Lessons from the frontlines of post-hurricane public health response
In September 2017, Puerto Rico was hit by the devastating Category 4 Hurricane Maria. With raging winds up to 156 miles an hour and 15 to 40 inches of rain resulting in flash foods, the island was devastated. It was the most damaging storm Puerto Rico has seen in 85 years and when it landed, the impact was nothing short of destruction. Unfortunately, natural disasters also bring with them an increased risk for infectious disease outbreaks.
In the wake of natural disasters, the displacement of people can often trigger outbreaks as the availability of clean water, adequate health services, are diminished and sanitation facilities are over-burdened. The stress natural disasters place on critical infrastructure, especially health care services, can amplify the spread of infectious diseases. In the case of Hurricane Maria, efforts to control tuberculosis became strained in Puerto Rico. Responders from the US Centers for Disease Control and Prevention (CDC)’s Division of Global Migration and Quarantine, Puerto Rico Department of Health, and the CDC’s Division of Tuberculosis Elimination have provided insight into their experiences following Hurricane Maria via notes from the field published in a January CDC Morbidity and Mortality Weekly Report.
The authors emphasized several unique facts that challenged public health efforts in Puerto Rico. For example, less than a week after the hurricane, 84% of hospitals there had no electrical power or fuel for generators, and within the span of 2 weeks there had been 2 declarations of major disasters due to Hurricane Maria and Hurricane Irma, which passed 57 miles north.
Prior to the storms, the Puerto Rico Department of Health Tuberculosis Control Program (PRTB) worked to prepare at its six regional clinics. The department “provided all patients receiving treatment for active TB with a 1-month supply of anti-TB medications before the hurricane and encouraged patients to tell health officers at shelters about their diagnosis if they had to be relocated from their homes.” Furthermore, the Puerto Rico Health Department worked to educate and inform shelters of the potential risk for tuberculosis transmission. They also provided guidance for screening procedures that extended beyond tuberculosis.
Within 5 days after the hurricane, PRTB was able to resume the minimum operational duties and worked to contact patients receiving treatment, as well as the 27 high-priority patients with active disease. Thankfully, their efforts were successful in that within 15 working days, they were able to account for 19 of the patients, and within 21 working days, all patients had been accounted for. Thankfully, as a result of their communication efforts and ability to supply patients with 1 month of medication beforehand, no patients had interruptions in their treatment process.
Unfortunately, surveillance efforts were hampered due to the PRTB laboratory sustaining substantial damage. Luckily, the CDC was able to assist and provide extra laboratory services through its Association of Public Health Laboratories— 3 state labs from Florida, Georgia, and Virginia.
The notes from the field for tuberculosis control in the face of a Category 4 hurricane are critical for future public health preparedness efforts. The authors emphasized that the situation was an extremely taxing time with limited personnel, and pointed out that multiagency collaboration and a robust preparedness plan are critical. They also suggested ensuring clinics have a minimum 2-month supply of medications to manage post-disaster needs, as well as a clinic-specific disaster response plan.
Natural disasters will continue to occur, but as Puerto Rico has shown, it is possible to plan accordingly to insure a certain continuity of public health.