Health and the Environment after Hurricane Katrina
2006; American College of Physicians; Volume: 144; Issue: 2 Linguagem: Inglês
10.7326/0003-4819-144-2-200601170-00029
ISSN1539-3704
Autores Tópico(s)Disaster Response and Management
ResumoCurrent Clinical Issues17 January 2006Health and the Environment after Hurricane KatrinaFREEJennifer Fisher WilsonJennifer Fisher WilsonAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-144-2-200601170-00029 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail When microbiologists went to emergency shelters 4 days after Hurricane Katrina struck the Gulf Coast on 29 August 2005, they faced oppressive heat, darkness from downed power lines, difficulty communicating by telephone, little fuel for their cars, and widespread devastation. Kellogg Schwab, PhD, assistant professor and co-director of the Johns Hopkins University Center for Water and Health, and his colleagues found that many shelters with running water had no equipment for determining if the water was safe. Some shelters with water that was known to be unsafe to drink considered turning it off entirely, a safety measure that in itself posed other health risks, since that meant people had to use portable toilets and forgo hand-washing and showers, Schwab said. There was concern that contaminated water would cause pervasive health problems.But this concern, and many other early health concerns related to the hurricane, proved less warranted than had been feared. A lack of water, food, shelter, and sanitation facilities led to dehydration and food poisoning in some instances, but large-scale communicable disease outbreaks of diarrhea and respiratory illness related to the contaminated food and water did not materialize. Warnings about typhoid and cholera proved unnecessary. After all, said Sandra Kemmerly, MD, medical director of infection control at Ochsner Clinic Foundation in New Orleans, "we do not have those infectious diseases in this country." Doctors at emergency clinics mostly provided chronic disease management and treated such acute minor injuries as lacerations, bites, and broken bones.With a few hospitals open throughout the crisis and with clinics available in emergency shelters and elsewhere, there was a general sense that access to good health care was available for anyone who needed it, according to Jeffrey G. Wiese, MD, the director of the internal medicine residency program at Tulane University and chief of medicine at the Medical Center of Louisiana at New Orleans. But, as the initial crisis has faded, health officials have recognized the potential for continued and lasting health effects from Hurricane Katrina, particularly in the New Orleans area. Threats lie in the mountainous debris; faulty sewage treatment; toxic chemical and oil spills; contaminated water; swirling dust; pesky insects and vermin; and mold, mold, and more mold. The potential severity of these threats remains mostly a mystery that public health officials are trying to solve."It's important to get our hands around the science and move rapidly to recovery," said George Benjamin, MD, executive director of the American Public Health Association, at an Institute of Medicine (IOM) meeting on the environmental impacts of Hurricane Katrina held last fall in Washington, DC. In an effort to do just that, public health officials and medical researchers are moving to assess the damage and determine the short-term and long-term health effects. Meanwhile, most New Orleans hospitals damaged by flooding have reopened and found ways to care for patients, but many require major rebuilding to return to a full-service capacity. Hospitals that were destroyed, including Tulane's "Big Charity" Hospital, face an uncertain future. With many New Orleans residents still living elsewhere, staffing hospitals completely has proven difficult, and most patients are uninsured, indigent workers. "We have a long way to go in monitoring and addressing regional health concerns from the hurricane," said Paul G. Rogers, JD, chair of the IOM roundtable on environmental health sciences, research, and medicine. Because hurricanes, earthquakes, and other natural events have recently overshadowed America's terrorism fears, he noted, "we will perform a great service if we can make progress here applicable to other natural disasters in the future."Assessing Environmental RisksThe hurricane demonstrated the need for improved standards for reporting and disseminating data on the environmental health effects of a natural disaster. Schwab noted that even basic definitions for dysentery, cholera, gastroenteritis, and other infectious conditions were needed in order to make reporting accurate. Also, scientists usually use bacterial levels as the standard for measuring the extent of water contamination. "However, there are more microorganisms than just bacteria, fungi, protozoa, and viruses, for example, and these microbes can persist in the environment for much longer. Water, sediment, and food can contain viral and protozoan pathogens even if there are no bacteria present," Schwab said. For instance, one of the largest disease outbreaks after the hurricane was caused by a norovirus that spread through the Houston Astrodome in Texas, which was housing 24 000 evacuees.From the start, the Environmental Protection Agency (EPA) continually analyzed floodwaters, coastal waters, and water pumped into Lake Pontchartrain, as well as air quality and sediment left over after floodwaters receded. Initial monitoring detected dozens of contaminants, including bacteria, lead, arsenic, and chromium, in water samples, but only about 8 contaminants exceeded EPA minimum risk levels for drinking water, according to Thomas Burke, MPH, PhD, who is a professor and co-director of the Johns Hopkins Bloomberg School of Public Health's Risk Sciences and Public Policy Institute.The EPA's post-Katrina assessment of the water, soil, and air in the Gulf Coast is ongoing. Its purpose is to track changing levels of contaminants released into the environment by the hurricane and flooding. Burke emphasized the need to track the health status of people living in the hurricane-affected areas to learn if they suffer any health effects from environmental exposure. This process might include biomonitoring to measure contaminant levels in their hair, blood, urine, nails, milk, or cord blood, he said, adding that dermal, respiratory, or ingestion exposure to environmental contaminants could have adverse effects on the hematologic, neurologic, hepatic, renal, gastrointestinal, and reproductive systems.Scientists generally agree, however, that the water in New Orleans was not the toxic soup that many people feared it would be after the hurricane and flooding caused at least 5 oil spills and citywide breakdowns in sewage and other waste disposal. Now that flood waters have receded, concerns have arisen over potential harm from the sediment left behind. It eventually turns into dust and particulate matter that could be dangerous to inhale. Possible dust-related air toxins include volatile pollutants, solvent emissions, and asbestos. "In New Orleans and the South, you will have dust and it will be made up of all kinds of things," said Paul Lioy, PhD, professor and vice-chair for the Department of Environmental and Occupational Medicine at University of Medicine and Dentistry of New Jersey–Robert Wood Johnson Medical School, who studied air quality issues in the aftermath of the 11 September 2001 terrorist attacks in New York City. "Characterize the dust now, know what's in it.… It's not just one single chemical, it's multiple toxins and biological agents, and these toxins alone can impact people, but they could react differently mixed together," he said.Mold is perhaps the most pressing air quality problem (see sidebar). "We're all concerned about the mold. There is the potential for unprecedented exposures, and the challenge is getting our arms around the magnitude of the problem," said Max Kiefer, associate director for the National Institute for Occupational Safety and Health (NIOSH). Mold—the furry fungi that thrive in damp environments, reproducing by means of spores—has covered carpets and walls in many homes and office buildings and has required the destruction of many structures already, and potentially many more.The Centers for Disease Control and Prevention is sponsoring studies on the health effects of this mold. "We're seeing levels higher here than traditionally studied, so this situation could yield valuable information about the impact of mold on health," said Howard Frumkin, MD, MPH, DrPH, director of the National Center for Environmental Health at the Centers for Disease Control and Prevention. Tulane University also has an environmental lung research group with expertise in studying inflammatory diseases related to particulate respiratory exposure, such as asbestos. The group plans to study the respiratory health of people returning to the city, according to John A. McLachlan, PhD, professor of environmental studies and pharmacology at Tulane and Xavier Universities.McLachlan is currently developing an online resource for tracking this research and all other environmental research related to the hurricane: the Katrina Environmental Research and Restoration Network (www.kerrn.org). "There needed to be some central place where you could find out what was going on during this restoration process. This will be a resource that isn't just related to biological or biomedical research, but also to ecological, wetlands, and cultural loss research, and architectural and environmental research, too," McLachlan said. "It will provide a way for people to know what research is going on and possibly a way to make cross-connections between the research."Tracking Changes in Health CarePublic health officials are most worried about the risk for environmental exposures experienced by workers who are removing debris, cleaning up oil spills, decontaminating flooded buildings, and rebuilding the city's infrastructure. The National Institute for Occupational Safety and Health has sent scientists to New Orleans to examine the hazards and exposures that these first responders face. The agency has called for workers to wear personal protective equipment, such as gloves and respirators. Contact with some compounds, such as fuel oils, can cause itchy, sore skin, and breathing some fuel oils might cause nausea, eye irritation, headache, and poor coordination and concentration, according to NIOSH's Kiefer. Inhalation of other contaminants in the air might result in lung damage, especially among people in ill health. Hospitals have already reported seeing an increased number of patients with allergy and cold symptoms; doctors have suggested that allergy to the mold and dust circulating in New Orleans is making residents susceptible to respiratory illness.Since the hurricane struck, the Louisiana Department of Health has monitored emergency department and outpatient hospital visits. Its goal is to be prepared to meet patients' emerging health needs and to learn of any emerging trends related to environmental exposure, according to Kevin U. Stephens, MD, JD, the health director for the City of New Orleans. New Orleans needs to design a formal, systematic cleanup plan to ensure the safety of returning residents, Lioy suggested. He said that the New York City experience after the 2001 terrorist attacks taught public health officials about the need to study postdisaster environmental risks that occur while rehabilitating a city. "You have to recreate an urban environment that is safe to live in," he said. Even now, years after the 2001 attacks, he noted, some New Yorkers are still concerned about the effects that contaminants in the air have had on their long-term health. In New Orleans, he said, it will be critical to assess the habitability of the residential structures that were flooded for days.Of course, environmental health risks are hardly the only concerns of the people who lived in Hurricane Katrina–affected areas. "A lot of the people on our resident and faculty team lost pretty much everything. The city has been decimated, and the fear is of what comes next. Will the city come back, and what will happen to our training and to our careers?" said Tulane's Wiese.Besides environmental exposure, mental health is the other major health concern following Hurricane Katrina. Because of stress and disenchantment, evacuees are at increased risk for depression and post-traumatic stress disorder, domestic violence, and domestic abuse, health officials warned. Many evacuees still face difficulty returning to the normal routines of life, as well as uncertainty about their future. These include physicians and health care workers, who played key roles in providing health care throughout the crisis but who continue to wait to return to New Orleans until the restoration of the hospitals and medical schools is more complete."The uncertainty of it all is scary," Wiese said. He has worked with other Tulane School of Medicine administrators to maintain the activities of the school at a temporary location in Houston. Students and residents have continued their studies and training, and the school has enrolled a new first-year class to enter in the fall of 2006. "It's been so important to set a plan early and focus everybody on what needs to be done now while also providing assurance that we're going to rebuild," Wiese said. "Rebuilding Tulane and New Orleans is a critical goal, something for us all to work towards, and it has taken away a lot of the fear. It will get done—both New Orleans and Tulane will eventually thrive."Sidebar: What Happened to ResearchHurricane Katrina flooded the lab of John A. McLachlan, PhD, professor of environmental studies and pharmacology at Tulane and Xavier Universities, and caused electricity outages that doomed much of his work at the Tulane Health Sciences Center. Dr. McLachlan has been starting over. The storm ruined his laboratory and many of the reagents and animal models that made up his active research. Before he can restart one animal study that used a chemical against breast cancer in a novel mouse model, he must first repeat the painstaking efforts of isolating the promising antiestrogen from soybeans. He must also recreate the mouse model, which had human breast tumors growing on one side of a mouse and murine tumors growing on the other side. "The model took a long time to set up and then grow, and we spent a really long time purifying all of this product from soybeans. We have to go back and do it all over again," he said.McLachlan lost a lot, but not everything. "Lots of people lost more," he said. He stored some of his reagents in nitrogen tanks, and he kept much of his data on a laptop computer that he carries with him. "We were prepared in some ways for a disaster like this, but after a few days, the level of preparation went down," he said. "For instance, some of the freezers could run on backup generators, but then there was no way to get extra fuel in to keep them going." To continue his work, McLachlan has set up a temporary laboratory at Baylor College of Medicine in Houston, Texas, staffed by some of his postdoctoral students. Similarly, other researchers have set up temporary laboratories while waiting for Tulane to restore its facilities.Clinical researchers also lost track of study participants in the aftermath of the storm. David C. Goff Jr., MD, PhD, professor of public health sciences and internal medicine at the Wake Forest University School of Medicine, noted that 2 major studies—the ACCORD (Action to Control Cardiovascular Risk in Diabetes) trial, which includes a clinic at Tulane University School of Medicine, and the REGARDS (REasons for Geographic And Racial Differences in Stroke) study, which is based at the University of Alabama at Birmingham—lost track of hundreds of participants. Many of their clinical records were also lost. "The status of their medical records is unclear, but in many cases, they were presumably destroyed—even electronic medical records because hard drives were damaged," Goff said. It was late October before Goff and his colleagues in the ACCORD trial acquired updated cell phone numbers for many study participants; they found about 150 who had been missing, but they still have not located about 40. Most of the participants have remained in the New Orleans area, but others are scattered across the United States.Some of the patients in the ACCORD trial, which is investigating ways to prevent heart disease in adults with type 2 diabetes, lost access to diabetes and heart medications when they were evacuated. The study organizers tried to help those who needed assistance with their medication by posting contact information on the ACCORD Web site. The REGARDS trial, a population-based study tracking risk factors for stroke among people living in the southern "Stroke Belt" and elsewhere in the United States, may end up also teaching physicians about the long-term health effects of the hurricane and flooding, according to Goff. The ongoing study includes about 700 patients in the Gulf Coast area whom the researchers have followed through regular telephone contacts for the past 2 years. They will continue to follow these patients for at least 2 more years.Sidebar: Basic Facts on MoldThe National Institute of Environmental Health Sciences has posted the following information about mold:There are various types of mold fungi that can be found in homes after flooding. Many of them produce spores that are allergens or irritants, and some also produce spores that are toxins (mycotoxins), which may have biological effects in humans.Exposure to molds can cause a variety of symptoms that range from aggravated allergies to asthma attacks. Allergic symptoms could include wheezing, sneezing, itchy/watery nose and eyes, and hives (skin rash). Because the effects of molds are not restricted to allergic reactions, individuals without allergies may also experience problems, such as irritation in the respiratory tract, eyes, and skin, and sometimes also headaches. The most susceptible people to the adverse effects of molds are those who already have an existing respiratory condition (for example, asthma) or are immunocompromised in some other way.To avoid potential adverse health effects, people should minimize exposure to mold. It is essential to immediately remove soaked and moldy materials from the home. All affected materials should be cleaned and dried when possible. However, porous materials (for example, upholstered furniture, mattresses, carpets, dry wall, and insulation) are nearly impossible to clean. Building materials and furnishings that are not salvageable should be discarded and replaced. The goal is to remove the mold and not just kill it because fungal spores/fragments do not need to be viable to cause allergic symptoms or irritation.When people clean and handle moldy materials, there can be exponentially more spores in the air than usual. In order to limit inhalation and skin/eye contact with molds, people should wear protective clothing (for example, disposable coveralls, gloves, and goggles) and respiratory protection (for example, an N-95 or HEPA [high-efficiency particulate air] respirator).Sidebar: Caring for Patients during a DisasterThe disaster recovery team at the Ochsner Clinic Foundation in New Orleans drilled on ways to maintain health care delivery during an emergency, but Hurricane Katrina taught them that it is not possible to anticipate everything, said Sandra Kemmerly, MD, medical director of infection control at Ochsner Clinic Foundation and hospital coordinator for physician deployment during disaster recovery. "We've always planned for this storm, year in and year out," said Kemmerly, who is also president of the Louisiana chapter of the American College of Physicians. "But as much planning as everybody did, nobody could have planned for everything that happened."They did not anticipate losing transportation for moving health care professionals back and forth between a satellite clinic in Baton Rouge and the New Orleans clinic; they ended up renting a limousine company with buses available to do the job. They did not expect to lose phone and e-mail service, but these were frequently unreliable in the wake of the storm; luckily, the hospital's internal telephone system remained continuously available. They did not expect so many patients to disperse all over the country, but electronic medical records facilitated patient requests for medical records and prescription refills. They did not plan on dealing with so many rumors and fears about outbreaks of cholera and other infectious diseases, which never did actually happen.The ability to cope with the disaster even when it brought unexpected challenges helped the New Orleans location of the Ochsner Clinic Foundation to remain open continuously throughout the hurricane and flooding, even after many staff members left the area. The organization set up a temporary primary care clinic in a separate pediatric building to provide emergency services under the protection of armed guards and members of the National Guard. Less than a week after the crisis began, clinic physicians even performed some scheduled surgeries, including a transplant surgery, and provided subspecialty care.Now, patient demand is beginning to return to normal levels with the slow and steady repopulation of the city, according to Kemmerly. "The patients are returning, and we're seeing a typical patient load. We have plenty of physicians available to provide care," she said. "Our biggest challenges now are nursing and ancillary support and housing for our employees who have lost their homes." Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: Disclosures: None disclosed.E-mail: [email protected]org PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byThe Impact of Natural Hazards on Older Adult Health: Lessons Learned From Hurricane Maria in Puerto RicoEmergency department visits associated with satellite observed flooding during and following Hurricane HarveyAdministrative Burdens and Citizen Likelihood to Seek Local Public Services: The Case of Hurricane SheltersTropical cyclones and risk of preterm birth: A retrospective analysis of 20 million births across 378 US countiesA Systematic Literature Review of Factors Affecting the Timing of Menarche: The Potential for Climate Change to Impact Women's HealthDisaster Preparedness among Older Adults: Social Support, Community Participation, and Demographic CharacteristicsThe post-disaster negative health legacy: pregnancy outcomes in Louisiana after Hurricane AndrewPerceptions of Toxic Exposure: Considering "White Male" and "Black Female" EffectsAdverse Respiratory Symptoms and Environmental Exposures among Children and Adolescents following Hurricane KatrinaAeroallergens, Allergic Disease, and Climate Change: Impacts and AdaptationEthics and Severe Pandemic Influenza: Maintaining Essential Functions through a Fair and Considered ResponseBad elements: Katrina and the scoured landscape of social reproductionA method for decontamination of animals involved in floodwater disasters10th Anniversary Review: Natural disasters and their long-term impacts on the health of communitiesEngaging the Dental Workforce in Disaster Mitigation to Improve Recovery and ResponseAprès le déluge: Microbial landscape of New Orleans after the hurricanes 17 January 2006Volume 144, Issue 2Page: 153-156KeywordsAllergy and immunologyDustEnvironmental healthFearFloodingHealth carePrevention, policy, and public healthPulmonary diseasesStormsToxins ePublished: 17 January 2006 Issue Published: 17 January 2006 Copyright & PermissionsCopyright © 2006 by American College of Physicians. 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