Keeping TB Treatment Going After Hurricane Maria, Puerto Rico, 2017

On September 20, 2017, Hurricane Maria struck Puerto Rico as a Category 4 storm, with sustained winds of 130–156 mph and 15–40 inches of rain that caused catastrophic flash floods. It knocked out electricity and communications, left large areas without water, and badly damaged roads, health care and agriculture. Six days later, 58 of 69 hospitals had no power or generator fuel. Maria came just 10 days after a disaster declaration for Hurricane Irma, a Category 5 storm that passed about 57 miles north and left 1 million people without power. Poorer and more remote communities, and those with many elderly or bedridden people, fared worst.

The TB program

The Puerto Rico Department of Health's Tuberculosis Control Program runs six regional clinics from a central office in San Juan, using directly observed therapy so patients take every dose. Since mid-2016 it had moved some patients to video-observed therapy by smartphone — impossible once power and wireless service went down.

Before the storm

Following its preparedness plan, the program:

• gave every patient under treatment for active TB a 1-month supply of TB medicines;
• urged patients to tell shelter health officers about their diagnosis if they had to leave home.

The health department also asked shelters to screen arrivals for infectious diseases such as TB, rabies and leptospirosis.

After the storm

• The program reopened with minimal staff on the fifth day and focused on reaching patients with active TB. Of 27 high-priority patients, 19 were accounted for within 15 working days and all 27 within 21.
• Thanks to the month's supply of medicine — a lesson from Hurricane Katrina — no patient's treatment was interrupted and none were lost to follow-up.
• Two non-infectious patients who moved to the mainland continued treatment after the program notified their new states.

Keeping lab testing alive

The program's laboratory was severely damaged. CDC's Division of Tuberculosis Elimination, the Association of Public Health Laboratories, state labs in Florida, Georgia and Virginia and the CDC Foundation arranged to ship and test specimens for Mycobacterium tuberculosis. The first package went out on October 17, four weeks after the storm, and shipments continued until local testing resumed in July 2018.

Lessons

• Each regional clinic should keep at least a 2-month supply of TB medicines on hand to cover post-disaster needs and delays in outside help.
• Each clinic should have its own emergency plan, covering resources, health services, transportation and patients' social and economic circumstances.

Despite what may have been the worst natural disaster ever to hit the island, the program's small staff, its partners and its preparedness plan kept TB treatment and laboratory services going.

Sources

Based on Aboukheir MK, Alvarado-Ramy F, Fernandez Vazquez M, Joglar O, "Notes from the Field: Tuberculosis Control in the Aftermath of Hurricane Maria — Puerto Rico, 2017," Morbidity and Mortality Weekly Report 68(2), CDC; a work of the United States government in the public domain.