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Infection Diseases Following Natural Disaster in Children: Health Prevention and Assessment
Children are a vulnerable group that is adversely affected physically, sociologically, and psychologically in natural disasters. The past natural disasters experienced by different countries at various times were lessons for all of the world, and there are important new lessons to be learned from natural disasters occurring in the aftermath of the post-coronavirus disease 2019 (COVID-19) pandemic. Not only does COVID-19 pose a continuing threat, but globally we are experiencing a rebound of common childhood infectious diseases due to disruption of immunization programs during the pandemic and removal of restrictions to reduce transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Data on pediatric health management are limited at this challenging time. In this editorial article, post-natural disaster infections and prevention strategies will be considered after the last two devastating earthquakes (7.7 and 7.6 magnitudes) that occurred, on February 6, 2023, in Kahramanmaraş, Türkiye.
As a result of population growth in the world, global warming, scarcity of living areas, and urbanization are observed in many countries, and people are unfortunately settling in regions that are more susceptible to natural disasters. Human interactions with the environment are getting closer. Human-zoonotic host interactions could increase after natural disasters such as earthquakes, floods, and tsunamis. Moreover, the impact of the global response to natural disasters can lead to the introduction of new infectious threats from outside that affected region.  For example, the Haitian cholera epidemic probably began with the accidental introduction of Vibro cholerae El Tor into Haiti via international aid efforts from a distant geographic source following the earthquake on 2010.
Respiratory, water-food borne outbreaks, vector-borne diseases, and skin and soft tissue infections are mostly reported among the earthquake survivor pediatric populations. Contamination of water resources, collapse of infrastructure, seasonal conditions, crowded camp environments, and malnutrition cause infections. In the impact period up to 4 days after the earthquake, infections secondary to injury are common. Applied fasciotomies cause open wounds and increase the development of infection. The post-earthquake wound infections are polymicrobial, predominantly caused by Gram-negative bacilli (Pseudomonas aeruginosa, Enterobacter spp., and Acinetobacter spp.).  Since these agents are resistant to many antibiotics, empiric treatment with broad-spectrum antibiotics should be initiated. If possible, antibiotic susceptibilities should be tested in the laboratory, to facilitate deescalation of antibiotic therapy where possible.
Tetanus is one of the most serious infections that can develop in people who are unvaccinated or who are incompletely vaccinated. Tetanus infections can progress with high mortality. Tetanus cases detected following the 2004 Indonesia, 2005 Kashmir, and 2006 Yogyakarta earthquakes had case fatality rates of 18.9, 15.8, and 36.6%, respectively. Cases of tetanus were also reported following the 2010 Haiti earthquake.  Most tetanus cases occur in areas with low rates of immunization. However, even in countries with high rates of immunization, immunity may have waned in older persons injured in a large-scale disaster. Thus, there will usually be a need to provide supplies of tetanus vaccine and tetanus immune globulin (which needs to be administered within 24 hours) early after a natural disaster.
In the post-earthquake period, the first wave of infectious diseases is caused by food-borne and/or water-borne infections, and/or by infections transmitted by respiratory droplets. Decreased access to reliable water resources due to damage to water networks in disaster conditions and/or contamination of water by sewage is a crucial problem that is frequently experienced. Children are more vulnerable and susceptible to diarrhea and its complications. A wide range of enteric pathogens (bacteria, viruses, and parasites) has been linked with diarrhea following disasters. For instance, Vibrio cholerae and enterotoxigenic Escherichia coli were detected post-flooding in West Africa. After the 1976 Friuli, Italy earthquake, there was a five- to six fold increase in Salmonella due to food contamination, poor sanitation, and overcrowding in camps. Heavy flooding in Pakistan, earthquakes and drought in Afghanistan and Somalia have dramatically enhanced the number of affected cholera cases. After the Haiti earthquake in 2010, an epidemic cholera outbreak occurred affecting over 170,000 people and killed more than 3,600.  Recommended protocols for therapy (rehydration and/or antibiotics in needed cases) and prevention strategies (providing of reliable water, enhanced access to hygiene) are ranked in priority for cholera epidemics. Studies of oral cholera vaccines (OCVs) have been in small groups and data are limited. Nevertheless, the World Health Organization has suggested the use of OCVs in chaotic disasters including earthquakes.
Hepatitis A and E are transmitted by the fecal-oral route related to poor sanitation and contaminated drinking water resources. These viruses are endemic mainly in developing countries. In addition, children living in these countries exhibit high immunity to particularly hepatitis A, early in life. Hepatitis E is associated with high mortality in pregnant women. Hepatitis A and hepatitis E were detected in Aceh, Indonesia following the 2004 tsunami.
Leptospirosis is an epidemic-prone zoonotic bacterial disease that is spread by contact with contaminated water particularly following flooding. Rodents (especially brown rats) shed the pathogens in their urine. The transmission of the disease emerges by direct contacts of skin with contaminated water and soil. Karande et al reported 30 children with diagnosis of acute leptospirosis in Mumbai after the flooding in 2000. 
Post-earthquake tsunamis and flooding can increase contamination of water with parasites such as Cryptosporidium spp., Giardia lamblia, and Enterobius vermicularis. Increased rates of G. lamblia and E. vermicularis infections in children was reported in Düzce, Türkiye after the earthquake in 1999. A previous study has shown that giardiasis was detected as the most prevalent parasite in children living in camps following the earthquake in Colombia.
Acute respiratory infections (ARIs) are a major cause of death and disability post-disasters in children less than 5 years. Post-disaster detected pathogens causing ARIs are commonly of viral and bacterial origins. Potential viral (influenza, respiratory syncytial virus, adenoviruses) and bacterial (Streptococcus pneumoniae, pertussis, tuberculosis, Legionella, Mycoplasma pneumoniae) agents commonly are detected in ARIs following diasaster. Globally, we are still experiencing a post-pandemic rebound in some respiratory viruses, which have, or are occurring, beyond prepandemic levels, and also the usual seasonality of these infections has not yet reverted to the prepandemic pattern. Although the number of COVID-19 cases globally has decreased significantly, the potential for SARS-CoV-2 to cause a post-disaster outbreak in crowded camp environments should not be overlooked. Currently, many countries are experiencing increased incidences of scarlet fever and life-threatening invasive group A streptococcus infections, especially among children. Outbreaks of group A streptococcus infection in camps could have devastating consequences, not just as a cause of respiratory infection, but also of wound infections. ARI was one of the leading causes of death among those displaced by the 2004 tsunami in Aceh, and they may present an even greater threat currently.
The crowded camp settings, poor sanitation, and malnutrition could facilitate the emergence of droplet-borne infections such as measles and meningococcus. The basal immunization status of children under the age of 15 is a very significant factor in the transmission and spread of measles.  A measles epidemic occurred in the Philippines in 1991 among displaced survivors by the eruption of Mt. Pinatubo, with over 18,000 cases reported. Since that time, thanks to widespread immunization, post-disaster measles cases in other natural disasters have been much lower.  However, in many countries immunization programs over the last 2 to 3 years have been interrupted by the COVID-19 pandemic, meaning that there may be a greater unimmunized population than expected. For this reason, the childhood vaccination schedule should be applied without interruption under any circumstances. After the Pakistan earthquake (2005) and the Indonesian tsunami (2004), limited meningitis outbreaks were reported. Rapid intervention with antimicrobial prophylaxis as practiced in Pakistan likely interrupted spread. Diseases with a long incubation period (leishmaniasis and leptospirosis) and vector-borne diseases such as malaria and dengue should be considered as possible infections during the recovery phase (> 4 weeks) of natural disasters. 
Unfortunately, compared to previous years, we are more likely to encounter the reality of natural disasters triggered by global warming, population growth, and unplanned urbanization. In order to overcome this disaster with the least damage, national and international organizations should create disaster policies and procedures to prevent and control the spread of infectious diseases. Early diagnosis, prophylaxis, immunization, and treatment approaches may prevent possible epidemics that may occur with infectious diseases. It is also vital to ensure surveillance and early warning to determine epidemic-prone diseases known to emerge in the natural disaster influenced area. Due to the increasing antivaccination mode all over the world, coupled with decreased rates of vaccination during the period of pandemic controls in many countries, decreasing community immunity against childhood diseases may increase new epidemics in future natural disasters. Thus, increasing vaccination in children must be one of the current measures to be taken to combat this kind of situation. Currently, patterns of childhood infectious diseases have not returned to prepandemic patterns. There has been, and in some cases, there are ongoing, rebounds of a range of infectious diseases (e.g., enterovirus infections, bronchiolitis, gastroenteritis, scarlet fever, chickenpox) to rates beyond their prepandemic levels that present risks following natural disasters that are potentially greater than in previous natural disasters.
Article published online:
12 April 2023
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