Global & Disaster Medicine

Archive for October, 2017

Plague in Madagascar


“…From 1 August to 24 October 2017, a total of 1 309 suspected cases of plague, including 93 deaths (7%), were reported. Of these, 882 (67%) were clinically classified as pulmonary plague, 221 (17%) were bubonic plague, 1 was septicaemic, and 186 were unspecified (further classification of cases is in process). Since the beginning of the outbreak, 71 healthcare workers (with no deaths) have been affected….”


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.

Puerto Rico has reported at least 76 cases of suspected and confirmed leptospirosis


“….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)…..”

WHO & Somalia working together to curb measles epidemic (almost 19 000 suspected cases reported in 2017)


WHO enhances surveillance capacity in Somalia ahead of nationwide measles campaign

25 October 2017, Puntland, Somalia—The World Health Organization (WHO) and Somali Federal Ministry of Health have conducted a series of trainings to enhance national capacity in early outbreak detection and response for measles ahead of a nationwide measles vaccination campaign in November.

The trainings aim to enhance measles case-based surveillance and laboratory confirmation, improve measles case management during seasonal outbreaks, and achieve the minimum routine measles vaccination coverage of 95%.

Somalia is currently facing its worst measles outbreak in 4 years, with almost 19 000 suspected cases reported in 2017 (as of 24 October). More than 80% of those affected by the current outbreak are children under 10 years of age. Minimum routine measles vaccination coverage is only 60%.

In early 2017, WHO and partners, in collaboration with national health authorities, vaccinated almost 600 000 children aged 6 months to 5 years for measles in hard-to-reach and hotspot areas across the country. Despite these efforts, the transmission of measles continues, compounded by the ongoing pre-famine situation, continued mass displacement, and undernourished children living in unhygienic conditions.

In order to contain the outbreak, a nationwide campaign is planned for November 2017 to stop transmission of the disease, targeting 4.2 million children. The campaign will also intensify efforts to strengthen routine immunization and reach unvaccinated children to boost their immunity.

“The Federal Ministry of Health (FMOH) has repeatedly highlighted the importance of surveillance in public health. Based on this national vision, public health professionals in Somalia are being updated on the measles case-based surveillance process,” said Dr Ghulam Popal, WHO Representative in Somalia. “FMOH and WHO are actively scaling up efforts to improve measles case management during outbreaks in general and ensure the proper implementation and high coverage of the upcoming measles campaign in particular,” he added.

On 24 October, WHO and FMOH concluded a 3-day training course on case-based surveillance for 35 health workers in Puntland. A training of trainers on measles campaign preparation and implementation was conducted in Mogadishu for 18 participants from the Ministry of Health, EPI Directorate, and other health partners on 16 October. At the regional level, a 2-day training course on measles epidemiology and outbreak response took place on 17–18 October for 68 participants from the South Central zones and the two States of Hiran Shabelle and Southwest.

WHO’s response to disease outbreaks, drought, and nutrition needs in Somalia has been made possible through the generous support of Japan, Germany, the Vaccine Alliance (GAVI), the Polio Global Eradication Initiative, the UN Central Emergency Relief Fund (CERF), and the UK Department for International Development (DFID).

Related links

WHO and Federal Ministry of Health of Somalia call for urgent support to address measles outbreak in Somalia
16 August 2017

WHO and partners scale up response in Somalia to protect children from deadly measles outbreak 
25 July 2017

WHO conducts measles surveillance workshop in Hargeisa
13 June 2017

Measles vaccination campaign launched in Mogadishu
21 May 2017

For more information, contact:

Ajyal Sultany, Communications Officer,

Interim results from Australia: Flu vaccine has an effectiveness of 33%!


Sullivan Sheena G, Chilver Monique B, Carville Kylie S, Deng Yi-Mo, Grant Kristina A, Higgins Geoff, Komadina Naomi, Leung Vivian KY, Minney-Smith Cara A, Teng Don, Tran Thomas, Stocks Nigel, Fielding James E. Low interim influenza vaccine effectiveness, Australia, 1 May to 24 September 2017. Euro Surveill. 2017;22(43):pii=17-00707.

“….Our study indicates that the new H7N9 mutants are lethal to chickens and pose an increased threat to human health, and thus highlights the need to control and eradicate the H7N9 viruses to prevent a possible pandemic…..”

Cell Research

Alice Y Guh, Susan Hocevar Adkins, Qunna Li, Sandra N Bulens, Monica M Farley, Zirka Smith, Stacy M Holzbauer, Tory Whitten, Erin C Phipps, Emily B Hancock, Ghinwa Dumyati, Cathleen Concannon, Marion A Kainer, Brenda Rue, Carol Lyons, Danyel M Olson, Lucy Wilson, Rebecca Perlmutter, Lisa G Winston, Erin Parker, Wendy Bamberg, Zintars G Beldavs, Valerie Ocampo, Maria Karlsson, Dale N Gerding, L Clifford McDonald; Risk Factors for Community-Associated Clostridium difficile Infection in Adults: A Case-Control Study, Open Forum Infectious Diseases, Volume 4, Issue 4, 1 October 2017, ofx171,

An explosion and inferno at a fireworks factory near Jakarta killed at least 47 and injured dozens today



Legionnaire’s in Queens


Health Department Investigates Community Cluster of Legionnaires’ Disease in Downtown Flushing, Queens

12 confirmed cases of Legionnaires’ disease have been reported in the area in the past two weeks

Legionnaires’ disease cannot be spread from person to person; those at high risk include people aged 50 or older, especially cigarette smokers, people with chronic lung disease or with weakened immune systems

New Yorkers with respiratory symptoms, such as fever, cough, chills and muscle aches, are urged to promptly seek medical attention

October 24, 2017 — The Health Department is currently investigating a community cluster of Legionnaires’ disease cases in downtown Flushing, Queens. A total of 12 patients have been confirmed with Legionnaires’ disease in the area in the past two weeks. Most patients had serious underlying health conditions. The patients range in age from early 30s to late 80s. Five persons are hospitalized and recovering, and seven have been discharged from the hospital. No patients have died. Two more cases are currently being investigated to determine whether they are part of this cluster. The Health Department is actively investigating these cases and has taken water samples from all cooling tower systems within the investigation zone to test for Legionella, the bacteria that causes Legionnaires’ disease. To raise awareness in the community, the Health Department and the Mayor’s Office are working with elected officials and sending outreach teams to transit hubs and senior centers in the area to distribute information about Legionnaires’ disease. The Health Department is also organizing a community meeting to inform residents, answer questions and address any concerns. The Health Department is urging residents in the area with respiratory symptoms, such as fever, cough, chills and muscle aches, to promptly seek medical attention. The Health Department has alerted health care providers in the area about this cluster. Legionnaires’ disease is a treatable infection using antibiotics for pneumonia. Every year, there are between 200 and 400 cases of Legionnaires’ disease in the city.

As of today, the Health Department has sampled all cooling towers in the investigation zone. Testing involves a two-step process that first identifies genetic evidence of the bacteria and then confirms if the bacteria are alive and able to cause disease. Positive results from the first step will enable the Health Department to identify towers that potentially have bacteria capable of making people sick. The owners of those buildings will be ordered to immediately increase the level of biocides that kill the Legionella bacteria or to change to a new biocide and report to the Department within 24 hours. This biocide remediation will be done as a precautionary step while the second step, growing the bacteria in culture, is being done to determine the presence of the live bacteria that causes Legionnaires’ disease. It takes two weeks to allow bacteria adequate time to grow. A positive culture indicates the presence of bacteria capable of causing disease. The Department will order the owner of any building with a positive culture result to fully clean and disinfect the cooling tower.

“The Health Department is currently investigating a cluster of Legionnaires’ disease cases in the downtown Flushing area of Queens, and I urge individuals in this area with respiratory symptoms to seek medical attention right away. People over the age of 50 and people with compromised immune systems are especially at risk,” said Health Commissioner Dr. Mary T. Bassett. “As with our previous Legionnaires’ disease investigations, we are in the process of investigating the source of the cluster and are working with building owners in the area to rapidly test and clean cooling towers.”

Legionnaires’ disease is caused by the bacteria Legionella. Symptoms include fever, cough, chills, muscle aches, headache, fatigue, loss of appetite, confusion and diarrhea. Symptoms usually appear two to 10 days after significant exposure to Legionella bacteria. Most cases of Legionnaires’ disease can be traced to plumbing systems where conditions are favorable for Legionella growth, such as cooling towers, whirlpool spas, hot tubs, humidifiers, hot water tanks, and evaporative condensers of large air-conditioning systems.

Legionnaires’ disease cannot be spread from person to person. Groups at highest risk for Legionnaires’ disease include people who are middle-aged or older, especially cigarette smokers, people with chronic lung disease or weakened immune systems and people who take medicines that weaken their immune systems (immunosuppressive drugs). Those with symptoms should call their doctor and ask about testing for Legionnaires’ disease.

Local Law 77
In response to the Legionnaires’ disease outbreaks of 2015, the Mayor and City Council passed Local Law 77 to reduce and contain Legionella growth in cooling towers, becoming the first U.S. municipality to adopt a set of robust requirements to ensure cooling tower maintenance. Changes to the Health Code went into effect in May 2016. In June of last year, the Health Department announced a plan to reduce the risk of Legionnaires’ disease outbreaks in the city, which, in addition to implementing the most aggressive cooling tower regulation in the nation, included the hiring of more inspectors and training of City personnel to inspect towers and better capacity to conduct lab testing. Since the implementation of the new law, the Department has identified and monitored over 4,000 cooling tower systems (over 6,100 cooling towers) in New York City.

To promote compliance, the Health Department has been educating building owners and managers in best practices for managing their cooling towers. The agency has distributed information about the Management Program and Plan template, how to build a cooling tower system team and general Frequently Asked Questions.

For more information about Legionnaires’ disease, please visit the Health Department website.



MEDIA CONTACT: Christopher Miller/Julien Martinez: (347) 396-4177

Uganda: As of 24 October, 5 cases of Marburg virus disease have been reported – one confirmed case, one probable case with an epidemiological link to the confirmed case, and three suspected cases including two health workers


Marburg virus disease – Uganda

Disease outbreak news
25 October 2017

On 17 October 2017, the Ugandan Ministry of Health notified WHO of a confirmed outbreak of Marburg virus disease in Kween District, Eastern Uganda. The Ministry for Health officially declared the outbreak on 19 October 2017.

As of 24 October, five cases have been reported – one confirmed case, one probable case with an epidemiological link to the confirmed case, and three suspected cases including two health workers.

Chronologically, the first case-patient (probable case) reported was a male in his 30s, who worked as a game hunter and lived near a cave with a heavy presence of bats. On 20 September, he was admitted to a local health centre with high fever, vomiting and diarrhoea, and did not respond to antimalarial treatment. As his condition deteriorated, he was transferred to the referral hospital in the neighbouring district, where he died the same day. No samples were collected. He was given a traditional burial, which was attended by an estimated 200 people.

The sister (confirmed case) of the first case-patient nursed him and participated in the burial rituals. She became ill and was admitted to the same health centre on 5 October 2017 with fever and bleeding manifestations. She was subsequently transferred to the same referral hospital, where she died. She was given a traditional burial. Posthumous samples were collected and sent to the Uganda Virus Research Institute (UVRI). On 17 October, Marburg virus infection was confirmed at UVRI by RT-PCR and it was immediately notified to the Ministry of Health.

The third case-patient (suspected case) is the brother of the first two cases. He assisted in the transport of his sister to the hospital, and subsequently became symptomatic. He refused to be admitted to hospital, and returned to the community. His whereabouts are currently not known though there is an ongoing effort to find him.

Two health workers who were in contact with the confirmed case have developed symptoms consistent with Marburg virus disease and are under investigation (suspected cases). Laboratory results to rule out Marburg virus disease are pending.

Contact tracing and follow-up activities have been initiated. As of 23 October, 155 contacts including 66 who had contact with the first case and 89 who had contact with the second case-patient have been listed in the two affected districts, including 44 health care workers. The number of family and community contacts is still being investigated.

Public health response

  • The Ugandan Ministry of Health has rapidly responded to the outbreak, with support from WHO and partners. A rapid response field team was deployed to the two affected districts within 24 hours of the confirmation.
  • To coordinate response activities, the National Task Force has convened, an Incident Management System (IMS) framework implemented with an Incident Manager appointed, a District Task Force has been established, and an emergency rapid response plan has been developed.
  • Marburg virus disease response activities have been initiated, including surveillance, active case search, contact tracing and follow-up, as well as monitoring within affected communities and healthcare centres.
  • Personal protective equipment has been deployed in the affected districts. Healthcare workers have been put on high alert and training sessions are planned, including a thorough review of infection prevention and control (IPC) protocols and capacity. An isolation facility is being prepared at the health centre and the hospital.
  • Training of teams for safe and dignified burials has been conducted in affected districts.
  • Community engagement and awareness campaigns are ongoing to reduce stigma, encourage reporting and early healthcare seeking behaviours, and acceptance of prevention measures. Information, education and communication materials and messages have been updated and are being produced.
  • International partners and stakeholders have been engaged at country level, and internationally to provide support and technical assistance for the response as needed. WHO has deployed additional staff, and six viral haemorrhagic fever (VHF) kits. Funding has been provided from the WHO Contingency Fund for Emergencies to ensure immediate support and scale up the response. WHO has alerted partners in the Global Outbreak Alert and Response Network (GOARN), and is coordinating international support for the response.
  • UNICEF is assisting with communication activities, and community engagement.
  • Médecins Sans Frontières has deployed to support setting up of treatment centres.

WHO risk assessment

Marburg virus disease is an emerging and highly virulent epidemic-prone disease associated with high case fatality rates (case fatality rate: 23–90%). Marburg virus disease outbreaks are rare. The virus is transmitted by direct contact with the blood, body fluids and tissues of infected persons or wild animals (e.g. monkeys and fruit bats).

Candidate experimental treatments and vaccine are being reviewed for potential clinical trials.

Uganda has previous experience in managing recurring viral haemorrhagic fever outbreaks including Marburg virus disease. Cases have historically been reported among miners and travellers who visited caves inhabited by bat colonies in Uganda. Marburg virus disease outbreaks have been documented during:

  • 2007 – 4 cases, including 2 deaths in Ibanda District, Western Uganda;
  • 2008 – 2 unrelated cases in travellers returning to the Netherlands and USA, respectively after visiting caves in Western Uganda;
  • 2012 – 15 cases, including 4 deaths in Ibanda and Kabale districts, Western Uganda; and
  • 2014 – 1 case in healthcare professional from Mpigi District, Central Uganda.

As of 24 October, five cases have been identified – one confirmed case, one probable case, and three suspected cases, and the outbreak remains localised. Ugandan health authorities have responded rapidly to this event, and measures are being rapidly implemented to control the outbreak. The high number of potential contacts in extended families, at healthcare facilities and surrounding traditional burial ceremonies is a challenge for the response. In addition, hospitalised cases were handled in general wards without strict infection control precautions, and one probable case refused to be hospitalised for a period of time.

The affected districts are in a rural, mountainous area located on the border with Kenya, about 300km northeast of Kampala on the northern slopes of Mount Elgon National Park. The Mount Elgon caves are a major tourist attraction, and are host to large colonies of cave-dwelling fruit bats, known to transmit the Marburg virus. The close proximity of the affected area to the Kenyan border, and cross-border movement between the affected district and Kenya and the potential transmission of the virus between colonies and to humans, increases the risk of cross-border spread.

These factors suggest a high risk at national and regional level, requiring an immediate, coordinated response with support from international partners. Tourism to Mount Elgon including the caves and surrounding areas should be noted and appropriate advice given and precautions taken. The risk associated with the event at the global level is low.

WHO advice

Human-to-human transmission of Marburg virus is primarily associated with direct contact with blood and body fluids, and Marburg virus transmission associated with provision of health care has been reported when appropriate infection control measures have not been observed.

Health-care workers caring for patients with suspected or confirmed Marburg virus should apply infection control precautions to avoid any exposure to blood and body fluids, and unprotected contact with possibly contaminated environment.

Surveillance activities, including contact tracing and active case search must be strengthened within all affected health zones.

Raising awareness of the risk factors for Marburg infection and the protective measures individuals can take to reduce human exposure to the virus, are the key measures to reduce human infections and deaths. Key public health communication messages include:

  • Reducing the risk of bat-to-human transmission arising from prolonged exposure to mines or caves inhabited by fruit bats colonies. During work or research activities or tourist visits in mines or caves inhabited by fruit bat colonies, people should wear gloves and other appropriate protective clothing (including masks).
  • Reducing the risk of human-to-human transmission in the community arising from direct or close contact with infected patients, particularly with their body fluids. Close physical contact with Marburg patients should be avoided. Gloves and appropriate personal protective equipment should be worn when taking care of ill patients at home. Regular hand washing should be performed after visiting sick relatives in hospital, as well as after taking care of ill patients at home.
  • Communities affected by Marburg should make efforts to ensure that the population is well informed, both about the nature of the disease itself to avoid community stigmatization, and encourage early presentation to treatment centres and other necessary outbreak containment measures, including burial of the dead. People who have died from Marburg should be promptly and safely buried.

WHO advises against the application of any travel or trade restrictions on Uganda or the affected area based on the current information available on this event. Travellers to the Mount Elgon bat caves are advised to avoid exposure to bats and contact with non-human primates, and, to the extent possible, to wear gloves and protecting clothing, including masks .

For further information on Marburg virus disease and prevention and control measures is available in the WHO Marburg virus disease factsheet.

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.


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