia during 1 year after the earthquake. SMRs increased significantly during the 1st-12th weeks. In the 2nd week, SMRs in coastal and inland municipalities were 2.49 (95% CI 2.02 to 7.64) and 1.48 (95% CI 1.24 to 2.61), respectively. SMRs of coastal municipalities were higher than those of inland municipalities.

CONCLUSIONS

An earthquake increased the risk of pneumonia death and tsunamis additionally increased the risk.

Characteristics of infectious diseases in hospitalized patients during the early phase after the 2011 great East Japan earthquake: pneumonia as a significant reason for hospital care

BACKGROUND

Natural catastrophes increase infectious disease morbidity rates. On March 11, 2011, a 9.0-magnitude earthquake and associated Pacific coast tsunami struck East Japan. The aim of this study was to investigate the characteristics of patients with infectious diseases who needed hospitalization after this disaster.

METHODS

We searched the medical records of 1,577 patients admitted to Tohoku University Hospital in the Sendai area within 1 month (March 11, 2011-April 11, 2011) after the disaster. We examined (1) changes in the rates of hospitalizations for infectious diseases over time and (2) the variety of infectious diseases.

RESULTS

The number of hospitalized patients with infectious diseases increased after the fi rst week to double that during the same period in 2010. Pneumonia comprised 43% of cases, and 12% consisted of skin and subcutaneous tissue infection, including tetanus. Pneumonia was prevalent in elderly patients (median age, 78 years) with low levels of serum albumin and comorbid conditions, including brain and nervous system disorders. Sputum cultures contained Streptococcus pneumoniae, Moraxella catarrhalis, and Haemophilus influenzae , known pathogens of community-acquired pneumonia in Japan. In addition, 20.5% of patients had positive results for urinary pneumococcal antigen.

CONCLUSIONS

Among hospitalized patients, infectious diseases were significantly increased after the disaster compared with the same period in 2010, with pneumonia being prominent. The analyses suggest that taking appropriate measures for infectious diseases, including pneumonia, may be useful for disaster preparedness and medical response in the future.

The Impact of Disasters on Populations With Health and Health Care Disparities

Context:A disaster is indiscriminate in whom it affects. Limited research has shown that the poor and medically underserved, especially in rural areas, bear an inequitable amount of the burden.

Objective:To review the literature on the combined effects of a disaster and living in an area with existing health or health care disparities on a community's health, access to health resources, and quality of life.

Methods:We performed a systematic literature review using the following search terms: disaster, health disparities, health care disparities, medically underserved, and rural. Our inclusion criteria were peer-reviewed, US studies that discussed the delayed or persistent health effects of disasters in medically underserved areas.

Results:There has been extensive research published on disasters, health disparities, health care disparities, and medically underserved populations individually, but not collectively.

Conclusions:The current literature does not capture the strain of health and health care disparities before and after a disaster in medically underserved communities. Future disaster studies and policies should account for differences in health profiles and access to care before and after a disaster.

(Disaster Med Public Health Preparedness. 2010;4:30-38)

Deterioration in regional health status after the acute phase of a great disaster: respiratory physicians' experiences of the Great East Japan Earthquake

BACKGROUND

The Great East Japan Earthquake occurred on March 11, 2011. The source of the ensuing devastation was not the tremors, but the subsequent tsunami. Responding emergency medical teams could not provide sufficient assistance, which led to many people dying before the rescue teams arrived. Thus, the main objective of healthcare professionals became to prevent deterioration in people's health statuses in the disaster area.

METHODS

One month after the earthquake, the Health-Promoting Association of Respiratory Medicine of Tohoku conducted a survey regarding changing disease prevalence among inpatients in respiratory medicine departments of regional core hospitals in Miyagi Prefecture, the area that suffered the most damage.

RESULTS

The number of patients from March 11 to April 10, 2011 was 2.7 times greater than that during the same period in 2010 (1223 vs. 443, respectively). The prevalence of asthma, exacerbations of chronic obstructive pulmonary disease, and community-acquired pneumonia were also 2-3 times greater in 2011 than in 2010 (98 vs. 32, 117 vs. 46, and 443 vs. 202, respectively) among all ages. Half of the community-acquired pneumonia cases originated in evacuation shelters. The number of inpatients with other diseases, including those who drowned, was relatively small, and mortality did not increase significantly at these hospitals.

CONCLUSIONS

The findings may result from poor shelter or dwelling conditions, as well as overpopulation and lack of basic resources. Adequate shelters, supply systems, and protection from infection, including vaccinations, are needed to prevent deteriorations in health status after the acute phase of a natural disaster.

Needs for disaster medicine: lessons from the field of the Great East Japan Earthquake

PROBLEM

The Great East Japan Earthquake, which occurred in Tohoku, Japan on 11 March 2011, was followed by a devastating tsunami and damage to nuclear power plants that resulted in radiation leakage.

CONTEXT

The medical care, equipment and communication needs of four Disaster Medical Assistance Teams (DMAT) during four missions are discussed. DMATs are medically trained mobile teams used in the acute phase of disasters.

ACTION

The DMATs conducted four missions in devastated areas from the day of the earthquake to day 10. The first and second missions were to triage, resuscitate and treat trauma victims in Tokyo and Miyagi, respectively. The third mission was to conduct emergency medicine and primary care in Iwate. The fourth was to assist with the evacuation and screening of inpatients with radiation exposure in Fukushima.

OUTCOME

Triage, resuscitation and trauma expertise and equipment were required in Missions 1 and 2. Emergency medicine in hospitals and primary care in first-aid stations and evacuation areas were required for Mission 3. In Mission 4, the DMAT assisted with evacuation by ambulances and buses and screened people for radiation exposure. Only land phones and transceivers were available for Missions 1 to 3 although they were ineffective for urgent purposes.

DISCUSSION

These DMAT missions showed that there are new needs for DMATs in primary care, radiation screening and evacuation after the acute phase of a disaster. Alternative methods for communication infrastructure post-disaster need to be investigated with telecommunication experts.

Prehospital Care of Tsunami Victims in Thailand: Description and Analysis

Introduction:

On 26 December 2004 at 09:00 h, an earthquake of 9.0 magnitude (Richter scale) struck the area off of the western coast of northern Sumatra, Indonesia, triggering a Tsunami. As of 25 January 2005, 5,388 fatalities were confirmed, 3,120 people were reported missing, and 8,457 people were wounded in Thailand alone. Little information is available in the medical literature regarding the response and restructuring of the prehospital healthcare system in dealing with major natural disasters.

Objective:

The objective of the study was to analyze the prehospital medical response to the Tsunami in Thailand, and to identify possible ways of improving future preparedness and response.

Methods:

The Israeli Defense Forces (IDF) Home Front Command Medical Department sent a research delegation to study the response of the Thai medical system to the 2004 earthquake and Tsunami disaster. The delegation met with Thai healthcare and military personnel, who provided medical care for and evacuated the Tsunami victims. The research instruments included questionnaires (open and closed questions), interviews, and a review of debriefing session reports held in the days following the Tsunami.

Results:

Beginning the day after the event, primary health care in the affected provinces was expanded and extended. This included: (1) strengthening existing primary care facilities with personnel and equipment; (2) enhancing communication and transportation capabilities; (3) erecting healthcare facilities in newly constructed evacuation centers; (4) deploying mobile, medical teams to make house calls to flood refugees in affected areas; and (5) deploying ambulance crews to the affected areas to search for survivors and provide primary care triage and transportation.

Conclusion:

The restructuring of the prehospital healthcare system was crucial for optimal management of the healthcare needs of Tsunami victims and for the reduction of the patient loads on secondary medical facilities. The disaster plan of a national healthcare system should include special consideration for the restructuring and reinforcement prehospital system.

Antimicrobial Therapy for Water-Associated Wound Infections in a Disaster Setting: Gram-Negative Bacilli in an Aquatic Environment and Lessons from Banda Aceh

Introduction:

As members of the Japan Disaster Relief (JDR) team in Banda Aceh, three of the authors treated 1,891 patients following the tsunami of 2004. Of the 367 cases with traumatic injuries, 216 cases required antimicrobial therapy. The medical services were continued by the Japan Self-Defense (JSD) Medical Team until mid-March 2005. Of the 216 cases initially treated by JDR, 54 required prolonged antimicrobial therapy for persistent symptoms despite repeated debridement.The aim of this study is to recommend an appropriate antimicrobial therapy for water-associated wound infections in the absence of laboratory services in disaster settings following tsunami.

Methods:

The JDR and JSD treatment records were analyzed retrospectively. In August 2006, 19 months after the tsunami, the authors investigated pathogens in natural aquatic habitats in the affected area in Banda Aceh. At the same time, interviews with tsunami survivors were performed to determine the influential factors that facilitated wound infections after the tsunami.

Results:

From the 49 water samples tested,Aeromonas sp.,Vibrio sp.,Klebsiella sp., andProteus sp.were isolated from 24, 16, 15, and six samples, respectively. Regardless of the genus, almost all of the isolated gram-negative bacilli were sensitive to ciprofloxacin and gentamicin.

Conclusions:

From the microbiological test results and analyses of the medical records and interviews, the researchers recommend the following regimen when clinical microbiological tests are not available: initial treatment with beta-lactam penicillins for three days, followed, if the first antimicrobial is not effective, by ciprofloxacin or any other relevant new quinolones, with the addition of gentamicin if necessary.

The global distribution of Burkholderia pseudomallei and melioidosis: an update

While Southeast Asia and northern Australia are well recognized as the major endemic regions for melioidosis, recent reports have expanded the endemic zone. Severe weather events and environmental disasters such as the 2004 Asian tsunami have unmasked locations of sporadic cases and have reconfirmed endemicity in Indonesia. The endemic region now includes the majority of the Indian subcontinent, southern China, Hong Kong and Taiwan. Sporadic cases have occurred in Brazil and elsewhere in the Americas and in island communities such as New Caledonia, in the Pacific Ocean, and Mauritius in the Indian Ocean. Some of the factors that are critical to further elucidating the global distribution of Burkholderia pseudomallei and melioidosis include improved access to diagnostic laboratory facilities and formal confirmation of the identity of bacterial isolates from suspected cases.

Gram-negative bacteria from patients seeking medical advice in Stockholm after the tsunami catastrophe

Microbiological cultures from 229 patients seeking medical advice in Stockholm after the tsunami catastrophe of December 2004 were analysed at the Clinical Microbiology Laboratory, Karolinska University Hospital, Stockholm, Sweden. Gram-negative bacilli were the most common findings from wound cultures. Common human pathogens such as Escherichia coli, Proteus species, Klebsiella spp., and Pseudomonas aeruginosa were isolated. More rare species of Gram-negative bacilli, e.g. Myroides odoratus, Sphingomonas paucimobilis and Bergeyella zoohelcum were also isolated. Resistance towards ordinary antibiotics was more extensive compared to our Swedish reference material for Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis and Acinetobacter spp., but not for Pseudomonas aeruginosa, probably reflecting that the resistant isolates were nosocomially acquired in Asia.

The revisit of 2004 tsunami in Thailand: characteristics of wounds

The name, tsunami that was unknown to most Thai people, had hit west southern coast of Thailand on 26 December 2004. Following the disaster, prices have been paid and many lessons have been learnt. The current report provides a historical background of the incident, which was reviewed by documents, brief discussion and observation. Data of the patients from three hospitals involved in the management were collected and reviewed. Some of the illustrations were from the operating rooms of Takuapa, Surat Thani and Songklanagarind hospitals. There were totally 2311 patients. Of these, 45% were males and 40% were multinationals. Nearly 40% suffered from salted water aspiration, while 2% developed complication associated with near drowning. The most common orthopaedic-related injury were minor [559 patients (24%)] and major wounds [586 (25%)]. Around 7% sustained fracture dislocation. Lower extremity fractures were more common. The characteristics of wounds associated with the tsunami were severe contamination, multiple sites and organ involvement. Another characteristic was the early development and spreading of infection. The lessons proposed by the study are that minor wound should be left open, small penetrating wound should be thoroughly explored and observed and lacerated wounds need emergency dressing, debridement and subsequent cleansing procedures. Re-evaluation and closed surveillance of the seriously injured patients are mandatory to eliminate the complicated infection and life-threatening conditions. Medical record of any disastrous event should be completed by health care professionals. The model and reporting system should be internationalised.

A case of prostatitis due to Burkholderia pseudomallei

BACKGROUND

A 67-year-old male, with a history of stable lower urinary tract symptoms, diabetes mellitus, benign prostatic hyperplasia, gonococcal urethritis, and excessive alcohol consumption, presented to the emergency room with sepsis and acute bacterial prostatitis. He had recently returned from a visit to Indonesia, where he had been a first-hand witness to the 2004 tsunami.

INVESTIGATIONS

Complete blood cell count, urine analysis, blood, urine, and prostatic abscess cultures, chest X-ray, contrasted CT of the abdomen and pelvis, and (18)F-fluorodeoxyglucose PET.

DIAGNOSIS

Melioidosis.

MANAGEMENT

Broad-spectrum empiric antibiotics were administered initially; therapy was then changed to intravenous imipenem plus cilastatin with slow initial clinical improvement. (18)F-fluorodeoxyglucose PET localized the prostate as the only nidus of infection. Ultrasound-guided fine needle aspiration of a small fluid collection of the prostate also grew Burkholderia pseudomallei. The patient improved clinically and was discharged to complete a 2-week course of intravenous imipenem plus cilastatin followed by a 3-month course of oral trimethoprim plus sulfamethoxazole. This medication was switched to co-amoxiclav and doxycycline to complete the 3-month course. The patient was well at his last follow-up, 3 months following hospital discharge.

One year ago not business as usual: wound management, infection and psychoemotional control during tertiary medical care following the 2004 Tsunami disaster in southeast Asia

Introduction

Following the 2004 tsunami disaster in southeast Asia severely injured tourists were repatriated via airlift to Germany. One cohort was triaged to the Cologne-Merheim Medical Center (Germany) for further medical care. We report on the tertiary medical care provided to this cohort of patients.

Methods

This study is an observational report on complex wound management, infection and psychoemotional control associated with the 2004 Tsunami disaster. The setting was an adult intensive care unit (ICU) of a level I trauma center and subjects included severely injured tsunami victims repatriated from the disaster area (19 to 68 years old; 10 females and 7 males with unknown co-morbidities).

Results

Multiple large flap lacerations (2 × 3 to 60 × 60 cm) at various body sites were characteristic. Lower extremities were mostly affected (88%), followed by upper extremities (29%), and head (18%). Two-thirds of patients presented with combined injuries to the thorax or fractures. Near-drowning involved the aspiration of immersion fluids, marine and soil debris into the respiratory tract and all patients displayed signs of pneumonitis and pneumonia upon arrival. Three patients presented with severe sinusitis. Microbiology identified a variety of common but also uncommon isolates that were often multi-resistant. Wound management included aggressive debridement together with vacuum-assisted closure in the interim between initial wound surgery and secondary closure. All patients received empiric anti-infective therapy using quinolones and clindamycin, later adapted to incoming results from microbiology and resistance patterns. This approach was effective in all but one patient who died due to severe fungal sepsis. All patients displayed severe signs of post-traumatic stress response.

Conclusion

Individuals evacuated to our facility sustained traumatic injuries to head, chest, and limbs that were often contaminated with highly resistant bacteria. Transferred patients from disaster areas should be isolated until their microbial flora is identified as they may introduce new pathogens into an ICU. Successful wound management, including aggressive debridement combined with vacuum-assisted closure was effective. Initial anti-infective therapy using quinolones combined with clindamycin was a good first-line choice. Psychoemotional intervention alleviated severe post-traumatic stress response. For optimum treatment and care a multidisciplinary approach is mandatory.

Atypical infections in tsunami survivors

After a tsunami hit Asia in December 2004, 2 survivors had severe infections due to multidrug-resistant and atypical bacteria and rare fungi weeks afterwards. Treating these infections is challenging from a clinical and microbiologic point of view.