- Aboukheir MK, et al. MMWR Morb Mortal Wkly Rep. 2019;68:46-47; Degraw C, et al. MMWR Morb Mortal Wkly Rep. 2006;55:332-335.
Hurricane Maria made landfall in Puerto Rico on Sept. 20, 2017, two weeks after Hurricane Irma left approximately 1 million Puerto Ricans without electricity. Maria produced high winds and catastrophic flash floods, resulting in damage to critical infrastructure and leaving large areas of the population without access to clean water, transportation and health care services.
During the first week after Maria, 58 of the 69 hospitals on the island had no electrical power or fuel for generator usage. People from economically disadvantaged communities were the most heavily affected, especially the medically frail and those more reliant on health care services, including people undergoing treatment for tuberculosis (TB).
During the initial response to a natural disaster, provision of shelter, sanitation, water and food are the most urgent public health priorities. Yet, it also is important to minimize the potential spread of infectious disease organisms, including Mycobacterium tuberculosis, during resettlement of displaced people.
How TB spreads
Tuberculosis is caused by infection with organisms of the M. tuberculosis complex and manifests with pulmonary and/or extrapulmonary signs and symptoms. Transmission of M. tuberculosis complex is airborne via inhalation of droplet nuclei produced by people with contagious upper or lower respiratory tract disease.
In the U.S., tuberculosis occurs most predominantly in urban, low-income areas and among specific groups, including immigrants and refugees, international adoptees, travelers from high-prevalence regions, intravenous drug users, and people living in correctional facilities or other congregate settings such as shelters.
During natural disasters, there may be a higher risk of transmission since many people are evacuated from their homes and seek safety in shelters or relocate to new communities where spread may occur.
Treatment regimens
In contrast to many other infectious diseases, successful treatment of tuberculosis is a critical public health responsibility. Standard treatment requires multidrug regimens administered for a minimum of six months. To ensure eradication of tuberculosis during treatment, directly observed therapy (DOT) is undertaken whereby a health care professional or trained third party administers medications to the patient and observes and documents that each dose is ingested.
Although contagiousness usually lasts no longer than a few weeks after initiation of effective drug therapy, it can last for months in patients with a positive acid-fast sputum smear and ongoing pulmonary symptoms. Therefore, interruptions in therapy may result in inadequate treatment, thus increasing the risk for transmission among close contacts.
TB treatment after hurricanes
After Hurricane Katrina struck the U.S. Gulf Coast in August 2005, more than 100 Louisiana residents undergoing treatment for tuberculosis lost access to DOT services when the Louisiana TB Control Program was forced to abandon its headquarters. Although all patients had been located by October 2005 and therapy was resumed if indicated, the extended period without therapy posed public health risks to communities across the U.S. where the New Orleans-area patients were relocated (see map).
Initial reported locations* of New Orleans-area residents who had been undergoing tuberculosis treatment
Critical lessons were learned from Hurricane Katrina prompting development of preparedness plans that have been utilized by tuberculosis programs in Louisiana and Texas in advance of Hurricane Rita and in Puerto Rico in the wake of Hurricane Maria.
On the island, the Puerto Rico Department of Health Tuberculosis Control Program (PRTB) oversees tuberculosis surveillance and control activities via six regional clinics. Generally, the PRTB utilizes both in-person DOT and video-observed therapy (vDOT) using a smartphone to ensure adherence to TB treatment. Following Hurricane Maria, widespread and prolonged power outages and disruption in wireless communication prevented the use of vDOT to monitor patients.
In anticipation of the hurricane, PRTB implemented its preparedness plan, which ensured the provision of a one-month supply of anti-TB medications to all patients before the storms arrived. Patients were encouraged to report their diagnosis to health officers within shelters if they needed to be relocated from their homes. Additionally, the Puerto Rico Department of Health recommended that all shelters screen people for various infectious diseases, including tuberculosis, rabies and leptospirosis, at time of entry.
Although the storms significantly damaged PRTB facilities, including the laboratory, limited operations were resumed by the fifth day after Hurricane Maria had passed, and the staff prioritized contacting patients with active TB (n=27). After 21 working days, all 27 high-priority patients had been accounted for. No patients experienced an interruption in treatment or were lost to follow-up.
Notably, the PRTB control program has strengthened its preparedness plan. Due to concerns regarding delay in external aid following severe natural disasters, it plans to ensure that a minimum two-month supply of TB medication is available in each regional clinic. Also, each clinic has been charged to develop its own emergency response plan based on available resources and the potential needs of the communities it serves.
A. Which of the following are components of the PRTB disaster preparedness plan?
B. Provision of at least a one-month supply of anti-TB medications to all patients with active TB infection.
C. Patient education promoting disclosure of TB diagnosis to the health officers of shelters and temporary housing facilities.
D. Implementation of screening procedures for pre-specified infectious diseases by shelter health officers and staff members at time of entry.
E. All of the above.
Answer: D
Dr. Grimsley Ackerley is a post-graduate training fellow in adult and pediatric infectious diseases at Emory University School of Medicine and Children’s Healthcare of Atlanta (CHOA). Dr. Pickering is adjunct professor of pediatrics at Emory University School of Medicine and CHOA.
