Global & Disaster Medicine

Archive for the ‘Flood’ Category

Puerto Rico: Official Death Toll: 62. Actual Deaths May Be 1,052.

NY Times

“…..The Times’s analysis found that in the 42 days after Hurricane Maria made landfall on Sept. 20 as a Category 4 storm, 1,052 more people than usual died across the island. The analysis compared the number of deaths for each day in 2017 with the average of the number of deaths for the same days in 2015 and 2016.…..”


The Nov. 21 floods in Jeddah killed 3 and left peple wondering if anything has changed to help rehabilitate infrastructure.



Approximately 1 month after the flood, the Louisiana Office of Public Health received notification through electronic laboratory reporting of two patients with serologic evidence of leptospirosis


Notes from the Field: Postflooding Leptospirosis — Louisiana, 2016

In August 2016, extensive flooding occurred in south-central Louisiana. Approximately 1 month after the flood, the Louisiana Office of Public Health received notification through electronic laboratory reporting of two patients with serologic evidence of leptospirosis (immunoglobulin M antibodies to Leptospira species). Both patients were hospitalized with severe illness at the time of laboratory testing and recovered after appropriate treatment. Hospital record review revealed that both patients were exposed to floodwater before illness onset. Because these two (sentinel) patients with leptospirosis represented a marked increase over the three cases reported in their respective parishes of residence during the previous 28 years (1), an investigation was undertaken to identify other cases of leptospirosis related to the 2016 flood.

Leptospirosis is a bacterial disease caused by infection with pathogenic Leptospira species (2). Humans can be infected through direct contact with urine from an infected animal or by contact with urine-contaminated soil or water, often during flooding (3). Approximately 90% of patients with leptospirosis experience a nonspecific, self-limited illness with symptoms of fever, chills, nausea, or headache (2). Pain in the calf and low back muscles and conjunctival suffusion without purulent discharge are distinctive features (2). Approximately 10% of patients develop severe illness, which is characterized by any combination of jaundice, renal failure, aseptic meningitis, cardiac arrhythmia, gastrointestinal symptoms, pulmonary hemorrhage, or circulatory collapse and is associated with a 5%–15% case fatality rate (2).

Image of someone working the soil.

Suspected leptospirosis cases were defined as the occurrence of fever with at least two nonspecific symptoms (myalgia, headache, jaundice, conjunctival suffusion, or maculopapular or petechial rash), or at least one diagnosis indicating severe illness (aseptic meningitis, renal insufficiency, pulmonary complications, electrocardiogram abnormalities, gastrointestinal symptoms, hemorrhage, or jaundice with acute renal failure) during August 13–September 21, 2016 in a patient exposed to floodwater (4). The Louisiana Early Events Detection System (LEEDS), a statewide electronic syndromic surveillance system, was queried to identify patients treated in hospitals serving the flood region during August 13–September 21 who had signs, symptoms, or diagnoses compatible with leptospirosis. The dates were selected to include the flooding period (August 11–August 20) and a leptospirosis incubation period beginning 2 days after flooding started and continuing through 30 days after water recession (2). Hospital records of patients meeting the symptoms or diagnosis components of the case definition were reviewed; patients without fever or with laboratory evidence supporting an alternative diagnosis were eliminated. The remaining patients were interviewed to ascertain floodwater exposure; those with floodwater exposure provided whole blood and urine specimens for leptospirosis polymerase chain reaction (PCR) testing and a serum specimen for microscopic agglutination test (MAT) testing. MAT was also performed on serum from both sentinel patients. An acute urine specimen from one sentinel patient was tested by PCR. All laboratory testing was performed by CDC.

LEEDS queries yielded 69 patients warranting medical record review. After eliminating patients who did not meet the case definition based on medical record review, 13 of 18 patients who met the case definition were contacted for interview; among these, four reported floodwater exposure and submitted blood and urine specimens. MAT and PCR were negative for Leptospira spp. infection among all LEEDS-identified patients. Leptospirosis was confirmed by MAT in both sentinel patients; urine PCR identified Leptospira kirschneri DNA in one sentinel patient.

Leptospira species are prevalent among Louisiana wildlife. According to the Louisiana Department of Wildlife and Fisheries (LDWF), anti-Leptospira spp. seroprevalence in the Louisiana feral swine population was 71% in 2015 (Rusty Berry, DVM, LDWF, personal communication, November 9, 2016), which is markedly higher than the 26% estimated by the United States Department of Agriculture in 2012 (5). LDWF surveillance also identified a substantial increase in leptospirosis in the deer population, from an average seroprevalence of 7% during 2007–2012 to 42% during the 2015–2016 hunting season. (Rusty Berry, DVM, LDWF, personal communication, November 9, 2016 and July 6, 2017).

No additional confirmed cases of postflooding leptospirosis were identified. Nonetheless, cases might have been missed because of flood-related access to care difficulties and patients not seeking medical care for less than severe illness. However, given the endemicity of Leptospira spp. among Louisiana wildlife, including documented L. kirschneri in feral swine isolates (6), and the two recent flood-related cases of leptospirosis, a high index of suspicion for leptospirosis among patients with compatible symptoms and exposure to untreated water is warranted, especially during flooding. Educating the public about leptospirosis prevention and clinicians about its clinical presentation might decrease the prevalence of severe disease by enabling early identification and treatment.

CDC recommendations to healthcare providers treating patients in Puerto Rico and USVI, as well as those treating patients in the continental US who recently traveled in hurricane-affected areas during the period of September 2017 – March 2018.


Advice for Providers Treating Patients in or Recently Returned from Hurricane-Affected Areas, Including Puerto Rico and US Virgin Islands

Distributed via the CDC Health Alert Network
October 24, 2017, 1330 ET (1:30 PM ET)

The Centers for Disease Control and Prevention (CDC) is working with federal, state, territorial, and local agencies and global health partners in response to recent hurricanes. CDC is aware of media reports and anecdotal accounts of various infectious diseases in hurricane-affected areas, including Puerto Rico and the US Virgin Islands (USVI). Because of compromised drinking water and decreased access to safe water, food, and shelter, the conditions for outbreaks of infectious diseases exist.

The purpose of this HAN advisory is to remind clinicians assessing patients currently in or recently returned from hurricane-affected areas to be vigilant in looking for certain infectious diseases, including leptospirosis, dengue, hepatitis A, typhoid fever, vibriosis, and influenza. Additionally, this Advisory provides guidance to state and territorial health departments on enhanced disease reporting.


Hurricanes Irma and Maria made landfall in Puerto Rico and USVI in September 2017, causing widespread flooding and devastation. Natural hazards associated with the storms continue to affect many areas. Infectious disease outbreaks of diarrheal and respiratory illnesses can occur when access to safe water and sewage systems are disrupted and personal hygiene is difficult to maintain. Additionally, vector borne diseases can occur due to increased mosquito breeding in standing water; both Puerto Rico and USVI are at risk for outbreaks of dengue, Zika, and chikungunya.

Health care providers and public health practitioners should be aware that post-hurricane environmental conditions may pose an increased risk for the spread of infectious diseases among patients in or recently returned from hurricane-affected areas; including leptospirosis, dengue, hepatitis A, typhoid fever, vibriosis, and influenza. The period of heightened risk may last through March 2018, based on current predictions of full restoration of power and safe water systems in Puerto Rico and USVI.

In addition, providers in health care facilities that have experienced water damage or contaminated water systems should be aware of the potential for increased risk of infections in those facilities due to invasive fungi, nontuberculous Mycobacterium species, Legionella species, and other Gram-negative bacteria associated with water (e.g., Pseudomonas), especially among critically ill or immunocompromised patients.

Cholera has not occurred in Puerto Rico or USVI in many decades and is not expected to occur post-hurricane.



These recommendations apply to healthcare providers treating patients in Puerto Rico and USVI, as well as those treating patients in the continental US who recently traveled in hurricane-affected areas (e.g., within the past 4 weeks), during the period of September 2017 – March 2018.

  • Health care providers and public health practitioners in hurricane-affected areas should look for community and healthcare-associated infectious diseases.
  • Health care providers in the continental US are encouraged to ask patients about recent travel (e.g., within the past 4 weeks) to hurricane-affected areas.
  • All healthcare providers should consider less common infectious disease etiologies in patients presenting with evidence of acute respiratory illness, gastroenteritis, renal or hepatic failure, wound infection, or other febrile illness. Some particularly important infectious diseases to consider include leptospirosis, dengue, hepatitis A, typhoid fever, vibriosis, and influenza.
  • In the context of limited laboratory resources in hurricane-affected areas, health care providers should contact their territorial or state health department if they need assistance with ordering specific diagnostic tests.
  • For certain conditions, such as leptospirosis, empiric therapy should be considered pending results of diagnostic tests— treatment for leptospirosis is most effective when initiated early in the disease process. Providers can contact their territorial or state health department or CDC for consultation.
  • Local health care providers are strongly encouraged to report patients for whom there is a high level of suspicion for leptospirosis, dengue, hepatitis A, typhoid, and vibriosis to their local health authorities, while awaiting laboratory confirmation.
  • Confirmed cases of leptospirosis, dengue, hepatitis A, typhoid fever, and vibriosis should be immediately reported to the territorial or state health department to facilitate public health investigation and, as appropriate, mitigate the risk of local transmission. While some of these conditions are not listed as reportable conditions in all states, they are conditions of public health importance and should be reported.


For More Information

Today’s FEMA SitRep on Puerto Rico and USVI after the hurricanes

FEMA Sit Rep

Puerto Rico

• Shelters: 92 shelters open with 4,154 (-102) occupants
• Disaster Assistance Registrations: 792k Power Outages / Restoration
• 21.6% (+5%) of customers with power restored
• 25.4% of transmission lines energized; 36.5% substations energized
• Generator failure reported in Centro Medico; emergency generators to be installed
• PREPA estimating 95% to be restored by December 15
• 85% (+24) of population live in areas where wireless coverage is available for voice and text messages
Health & Medical
• 61 (-2) of 67 hospitals open
• 2 Federal Medical Stations operational Water Restoration
• 72% of PRASA customers have potable water service
• 65 water filter plants are operating
Guajataca Dam
• Water has stopped flowing over spillway; reservoir pool is 4 feet below spillway; there is no longer any seepage noted under spillway slabs
U.S. Virgin Islands
• Shelters: 5 shelters open with 290 (-17) occupants
• Disaster Assistance Registrations: 14.9k
Power Outages / Restoration
Customers receiving power from grid: St. Thomas: 29% St. Croix: 1.6%; St. John: no grid power, restoration expected in 2-3 weeks Communications:
• 88% of population lives in area where wireless coverage is available for voice and text
Health & Medical
St. Thomas: Schneider Medical Center sustained damage; established mobile medical facility
• St. Croix: Charles Harwood Facility closed; Governor Juan Luis Hospital partially open despite damage
FEMA Response
• NRCC: Modified Level III (day shift, 8:00 am – 6:00 pm EDT)
National IMAT East-1 & 2, & Region III IMAT deployed to PR
• FEMA Region II & X IMATs: deployed to USVI • MERS teams deployed to both USVI & PR

NEJM: The View from Puerto Rico — Hurricane Maria and Its Aftermath


The View from Puerto Rico — Hurricane Maria and Its Aftermath

Carmen D. Zorrilla, M.D.

DOI: 10.1056/NEJMp1713196

“…..As of 16 days after the hurricane, 25 hospitals were working, only 9.2% of people had power, 54% had water, 45% had cell phone service, and the Federal Emergency Management Agency had distributed 433,000 food packages and 42,000 gallons of water…….”

Puerto Rico Goes Dark


Puerto Rico Goes Dark

Late on September 21, 2016, a fire at a power plant substation in southern Puerto Rico triggered a cascade of problems across the island’s aging electrical grid. The event knocked out power to nearly 1.5 million customers.

From space, the effects appeared dramatic. The Visible Infrared Imaging Radiometer Suite (VIIRS) on the Suomi NPP satellite captured these nighttime images of Puerto Rico before and after the outage. The upper image was acquired at 2:50 a.m. local time (06:50 Universal Time) on September 21, 2016; the lower image shows the island at 2:31 a.m. local time (06:31 Universal Time) on September 22, 2016.

Both images were captured by the VIIRS “day-night band,” which detects light in a range of wavelengths from green to near-infrared and uses filtering techniques to observe signals such as gas flares, city lights, and reflected moonlight. Note that the brightness of the ocean surface varies between the images due to slightly different angles of moonlight on the water. Use the slider tool to compare the images.

The widespread loss of electricity appears across Puerto Rico in all areas outside of the San Juan metropolitan area. Ponce, Humacao, Aguadilla, Arecibo, and Mayagüez all had large numbers of customers losing power.

The fire occurred at the Aguirre power plant in Salinas after a power switch overheated. This caused a 2,000-gallon (8,000 liter) mineral oil tank to explode and trigger a fire across a 3-acre (1 hectare) area. According to news reports, the collapse of the power system has caused widespread losses of water and air conditioning, traffic jams, and business and school closures.

“With something of this scale, we’re not just seeing an outage. We are seeing a complete stoppage in the rhythms of daily life,” said Miguel Román, a scientist at NASA Goddard Space Flight Center and member of the Suomi NPP science team.

“These nighttime satellite images help bring a level of situational awareness so we can clearly identify the extent of the impacts into key lifelines of a city’s infrastructure,” added David Green, the program manager for NASA’s Disaster Response Program. “We hope that power, civil, and health authorities can use imagery and data like this to map the extent of affected areas and prioritize their personnel and resources to restore critical infrastructure.”

NASA Earth Observatory image by Jesse Allen, using VIIRS day-night band data from the Suomi National Polar-orbiting Partnership provided by Miguel Roman (NASA/GSFC). Suomi NPP is the result of a partnership between NASA, the National Oceanic and Atmospheric Administration, and the Department of Defense. Caption by Adam Voiland.



Puerto Rico: Grappling with growing health concerns due to a lack of reliable access to medical care, supplies and clean water.


  • The official death count has risen to 34 from 16.
  • Thr deaths were due to failed oxygen delivery following electrical outages.
  • Other causes of death include suicide following the storm, heart attacks and drownings.
  • Two deaths occurred during search and rescue operations.


9/28/17: Puerto Rico Landscape Ravaged by Hurricane Maria

Puerto Rico Landscape Ravaged by Hurricane Maria

acquired September 26, 2017 download large image (1 MB, JPEG, 2490×2713)
Puerto Rico Landscape Ravaged by Hurricane Maria

acquired September 23, 2016 download large image (1 MB, JPEG, 2490×2713)
acquired September 23, 2016 download large image (406 KB, JPEG, 720×480)
acquired September 26, 2017 download large image (342 KB, JPEG, 720×480)

Hurricane Maria tore across Puerto Rico on September 20, 2017, ravaging both urban and rural areas with category 4 winds and intense rainfall for several days. Most of the electric power grid and telecommunications network was knocked offline; towns both inland and at the coast were swamped with floodwaters and storm surges; and the lush green landscape turned brown from damaged vegetation and mud and debris deposits.

On September 26, 2017, the Operational Land Imager (OLI) on the Landsat 8 satellite captured some of the first natural-color satellite images of Puerto Rico after Hurricane Maria. Cloud cover is common in the tropics and has been particularly bad in the days since the storm, so researchers have been unable to see much from orbit.

The images above show the Rio Grande de Loíza, the island’s largest river by volume, where it meets the Atlantic Ocean several miles east of San Juan and west of Suárez. The images below show an interior portion of the island around the Lago Loíza reservoir, south of San Juan and north of Caguas. In each pair the second image shows the same area one year ago (September 23, 2016) so as to provide a proper seasonal comparison. (Note: the green color of the lake in 2016 could be an algae bloom or some other form of water vegetation.)

NASA’s Disasters Program has delivered to the Federal Emergency Management Agency (FEMA) a map of areas in eastern Puerto Rico that have likely been damaged as the result of the landfall of Hurricane Maria. The “damage proxy map” was created by the Advanced Rapid Imaging and Analysis team (Jet Propulsion Laboratory) and derived from synthetic aperture radar images from the European Space Agency’s Copernicus Sentinel-1A and Sentinel-1B satellites.

The National Oceanic and Atmospheric Administration is making aerial surveys of the U.S. states and territories affected by hurricanes Harvey, Irma, and Maria. Click here to see photos as they become available.

NASA Earth Observatory image by Joshua Stevens, using Landsat data from the U.S. Geological Survey. Story by Mike Carlowicz.

Landsat 8 – OLI
Landsat 8 – TIRS

NYC is home to 700,000 Puerto Ricans & what are they doing about Puerto Rico?

NY Times

“…..Gov. Andrew M. Cuomo announced the launch of the Empire State Relief and Recovery Effort for Puerto Rico, and Mayor Bill de Blasio sent emergency workers to the island to provide aid.

There are now more than 140 city personnel on the ground in Puerto Rico.

Among them: New York Task Force One, our urban search and rescue team; workers from the city’s Buildings Department who have expertise in inspections; members of our Police and Fire Departments who specialize in structural collapses and water rescues; and members of both departments’ Hispanic societies…..”



A dam in northwestern Puerto Rico suffered structural damage on Friday prompting the evacuation of 70,000 nearby in the aftermath of Hurricane Maria.

NY Times



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