Welcome, once again, everyone, to the National Education Curriculum for Preventive Medicine Residents in Emergency Preparedness and Response. We welcome you today for the 12th and final webinar in the series. Dr. Liszewski or Natasha, could either of you confirm with a thumbs up that you're able to see the screen? Perfect. Perfect. Just a moment of housekeeping before I turn the floor or the screen, if you will, to our faculty today, Dr. Liszewski. Please attend the webinar completely and feel free to ask the questions to the faculty. They're here for you today around 745, right when the Q&A session starts. My colleague or I will post the survey in the chat, and either please take a moment to complete the survey and help us improve. This is a pilot series. Please continue the discussion on this topic and other topics of the webinar on ACPM Pulse, which is, as you know, a relatively new online discussion forum exclusively for ACPM members. This webinar is, of course, being recorded, and ACPM will send you instructions to access the recording of this webinar and past webinars. All the webinars in this series are available at no cost for current PM residents of PREV-MED, OCMED, and AM specialties. And with that, it is my pleasure, privilege, and honor to host this webinar today and turn over the screen to our faculty, Dr. Liszewski. Dr. Liszewski, take it away. Good afternoon or evening or morning to everyone, wherever you are. So again, my name is Dr. Rhonda Liszewski. I'm the Deputy Science Director for Navy Medical Research Command. We're located here in Silver Spring. And so it's my pleasure to talk to you today about public health emergency preparedness and response. So I am an active duty Navy preventive medicine physician, and I have been involved in some humanitarian assistance, disaster relief. I've been deployed. I was in the Operation Enduring Freedom. And so I've been through a couple of places, also stationed overseas, that have given me the opportunity to work in some unique environments. And that's what I'm going to bring with me today, as well as some of my own training in humanitarian assistance and disaster relief and public health emergencies. Next slide. So I have nothing to disclose, but I do have a disclaimer in that these are my views and do not reflect any official policy or positions of the Department of Navy, Department of Defense, and the United States government. So we have some learning objectives for you today, and that's important for our CMEs. So what we're going to talk about today, I want to make sure that everybody understands the unique details of an emergency or disaster situation that affects disease consideration from a public health perspective. So I want you to be able to think of this as in an all hazards approach, not just a specific situation causing a specific disease. So we're going to talk about how to analyze the five Ws, if you will, who, what, when, where, and why of any disaster or mass displacement to determine some of the infectious disease priorities that you have to keep in mind. Because if you've seen one disaster, you've seen one disaster, just like we would say with our public health departments, right? You've seen one public health department, you've seen one public health department. There are, of course, some similarities and things of that nature that you're going to be able to pick up on patterns, but it's really important that you look at each situation and think about what is unique to that particular situation when you're applying it in practice. So we're also going to kind of compare and contrast humanitarian assistance and disaster relief. That's a common terminology is HADR for some of these events. And so you'll see how these things fit in with either a humanitarian assistance or disaster relief or a combination of both. We're also going to talk about some of the top four causes of mortality in an acute humanitarian emergency. This is not necessarily in the United States, but worldwide. Those are diarrhea, acute respiratory infections, measles, and malaria. And then we're going to run through some other important potential infectious disease causes of mortality of morbidity and mortality again, worldwide, but also here in the United States, cholera, not so much, but skin and wound infections, vector-borne disease, tuberculosis, and leptospirosis. Next slide. And then we're going to talk about the SPHERE guidelines to decrease the risk of infectious disease during emergency relief. And this is available online, free, and I'll show you the link for it, but it gives you some standards to go through. This was developed in partnership with over 47,000 relief workers who have written in an almost like a group way. And it's a very well-known set of guidelines that help us in a situation to ensure the best standards and best practices, especially in a humanitarian relief. All right. And then we're also going to talk about dealing with the dead and understanding infectious diseases and corpses. There's some fact and fiction that we're going to go through. This is something that has come up repeatedly and people get very concerned about those risks. So we'll talk about them as well. All right. So let's dive right in. Next slide. So what is a disaster? So how many people do we have online here? I think we have 13 participants. Do I have any, do I have anybody that wants to take a guess? What would you consider a disaster? Feel free to type the answers into the chat. All right. I'll give you a hint. Go ahead and hit the next slide. Anything that requires services. So there's a good idea. So it could be, there are a lot of different things that can be a disaster. So if you go ahead and advance one. Catastrophic event causing a massive disruption. Right. So we have this one. War. Next. A nuclear incident, maybe. An event causing morbidity and destruction. Right. We have famine. That happens. Good. And political upheaval. And then, yep. Natural or man-made. So those are some of the more man-made ones. Some of the natural ones. Flooding. Next. Earthquakes. Tornadoes. So there are a lot of different types of hazards. We can look at them. Oh, you can go ahead. Go to the next slide. Great. So we have emergencies. And this is a review from your December lecture. There's FEMA categorizes 18 natural or man-made hazards. And then we have natural or man-made. So those are some of the more man-made ones. Some of the natural ones. Flooding. Next. Earthquakes. Tornadoes. So there are a lot of different types of hazards. We can look at them. And this is a review from your December lecture. There's FEMA categorizes 18 natural hazards that could potentially cause a disaster. Now, not every time that you have something like this happen is it a disaster. So we had hail here on New Year's Eve, as a matter of fact. It wasn't quite a disaster. So there are also, and there are different ways to look at that. And again, if it's an acute situation and it affects a large population where there's disruption or displacement, neither the population nor its government is capable of providing for all of the basic needs, that would be something that would be a humanitarian emergency. Something that requires a response might be a disaster relief effort. And so we could also, in addition to the 18 natural hazards, you could also look at them in three different ways as hydro meteorological, geophysical, or geomorphological. So hydro meteorological, like storms, floods, tropical cyclones. Tropical cyclones include typhoons and hurricanes. And then geophysical with wildfire, volcanic eruptions, earthquakes, and geomorphological we don't see as much with the avalanche as being a massive disruption. Sometimes with landslides we do. So there are a lot of different situations and each one of them is going to have a different potential impact on what infectious diseases you need to think about. So that's your what. What are you dealing with? Are you dealing with a flood? Are you dealing with a hurricane? Are you dealing with wind? Are you, that was, for instance, it was related to, it was about the same year as Sandy, Hurricane Sandy. We had what was called an inland storm, El Derecho, in this area, and it caused winds in excess of 50 miles an hour. We were out without power for about a week and a half. And that was not actually, it was the same year as Sandy, but it was not associated with the hurricane. So there are different, these natural hazards that can produce an emergency, even sometimes when it's not something that you would necessarily consider a big storm or situation. Okay, next slide. So again, we have kind of looking at them from two different types. We have the man-made disasters. We just talked about the natural disasters. So looking at another type, a man-made disaster, we have two different kinds. So you have the technological disasters and the complex disasters. So technological disasters like Chernobyl or Fukushima or the Bhopal, India, toxic gas release. Those incidences have usually not as much of an infectious disease specific concern. However, there certainly could be, and we'll get into a little bit also with the timing and how that affects it. Your complex disasters, things like civil unrest, war, mass displacement, those often have a infectious disease component with them. And we're going to move on here and talk a little bit about who is involved in those. Because once you've looked at what type of disaster or humanitarian emergency you're looking at, then you need to know who is your population and how is that going to affect what could be the infectious disease considerations at that time. Go ahead to the next slide. So in our population, that's what we're always looking at as preventive medicine physicians, right? That's very important to us is knowing our population. And as you're very well aware, different infectious diseases are common in different populations and whether they're endemic or even potentially epidemic in a particular population. But you need to look at the extremes of age. So usually in these situations, you are vulnerable populations, you're young, you're elderly, specifically five and under are a very vulnerable population. Women specifically pregnant women, again, can be a very vulnerable population. And then as I mentioned, the elderly or those with special needs. So if they came into the situation with chronic illness, something like HIV or tuberculosis, we'll talk about a little bit, but because those have preventive services that usually help them stay under control, if those are disrupted, then that's a consideration as well. Now I put in here also animals, wild or domestic, because if there's a mass disruption, particularly on the ecological scale with something environmental, a storm, a famine, a tsunami, these sorts of things, there's going to be a displacement also of domestic and wild animals as well. And they could potentially be a vector for disease. Now vectors also we'll talk about are mixed in with this as well. And if there's a proliferation of vectors that could affect, now you have your human population mixing in with increase in vectors, and that's a concern for infectious disease as well. Okay, next slide. So when, so when this happens, what, what are you looking at? We talked a little bit about, and this is probably a familiar slide to people as we're talking about the different phases of an emergency. So when you're talking about the acute early phase of an emergency, there's that initial chaos, you have a rapid response that people are trying to get in to ameliorate the problem. And people have basic needs that they're going to have to go through for housing and food, and water. And those are trying to be addressed in that early phase of the emergency when, and this is also specifically in disasters, when there's a high fatality rate. And that's mostly from trauma, not from infectious disease. There may be infectious diseases in that beginning in that early phase with that are things that have a short incubation, or things that were prevalent in the community prior to the emergency that are being exacerbated. But again, it's that short period, the first zero to one month. And that's a time when you need to think about some of potentially diarrheal illnesses. And we'll talk about some of the examples as we go on. And then when we get into this response portion, and the recovery phase, where now you usually, and these are, these are approximate times, right? Like nobody is setting their watch clicking and saying, okay, exactly at one month, this is, you know, now something's going to change. So these are a continuum and just a guideline to look at. So in that recovery phase, and one to six months, potentially, you're looking at expanded relief efforts. Now, there's been time for moving logistics and supplies that are able to get in to an area, hopefully improve some conditions. However, now you may have outbreaks that become established that have a longer incubation and are related to that mass displacement and overcrowding. So before you had what was maybe in the population, maybe some shorter incubation period, infectious diseases that are, that are in a, in direct contact with the individuals. But once you're getting into that phase where people are starting to go into camps or, or overcrowded conditions in temporary shelters and things like that, then you may have outbreaks that are related to that. And then we get into the six month and longer, the population starts to look a little bit more like a typical community. And there may become endemic diseases in that community that you need to monitor for. If this is a long-term situation, again, like a humanitarian assistance effort where, or a humanitarian emergency where you have IDP camps and things like that. Now you have a camp and you're going to have specific diseases that you have, you have to be concerned about. We're going to talk about those in a minute, but those are the big four that I, that I talked about earlier. We'll go into depth with, with each one because of the overcrowding issues, because you may have malnutrition and things like that. These diseases tend to rise to the top. All right, next slide. Where location, location, location, just like real estate. So, and that's one of the interesting things, right? About doing preventive medicine and, and the epidemiology is we have, we have very different diseases in different locations. So that's another very important concept to make sure that you drive home when you're looking at where this happened. So the infectious disease considerations that you're going to have in Japan are going to be very different than sub-Saharan Africa, which is also very different from North Carolina. Now, there may be some, again, some similarities, but there may be special considerations that you need to know, particularly what's endemic, right? So we have some things that are very ubiquitous E.coli or, or a Pseudomonas or something like that, that are in many, many different places, pretty much everywhere. But then you have some, and leptospirosis for that matter as well. However, we know there are places that are more likely to have a leptospirosis outbreak or a Melioidosis that's a concern, vectors, right? And what vectors are there? So if you don't have Anopheles mosquitoes in an area, then you're most likely not going to have to worry about malaria. But if Anopheles are present there, then that's something that you have to consider. Are you at altitude? So is there absolutely no chance that you're going to wind up with a malaria issue because you're in the Andes, for example. And when we were working in Peru, we didn't have to worry about when we, when we would go up in, into those higher elevations that malaria wasn't an issue. Then altitude was an issue. But from an infectious disease standpoint, it was different. So then also, where are your susceptible hosts and what are their immunity levels? Are they in contact with those vectors? And then what's the climate like in that location? Is it someplace that's hot? Is it cold? Is it someplace that's near water? So all of those things, as you can open your aperture and you're looking at, someone says, all right, well, we need you to go in. There's a particular humanitarian crisis and we need you to go to Sudan. You know, so flooding is not going to be maybe first up on your list. So those are the, those are some important considerations there in terms of location. And this one in particular, this picture is a map of a heat map of flooding from 2024. So you can show, you see some of the, the increased areas of, of where flooding is a problem and where it's not. So that's an important thing to note. All right. Next slide. All right. And the why. And why is very important. It's one of the questions that we ask ourselves, why did this happen? And what do I need to look for because of what's going on? Mass disruption is really one of the big whys. So why is there, why do I need to be concerned with the environmental changes? Well, with that disruption, like I said, you have increased breeding sites for vectors, things like rodents, mosquitoes, potential, potentially disrupted populations of wild animals is really something that you need to be concerned about. So then also we have increased exposure to those vectors because of lack of shelter, perhaps. So are people sleeping outside or are they in very crudely built tents? And what's that put them in contact with? You have environmental changes like standing water and things like that. There's a disruption to the healthcare infrastructure. So in addition to the fact that they've had this emergency happen, there may be limited or no healthcare access. There could be potential antibiotic resistance from incomplete regimens of antibiotics. So if someone was on an antibiotic prior to the emergency and now they can't get, they've had to leave their home or they just don't have access to get a refill and they didn't complete the regimen. They may leave their home hastily and forget to take their medications with them. They may have grandma's medications on hand and decide that they're gonna treat themselves with grandma's medication. So if they're improperly using their antibiotics, that could also create antibiotic resistance on top of the other issues that they're having. So we also talk about disruption of prevention programs. So if there's a mosquito control program that's going on, but now you've had a disaster and they can't get the trucks out for spraying or they can't, the individuals that normally do that are being utilized for disaster response, then that could cause the mosquito population to increase. Even something like the COVID pandemic, we were not able to continue the mosquito control in Peru that was helping with things like malaria in the Amazon. And we saw increased cases of malaria and dengue, specifically dengue, really spike. So also immunization programs may fall to the wayside and surveillance as well. We talked a little bit about tuberculosis. So then also in a disruption, I talked about farming and potentially animals that are disrupted, but what about the scarcity of food? People aren't able to eat if they're not able to continue their farming, if that was how they were getting their food or even disruption of supply chains. Now you may have malnutrition on top of the potential for infectious disease. We know if you have a low level of vitamin A, then that can increase your risk for measles. Can't just treat it with vitamin A, but it may be an important supplement specifically in a malnourished aspect in something like a humanitarian aid situation. So also, and then displaced populations usually don't have basic sanitation and hygiene because of the overcrowding and contaminated water. And you're gonna see these themes throughout all of the diseases that we're gonna talk about today. All right, next slide. Okay, so what is humanitarian assistance? So these are often from complex emergencies. And like I said, it's an acute situation. It affects a large population whether it's through disruption or displacement and the population nor its government are capable of providing for all of their basic needs. It can be an acute or a chronic timeline. So there may be an acute displacement that happens. And then again, those individuals are not able to go back to their normal lives. And then this becomes a permanent situation. So you have internally displaced persons, IDPs versus refugees. So basically IDPs, they left home, but they didn't cross the border. So they're internally displaced. They have not left their home country. Refugees crossed the border. So you have about 44 million worldwide refugees as of 2020, as of WHO's 2020 for statistics and then about 69 million worldwide IDPs. Now, the difference between those two is important specifically because for refugees, the United Nations High Commission for Refugees has authority over them. And there are certain protections under humanitarian law if you have the designation as refugee. So sometimes that's important for people in getting relief services. So again, in a humanitarian assistance, we're gonna talk about the top four causes of mortality and those are diarrhea and acute respiratory infections, measles and malaria. Also some long-term infectious disease considerations for some of the more vulnerable populations and the deaths in a humanitarian assistance specifically in IDP and refugee camps tend to be again, the very old and the very young. And so those are important things to consider when you're looking at these situations and if you're gonna be responding to them. All right, so next slide versus disaster relief, where we're really focusing on a specific event that happens usually something with environmental, although disaster relief can be manmade. Again, like I said, a terrible situation, the tsunami in Japan with Fukushima because there was a disaster relief component to that as well. So the acute initial response is very safety focused and very much looking at lifesaving. That's not usually where we're overly concerned about infectious disease and usually everything because again, the initial acute phase for the disaster, often the majority of mortality there is from trauma. And then the infectious disease are related to that delayed restoration and infrastructure, basically sanitation and contaminated water, loss of electric power, displacement of populations, even if it's part of the initial relief effort. And the basic priority there is providing for those Maslow's basic needs, right? So housing, shelter, clothing, food, water. And oftentimes we're focused on mitigating the damage that's been done in a disaster relief effort. And again, this is something that we usually, when aid comes in very quickly, focused on organizing the chaos. There are important infectious disease considerations, but you're going to be looking at it through a different lens in terms of prevention when you're in the acute phase. So let's go and talk about some specific infectious diseases. So next slide, we're going to talk about diarrhea. I know it doesn't sound like a sexy topic. And sometimes we have people thinking this really can't be true, but it is. So two thirds of your mortality are from diarrhea and acute respiratory infections, especially for children. And in disaster camp settings, there could be up to 40% mortality ratio from diarrhea. Specific etiologic agents, obviously norovirus is going to spread in a crowded condition and it spreads like wildfire, rotavirus as well. Bacterial or bacterial diarrheal infections are important as well with all, like an example here in flooding, in this picture in flooding in Bangladesh, your exposure to water, water that potentially has sewage in it, and then a lack of clean drinking water all can cause you to be infected with bacterial diarrhea. And I don't know if any of you have ever had a very, very bad piece of bacterial diarrhea. I have, and I had a campylobacter in Egypt and 102 fever and it was nothing to laugh about. And then also of course, parasites, dyspridium and giardia are well-known with flooding and contaminated water. All right, next slide. So frequently associated with the disasters and displacement in flooding and hurricane disasters, as I said, so we'll talk a little bit more about Katrina at the end. And these are a list of some of the diarrhea outbreaks that occurred, as I said, Japan and the tsunami that had occurred there, flooding in Bangladesh. So you see, these are a lot of flooding issues, but there are also some with earthquakes as well. And that's again, likely to be because of poor sanitation and damaged infrastructure. Also, like I said, water contaminated with sewage is a problem and overcrowding and malnutrition. Next slide. So when we talk about diarrhea, obviously the most important thing is getting clean drinking water and water treatment and then oral rehydration solutions. And I put up a little recipe here for you for a simple ORS that's using table sugar and salt. If you don't have access to actual packets, this can be made up at home. A lot of times people won't have the potassium chloride, but you could substitute something like a banana, oranges or tomatoes, something that has high potassium in it. But this is something that can be made up at home. And also we talk about zinc supplementation because it reduces the duration and severity of diarrhea. So if you're trying to treat, let's say children that are having diarrheal episodes, this is something that you can add to that as well. One, I'm gonna list the vaccines, but getting vaccines into an IDP camp or at a time of the acute phase can be difficult because like I said, you're dealing with the traumas right there. At that point in time, you're not necessarily able to just launch right into a vaccine program. But it's important to note that, that rotavirus vaccines out there and we'll talk about cholera in a little bit and then antibiotics as well. Don't use fluoroquinolones because most, especially the bacterial diarrheas are resistant to that. So go ahead to the next slide. Cholera. So cholera is really important, especially if you're talking about IDP and refugee camps and the humanitarian assistance aspect of it. So even though we don't see cholera here with the exception of occasionally in the Gulf, it is a, it's still a killer. And we have still seen those in as recent as the Haiti earthquake in 2010. And even here in 2025, WHO reported, like I said, over 1,600, over 16,000 cases and 1,500 deaths from cholera worldwide. So here we have just a few of the, oh, there we go. Here we have just a few of the important things to know about cholera. So cholera does actually exist in the environment. It's found in brackish water and saltwater. So you go to oral transmission, obviously one to five day incubation. And this is what we talk about, our rice water stools, very profuse diarrhea. And it can be asymptomatic, actually. And so you can have asymptomatic carriers, but as well, you could progress into shock and death within 24 hours. So in the WHO's clinical case definitions, if you don't have testing that's available, it's important to look at, if you're in this kind of humanitarian assistance realm when you don't have good lab tests or things like that, which obviously if you're in a disaster timeframe, if you're in a disaster, might not happen. You might not have that lab capacity. So that's an important thing to look at as your case definition. Next slide. So, well, again, cholera is very significant mortality when it's untreated, but it can be successfully treated with ORS. We do have vaccines now. So if you're gonna have to go to an area that cholera may be part of a humanitarian assistance, situation, you might consider having that vaccine prior to going. It can be used in an outbreak situation to control outbreaks in an IDP camp as well. And then there are times when you might use antibiotics if the ORS isn't working well enough, or just to reduce the burden in the diarrhea and to reduce the volume of the diarrhea. And that can be helpful as well, especially in spreading to others. So those are just some pearls from the cholera perspective. But moving to the next slide, we're gonna move out of diarrhea and talk a little bit about respiratory conditions. So again, acute respiratory infections, common things being common, this is still something that you have to consider as an important cause of morbidity and mortality in a disaster situation. So still common things being common, a lot of these viruses are gonna resolve on their own and you don't need to give antibiotics for them. And antibiotics may actually exacerbate a situation where you may cause diarrhea or antibiotic resistance. And so you definitely don't wanna do that. But what you do wanna do is make sure that you understand what the danger signs are. So again, I've listed here some of the common etiologies, flu, COVID, RSD, diphtheria and pertussis, pneumonias, bacterial pneumonias, meningitis. Again, where in the world are you? If you're in the meningitis belt in Africa and Asia, this might be very significant. Tuberculosis, not so much in the acute phase, but later on it could become an issue. We'll talk about that with Katrina. But the danger signs are really important. So things like cyanosis, retractions, flaring, and lethargy, seizures, obviously, if you can't take PL, then you need to make sure that you're treating those with antibiotics and that you bring those individuals that you might see to medical attention as much as possible. But realize you're not likely gonna have an X-ray capability and you may just have to rely on your clinical diagnosis at that point. Okay, next slide. So again, why are these a big deal? You have crowded conditions and temporary shelters and lack of access to healthcare, limited resource environment. So again, you're gonna have to use clinical judgment on some of these things because you're not gonna be able to send out for testing depending on the situation. But again, worldwide, these are, how for 20% of deaths in children under five in humanitarian assistance and disaster relief situation. So you might wanna consider, is there any way to decrease the crowded conditions? Can you isolate people? Is there vaccination? If you're at that stage in the disaster where you were or in the humanitarian relief where you can actually start a vaccine program, potentially masking. And then I listed some of the disasters and that there were significant deaths due to acute respiratory infections there. All right, next slide. So speaking of respiratory, measles. And here, so not just in IDP camps or refugee camps, but here in the United States as well, where we are seeing a research in some measles. So we'll just go through a little bit of basic microbiology since this is so timely, but single-stranded negative enveloped negative sense and enveloped RNA virus. And basically it affects the alveolar macrophages and dendritic cells. This is a person-to-person. You know, we talked about airborne, air droplets, transmission, and an attack rate of about 90% with close contact. So think about that in the sense of a crowded condition. And we're seeing that here now. I saw on FBX today, just another call out for a different state for measles cases. One of the most famous cases, there was transmission documented two hours after a case left in the exam room. It's just, it's that contagious. So you're looking at your incubation periods that range from seven to 16 days, and you're usually contagious two to four days before and four days after the rash. So that has a huge outbreak potential when you're contagious before you even see the rash or have a fever. And then you're generally infectious for a seven to 10 day period. Go ahead to the next slide. We have a nice picture of a kiddo with the rash. So you've got your two to four day prodrome with the high fever, your classic C's, cough, conjunctivitis, and choriza. And then you may actually have some diarrhea and it's worse, like I said, if you're malnourished. And again, that's why we would give maybe a vitamin A supplementation. The coblic spots and the buccal mucosa occur one to three days before the rash, but it's not something that people are gonna be looking for necessarily. And so they might miss that. So the maculopapular rash, when it starts kind of behind the ears at the hairline and then it spreads down for two to three days, it starts to coalesce and then it kind of desquamates and their recovery takes 10 to 14 days. Next slide. And obviously this is vaccine preventable, but with a decrease in vaccination, you're gonna have cases. So once you've been vaccinated, 95% of people are unlikely to contract the disease. And it was actually declared non-endemic in the US in 2000. However, our current outbreak is over 800 cases now. And so you can see as vaccine, as immune status goes down, cases are gonna come up. So pretty simple math there. So go ahead to the next slide. We'll talk about that in the context of some other cases as well. In a earthquake in Pakistan, 2005, they had 400 cases that were unvaccinated in IDP camps there and then also in the Banda Aceh after the tsunami, there were several cases. So this is again, disruption in... This is a lot of mass disruption. People are moving. They're in crowded spaces and you have a disruption of the usual prevention programs. And so of all of the vaccines that we have and that we're gonna talk about, this is the one that is most important to start right away. Like I said, you might not have the ability to do a rotavirus vaccine campaign, but if there's one vaccine that you have time and resources to do in a humanitarian assistance or disaster relief situation, MMR is the most important to do. All right, next slide. I'm going a little bit slower than I thought. Sorry, everybody. So malaria, I'll just, I'm not gonna go into the whole life cycle here. You can take a look at that, but you're, as I mentioned, in endemic regions, this is a significant mortality risk, especially for children under five. The children and infants, pregnant women and malnourished are very susceptible to severe fatal malaria as well as the non-immune. So if you are going in as an aid worker or something like that, then you want to make sure that you're taking prophylaxis. Next slide. So some of the clinical presentation, the fevers and chills is classic, the headache and myalgias. And then in some people though, they're going to have absolutely, I had a guy walk into clinic one time, said he had a headache. We took a look at his smear and went, whoa, you should have a lot more than a headache. You know, we were having a hard time finding something that did not have faucet for a minute. So, you know, just be aware that there is that range for individuals, but severe malaria is someone that has an altered mental status, hyperglycemia, hyperparasitemia is greater than 10% and severe anemia. Next slide. And it is a major cause of global morbidity and mortality. And it can also be drug resistant, especially with mefalciparol. When you have plasmonium bivacs in a valley, they can be relapsing as well. And so you have to make sure that when you're treating it, that you treat that liver stage in addition to make sure that you're not gonna have relapsing. It's important to know, again, when we talked about location. So do you have, are you in an area that's 90% falciparol or are you in an area that is mostly bivacs? Because then your strategies are gonna be a little bit different. And then in terms of prevention, you know, consider bed nets, chemo prophylaxis, but you may not be able to do that. And then you may just have to kind of target individuals who are, oops, you may have to target individuals that have malnutrition or comorbidities with when you're looking at controlling the malaria. All right, so next slide. Okay. So we talked a little bit about this. Being with trauma, you may have lacerations or injuries. And then in like a flood situation, you're gonna have contaminated water and debris. And so all of that can lead to wound infections. We'll see this also in, I talk a little bit about Katrina in the next couple of slides with Vibrios because they're having to be present there. And that was a significant cause of wound infections. And then also the disruption in healthcare. We talked about the antibiotic resistance happening. And so all of that can compound things and lead to skin and soft tissue infections, MRSA from scratching and your poor hygiene. Specifically in military operations in Iraq, we had a big problem with Esonita Bacteria, Bulmanii, and it was highly resistant. Next slide. All right. So the vector-borne disease, we talked about a little bit with malaria, but also big ones to remember, Dengue, Zika, Chikungunya with the Aedes aegypti. Aedes is very well adapted to urban environments. So these are the ones that are gonna be breeding in your bottle caps and things like that. And so, you wanna make sure that if you can, to make sure that garbage and food sources, oh, I'm sorry, that the water is controlled. Rheumatic proliferation is a big issue for leptospirosis. So getting rid of garbage as a food source and if there's any way to make control measures that's important as well. Listed some of the outbreaks that are associated with vector-borne disease, particularly with leptospirosis. So go ahead to the next slide. Well, we skipped tuberculosis, but that's okay. Well, here we go. We'll talk about tuberculosis for just a second. Basically, again, when you have disruption to use some of your directly observed therapy programs, this could be a problem. It's not usually a big problem, especially initially, but the longer that people are in camps or things like that, it can become a problem. And it's just something to think about. Okay, next slide. Talk a little bit about leptospirosis. Again, it's a spirochete. You have high fever, headaches, conjunctival suffusion, jaundice and rash. Can actually have a hemorrhagic presentation and respiratory distress. We've seen this a lot in Japan. It's been reported in Puerto Rico. And then to be a flooding. And then again, this is something that broken skin, mucous membranes, you can actually, the spirochete can be the transmission of the spirochete and ensuing infections from especially rodent urine. We talk about there's some, and not getting in the water. So the next slide shows you a couple of the outbreaks that were associated with this. Even some in the United States in 2004 from flooding and in South America and in Asia as well. Next slide. So we have just have a couple of minutes. Here's just a quick discussion about Hurricane Katrina and some of the things that we saw from the flooding in there. There were 30 cases of MRSA, 24 cases of Vibrio from again, infected wounds. And that's something when we talk about where, knowing where you're at. Like I said, Vibrio lives in brackish waters and it's very common in the Gulf. So there were actually 13 cases that were reported on average from 2017 to 2022. So it's something that's endemic and that you have to think about. They also had high cases of diarrhea and respiratory illness. And you can see that bottom picture. So the top picture is actually Canal Street right before you go into the corridor. So I'm a Tulane grad and so I know the street well. And then that's the picture in the Superdome. So if you want to think a thought about what overcrowding looks like, that's a good one. Next slide. All right. So I'm going to run through this really quick. Here's a list. You guys will have access to the slides. Another list of virus, bacteria and fungi, things to think about after hurricanes in the US. I want to talk a little bit about the myth of infectious diseases from corpses. That's the next slide. And basically, the bottom line is very, very, very few times you have to worry about dead bodies. There's a lot of fear, but not a lot of data. The notable exceptions, as I listed on the top, Ebola, Lassa, Crimean Congo, hemorrhagic, Marburg, Sudan virus. So your hemorrhagic fever viruses require special management and increased PPE. But other than that, there were no documented outbreaks related to corpses in the earthquake or in the tsunami in Japan or in Haiti. There may be a little bit with cholera that cholera can last a little bit longer and tuberculosis. But for the majority of the time, decaying organisms are not pathogenic to humans and so basic PPE for bloodborne pathogens like HIV, hep C for military personnel is adequate. You want to have body bags and disposable gloves when possible and practice good hygiene. And you really want to give the families the respect from their local culture for a burial. With very few exceptions, like I said, with some of the hemorrhagic fevers, they can still do that. And even with the hemorrhagic fevers, there's ways to modify that so that the family can have that peace of mind. And that's very important culturally and from a humanitarian, from a sensitivity as well. All right, I'm going to go through the next couple of slides very quickly. So this is the link to the Sphere Handbook. And like I said, you can get it online. And the best part about this is it is, next slide. So it created in 1997 and it's been used with, it was created by NGOs and with the Red Cross and the Red Crescent and it gives you standards. So if you're like, if you're asked to create, to help with a humanitarian assistance, a disaster relief, any kind of emergency and you want to know, how much water do I need? How much food do I need? So go ahead to the next slide. So if, you know, or if, you know, like me, you were just camping, what do you need per day? So here are some of the basics. Basically for survival needs, drinking, basic hygiene and cooking, those are the numbers there. Your total basic water needs, think about seven and a half to 15 meters per person per day. Next slide. And then for your water supply, if you have a tap or if you have a well, here's some of the standards that they recommend in terms of how far away are you from the nearest water point? You want it less than 500 meters. Next slide. And then your sanitation, like, what do you need for toilets and hygiene? You want to make sure that you're collecting and transporting safe drinking water, managing that supply chain, encourage people to wash their hands with soap, making sure that there are latrines that are close. Consider cultural taboos with that as well. So you want to make sure that people feel safe to use that and that you are allowing them the opportunity to be in a safe space. So next slide. One shared toilet per 20 people, minimum of 30 meters away. Next slide. And then shelter and settlements in terms of how many people should be per square meters of living space. Next slide. And then just kind of overall view of community standards. If there's an outbreak, things that you need to do and things like developing outbreak preparedness, looking at monitoring diseases, and then your priority interventions with sanitation, hydration of water. And there's a lot more to it than that. And then I think the next slide is my references. Yep. And so I'm sorry, I did take the full hour talking, but I'm happy to take any questions that anybody has. And so these are just some things that different ways to consider, different things to consider in an emergency from an infectious disease standpoint. And I'm very glad that we got to share this hour together. And I hope you learned something. Thank you, Dr. Luzewski. That was an incredibly informative and educational presentation. Thank you. At this time, we are at eight o'clock, but Dr. Luzewski, if it's okay with you, we're happy to stay back just for a couple of minutes and answer any questions come in. No questions have come in yet, but we are happy to stay on just for a couple of minutes and answer any questions from those who are still on the call. Please feel free to pose any questions that you may have for Dr. Luzewski. Thank you. And we have one question that's come in. So the question is, where did one toilet for 20 people come from? What is the rationale for that? So again, the SPHERE guidelines, that's the SPHERE guidelines. And it's taking into account how crowded, how likely A, you are to use the facility. If there are too many people, then it may overflow. So usually most of the time, these are pit latrines. And so you wanna make sure that you're not, it's not gonna fill up too fast. You also wanna make sure that it's not gonna contaminate the groundwater. I can't tell you exactly off the top of my head. I'd have to go back to the handbook to look at all of the resources, but that's the great part about the SPHERE handbook. And I really wanted to just give you a few little snippets from it. The handbook itself, I think, is a couple of hundred pages with a lot of detail into, and basically it's kind of like learning calculus and how to do ATDR, math, if you were to set up an IDP camp or something like that. So those are some of the considerations, how the exact math worked out and why it's like 20 and not 19 or 18. They do keep things at round numbers for the most part. And so I think that goes into it as well. Did that answer your question? Yeah. There are just a couple of more questions. One that's come in the chat. Would you vaccinate for measles regardless of community vaccination rates prior to disaster? So it is, you need to have about a 90% vaccine rate to make sure that you're going to, not gonna have large outbreaks. If you knew that your community was already at that, then you might not need to do a vaccination campaign. So again, this is where each individual situation has to be taken into account. If you don't know for sure, then that may be something that you do want to do right away. And you also have to consider the timing. How long do you think that people are gonna be in this community or how long are they gonna be in this encampment? Is this something that's probably only gonna last two or three weeks? And by the time you even get started with the campaign that you're not gonna be able to complete it. Do you have limited resources? So is it something where you want to make sure that you're not necessarily just blanket vaccinating everyone because you only have a certain amount of vaccine and you want to look at again, the younger individuals for that. I would definitely want to know what the vaccination rates were prior to the disaster and to make that decision. But realizing that you might not know, I would do the research though to find out. I would talk to people that were in the community before the disaster happened, people in their ministry of health. I would talk to their health department. I would see if there's any records that are available and kind of take a pulse of the community as well. And then I might, if I really can't get a good sense, then I might offer it, yeah. So we'll take a couple of more questions and then just wrap it up with a comment, Dr. Lisowski, if that's okay with you. Just second last question here. Were there protocols in place to manage outbreaks of infections prior to the downfall of Hurricane Katrina? Were there protocols to- Manage outbreaks of, so were there protocols in place to manage the outbreaks of infections prior to Hurricane Katrina? So we had a very robust medical system in New Orleans prior to Katrina. But there weren't, there was not the expectation that this was gonna happen. So there was not as well thought out protocols now. And a lot of what FEMA has done and the ICS system that's happened kind of grew out of Katrina. And so we learned a lot in that situation and things have gone forward. There was a lot of endemic disease as well in New Orleans that had to be dealt with. Like I said, there's a fair amount of TB and a fair amount of HIV as well. I worked at the Hop Clinic there. As a med student and to like something like that, like the Hop Clinic was the HIV outpatient clinic was no more for several months. And so people were getting their enterotrophic virals and things like that. So, and we learned a lot about that from Katrina. We could probably do a whole class. I wouldn't even just be me, there would need to be another. So we learned a lot about that from Katrina. Some other folks as well, but yeah. Thank you. The last question and a comment. So this question is, what are the pros and cons of digging wells versus bringing in water? So that's partly timing. Is this a short time issue? Is this gonna be a longer time if you're gonna be in an encampment and you know that this is gonna be probably something that's gonna be lasting longer than a month, maybe even into six months or a year, you're gonna want wells. Because trucking in water is A, expensive and B, might not even be feasible. Because if we're in a complex emergency, so maybe this started off as a disaster with a hurricane or flooding or something like that, you have mass migration. And then on top of it, somebody's politics doesn't agree with somebody else and they're shooting involved. Now you might not even be able to get the trucks in. So bottled water sounds great for things like in the United States where maybe it's like for a short period of time, bottled water is heavy. Then you have plastics that you have to deal with and trash and those little cats. Like I said, those, oh my goodness, those 80s mosquitoes, they will go to town in a little bottle cap. And then you've got dengue and chikungunya on your hands. So digging a well is preferable, especially if you're gonna be there for a while. If you're not gonna be there for a while, you might need to do the bottled water. You might need to do, to truck in water and have water buffaloes, is what we call them in the military where you've got like a central water point. The opposite side of that is then you gotta make sure that stays clean because if it's sitting there for too long, we would have to go and inspect them on a regular basis. But those are some of the considerations. And then I saw something else that says, does it seem limited resource areas that toilet ratio may be difficult to adhere to? Yes. And so all of these fear guidelines are kind of best practices that you can get to, but there's exceptions for every single one of them. Like I said, with the toileting, you wanna make sure that like, that you're, especially your vulnerable populations, maybe children or women, feel comfortable to go to these spaces. So it needs to be private, but maybe not too private. And then, there are things that you're gonna have to think about. Topography, are you on a hill? You gotta think about that. Where's that water runoff gonna go? So there's a lot of thought that goes into this. Well, thank you so much, Dr. Lizowski. This was an incredibly informative lecture and what a fantastic way to finish the webinar series. We hope many of the people in the audience, the residents in the audience will join us for the inaugural resident workshop that's taking place in emergency preparedness and response at the PM25 annual conference on May 5th. And we will continue to promote these webinars through our various communications channels. Thank you everyone, and have a wonderful evening. Have a great night. Thank you.

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