Hurricane season is accompanied by an uptick in infectious diseases associated with environmental and water exposures.
According to the National Hurricane Center, September 10 marks the peak of the Atlantic hurricane season, with the peak of the Pacific season occurring in late August.1 These tropical cyclones have made a significant impact on the United States, with an average of 22.8 billion dollars per event. September 28 marks 1 year since Hurricane Ian made landfall in the southwest coast of Florida, and was ranked as the costliest disaster in the US in 2022, with costs estimated over 100 billion dollars.2
The economic impact, however, is only the tip of the iceberg (or the eye of the hurricane, if you will). There are numerous immediate and downstream impacts of natural disasters, especially those that involve significant exposures to contaminated food and water.3
An increase in infectious diseases such as gastrointestinal illness, skin and soft tissue infections, and respiratory illnesses (bacterial and fungal) have been reported after major hurricanes. Vector-borne diseases such as West Nile virus and Dengue fever can be transmitted through mosquitos, which thrive in the post hurricane environment due to standing flood waters and warm climates. Significant rain and flood waters will alter the microbial make up of the environment, and can come into direct contact with individuals affected by the disaster. Additionally, lack of access to clean and running water and lack of electricity contribute to the risk of exposure to contaminated food and water.4
Skin and soft tissue infections arise through direct exposures to bacteria through flood waters, which often contain ocean runoff, soil microbes, and sewage overflow.4 Microorganisms isolated in post-hurricane reports include common species such as Staphylococcus aureus (clusters of MRSA reported after Hurricane Katrina) and Streptococcus pyogenes (reported after Hurricane Harvey in 2017), as well as water associated pathogens such as Vibrio species and Aeromonas species.5,6
Clusters of Vibrio vulnificus infections have been reported after Hurricane Katrina, Hurricane Irma (2017) and more recently after Hurricane Ian (2022). After Hurricane Ian, there were a total of 38 reported vibriosis cases with the most common isolated pathogen being V vulnificus. V vulnificus can cause life threatening, necrotizing skin infections that warrant urgent surgical debridement. Presentation typically occurs after an open wound is directly exposed to flood waters. Patients often present with systemic signs of illness, including fever, hypotension, sepsis, and bullous skin lesions.7-9
Treatment recommendations include third generation cephalosporins, tetracyclines, and fluoroquinolones. Initial treatment of Vibrio species necrotizing skin infections include combination therapy with a third generation cephalosporin such as ceftriaxone in combination with doxycycline.10 In one 2006 retrospective analysis of 93 patients with V vulnificus necrotizing skin infections, a third generation cephalosporin in combination with a tetracycline was an independent factor for lower mortality ((OR, 0.037; 95% CI, 0.007-0.192; P<.001)).11 Furthermore, combination therapy is supported by a 2012 cohort that demonstrated lower mortality in patients who received a fluoroquinolone +/- minocycline or a 3rd generation cephalosporin + fluroquinolone.12 Once surgical debridement has been completed and source control is achieved, in vitro susceptibilities have been demonstrated, and a patient is hemodynamically stable, step-down to monotherapy is reasonable.
Acute rises in infectious diarrheal illnesses have been reported after major hurricanes. After hurricane Katrina, norovirus outbreaks were reported in clusters in Louisiana and in the Reliant Park mega shelter in Texas.13 Similarly, Hurricane Sandy (2012), Matthew (2016) and Florence (2018) led to reported rises in viral gastroenteritis cases and ED visits due to GI illnesses following the disasters.14,15 In addition to viral gastroenteritis, an increase in diarrheal illnesses due to bacterial organisms may occur. Though routine diagnostics are not recommended in the mild or moderate setting, they may be considered in patients with severe presentation or sepsis. Bacterial pathogens such as E coli, Salmonella, Campylobacter, Vibrio, and Aeromonas may be associated with exposures to contaminated food and water.16
Supportive care is the mainstay of treatment for acute infectious diarrhea. Prevention of severe dehydration with fluid repletion utilizing oral rehydration solutions is recommended. In mild or moderate presentations, antimotility agents such as loperamide can be considered, however these should be avoided in patients with features of dysentery (fever, bloody or mucoid stools) due to the risk of prolonging or worsening the disease course. Bismuth salicylate may also be considered but is less efficacious for symptomatic management. If indicated, antiemetics may be administered.17
Antibiotics are not recommended for most cases of mild or moderate diarrhea. For severe presentations, signs of sepsis or invasive bacterial infections, or high risk patients, antibiotics may be considered. If indicated, empiric antibiotic recommendations include flouroquinolones (ciprofloxacin or levofloxacin) or azithromycin, though antibiotics should be tailored to the isolated pathogen.17
Though we cannot prevent natural disasters like hurricanes from occurring, we can however protect ourselves from vaccine preventable illnesses like tetanus. Clostridium tetani is found in the environment and the soil and the post hurricane environment may increase the risk for contaminated deep or puncture wounds. There are approximately 30 cases reported in the US annually, with those that develop typically found in unvaccinated individuals or those not updated with the 10 year booster.18
Hurricane season is upon us and preparation is key. Are you ready?