Healthcare Challenges after the Earthquake

Nila Manandhar, MD

Photo Source: EPA

A month has passed since the massive April 25th earthquake in Nepal, and the Nepalese people still continue to experience several aftershocks. Despite the daunting adversities that lie ahead, many are eager to start rebuilding their homes and country.  As the Nepalese people move forward, they need to be aware of another type of natural disaster - one involving their health. Nepal has lost thousands of lives to the earthquake, but more lives could be lost with a health epidemic.  Many earthquake victims who have lost their homes have camped outside in crowded conditions which, coupled with the lack of clean water and sanitation, could be catalysts for the spread of a variety of diseases. This could be compounded by the upcoming monsoon season, which will bring with it a rich environment for disease carrying hosts. Past earthquake in various parts of the world have taught lessons that need not be repeated.

The incidence of tetanus increases after natural disasters like earthquake and tsunamis. Increased rates of tetanus were observed in Indonesia after the 2004 earthquake, as well as the 2011 earthquake in Japan.¹  Lockjaw is a feared and widely recognized clinical manifestation. Tetanus spores are introduced into the body through injuries involving splinters and puncture wounds, like those experienced by earthquake victims and relief workers in Nepal. The Clostridium tetani bacteria then release a toxin that causes muscle spasms and rigidity. Death can result from respiratory failure. The incubation period for the bacteria can be between 2-38 days. Proper wound washing and active immunization are crucial in preventing an infection. Treatment is mainly supportive and involves care in the intensive care unit.⁴  

Infectious diseases first begin to appear about a month after the disaster has occurred. Diarrheal diseases are the most common and have caused 40% of disaster related deaths in the past.² Crowded condition, lack of soap and clean water supply, improper water storage, as well as poor sanitation are some of the factors to blame. The most common organisms identified are Shigella and Vibrio cholerae. In Haiti, over 200,000 cases of cholera emerged just four months after the earthquake. Preventative measures include hand washing, disposal of waste, proper food handling, breast feeding infants, and control of flies. Volume and electrolyte replacement are the most essential components of treatment. Empiric antibiotic therapy is not warranted for most types of watery diarrhea. However, it has shown benefit for cholera as well as cases of bloody diarrhea (dysentery).³ Typhoid fever, caused by Salmonella, is another disease resulting from poor sanitation. Often seen in children, it is characterized by fever and abdominal pain.  Treatment involves antibiotics along with oral rehydration therapy.

Standing water from the upcoming monsoon rain will provide a breeding ground for mosquitoes which carry diseases such dengue, malaria, and Japanese encephalitis, which are already prevalent in Nepal. All of these are febrile illnesses. Patients with Japanese encephalitis can additionally present with seizures, and those with dengue can experience abdominal pain.⁶ Mosquitoes can be controlled with spraying of insecticides and insecticide treated nets. While vaccination is available for Japanese encephalitis, no effective vaccine has yet been developed against malaria or dengue. Treatment for dengue and Japanese encephalitis are unfortunately just supportive. There are a number of options for the pharmacological treatment for malaria, although drug resistance is becoming a growing issue. 

Among the various air-borne diseases that are likely to spread with people living in close quarters after the earthquake, Tuberculosis (TB) is one of the deadliest. Nepal is very familiar with TB incidences, and the extensive efforts by the Nepalese officials, in partnership with WHO, have been largely successful with a 90% cure rate.¹ However, rates of TB could increase in the coming months. While effective medications are available, health care providers need to be wary of multi-drug resistant tuberculosis.

These are only a few of the multitude of diseases that could appear in the coming weeks and months. While the people and government of Nepal have had to face these diseases in the past, they will now need to be prepared to confront it on a much larger scale. The rates of some of these diseases could increase to epidemic proportions. Prevention measures may seem simple, but due to the lack of resources, the task could prove to be logistically challenging. The efforts of many professionals and volunteers will be needed to provide awareness, education and deliver care to millions during this crucial time. The need for fast and adequate funding cannot be emphasized enough.  The scene in Nepal post-earthquake will soon become a case study for public health workers, aid organizations, government officials, and health care providers. Let's hope it will be a successful one.

Nila Manandhar MD, a native Nepalese, is a recent graduate of the University of Missouri-Columbia School of Medicine and will be starting as a resident physician at the Medical University of South Carolina in July. 

Bibliography

1. Donnelly, J. (2010). Nepal has lessons to teach on TB. The Guardian .
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5. Takashi, T. e. (2012). Infectious Diseases after the 2011 Great East Japan Earthquak. ournal of Experimental & Clinical Medicine , 4 (1), 20-23.
6. Whitehorn, C. (2015). Mosquito vectors of infectious diseases. UpToDate .