By Molly Gayden
On May 22, 2011, an F5 Tornado ripped through the heart of Joplin, Missouri, a city of more than 50,000 people. Almost 160 people were killed and thousands of lives were completely uprooted. The tornado damaged more than 7,000 buildings, one third of the city. St. John’s Regional Medical Center, Joplin’s main hospital, was directly in the path of the three-quarter mile wide tornado, with almost 200 patients and even more medical staff inside. The physical and psychological damages the city of Joplin sustained are devastating, as was the traumatic injuries inflicted on many of the residents.
Trying to Heal
When people sustain massive traumatic injuries, it puts so much stress on the body that it becomes difficult to fight off infections. This paves the way for germs—also called pathogens—which can infect humans when the body’s natural defenses are weakened. A pathogen can be any living thing that causes disease, such as bacteria, viruses, fungi, or even other microbes like amoebas. Cuts, scrapes, burns, and even a splinter can allow pathogens to enter the body through the skin. Unfortunately, during a disaster, skin injuries are something that comes with the territory. When residents are scrambling to protect themselves during extraordinarily stressful and frightening circumstances, there is no way to avoid getting a little dirt in your wounds, much less getting it out once it’s in there.
Unfortunately, the events that occurred in Joplin created the perfect environment for exposure to these pathogens, and some injured survivors began showing signs of an unusual wound infection. The problem with these infections is that it’s not always everyday microbes that infect a wound. We’ve all heard of staph infections, which can be extremely severe and hard to treat. Because they are the usual suspects for types of wound infection, treatment for those infections usually begins right away. But when an unusual germ infects a wound, it can take days to notice that the standard treatment isn’t working. Then it becomes a mad rush for the medical team to figure out what is causing the infection. It’s not nearly as simple as it sounds; there are thousands of germs that can cause an infection like this and many treatments to be considered. This kind of medical conundrum is worthy of even House M.D. and his diagnostic team. That’s where CDC comes in.
The CDC Mycotic Diseases Branch sent a team to Missouri to help with an investigation of a cluster of serious fungal skin infections that occurred among people injured in the Joplin tornado. I have been fortunate enough to work alongside the CDC Mycotic Diseases Branch during the past few weeks while participating in an internship for my Master of Public Health degree from Tulane University. The investigation team shared with me their experiences from Joplin, including their professional challenges and personal reactions to this disaster.
In the Field
The first people to report the fungus were the doctors who treated multiple patients with similar symptoms, which suggested an unusual fungal infection. Once the local public health authorities and hospitals were notified of this unusual pattern of symptoms, more cases were discovered. When the news of a potential outbreak of fungal infections reached the community, there was a lot of fear and concern, especially for relief workers who worried they might also be at risk. CDC’s Mycotic Diseases Branch epidemiology team was alerted that further investigation was necessary, and within a day a team was on their way to Missouri. The team included two Epidemic Intelligence Service officers, Drs. Robyn Neblett Fanfair and Sarah Bennett, along with epidemiology fellow Kaitlin Benedict, and medical student Tolulope Adebanjo. They worked in conjunction with other disaster relief and health agencies on the federal, state, and local levels.
Whenever a team goes into the field to investigate an outbreak, they focus on trying to find out how people who got the infection are different from people who didn’t. This involves meticulous review of medical documents, as well as interviews with patients or their families. Reviewing medical records can be especially difficult after a disaster; in many cases the information is hard to find because of the large number of critically injured patients treated during a short period of time.
In the Lab
When a medical team realizes that they have an unusual pathogen on their hands, they may send samples to the laboratories at CDC to help them identify exactly what they’re dealing with. It’s critical to know what type of pathogen is infecting a wound; the type of treatment needed depends on it. Although the laboratory staff at the CDC doesn’t usually set foot in the field, they play an essential role in the investigation. They must work as quickly as possible, with samples that are usually less than ideal in size and quantity, to determine not only what type of pathogens are present but also the species and specific strains.
The local laboratories in Missouri were quickly able to identify the fungal infection as mucormycosis so that the medical teams could begin the correct treatment. When the first samples arrived at the CDC from Joplin, the laboratory team already knew that some of them would contain the fungus that causes mucormycosis, but the type of fungus was not yet confirmed. It was also not initially clear if all of the samples contained the same type of fungus. All of these clues can help the investigation team determine which, if any, of the patients had a common exposure and if any changes in treatment were necessary. Through diligent work, the laboratory team was able to identify the type fungus causing the mucormycosis skin infections, Apophysomyces trapeziformis. This type of fungus naturally lives in soil and water around the world and has been known to occasionally cause mucormycosis skin infections after motor vehicle crashes and other disasters. This knowledge was helpful, but epidemiologists are still trying to identify how people were exposed to the fungus.
Nothing can prepare an investigation team for the emotional interviews with trauma survivors. The team was worried about how people would react to the investigation, especially because they knew they would have to ask survivors to relive the moment when the tornado hit. As difficult as these questions might be, they provide crucial information. Knowing whether a survivor was hit by a tree branch or a two-by-four can help determine if there was a common source of exposure to the fungus.
The investigation team was impressed with the bravery and compassion shown by those who chose to participate in the investigation. Sometimes it’s difficult to find people who are willing to share their traumatic experiences and their sensitive medical information, but everyone the team encountered was ready to do anything asked of them in order to help their community. Without the participation of these inspiring people, it would be impossible to complete the investigation. It was a very emotional and moving experience for all of the team members; many of them say they will always be affected by the stories of devastating losses and the miraculous acts of heroism shared between the members of this community.
“I am genuinely in awe of the generosity, strength, and resilience that the residents of Joplin have demonstrated.”
“[The survivors] grief was so raw and new I didn’t want to be a burden or add to their suffering in any way. However, their strength and desire to help others even in their time of need is a true testament to the strength of the human spirit.”
“I have never seen anything like [the disaster aftermath] before, and I think the images will always be ingrained in my mind. Seeing how the people of Joplin came together to help and uplift each other in light of the destruction that occurred is something I will never forget”
“Every disaster is different, and probably whether you witness one or a hundred, every single one of them is going to leave a lasting impression. I will never, ever forget some of those stories or the devastation that we saw in Joplin.”
Joplin may not have any more pathogens in its environment than any other community; the residents there were certainly unlucky that one of the most deadly tornados in US history barreled right through their backyards and opened the doors to infection. Despite these unfortunate events, the people of Joplin have truly come together and shown how a community can survive a disaster and even begin to rebuild from the wreckage. We will hopefully learn something from this unusual outbreak, so that people will be able to avoid, recognize, and treat these kinds of infections in the future. We won’t be able to prevent every infection, but the more we know about how these exposures happen, and what people unknowingly did to avoid them, the better we will be able to develop new guidelines about disaster preparation, as well as what to do when disaster strikes.
For more information check out the article in the Morbidty and Mortality Weekly Report (MMWR)