By Renee DiIulio

 Hospitals plan for disasters. The nature of their business and, in some cases, the law, requires it. But when the disaster is catastrophic, as in the case of Hurricane Katrina, “all the planning in the world may not help,” says James R. Greenwood, PhD, MPH, adjunct professor of epidemiology at the University of California, Los Angeles (UCLA). With power out, staff gone, and facilities waterlogged, the Gulf Coast region is facing two health care crises: The first is the medical care of the area’s inhabitants and rescue workers, and the second is the destruction of its health care infrastructure.

Naturally, the latter impacts the former, meaning that much of the needed health care has been delivered in battlefield conditions. Physicians don’t have time to wait for test results and have often begun a reasonable course of treatment immediately. But lab results offer confirmation and must still be turned around quickly, which is a challenge considering the obstacles presented to specimen transportation alone.

Fortunately, no unexpected health care crisis has risen to the fore, and illness outbreaks have stayed contained. Unfortunately, it will not be as easy to regain control of the infrastructure. Area labs are reporting damage to equipment and inventories and are in need of personnel and supplies. It could be months before some facilities are up and running again.

Systems, such as the Laboratory Response Network (LRN), are helping to fill in some of the gaps, but the scope of the disaster overwhelmed everyone in the early stages. Fortunately, disasters of this scope don’t happen very often, at least in the United States. “Most disasters aren’t as big as Katrina, and existing emergency planning can see a hospital through those times,” says Greenwood.

Hospital Hazards Minimized
Despite some reports of hazardous waste removal from hospitals, the experts CLP spoke to felt that clinical lab hazards were minimal.

Jared Schwartz, MD, PhD, of Presbyterian Healthcare, says, “Considering the massive amounts of water, I would think the hospital toxins were diluted and pose very little risk”—a point he feels holds true even in cases of radioactive materials used in radiology departments.

UCLA’s James Greenwood, PhD, MPH, agrees, citing toxic competition from sewage, chemical plants, refineries, and fires. Viral agents can also be a concern. “Research and some reference labs may have biological warfare agents, and these would have to be moved or secured. However, any move would need to first be approved by the CDC,” says Greenwood.

Disease Watch
The medical community can definitely create a plan to respond to expected diseases. The Centers for Disease Control and Prevention (CDC of Atlanta) has compiled a list of diagnoses to watch for in evacuees, in addition to common medical problems.

Many are related to contact with contaminated water via the skin or mouth. Others are worrisome because of their communicability. “When you have people sheltered closely together, you worry about communicable diseases that are spread via the respiratory tract or hand to mouth,” says Jared Schwartz, MD, PhD, director of pathology and laboratory medicine at Presbyterian Healthcare (Charlotte, NC).

As of September 26, more than 80,000 evacuees were sheltered in 814 facilities nationwide. The CDC has been conducting rapid needs assessments and supporting infectious-disease-outbreak surveillance. Some of the most serious conditions seen have been caused by Vibrio infections, which were diagnosed in 32 people in the 20 days following the hurricane’s landfall [August 29, 2005], according to the CDC’s September 19 update. Six have died. The CDC investigation suggested that increased physician awareness, appropriate specimen culturing, and empiric treatment would improve response to the illnesses caused by the Vibrio species, including V. vulnificus, V. parahaemolyticus, nontoxigenic V. cholerae, and toxigenic V. cholerae.

As of October 7, the CDC has not seen any cases resulting from toxigenic V. cholerae, also known as cholera. Nor have any other widespread outbreaks occurred. There were clusters of respiratory infections and scabies, but they remained contained. Between September 10 and 12, the most common conditions seen, according to the CDC, were related to hypertension, cardiovascular disease, diabetes, new psychiatric conditions, pre-existing psychiatric conditions, rashes, asthma/COPD, flu-like illnesses or pneumonia, toxic exposure, other infections (such as pertussis, rubella, hepatitis, and tuberculosis), and diarrhea. By October 4, injuries were the most common diagnosis (26.2%) in reporting hospitals.

Disease Control
Screening after a disaster, at least initially, is conducted on a symptomatic level. “The systems are so taxed that they are screening after people are symptomatic,” says Greenwood, adding that in some cases, it’s easier to test the water for exposure to contaminants than it is to test people.

Schwartz concurs that testing, initially, is limited. “There is no infrastructure or even need to test every single person. In mass-casualty situations, we look to the military for battlefield medical tactics. They set up field hospitals and perform triage, screening, diagnoses, and antibiotic delivery. There may not be a lot of testing,” says Schwartz.

He expects that to change once they become more organized. “They were beginning to get there, but were interrupted by Rita [Hurricane Rita made landfall September 24]. Once organized, they will be able to collect specimens quickly and send them off,” says Schwartz. Armed with the test result for one patient, doctors can begin to lump patients who share symptoms without having them all tested. “These patients are treated with the same drugs,” says Schwartz.

 Jared Schwartz, MD, PhD

Testing, Testing
Even before a diagnosis is confirmed, however, physicians will begin treatment. “Typically, they’ll make a clinical determination and start treatment, sending the test for confirmation. You can’t wait with high-risk patients or crowded situations. However, they may change the therapy based on the test results, so there is still a lot of pressure to turn specimens around quickly,” says Schwartz.

Schwartz believes that POC [point-of-care] products would be perfect for use in the Gulf Coast region. “If they are handheld and do not require power to make a rapid diagnosis, then these tests would be ideal,” he says. But they are not available for all of the conditions included on the CDC watch list.

Many tests still require more complicated techniques, such as culture and PCR. Those requiring automated equipment must be sent elsewhere, which adds transportation time. Result delivery can also take extra time if electricity and phone lines do not work.

Seeking Staff and Supplies
Having just returned from CAP [College of American Pathologists of Northfield, Ill] ’05—The Pathologists Meeting, Schwartz was able to talk with members of the medical community from the Gulf Coast. “We need to be realistic. The destruction is significant, and the ability of some hospitals to open over the next several months—it won’t happen,” suggests Schwartz.

Greenwood agrees. “If you can’t live there, you can’t work there,” he says, citing issues surrounding electricity and personnel. According to the CDC’s September 26 update, 35 hospitals remained closed in Louisiana. By October 4, 38 of the 60 hospitals in the Hurricane Rita-damaged areas of Louisiana were restored, with 8 partially restored and 14 not yet restored.

“Many labs will probably have to replenish their supplies of reagents, which went bad with the loss of refrigeration,” says Greenwood. But if the electricity is still off, those labs will continue to have issues with maintaining the integrity of supplies. But, if they don’t have staff, that may not even be an issue. “Folks can’t come to work,” says Greenwood.

Schwartz notes that CAP, at the request of the CDC lab division, sent out a query to the region’s labs asking what they needed. Because communications were still knocked out, CAP expected few replies. Those labs that responded requested staff and supplies. “Some of the facilities on the periphery have opened, and organizations are trying to get supplies to them,” says Schwartz, noting that efforts had paused to allow Hurricane Rita to pass.

On the other side of the personnel issue are the professionals now out of work. With many facilities in disrepair, many of these people will need to find work while they wait for their old jobs to come back, if ever.

“It’s important that people stay aware of the need for evacuees to find work — they still need to eat, live, and take care of their families,” says Schwartz. He suggests that if labs have open positions, they offer them to these displaced workers, even if only on temporary bases.

However, he also acknowledges that regional outflow is a potential problem as well. “It’s possible that some people won’t return to the Gulf Coast, but I don’t think New Orleans will be left bereft. When the opportunities arise, they’ll come back,” says Schwartz.

Lab Response
In the meantime, a few systems are helping to monitor and provide health care in the region. The Association of Public Health Laboratories (APHL of Washington, DC) has been helping to coordinate laboratory response to Hurricane Katrina. The association’s Web site noted that as of October 13, the Louisiana state public health lab’s capacity had been disrupted, with some tests being diverted from the central Louisiana public health lab to other selected public health labs, both inside and outside of the state. Mississippi’s state public health facilities were operational, and the state department of health was assessing the status of clinical labs. All of the laboratories in Alabama are up and running.

Health care needs and operational issues are also being monitored through EMSystem’s Web-based Critical Infrastructure Data System (CIDS). The West Allis, Wis-based company has donated services to the US Department of Health and Human Services. Information has been collected from hospitals, community health centers, mental health and substance abuse facilities, federal medical shelters, and other institutions to provide daily data on facility status, critical needs, available resources, and outbreak trends.

The CDC can also rely on the Laboratory Response Network (LRN) which, though created in response to bioterrorism, can still be called upon in national emergencies. The network is composed of 140 biological and 63 chemical labs. Immediate-response activities aim to help on a local level by increasing the number of trained professionals and distributing supplies; longer-term goals include supporting the acquisition of advanced technologies and facility improvements.

Emergency Preparedness
Of course, labs should also have their own emergency-response plans. “We have to think ahead and prepare for all contingencies. What will you do if the power is out for a long time? You must think about staff, supplies, specimen transport, reagent issues, and data backup,” says Greenwood, who advocates arrangements with other facilities.
“We have a mirror site halfway across the country that houses our backup data,” says Greenwood. “Labs can also make arrangements to possibly use staff or process specimens if needed. This can help to avoid a loss of clients while the lab resumes operations,” he adds.

“There are degrees of emergency preparedness,” concurs Schwartz. “To be prepared typically means 3 to 7 days of water, food, and generator fuel, which works for a normal emergency. But Katrina was different and demonstrated that the emergency plans won’t work for mass-casualty episodes,” says Schwartz.

“Maybe the Gulf region could have evacuated earlier, possibly saved some of their expensive equipment by moving it out in trucks, but there really is nothing they could have done to prepare them to stay open in the aftermath of this hurricane,” says Schwartz.

Renee DiIulio is a contributing writer for Clinical Lab Products.