Hurricane-Associated Mold Exposures Among Patients at Risk for Invasive Mold Infections After Hurricane Harvey - Houston, Texas, 2017

Hurricane Harvey and the risk of spontaneous preterm and early-term birth

Background

Hurricane Harvey made landfall in August 2017 and resulted in catastrophic flooding in Houston, Texas. Prior studies of hurricanes and preterm birth have found conflicting results. We tested the hypotheses that exposure to Hurricane Harvey was associated with a higher risk of spontaneous pre- and early-term birth and assessed vulnerable subpopulations.

Methods

We conducted a retrospective study of singleton births using administrative birth records in the nine-county greater Houston area from 2015 to 2019. We estimated the likelihood of pre- and early-term births using logistic regression, comparing births occurring during or within 1, 2, or 4 weeks of Hurricane Harvey to unexposed reference periods encompassing the same dates 2 years prior and after. Stratified models assessed effect modification by degree of flooding, birth parent age, high- vs. low-risk pregnancy, race/ethnicity, and prenatal care.

Results

Among 15,564 births, we found no association between exposure to Hurricane Harvey and spontaneous preterm birth within 1 week adjusted (odds ratio [OR], 1.06; 95% confidence interval [CI] = 0.91, 1.25) but a 14% higher odds of spontaneous early-term birth (OR, 1.14; 95% CI = 1.04, 1.25). The odds of early-term birth were even higher in neighborhoods with severe flooding (OR, 1.21; 95% CI = 1.05, 1.38), segregated neighborhoods (OR, 1.23; 95% CI = 1.03, 1.47), and among foreign-born Hispanics (OR, 1.21; 95% CI = 1.04, 1.53) and pregnant people receiving no prenatal care (OR, 1.37; 95% CI = 1.03, 1.82). Effect estimates were attenuated or null when considering 2-week or 4-week lags to define exposure.

Conclusions

Hurricane Harvey was associated with higher odds of spontaneous early-term birth up to 1 week later, especially among socially marginalized populations.

The Impact of Climate Change on Global Oncology

Climate change is the greatest threat to human health of our time, with significant implications for global cancer control efforts. The changing frequency and behavior of climate-driven extreme weather events results in more frequent and increasingly unanticipated disruptions in access to cancer care. Given the significant threat that climate change poses to cancer control efforts, oncology professionals should champion initiatives that help protect the health and safety of patients with cancer, such as enhancing emergency preparedness and response efforts and reducing emissions from our own professional activities, which has health cobenefits for the entire population.

Climate change and cancer: the Environmental Justice perspective

Despite advances in cancer control-prevention, screening, diagnosis, treatment, and survivorship-racial disparities in cancer incidence and survival persist and, in some cases, are widening in the United States. Since 2020, there's been growing recognition of the role of structural racism, including structurally racist policies and practices, as the main factor contributing to historical and contemporary disparities. Structurally racist policies and practices have been present since the genesis of the United States and are also at the root of environmental injustices, which result in disproportionately high exposure to environmental hazards among communities targeted for marginalization, increased cancer risk, disruptions in access to care, and worsening health outcomes. In addition to widening cancer disparities, environmental injustices enable the development of polluting infrastructure, which contribute to detrimental health outcomes in the entire population, and to climate change, the most pressing public health challenge of our time. In this commentary, we describe the connections between climate change and cancer through an Environmental Justice perspective (defined as the fair treatment and meaningful involvement of people of all racialized groups, nationalities, or income, in all aspects, including development, implementation, and enforcement, of policies and practices that affect the environment and public health), highlighting how the expertise developed in communities targeted for marginalization is crucial for addressing health disparities, tackling climate change, and advancing cancer control efforts for the entire population.

The climate crisis and healthcare: What do infection prevention and stewardship professionals need to know?

The climate crisis calls for urgent action from every level of the US healthcare sector, starting with an acknowledgment of our own outsized contribution to greenhouse gas emissions (at least 8.5% of carbon emissions). As the climate continues to become warmer and wetter, the medical establishment must deal with increasing rates of pulmonary and cardiovascular diseases, heat-related illness, and emerging infectious diseases among many other health harms. Additionally, extreme weather events are causing healthcare delivery breakdown due to physical infrastructure damage, slowed supply chains, and workforce burden. Pathways for healthcare systems to meet these challenges are emerging. They entail significant measures to mitigate our carbon footprint, embrace shared and equity-driven governance, develop new metrics of accountability, and build more resilience into our care delivery processes. We call upon SHEA to play a unique leadership role in the fight for sustainable, equitable, and efficient health care in a rapidly changing climate that immediately threatens human well-being.

Diagnosis Codes for Mold Infections and Mold Exposure Before and After Hurricane Harvey Among a Commercially Insured Population-Houston, Texas, 2016-2018

OBJECTIVE

Indoor mold after flooding poses health risks, including rare but serious invasive mold infections. The purpose of this study was to evaluate use of International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes for mold infection and mold exposure in Houston, Texas, during the year before and the year after Hurricane Harvey.

METHODS

This study used data from MarketScan, a large health insurance claims database.

RESULTS

The incidence of invasive mold infections remained unchanged in the year after Hurricane Harvey; however, the incidence of diagnosis codes for mold exposure nearly doubled compared with the year before the hurricane (6.3 vs 11.0 per 100 000 enrollees, rate ratio: 1.7, 95% confidence interval 1.0-3.1).

CONCLUSIONS

Diagnosis codes alone may not be sufficiently sensitive to detect changes in invasive mold infection rates within this population and time frame, demonstrating the need for more comprehensive studies.

Invasive Mold Infections Following Hurricane Harvey-Houston, Texas

Background

Characterizing invasive mold infection (IMI) epidemiology in the context of large flooding events is important for public health planning and clinical decision making.

Methods

We assessed IMI incidence (per 10 000 healthcare encounters) 1 year before and after Hurricane Harvey at 4 hospitals in Houston, Texas. Potential IMI cases were assigned as proven or probable cases using established definitions, and surveillance cases using a novel definition. We used rate ratios to describe IMI incidence and multivariable logistic regression to examine patient characteristics associated with IMI case status.

Results

IMI incidence was significantly higher posthurricane (3.69 cases) than prehurricane (2.50 cases) (rate ratio, 1.48 [95% confidence interval, 1.10-2.00]), largely driven by surveillance IMI cases. Aspergillus was the most common species cultured (33.5% prehurricane and 39.9% posthurricane). About one-quarter (25.8%) of IMI patients lacked classical IMI risk factors such as hematologic malignancy and transplantations. Overall, 45.1% of IMI patients received intensive care, and in-hospital all-cause mortality was 24.2%.

Conclusions

IMI incidence likely increased following Hurricane Harvey and outcomes for IMI patients were severe. Patient and clinician education on IMI prevention and identification is warranted, particularly as the frequency of extreme weather events increases due to climate change.

Perceptions, knowledge, and communication preferences about indoor mold and its health implications among persons affected by Hurricane Harvey: a focus group analysis

Background

Among people affected by Hurricane Harvey, we assessed experiences and perceptions (e.g., knowledge, attitudes, and practices) regarding mold and its impact on health and elicited participants’ opinions about how to improve public health messaging about indoor mold after a large flooding event.

Methods

Houston Health Department conducted four focus groups with 31 Houston metropolitan area residents during January to March 2020, using a semi-structured discussion guide and federal communication materials about indoor mold. Drawing from a theoretical framework analysis, transcripts were grouped into relevant themes using inductive and deductive coding.

Results

Hurricane Harvey had a large impact on participants’ living standards, and widespread financial barriers to remediation led to long-term mold exposure for many participants. Knowledge about mold’s impact on health and proper mold clean-up practices varied, and clean-up behaviors did not commonly align with federal guidance. Participants generally preferred traditional forms of outreach, such as in-person, radio, and television announcements, to communicate public health messaging.

Conclusions

More strategic dissemination of expanded public health educational materials about proper mold clean-up practices and the health risks of mold exposure following flooding events is needed.

Invasive mould infections in patients from floodwater-damaged areas after hurricane Harvey - a closer look at an immunocompromised cancer patient population

OBJECTIVES

Extensive floodwater damage following hurricane Harvey raised concerns of increase in invasive mould infections (IMIs), especially in immunocompromised patients. To more comprehensively characterize the IMI landscape pre- and post-Harvey, we used a modified, less restrictive clinical IMI (mcIMI) definition by incorporating therapeutic-intent antifungal drug prescriptions combined with an expanded list of host and clinical features.

METHODS

We reviewed 103 patients at MD Anderson Cancer Center (Houston, Texas), who lived in Harvey-affected counties and had mould-positive cultures within 12 months pre-/post-Harvey (36 and 67 patients, respectively). Cases were classified as proven or probable IMI (EORTC/MSG criteria), mcIMI, or colonization/contamination. We also compared in-hospital mortality and 42- day survival outcomes of patients with mcIMI pre-/post-Harvey.

RESULTS

The number of patients with mould- positive cultures from Harvey-affected counties almost doubled from 36 pre- Harvey to 67 post- Harvey (p < 0.01). In contrast, no significant changes in (mc)IMI incidence post-Harvey nor changes in the aetiological mould genera were noted. However, patients with mcIMIs from flood affected areas had significantly higher in-hospital mortality (p = 0.01).

CONCLUSIONS

We observed increased colonization but no excess cases of (mc)IMIs in immunosuppressed cancer patients from affected areas following a large flooding event such as hurricane Harvey.

Hurricane María drives increased indoor proliferation of filamentous fungi in San Juan, Puerto Rico: a two-year culture-based approach

Extensive flooding caused by Hurricane María in Puerto Rico (PR) created favorable conditions for indoor growth of filamentous fungi. These conditions represent a public health concern as contamination by environmental fungi is associated with a higher prevalence of inflammatory respiratory conditions. This work compares culturable fungal spore communities present in homes that sustained water damage after Hurricane María to those present in dry, non-flooded homes. We collected air samples from 50 houses in a neighborhood in San Juan, PR, 12 and 22 months after Hurricane María. Self-reported data was used to classify the homes as flooded, water-damage or dry non-flooded. Fungi abundances, composition and diversity were analyzed by culturing on two media. Our results showed no significant differences in indoor fungal concentrations (CFU/m³) one year after the Hurricane in both culture media studied (MEA and G25N). During the second sampling period fungal levels were 2.7 times higher in previously flooded homes (Median = 758) when compared to dry homes (Median = 283), (p-value < 0.005). Fungal profiles showed enrichment of Aspergillus species inside flooded homes compared to outdoor samples during the first sampling period (FDR-adjusted p-value = 0.05). In contrast, 22 months after the storm, indoor fungal composition consisted primarily of non-sporulated fungi, most likely basidiospores, which are characteristic of the outdoor air in PR. Together, this data highlights that homes that suffered water damage not only have higher indoor proliferation of filamentous fungi, but their indoor fungal populations change over time following the Hurricane. Ultimately, after nearly two years, indoor and outdoor fungal communities converged in this sample of naturally ventilated homes.

Emergency department visits associated with satellite observed flooding during and following Hurricane Harvey

BACKGROUND

Flooding following heavy rains precipitated by hurricanes has been shown to impact the health of people. Earth observations can be used to identify inundation extents for subsequent analysis of health risks associated with flooding at a fine spatio-temporal scale.

OBJECTIVE

To evaluate emergency department (ED) visits before, during, and following flooding caused by Hurricane Harvey in 2017 in Texas.

METHODS

A controlled before and after design was employed using 2016-2018 ED visits from flooded and non-flooded census tracts. ED visits between landfall of the hurricane and receding of flood waters were considered within the flood period and post-flood periods extending up to 4 months were also evaluated. Modified Poisson regression models were used to estimate adjusted rate ratios for total and cause specific ED visits.

RESULTS

Flooding was associated with increased ED visits for carbon monoxide poisoning, insect bite, dehydration, hypothermia, intestinal infectious diseases, and pregnancy complications. During the month following the flood period, the risk for pregnancy complications and insect bite was still elevated in the flooded tracts.

SIGNIFICANCE

Earth observations coupled with ED visits increase our understanding of the short-term health risks during and following flooding, which can be used to inform preparedness measures to mitigate adverse health outcomes and identify localities with increased health risks during and following flooding events.

Patient notification about suspected hospital-associated outbreaks of invasive mold infections: Considerations for public health and hospital personnel

A common type of fungal disease investigation involves hospital-associated clusters of invasive mold infections (IMIs), which typically occur among immunocompromised patients. Responding to IMI clusters can be challenging for public health and hospital personnel for several reasons such as difficulty of confirming the existence of an outbreak, difficulty of determining source. Although many resources exist to guide patient notification about healthcare incidents (eg, bloodborne exposures, disease outbreaks), IMI clusters involve special considerations related to the complex diseases, uncertain exposures, and differential benefits and risks of notification. Early, nuanced communication about hospital-associated IMI clusters is almost always the best course of action to help reduce risks to patients' health and foster trust between patients and hospitals.

Fingolimod-related cryptococcal meningoencephalitis and immune reconstitution inflammatory syndrome in a patient with multiple sclerosis

Fingolimod is an oral medication for multiple sclerosis that sequesters certain subsets of lymphocytes in lymph nodes, reducing egress into blood and their subsequent CNS migration. The initial multi-site randomized Phase III controlled trials found rates of infection similar to those in control groups. However, post-marketing surveillance has revealed an association with several opportunistic infections, including cryptococcosis. We report a case of fingolimod-related cryptococcal meningoencephalitis and IRIS after drug discontinuation and suggest a surveillance and risk mitigation strategy.

Pediatric Emergency Departments and Urgent Care Visits in Houston after Hurricane Harvey

Introduction

Natural disasters are increasingly common and devastating. It is essential to understand children’s health needs during disasters as they are a particularly vulnerable population. The objective of this study was to evaluate pediatric disease burden after Hurricane Harvey compared to the preceding month and the same period in the previous year to inform pediatric disaster preparedness.

Methods

This was a retrospective cross-sectional study of patients seen at pediatric emergency departments (ED) and urgent care centers (UCC) 30 days before (late summer) and after (early fall) the hurricane and from the same time period in 2016. We collected demographic information and the first five discharge diagnoses from a network of EDs and UCCs affiliated with a quaternary care children’s hospital in Houston, Texas. We calculated the odds of disease outcomes during various timeframes using binary logistic regression modeling.

Results

There were 20,571 (median age: 3.5 years, 48.1% female) and 18,943 (median age: 3.5 years, 47.3% female) patients in 2016 and 2017, respectively. Inpatient admission rates from the ED a month after Harvey were 20.5%, compared to 25.3% in the same period in 2016 (P<0.001). In both years, asthma and other respiratory illnesses increased from late summer to early fall. After controlling for these seasonal trends, the following diseases were more commonly seen after the hurricane: toxicological emergencies (adjusted odds ratio [aOR]: 2.61, 95% [confidence interval] CI, 1.35–5.05); trauma (aOR: 1.42, 95% CI, 1.32–1.53); and dermatological complaints (aOR: 1.34, 95% CI, 1.23–1.46).

Conclusion

We observed increases in rashes, trauma, and toxicological diagnoses in children after a major flood. These findings highlight the need for more medication resources and public health and education measures focused on pediatric disaster preparedness and management.

Socioeconomic disparities in incidents at toxic sites during Hurricane Harvey

BACKGROUND

Hurricane Harvey facilitated exposure to various toxic substances and floodwater throughout the greater Houston metropolitan area. Although disparities exist in this exposure and vulnerable populations can bear a disproportionate impact, no research has integrated disparities in exposure to toxic incidents following Hurricane Harvey.

OBJECTIVE

The objective of this study was to analyze the relationship between flooding, socioeconomic status (SES), and toxic site incidents.

METHODS

Data on toxic site locations, reported releases, and flood water depths during Hurricane Harvey in the greater Houston area were compiled from multiple sources. A multivariable logistic regression was performed to predict the odds of a toxic site release by flooding at the site, SES and racial composition of the census tract.

RESULTS

83 out of 1403 toxic sites (5.9%) had reported releases during Hurricane Harvey. The proportion of toxic sites with reported incidents across increasing SES index quintiles were 8.35, 7.67, 5.14, 4.55, and 0.51, respectively. The odds of an incident were lower in the highest SES quintile areas (OR_adj = 0.06, 95% CI: 0.01-0.42) compared to the lowest SES quintile. Flooding was similar at toxic sites with and without incidents, and was distributed similarly and highest at toxic sites located in lower SES quintiles.

SIGNIFICANCE

Despite similar flooding across toxic sites during Hurricane Harvey, areas with lower SES were more likely to have a toxic release during the storm, after accounting for number of toxic sites. Improving quality of maintenance, safety protocols, number of storm-resilient facilities may minimize this disproportionate exposure and its subsequent adverse outcomes among socioeconomically vulnerable populations.

Measuring inequality in community resilience to natural disasters using large-scale mobility data

While conceptual definitions provide a foundation for the study of disasters and their impacts, the challenge for researchers and practitioners alike has been to develop objective and rigorous measures of resilience that are generalizable and scalable, taking into account spatiotemporal dynamics in the response and recovery of localized communities. In this paper, we analyze mobility patterns of more than 800,000 anonymized mobile devices in Houston, Texas, representing approximately 35% of the local population, in response to Hurricane Harvey in 2017. Using changes in mobility behavior before, during, and after the disaster, we empirically define community resilience capacity as a function of the magnitude of impact and time-to-recovery. Overall, we find clear socioeconomic and racial disparities in resilience capacity and evacuation patterns. Our work provides new insight into the behavioral response to disasters and provides the basis for data-driven public sector decisions that prioritize the equitable allocation of resources to vulnerable neighborhoods.

Understanding how cities respond to extreme weather is critical; as such events are becoming more frequent. Using anonymized mobile phone data for Houston, Texas during Hurricane Harvey in 2017, the authors find that mobility behavior exposes neighborhood disparities in resilience capacity and recovery.

Governors' Use of Executive Orders and Proclamations in Hurricane Response, 2006-2018

Hurricanes can destroy or overwhelm communities and cause or exacerbate health conditions. Legal mechanisms and practices may aid or impede hurricane response. In the United States, where states have primary public health responsibility, state governors possess legal powers to address hurricanes. They often exercise these powers using executive orders and proclamations-legal mechanisms that direct public and private parties. Although executive orders and proclamations are critical for hurricane preparedness and response, how governors use them to respond to hurricanes is not fully understood. Using legal epidemiology, we systematically identified and analyzed hurricane-related executive orders and proclamations issued in the United States from January 1, 2006, through December 31, 2018. We found 468 relevant executive orders and proclamations, 14% of which were issued, at least in part, to benefit a jurisdiction other than the issuer's state. We observed variations in when and where such orders and proclamations were issued. Executive orders and proclamations were most commonly used to direct government response or recovery (32%), handle and administer government resources (31%), and suspend legal requirements perceived to inhibit response (27%). Fewer orders and proclamations regulated private parties (10%). Understanding how governors use executive orders and proclamations to respond to hurricanes can bolster future preparedness and response efforts.

Mold clean-up practices vary by sociodemographic and allergy factors

We examined mold clean-up practices in a general population (not selected on history of natural disaster). We used a population-based survey (n= 3,624) to assess associations between sociodemographic/ housing/ respiratory health variables and mold clean-up, PPE use, and cleaning agent use. Bleach was the most commonly used cleaning agent with approximately 90% of residents reporting using bleach alone or with other agents. More respondents used gloves (76%) than any other PPE. The use of PPE varied; 42% of bleach users wore a breathing mask/respirator compared with only 19% of soap and water users. Hispanic populations frequently reported mold clean-up. Bleach use was less likely in the West and among Asians. Although "Green" products were rarely used, Asians were more likely to use them. Bleach was the most commonly used cleaning agent for mold, and PPE use was common when using bleach, supporting the need for current CDC safe use recommendations.

Moulds on cementitious building materials-problems, prevention and future perspectives

Materials rich in organic and inorganic compounds, such as building materials or paints, represent an excellent substrate for the development of moulds. Several conditions affect mould's growth on cementitious materials, such as nutrient and water availability, temperature, pH and moisture. Microorganisms, and especially moulds, attack these surfaces and contribute to their erosion, thereby reducing the life of the structure itself and negatively affecting human health through inhalation, ingestion and dermal contact with spores. Interventions are based on The European Communities Council Directive 89/106/EEC, that obliges the use of materials, products and building elements that are resistant to fungi and other forms of degradation, and that do not constitute a health risk for users and the environment. This mini-review summarises the current state of problems related to mould growth on cementitious building materials, emphasising new innovative approaches for limiting or contrasting their growth. In particular, the use of nanoparticles and the related nanomaterials as well as the potential use of new "biocides" from natural sources is discussed.