On October 29, 2012, Hurricane Sandy struck the U.S. northeast and mid-Atlantic seaboard;
the effects of the storm extended to southeastern and midwestern states and to eastern
Canada. At the time, 1,899 residents in the most affected areas were undergoing treatment
for tuberculosis (TB) disease or infection. To ascertain the operational abilities
of state and local TB programs during and after the storm and to determine whether
lessons learned from a previous hurricane were effective in ensuring continuity of
TB patient care, CDC interviewed staff members at all of the affected state and city
TB control programs, including those in areas with power outages and flooded streets,
tunnels, and subway lines. The interviews determined that continuity of care for TB
patients in programs affected by Hurricane Sandy was better preserved than it had
been during and after Hurricane Katrina in August 2005. This improvement might be
attributed to 1) prepared-ness measures learned from Hurricane Katrina (e.g., preparing
line lists of patients, providing patients with as-needed medications, and making
back-up copies of patient records in advance of the storm) and 2) less widespread
displacement of persons after Hurricane Sandy than occurred after Hurricane Katrina.
Maintaining readiness among clinicians and TB control programs to respond to natural
disasters remains essential to protecting public health and preserving TB patients’
continuity of care.
TB Programs Most Affected
Hurricane Sandy traveled along the Atlantic coast, affecting 24 states from Florida
to Maine and west to West Virginia, Michigan, and Wisconsin. Coming ashore near Atlantic
City, New Jersey, Hurricane Sandy caused particularly severe damage in New Jersey
and New York. Overall, the 15 most affected TB control programs were in the mid-Atlantic
(Delaware, District of Columbia, Maryland, North Carolina, Pennsylvania, Virginia,
and the cities of Baltimore and Philadelphia) and northeast (Connecticut, Massachusetts,
New Hampshire, New Jersey, New York, Rhode Island, and New York City).
By 1 week after Hurricane Sandy made landfall, all TB control programs had resumed
normal patient-care operations. At least 10 of the 15 programs had been closed for
2 days (including those serving New Jersey, New York state, and New York City), either
because of preparations in anticipation of the storm or because of the direct effects
of the storm. None reported any significant damage to TB program infrastructure or
equipment. Immediately after the storm, all TB program employees were accounted for;
unlike the experience after Hurricane Katrina (1), there was no loss or gain of TB
patients as a result of Hurricane Sandy. At least two programs reported giving their
patients medications in advance of the storm for self-administered therapy (SAT),
including medications that would otherwise have been administered using directly observed
therapy (DOT). Reportedly, all patients who were placed on SAT were returned to DOT
within a week after the storm had passed.
After the storm, program consultants from CDC’s Division of Tuberculosis Elimination
(DTBE) assessed the affected programs and determined that no special assistance from
DTBE was needed. Similar to what was done in the aftermath of Hurricane Katrina, DTBE
activated the DTBE help desk on November 2, 2012, to facilitate Hurricane Sandy–related
communications among TB controllers and nurse consultants throughout the country.
However, unlike the extensive and sophisticated chain of communications after Hurricane
Katrina, no calls were received by the help desk before it was deactivated on November
15.
Overall, in the 15 most affected TB control jurisdictions (11 states, three cities,
and the District of Columbia), a total of 1,899 patients (including those with verified
cases of active disease, suspected disease, and those treated for latent TB infection
[LTBI]) were being treated by the TB programs just before Hurricane Sandy struck.
By November 12, 2012, all active disease TB patients from the affected areas had been
located and, if still indicated, had resumed TB treatment on DOT; all patients treated
for LTBI also were accounted for. One patient (an LTBI patient from New Jersey) initially
was thought to be lost to follow-up. However, it was subsequently confirmed that this
patient had completed her course of treatment on SAT. Therefore, all 1,899 patients
under treatment before the storm remained under treatment afterward.
New York City
During and after Hurricane Sandy, New York City Department of Health and Mental Hygiene
(DOHMH) TB clinics remained open with only minimal reduction in service; hours were
reduced on the afternoon that the storm arrived, and one clinic in Staten Island was
closed for 1 day after the storm because no patients were scheduled for appointments
that day. Initially, there were difficulties with testing specimens for TB because
the public health laboratory was operating for several days on back-up generator power
and had limited Internet connectivity, and because many hospital, commercial, and
reference laboratories were not functional as a result of storm-related complications.
The New York State Department of Health Laboratory provided short-term backup for
transport and processing of some TB specimens.
What is already known on this topic?
State and local tuberculosis (TB) control programs plan for emergencies with the potential
to result in mass displacement of patients and disruptions in access to diagnostic
services.
What is added by this report?
The lessons learned from the experience of Hurricane Katrina in 2005 were applied
successfully in maintaining preparedness and TB control activities for persons undergoing
TB treatment after Hurricane Sandy. All of the 1,899 patients undergoing treatment
in the 15 TB control program areas most affected were fully accounted for; unlike
Hurricane Katrina, there was no loss or gain in the number of TB patients within programs
as a result of Hurricane Sandy.
What are the implications for public health practice?
To address issues of natural disasters in an efficient, effective manner, TB control
programs need to continue to conduct systematic planning that will enable timely response.
Because of flooding and loss of power, Bellevue Hospital had to evacuate all of its
patients, and the New York City TB program immediately had to find another secure
hospital ward for six TB patients in Bellevue’s detention unit. All six were safely
transferred to Lincoln Hospital in the Bronx. Two of the patients were considered
infectious; they were transferred to negative-pressure isolation rooms. Within a week
of their transfer to the new facility, a physician from DOHMH went to Lincoln Hospital
to visit the patients and to consult with the physicians involved in their care. Each
patient was assigned a DOHMH staff worker for case management. An outpatient TB clinic
also was affected by closure of Bellevue Hospital.
Within a week, DOHMH had contacted 26 of the 27 patients who previously had been receiving
antituberculosis medications through the DOT program at Bellevue Hospital. As patients
began running out of medications, all contacted patients were given appointments at
DOHMH clinics. By November 16, a total of 24 of 27 patients had been evaluated at
DOHMH clinics and continued with DOT, either at a DOHMH clinic, through the DOHMH
field staff, or through DOT field staff members from Bellevue Hospital. During the
approximately 1 month that Bellevue Hospital remained closed, four patients were discharged
as having completed therapy. Four patients decided to continue treatment at DOHMH
clinics, and the remaining 16 patients returned to Bellevue Hospital for further evaluation
and treatment.
New Jersey
After Hurricane Sandy struck, the state motor pool in Newark initially had no fuel;
however, all vehicles including those used by the TB program were accounted for, and
none were damaged. The Global Tuberculosis Institute at the University of Medicine
and Dentistry of New Jersey (UMDNJ) in Newark and the Waymon C. Lattimore Practice
that administers ambulatory-care services at University Hospital at UMDNJ reopened
on November 5, 2012. Immediately after the storm, communication with the coastal areas
in New Jersey was limited because phone lines and cell towers had been damaged or
destroyed by the storm. Also, access to affected areas was restricted to those who
could show proof of residency or property ownership.
Twelve active TB patients lived in the most severely affected areas of New Jersey,
and these patients had been given their TB medications before the storm to conduct
SAT. Two counties that did not provide TB medications to patients before the storm
subsequently added the number of days that therapy had been missed to the end of the
patients’ course of therapy.
Editorial Note
Ensuring appropriate diagnosis, treatment, and prevention of TB is the responsibility
of the National TB Control Program and of TB control programs in public health departments
across the United States. This report describes the challenges faced by TB programs
in affected jurisdictions when Hurricane Sandy disrupted normal operations. Standard
treatment and cure of TB disease requires a multidrug regimen administered under DOT
for at least 6 months (2). Recommended treatment for LTBI can be for 3 months using
a new 12-dose regimen (3) or ≤9 months using older daily regimens (4). Despite the
challenges, health department workers helped ensure continuity of treatment for TB
disease or infection for the 1,899 patients in the 15 most affected TB control jurisdictions.
Unlike the situation after Hurricane Katrina struck the U.S. Gulf Coast in 2005, causing
displacement of 62 (48%) of the 130 New Orleans–area patients (1), none of the affected
areas reported displacement of any TB patients after Hurricane Sandy.
In preparation for Hurricane Sandy, the TB programs in New York City, New York state,
and New Jersey implemented measures in advance of the storm to ensure continuity of
care, including 1) preparing line lists of patients who might be affected, 2) providing
patients with medications to self-administer in the event DOT was interrupted, 3)
providing patients with a list of phone numbers to reestablish contact with the health
department if they were displaced and obtaining contact information for patients’
relatives and friends in other parts of the country, 4) making back-up copies of patient
records for potential sharing with new jurisdictions, and 5) moving essential TB treatment
supplies to safer areas. These activities reflected lessons that had been learned
from the disruptions in patient care after the landfall of Hurricane Katrina in 2005
(1).
During an initial disaster response, the most urgent public health priorities are
providing safe and adequate shelter, water, food, and sanitation. Also important are
interventions to minimize potential spread of communicable diseases, including TB,
because displaced persons congregate in shelters and resettle in new communities.
A lesson learned from both Hurricane Katrina and Hurricane Sandy was that all TB control
programs should consider planning for emergencies that might result in mass displacement
of patients or in disruptions in access to laboratory or other diagnostic services,
and in supply of medications.