Curr Infect Dis Rep (2012) 14:47–52
DOI 10.1007/s11908-011-0225-5
INTRA-ABDOMINAL INFECTIONS, HEPATITIS, AND GASTROENTERITIS (DA BOBAK, SECTION EDITOR)
Gastrointestinal Infections in the Setting of Natural Disasters
Richard R. Watkins
Published online: 26 November 2011
# Springer Science+Business Media, LLC 2011
Abstract Gastrointestinal illness following natural disasters is
a common occurrence and often results from the disruption of
potable water supplies. The risk for outbreaks of gastrointes-
tinal illness is higher in developing countries because of fewer
available resources and poorer infrastructure. But industrial-
ized countries are not immune from this problem, as
demonstrated by an outbreak of gastroenteritis from norovirus
that followed in the wake of Hurricane Katrina in 2005. Rates
of gastrointestinal illness following natural disasters are
influenced by the endemicity of specific pathogens in the
affected region before the disaster, the type of disaster itself, the
availability of health care resources, and the response by public
health personnel after the disaster. Ensuring the uninterrupted
supply of safe drinking water following a natural disaster, like
adding chlorine, is the most important strategy to prevent
outbreaks of gastrointestinal illness.
Keywords Gastrointestinal illness . Earthquakes . Floods .
Tsunamis . Hurricanes . Cholera . Typhoid fever .
Norovirus . Hepatitis A . Hepatitis E . Vaccines
Introduction
Gastrointestinal illness following natural disasters is a
common scenario that has been well described in the medical
R. R. Watkins (*)
Division of Infectious Diseases, Akron General Medical Center,
224 W. Exchange St. Suite 290,
Akron, OH 44302, USA
e-mail: rwatkins@agmc.org
R. R. Watkins
Department of Medicine, Northeast Ohio Medical University,
Rootstown, OH, USA
literature. Natural disasters have been defined as catastrophic
events with atmospheric, geologic, and hydrologic origins and
include earthquakes, volcanic eruptions, landslides, tsunamis,
floods, and drought [1]. There are many pathogens that can
precipitate gastrointestinal infections after natural disasters
including viruses, bacteria, and protozoa (see Table 1). In the
United States and other industrialized countries, outbreaks of
gastrointestinal illness following natural disasters are rare.
But developing countries are disproportionately affected
because they often lack resources, infrastructure, and
disaster-preparedness programs [1]. After a large earthquake
struck Haiti in January 2010, public health experts expressed
concern for the potential of an outbreak of cholera or
typhoid. Then, in October 2010, an outbreak of cholera was
reported by the Haitian National Public Health Laboratory
[2•]. By December 17th a total of 121,518 cases resulting in
2,591 deaths had occurred. In addition, several cases were
reported in the United States from travelers to Haiti. This
review will focus on the consequences of natural disasters as
they relate to gastrointestinal illness as well as the current
state of knowledge on the epidemiology and management of
these important human pathogens.
Contamination of Potable Water Supplies
Access to safe water is often limited following a natural
disaster. Flooding, for example, causes disruption of sewage
systems and contamination of drinking water [3]. Following a
storm in West Bengal, 33% of analyzed water samples
obtained from taps, wells, and ponds were found to be
contaminated with V. cholerae [4]. Levels of contamination
in water supplies following the 2004 flood in Bangladesh
ranged from 23% to over 90% and included fecal coliforms,
fecal streptococci, and Vibrio cholerae [5]. A study from
Indonesia reported that one-third of groundwater wells
48
Table 1 Infectious agents causing gastrointestinal illness after natural
disasters
Bacteria Viruses Protozoa
Escherichia coli Hepatitis A, E Cryptosporidium
Salmonella Enterovirus Giardia
Shigella Norovirus
Vibrio species Rotavirus
Vibrio cholerae
Vibrio parahaemolyticus
Vibrio vulnificus
following a flood were contaminated with enteric viruses
(hepatitis A, enterovirus, norovirus, and adenovirus) while
no viruses were detected in groundwater wells in non-
flooded areas and tap water samples [6]. The disruption of
safe water supplies may take a long time to ameliorate as
demonstrated after the 2004 flood in Indonesia, when
6 months later only one-fifth of individuals in one rural area
had regained access to potable water [7].
Risk of Gastrointestinal Illness from Dead Bodies
After a natural disaster resulting in a large number of
fatalities, a temporary workforce is often assembled to
collect, transport, store and dispose of the dead. These
workers are likely to be exposed to gastrointestinal illnesses
because dead bodies often leak feces. Transmission of
enteric pathogens can occur after direct contact with the
victim’s body and clothing through the fecal-oral route [8].
However, enteric pathogens do not survive long in the
environment and the risk for transmission is low when
bodies have decayed or have been in water [9]. To reduce
the risk of gastrointestinal illness workers should follow
universal precautions, wear gloves when handling bodies,
practice good hand washing, and carefully disinfect
equipment and vehicles used for transportation [10].
Specific Infectious Etiologies
Cholera
The etiologic agent of cholera, Vibrio cholerae, is a gram-
negative, comma-shaped bacillus with a polar flagellum.
Over 200 serogroups have been identified, but only O1 and
O139 are associated with clinical disease. Vomiting and the
passage of large volumes of liquid stool are characteristic
features of cholera. V. cholerae causes diarrhea by releasing
an enterotoxin that causes the secretion of fluids and
electrolytes by the small intestine. While contaminated
food and water are the main routes of infection in humans,
a recent study showed a high incidence of symptomatic V.
Curr Infect Dis Rep (2012) 14:47–52
cholerae infection in household contacts of cholera patients
[11]. Areas where cholera is endemic are susceptible to
outbreaks after natural disasters, as demonstrated by a large
outbreak of diarrhea (97,934 cases) that followed a cyclone
in India [12]. Molecular analysis confirmed that the
outbreak was caused by the endemic strain of V. cholerae.
Those infected with cholera develop memory B-cell
responses of both IgG and IgA subtypes that are detectable
for at least 1 year after infection and persist even after V.
cholerae antigen-specific antibody-secreting cells and serum
antibody titers have returned to baseline [13]. T-cell responses
to V. cholerae may play a role in protective immunity as well
[14]. The principles of treatment include restoring fluid
losses with oral or intravenous hydration and administering
antibiotics. A clinical trial demonstrated that patients with
severe dehydration who are treated with tetracycline had a
decreased duration of diarrhea and reduced volume of stool
by 50% [15]. The currently preferred regimen is a single
dose of doxycycline (300 mg) and alternatives include
trimethoprim-sulfamethoxazole, erythromycin, furazolidone,
ciprofloxacin, or azithromycin. However, there have been
reports of increasing resistance of V. cholerae to quinolones
which may be due to transferable resistance genes including
qnrVC3 [16]. Other resistance mechanisms discovered in V.
cholerae include efflux pumps, spontaneous chromosome
mutations, conjugative plasmids, SXT elements, and inte-
grons [17]. The addition of oral zinc (30 mg/day) to the
treatment regimen of children in Bangladesh resulted in a
12% reduction of duration of diarrhea and an 11% decrease
in volume of stools [18].
Fear of cholera outbreaks after natural disasters is at the
forefront of decisions for policy makers. Vaccination of
native populations against cholera is an attractive strategy,
especially in regions prone to natural disasters. Oral cholera
vaccines (OCVs) which are more convenient to administer
in low resource countries than parenteral ones have proven
to be less immunogenic and less protective for people in
less developed countries compared to those in industrialized
ones [19, 20]. This may be due to a so-called “intestinal
barrier” to successful immunization in people from less
developed countries because their gut flora reflects their
continual exposure to fecally contaminated environments,
resulting in small bowel bacterial overgrowth [21]. Follow-
ing the massive tsunami that hit South Asia on December
26, 2004 the Indonesian Ministry of Health, in conjunction
with the World Health Organization, began a mass-
immunization campaign using OCVs [22]. This was the
first time such a campaign following a natural disaster had
been orchestrated. The project took much longer to complete,
6 months rather than the two that had been planned, and was
much more expensive than originally budgeted. These results
exposed the limits to using the oral two-dose killed whole-cell
B subunit cholera vaccine (WC/rBS) in the setting of a natural
Curr Infect Dis Rep (2012) 14:47–52
disaster. Furthermore, a recent study showed that the WC/rBS
vaccine offers only short-term protection compared to natural
disease because of diminished memory B cell responses to the
cholera toxin B subunit and lipopolysaccharide [23].
The outbreak of cholera that began in Haiti in October 2010
subsequently spread to every region of that country. The
origin of the outbreak has aroused considerable interest as
there had not been a reported case of cholera in Haiti in over
100 years. Investigators used a third-generation, single
molecule, real-time DNA sequencing method to determine
the genome sequences of two Haitian V. cholerae isolates and
three V. cholerae clinical isolates from other regions of the
world [24•]. They found that strain originated in South Asia
which implied that the outbreak was a result of human
activity and not a consequence of the earthquake. This
finding has important public health implications for Latin
America because the South Asian variant V. cholerae El Tor
strain now in Haiti (which has increased antibiotic resistance,
higher relative fitness, and the ability to cause severe disease)
could displace the resident strain [24•]. The authors
suggested vaccination would help prevent the spread of
disease along with adequate sanitation and clean water.
However, cholera vaccine is in limited supply in Haiti. A
mathematical model predicted that providing cholera vaccine
late in the epidemic would have only a modest effect on the
course of the outbreak [25]. Conversely, two recent reports
demonstrate that oral cholera vaccination can help control
disease after an outbreak has begun [26, 27].
Typhoid Fever
The etiologic agents of typhoid fever, Salmonella Typhi and
Salmonella Paratyphi serotypes A, B, and C, have no known
hosts except humans and are transmitted by fecal contami-
nation of food or water. Typhoid fever can cause serious
outbreaks after natural disasters, such as the one that
occurred in Puerto Rico after Hurricane Betsy in 1956 and
in Indonesia after the tsunami in 2004 [28]. As in the case of
cholera, areas with endemic typhoid fever typically have
poor sanitation and lack access to clean drinking water; these
regions are particularly susceptible to large outbreaks
following natural disasters. Investigators found that follow-
ing the 2004 Indonesian tsunami, transmission of typhoid
fever occurred among internally displaced people as a result
of improper food preparation due to the lack of clean water
and bacterial contamination of drinking water [28]. The lack
of availability of effective antimicrobial drugs also contrib-
uted to the spread of disease. Since the 1970’s many strains
of S. Typhi have developed plasmid-mediated multidrug
resistance, and by 2005 22% of S. Typhi strains from New
Delhi, India were resistant to ciprofloxacin and 16% were
resistant to ceftriaxone [29]. This is concerning especially in
the context of treating typhoid fever after natural disasters,
49
when the already poor infrastructure of these limited resource
countries is further stressed by unavailability of effective
antibiotics. Two commercially available vaccines exist for
typhoid and theoretically it should be possible to eliminate
the disease through improved sanitation. However, its wide
prevalence and lack of resources for sewage disposal and
water treatment in resource-limited countries currently makes
eradication an unrealistic goal.
Shigellosis
Shigella is the most communicable bacterial cause of diarrhea.
While it is less common than cholera and typhoid fever,
outbreaks of Shigella are possible following any natural
disaster that causes contamination of food and water supplies.
Researchers investigating an increase of diarrheal illness
following a large earthquake in Turkey in 1999 found
Shigella species to be the most commonly identified isolate
[30]. A study that evaluated diarrheal epidemics following
three separate floods in Bangladesh found an increase in the
mean cases/day of Shigella-related infections during flood-
related epidemics [31]. The authors surmised that the increase
was due to a generalized increase in fecal-oral transmission in
post-flood epidemics. The patients in this study also were
more severely dehydrated than those who presented during
non-flood periods, suggesting an inherent difficulty of
seeking medical care during the post-flood period. Oral
hydration and antibiotics including fluoroquinolones or
azithromycin for multidrug-resistant species are the current
recommended agents. Like Salmonella, antibiotic resistance
has been spreading in Shigella including for ciprofloxacin
and cephalosporins, limiting treatment options [32–34].
Enterotoxigenic Escherichia Coli
Infections caused by enterotoxigenic Escherichia coli (ETEC)
range from asymptomatic carriage to severe cholera-like
illness. ETEC are known to spread though contaminated
water [35]. After the 2004 floods in Bangladesh, diarrheal
illness caused by ETEC was prevalent with comparable
numbers of ETEC and V. cholerae isolated [36]. The authors
of this study found many patients with ETEC required
intravenous hydration and that children under 2 years of age
were particularly susceptible. They hypothesized that flood
waters contaminated by sewage caused the ETEC outbreak
and that developing vaccines should be a goal to prevent
future ones. However, this has been difficult to achieve
because of the heterogeneity of antigenic determinants
needed for protective immunity. Recently the heat-stable
enterotoxin of ETEC has been proposed as a potential
vaccine component since it is present in 75% of clinical
isolates and is associated with more severe disease than the
heat-labile enterotoxin [37].
50
Gastrointestinal Viruses and Viral Hepatitis
Following Hurricane Katrina in 2005, a large outbreak of
norovirus occurred among evacuees housed in a temporary
megashelter in Houston, Texas [38•]. The outbreak affected
persons of all age groups and involved multiple strains, which
suggested that there were multiple sources of infection. Public
health authorities were unable to stop the spread of the
outbreak despite daily efforts and the outbreak continued until
the facility was finally closed. In 1988, Bangladesh suffered
heavy rainfall after a monsoon that caused widespread
flooding. The flooding coincided with an increase in patients
admitted to hospitals with diarrhea. Investigators found that
over one half of the cases were caused by rotavirus and most
were from strains different from the epidemic strain prevalent
before the flood [39]. However, they did not test for
protozoan or bacterial pathogens.
Hepatitis A virus (HAV) and Hepatitis E virus (HEV) are
spread by fecal-oral contamination and disruption of sanitation
following natural disasters can lead to outbreaks. In endemic
areas, HEV outbreaks often follow flooding [40]. Symptoms
are usually mild such as nausea, vomiting, loss of appetite,
and jaundice but can be severe in pregnant women [41]. In a
retrospective study from Bangladesh, acute HEV infection in
the third trimester of pregnancy was associated with 80%
mortality [42]. These authors also found that HEV caused a
high incidence of fulminant hepatic failure. Four years after
an earthquake in Turkey, investigators found a high sero-
prevalence rate of HAV among children who survived the
earthquake (63%) and a low rate of HEV (0.3%) [43].
Protozoa
Following a flood of the Mississippi river in 2001, the
concentration of Giardia in drinking water increased 330%
which correlated with an increase in gastrointestinal illness
(incidence rate ratio=1.29) [44]. The two major risk factors
for gastrointestinal illness were if the person participated in
clean-up efforts and whether their yard or home was flooded.
Water-purifying devices had no effect, which suggests that
the acquisition of illness likely occurred through a route
other than drinking contaminated water such as consumption
of food that had been contaminated by floodwater. After
Hurricanes Katrina and Rita, floodwaters were found to
contain a high concentration of fecal bacteria and both
Giardia and Cryptosporidium were detected in canal waters
[45]. Two reports of gastrointestinal infections in children
after earthquakes found a high prevalence of Giardia in fecal
samples [46, 47]. Residence in temporary housing after the
earthquake and use of communal toilets were risk factors for
acquisition of disease. The volcanic eruption of Mt. St.
Helens lead to an outbreak of gastrointestinal illness in
Montana. Giardia was identified in the stool samples of 51%
Curr Infect Dis Rep (2012) 14:47–52
of those with symptoms and in 13% of asymptomatic
persons (p=0.00045) [48]. Unfiltered and inadequately
chlorinated water from the city water system was subse-
quently identified as the source of the outbreak.
Prevention of Gastrointestinal Illness following Natural
Disasters
One of the most important tasks of public health authorities
after disasters is surveillance for disease. The ability to detect
greater-than-baseline incidences of diarrhea is vital for the
management of an outbreak [49, 50]. A key prevention
measure is the provision of safe drinking water through
chlorination, which is effective against nearly all waterborne
pathogens. After the South Asia tsunami in 2004 chlorina-
tion of stored water, either in tankers or at the household
level, was the only intervention associated with a decreased
risk of E. coli in drinking water [51]. Additionally, this study
found that boiled water was no more likely to be free of
contamination of E. coli than untreated water. These findings
cast doubt on a statement from a foreign aid agency of the
Unites States government that boiling prevented the devel-
opment of diarrheal diseases after the tsunami [52]. Another
study investigated batch solar disinfection for Giardia and
Cryptosporidium and found that the technique rendered the
spores completely ineffective after 4 and 10 hours of
exposure, respectively [53]. The investigators suggested that
the method could be effective as an emergency intervention
for household water treatment after a natural disaster. Further
large-scale studies should be conducted before its widespread
use is recommended.
Another important prevention strategy is promoting hand
washing with soap and water. This intervention was found
to be the most cost-effective intervention in the post-
disaster setting to stop the spread of diarrheal illness [54].
However, efforts by public health personnel to improve
personal hygiene during the norovirus outbreak in Hurricane
Katrina evacuees were not successful in stopping the outbreak
[38•]. Alcoholic hand sanitizers are effective against many
pathogens that cause gastrointestinal illness but have limited
activity against norovirus [38•].
The logistical difficulties and cost of the cholera vaccine
have limited its widespread use after natural disasters. As
previously mentioned the widespread oral cholera vaccination
campaign in Indonesia after the 2004 tsunami was marginally
successful and ran over budget [22]. A recent study from
Vietnam showed that a killed OCV produced in that country
was 76% protective against cholera in an outbreak setting
[27]. Whether these results can be duplicated in the setting of
a natural disaster is an area for further research. The HAV
vaccine was recommended in Poland after widespread flood-
ing occurred in 1997 but data on its effectiveness are lacking
[55]. Typhoid vaccination is generally not recommended for
Curr Infect Dis Rep (2012) 14:47–52
preventing outbreaks after natural disasters since there is no
evidence that it is effective in this setting.
Conclusions
The specter of gastrointestinal illness after natural disasters
continues to be an important challenge to public health in
the 21st century. Outbreaks are usually the result of endemic
organisms rather than novel ones. Their severity often
correlates with the degree of disruption to water supplies
and sanitation. Surveillance should be established as soon
as possible in order to detect outbreaks early in their course
with the goal of ameliorating their effects on the afflicted
population. The early diagnosis and treatment of diarrheal
diseases is paramount, especially in vulnerable populations
like the elderly and those aged <5 years. It is also vital to
ensure the availability of oral rehydration salts and anti-
biotics in the management of diarrheal diseases. Knowledge
of local antibiotic resistance patterns is needed given the
global spread of antibiotic resistance in enteric pathogens.
Public health authorities have an obligation to distribute
health education messages after natural disasters including
promoting good hygiene like hand washing with soap,
promoting safe food preparation techniques, chlorination of
water, and early treatment of illness. It is important that
evidence-based interventions are utilized to provide the
most effective solutions after natural disasters. Unfortu-
nately the data on effective interventions for gastrointestinal
infections after natural disasters are limited, especially in
resource-limited settings. One area of promise is a recently
identified norovirus strain in mice that grows well in cell
culture and may lead to new discoveries related to viral
inactivation and spread. Despite daunting challenges,
continued research on effective vaccines for gastrointestinal
diseases is imperative given their potential for reducing
global human suffering.
Disclosure No potential conflicts of interest relevant to this article
were reported.
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