Harsh lessons of Katrina may help in future disasters, attacks

National tragedy seen as ultimate training drill

The bitter lessons of Hurricane Katrina continue to inform public health and hospital preparations for natural disasters or bioterrorism attacks. Disaster management problems in the wake of Katrina have been well documented at the local, state, and national levels. The question is will Katrina’s lessons be learned before the next natural or intentional calamity besets us?

In late August 2005, the catastrophic hurricane devastated the Gulf Coast, leaving New Orleans flooded and some 1,300 people dead. It was, according to the official government report, "the most destructive natural disaster in American history."1

"The lessons that we learned are not just those that deal with infection control or hospital issues," said Dan Jernigan, MD, a medical epidemiologist at the Centers for Disease Control and Prevention. "They are across the board in terms of [the need for] increased communication between federal agencies. That is something that clearly came out. There have been [government] reports recently that point out that there needs to be improvement at the federal level among the different agencies and better coordination with the state health departments and emergency management systems. That is something that we learned."

The section of the White House report dealing with the medical and public health response cites swamped hospitals and displaced people with chronic conditions and no medication. The report emphasized the need to "strengthen the federal government’s capability to provide public health and medical support during a crisis. This will require the improvement of command and control of public health resources, the development of deliberate plans, an additional investment in deployable operational resources, and an acceleration of the initiative to foster the widespread use of interoperable electronic health records systems," it stated.

Indeed, the reported problems with dispensing medication to the chronically ill have led some to suggest including such drugs and treatments in the national strategic stockpile. "The strategic national stockpile does not have those kinds of meds currently," Jernigan said. There are ongoing discussions about whether it might be possible to stockpile such medications as part of pre-event preparations, "but whether that ends up as the strategic national stockpile I don’t know," he recently said in Chicago at the annual meeting of the Society for Healthcare Epidemiology of America (SHEA).

The situation of treating the displaced chronically ill also was addressed by another CDC official during a "lessons learned" training broadcast on Hurricane Katrina held recently at the University of North Carolina School of Public Health in Chapel Hill.

"Katrina taught us that special needs are a major area of concern," said Richard E. Besser, MD, director of the CDC office for terrorism preparedness and emergency response. "Before an event happens we need to assess what the burden of chronic disease is in the community and anticipate what those needs are going to be. We need to make sure we are able to relocate the resources to manage chronic diseases. Things like dialysis machines, asthma medications — those have to be available where the patients are going to be moved to. We need to prepare the evacuation sites to be able to handle people with special needs and chronic conditions."

For all the criticism and controversy in Katrina’s aftermath, it must be remembered that public health, state, and federal officials oversaw one of the largest mass migrations of people in United States history. Though it has been largely forgotten in the muddled aftermath — more than 1 million people fled the storm’s path before it made landfall.

"The migration of individuals was one of the largest — if not the largest — mass migration that we have seen in the United States in many years," Jernigan reported. "In the week following Hurricane Katrina, there were at least 490 evacuation centers set up. So this was clearly one of the largest [public health] responses that we have ever had in U.S. history. Upwards of 229,000 evacuees were distributed to at least 14 states."

Lessons learned from the situation could serve disaster planners well when nature or terrorists strike again. "With every major event that we go through — certainly that [immediate] response is of primary importance — but it also is something that helps prepare us for the next event," Jernigan said. "Katrina was a very large event requiring lots of different parties. [It raised] not just infectious disease issues but also those to do with infrastructure and supplies. It was a very good learning experience and a good way for us to identify [problems]."

For example, if a "dirty bomb" was used to release radioactive contamination over a densely populated area, the lessons of Katrina would come immediately to bear if there were a rapid migration from the epicenter.

"We learned a lot about how to anticipate the problems that you would have in evacuation centers, how to anticipate the communications command and control problems that might arise," Jernigan said. "So for that reason, I think we are in much better shape after Katrina for any mass migration that we have in the future."

Another speaker at the SHEA session on Katrina reminded that — as bad it was — the hurricane actually fell short of the worst-case scenario.

"The good news was that before it made landfall, it made a tiny jog eastward and came in over the border of Mississippi and Louisiana," said Sandra A. Kemmerly, MD, a hospital epidemiologist at Ochsner Clinic Foundation in New Orleans. "Had this storm come up the Mississippi River, [its] levees would have probably have been topped by a 30-foot storm surge and we would probably still be under water. So this is not the worst [scenario]. That is somewhat sobering if you happen to live there."

Through some combination of planning, providence, and geography, the hospital managed to remain open during and after the storm. "A key to our success was adaptation and the decision 30 years ago to build a well in case the Mississippi levee broke," she said. "Even though it was not drinkable water it gave us the ability when the temperatures exceeded 100 degrees in the buildings for people to have showers, cool off and get clean. Everybody felt that the well was probably our biggest asset."

The decision was made not to evacuate the hospital as the storm approached, as the facility was designed to withstand a Category 5 hurricane. "But when the electricity went out and the temperature exceeded 100 degrees by day three, we did start having to evacuate [some areas]," Kemmerly said. "Certainly from an infection control perspective in a hospital that was still open, we were worried about the air conditioning, potable water, food, sterility in the OR. All of that was an ongoing day-to-day crisis management and concern."

The problem for many New Orleans hospitals was not so much the initial storm but the subsequent flooding when levees broke. The latter development flooded generators and left many facilities without power. The crisis was vividly recalled during the aforementioned "lessons learned" broadcast at UNC.

"We had always planned and we were always told . . . that you need to be prepared to sustain on your own for 72 hours," said Coletta C. Barrett, RN, MHA, FAHA, vice president of resource development and member services at the Louisiana Hospital Association. "We planned that in our scenario, and that’s why we had supplies and things like that. What we didn’t plan for was loss of generator power."

It goes without saying that backup plans for generators and other redundant energy sources now are under review by disaster response planners. In general, hospitals should consult their local engineers and determine what pre-disaster adjustments they can make, emphasized another speaker at the UNC broadcast.

"Hospitals need to analyze their vulnerability in advance, but it is not just medical personnel who need to be included in disaster planning," said John H. Morrow, MD, MPH health director for Pit County, NC. "Engineers for example, can be a critical component when making sure that things go right when disaster strikes. During Hurricane Floyd, some ingenious engineering allowed our hospital to use the swimming pool in the rehab unit as a water tank to pressurize the water system for the whole hospital. This provided flushable toilets and potable water for the hospital while the rest of the surrounding area was without. So the lesson here is [to] identify locally what you consider as critical infrastructure in your community and then include the people who are responsible for maintaining that infrastructure in your emergency plan."

Expect truth to be the first casualty

Expect truth to be the first casualty as rampant rumors surface about all manner of infectious disease outbreaks. "There were tons of unbelievable rumors about cholera, malaria, typhoid, hepatitis A, B and C, West Nile virus, toxic water, and snakes, alligators and sharks," Kemmerly recalled.

Likewise, rumor control was an ongoing issue at the evacuation centers. "It was important to rapidly address these fears of workers and evacuees," Jernigan said. "Our team was on call for a lot of things but one of them was for rumor control."

Yet it was exceedingly difficult to set the record straight at the disaster sites because communication breakdowns were rampant. "I don’t really have any way to tell you how bad this was," Kemmerly said at SHEA. "The land lines were inoperable; the circuits were overwhelmed if the lines weren’t down. Cell phones did not work. The towers did not have any electrical power and did not have generators. It turned out that the old ham radio systems worked, so people were able to communicate that way."

Despite the atmosphere of chaos and fear, relatively few infectious disease problems occurred. Somewhat surprisingly, that generally held true at the evacuation centers as well, Jernigan added. There were respiratory infections at some centers, and an outbreak of norovirus hit primarily children at the Astrodome in Houston.

"The Katrina cough’ was something that a number of people had, and we were never able to find a [etiologic] reason for that," he said. "We had a few cases of pertussis, a few cases of TB, but really there was not a lot of infectious disease transmission in the evacuation centers."

Some credit for that result must be ascribed to the infection control measures put in place at the evacuation centers. Those included infection control education, distribution of alcohol hand disinfectant, and daily evaluations of food service and restrooms.

"We found that about 50% of folks [in shelters] were washing their hands, which is not the greatest but is not terrible," Jernigan said. "We did make sure that alcohol based hand gels were prevalent throughout the evacuation centers to the point that they smelled like alcohol all the time. I think we were able to maintain infection control probably [at a level] that you don’t normally have at home."

But the lack of outbreaks may also reflect the absence of endemic infectious diseases in the displaced population. "These people did not have the burden of disease similar to what you might find in some other countries," Jernigan said. "For that reason, we started off at a better place, and were therefore probably less likely to have outbreaks of these kinds of explosive diseases that you might see in [Third World] countries."

Reference

  1. The White House. "The Federal Response to Hurricane Katrina: Lessons Learned," February 2006. On the web at: www.whitehouse.gov/reports/katrina-lessons-learned/index.html.