Will Dominica suffer public health nightmare after storm?

By Caribbean Medical News Staff
With twenty-two (22) dead and 9 missing and the death toll possibly rising as friends and family form teams to find the lost and missing beneath mud, the World Health Organization (WHO’s) Fact Sheet on flooding speaks to the possibility of a potential public health nightmare since 50% of the population of Dominica has access to water and telecommunications in some areas are down. Further, there is the risk of vector borne illness and food and water are in short supply.

According to the WHO, floods can potentially increase the transmission of water-borne diseases, such as typhoid fever, cholera, leptospirosis and hepatitis A and Vector-borne diseases, such as malaria, dengue and dengue haemorrhagic fever, yellow fever, and West Nile Fever depending on the region. Having just recovered from a year of chikungunya in 2014, CARPHA and PAHO along with international aid organizations through DFID, DFATD and UNDP need to rush to work through CDEMA to help rebuild Dominica. We are reminded of the sombre situation in Haiti post the 2010 earthquake.
Water-borne diseases
WHO says flooding is associated with an increased risk of infection, however this risk is low unless there is significant population displacement and/or water sources are compromised. Of the 14 major floods which occurred globally between 1970 and 1994, only one led to a major diarrhoeal disease outbreak – in Sudan, 1980. This was probably because the flood was complicated by population displacement. Floods in Mozambique in January-March 2000 led to an increase in the incidence of diarrhoea and in 1998, floods in West Bengal led to a large cholera epidemic (01,El Tor, Ogawa). In 2013, the floods of St Vincent ravaged the island causing death and destruction. International aid invariably has to reach a certain threshold for monies to be releases, what if Dominica is a few hundred thousand dollars below this threshold? Will they be able to rebuild? Who do the ask for help?

These are burgeoning questions that must be asked long before a tropical wave starts off the coast of Africa and slowly makes its way to the region to pick up speed and swirl around the Caribbean causing death and destruction. One major risk factor for outbreaks, says WHO, is associated with flooding is the contamination of drinking-water facilities, and even when this happens, as in Iowa and Missouri in 1993, the risk of outbreaks can be minimized if the risk is well recognized and disaster-response addresses the provision of clean water as a priority. In Tajikistan in 1992, the flooding of sewage treatment plants led to the contamination of river water.

There is an increased risk of infection of water-borne diseases contracted through direct contact with polluted waters, such as wound infections, dermatitis, conjunctivitis, and ear, nose and throat infections. However, these diseases are not epidemic-prone said a WHO release on flooding.

“The only epidemic-prone infection which can be transmitted directly from contaminated water is leptospirosis, a zoonotic bacterial disease. Transmission occurs through contact of the skin and mucous membranes with water, damp soil or vegetation (such as sugarcane) or mud contaminated with rodent urine. The occurrence of flooding after heavy rainfall facilitates the spread of the organism due to the proliferation of rodents which shed large amounts of leptospires in their urine. Outbreaks of leptospirosis occurred in Brazil (1983, 1988 and 1996), in Nicaragua (1995), Krasnodar region, Russian Federation (1997), Santa Fe, USA (1998) Orissa, India (1999) and Thailand (2000). It is likely that environmental changes increased the vector (rodent) population which facilitated transmission”, the statement said.

Vector-borne diseases

Floods may indirectly lead to an increase in vector-borne diseases through the expansion in the number and range of vector habitats. Standing water caused by heavy rainfall or overflow of rivers can act as breeding sites for mosquitoes, and therefore enhance the potential for exposure of the disaster-affected population and emergency workers to infections such as dengue, malaria and West Nile fever. Flooding may initially flush out mosquito breeding, but it comes back when the waters recede. The lag time is usually around 6-8 weeks before the onset of a malaria epidemic. Malaria epidemics in the wake of flooding are a well-known phenomenon in malaria-endemic areas world-wide. For instance, an earthquake and subsequent flooding in Costa Rica’s Atlantic region in 1991 and flooding on the Dominican Republic in 2004 led to malaria outbreaks. Periodic flooding linked to El Nino-Southern Oscillation (ENSO) is associated with malaria epidemics in the dry coastal region of northern Peru and with the resurgence of dengue in the past 10 years throughout the American continent.

No real risk posed by corpses

According to the WHO and contrary to common belief, there is no evidence that corpses pose a risk of disease “epidemics” after natural disasters. Most agents do not survive long in the human body after death (with the exception of HIV -which can be up to 6 days) and the source of acute infections is more likely to be the survivors. Human remains only pose health risks in a few special cases requiring specific precautions, such as deaths from cholera or haemorrhagic fevers.

“However, workers who routinely handle corpses may have a risk of contracting tuberculosis, bloodborne viruses (such as Hepatitis B/C and HIV), and gastrointestinal infections (such as rotavirus diarrhoea, salmonellosis, E. coli, typhoid/paratyphoid fevers, hepatitis A, shigellosis and cholera). Tuberculosis can be acquired if the bacillus is aerosolized (residual air in lungs exhaled, fluid from lungs spurted up through nose/ mouth during handling of the corpse). Exposure to bloodborne viruses occurs due to direct contact with non-intact skin of blood or body fluid, injury from bone fragments and needles, or exposure to the mucous membranes from splashing of blood or body fluid. Gastrointestinal infections are more common as dead bodies commonly leak faeces. Transmission occurs via the faeco-oral route through direct contact with the body and soiled clothes or contaminated vehicles or equipment. Dead bodies contaminating the water supply may also cause gastrointestinal infections”, the statement said.

Other health risks posed by flooding
• These include drowning and injuries or trauma. Tetanus is not common after injury from flooding, and mass tetanus vaccination programs are not indicated. However, tetanus boosters may be indicated for previously vaccinated people who sustain open wounds or for other injured people depending on their tetanus immunization history. Passive vaccination with tetanus immune globulin (Hypertet) is useful in treating wounded people who have not been actively vaccinated and those whose wounds are highly contaminated, as well as those with tetanus.
• Hypothermia may also be a problem, particularly in children, if trapped in floodwaters for lengthy periods. There may also be an increased risk of respiratory tract infections due to exposure (loss of shelter, exposure to flood waters and rain).
• Power cuts related to floods may disrupt water treatment and supply plants thereby increasing the risk of water-borne diseases as described above but may also affect proper functioning of health facilities, including cold chain.

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