In the four weeks since Hurricane Maria ravaged the island of Puerto Rico, 76 people have fallen ill with suspected Leptospirosis, according to CNN, and two have died from the bacterial disease, which is spread through water, food, or soil contaminated with the urine of infected animals.

One patient, a 61-year-old bus driver from Canóvanas, a city in northeast Puerto Rico, became sick after drinking from a stream near his house one week after the storm, according to press reports. Within a few days, he developed a fever, turned yellow, and eventually died at a local hospital.

Outbreaks of Leptospirosis are common after natural disasters and floods and a number of the patients appear to have contracted the illness the same way the bus driver did—by drinking from local streams after being without running water in their homes. People may have also acquired the infection by bathing or wading in contaminated freshwater as the bacteria can easily enter blood stream through open cuts or wounds, or via mucous membranes in the eyes, nose, or mouth.

The island’s deadly Leptospirosis outbreak is just one example of the sort of health crisis that can arise in the aftermath of a hurricane. In the midst of what’s been one of the most active hurricane seasons in recorded history, here’s a look at some of the serious health hazards that can lie in a storm’s wake.

Pathogenic Floodwaters

When Hurricane Harvey dumped more than 19 trillion gallons of rain on the Houston area in late August, it turned low-lying streets into rivers—but the river that ran through southeast Texas was little more than a toxic cesspool tainted by human waste, chemicals, and other contaminants, according to USA TODAY.

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J.R. Atkins, a former firefighter and paramedic from Missouri City, Texas, nearly lost his arm after contracting infection from the floodwaters while helping to rescue stranded neighbors. Atkins told ABC News it all started with small bug bite on the top of his arm. Within 24 hours, the small bite turned into a raging infection that was diagnosed as necrotizing fasciitis, or flesh-eating bacteria.

After a harrowing few days in intensive care, Atkins recovered from the nasty bug, but others have not been as lucky. Nancy Reed, a 77-year-old Houston woman, developed a flesh-eating bug after she fell inside her son’s flooded home and broke her arm. She died approximately two weeks later. On October 16th, a 31-year-old man who had been repairing hurricane damaged homes in Galveston also died after developing an infection in his arm with flesh-eating bacteria.

Floodwaters are a haven for microbes. Water samples taken from one flooded Houston home contained the fecal bacteria E. coli at 135 times the upper limit of what is considered safe, according to The New York Times, which organized the testing. The testing also turned up an unspecified strain of the Vibrio, a Gram-negative bacteria that thrives in coastal waters and can cause severe and sometimes fatal illness, including necrotizing fasciitis.

While there were no reported cases of flesh-eating bacteria in Florida following Hurricane Irma, several east coast beaches, rivers, and lagoons reported high levels of enteric bacteria, indicating fecal contamination. Coming into contact with the pathogens cause upset stomach, diarrhea, eye irritation and skin rashes, according to the Florida Department of Health.

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Puerto Rico, meanwhile, continues to face a critical situation with 1 million people – nearly 30% of the island’s population—still lacking access to drinkable tap water, according to Residents there are urged to boil water before drinking and not to drink from streams, which may be contaminated with sewage, but as the current Leptospirosis outbreak indicates, some are not heeding that advice.

Mosquito-Borne Disease

Mosquitoes are the planet’s most deadly creatures, transmitting diseases that cause millions of deaths worldwide each year. Unfortunately, the conditions after a hurricane—in particular, the abundance of standing water left behind—make it ripe for mosquito breeding.

Two weeks after Irma walloped Florida, Hernando County Mosquito Control, which covers a region located about 53 miles north of Tampa on Florida’s Gulf Coast, trapped roughly 26,000 mosquitoes over the course of 16 hours. A normal catch for that time frame would be about 500 mosquitoes.

Mosquitoes can spread an array of diseases, including dengue, chikungunya, West Nile virus, and Zika. Zika can cause serious birth defects like microcephaly. There have been 40,000 cases of the disease in Puerto Rico since 2016, though in June the island declared its outbreak of the virus was over.

While there have been no reported outbreaks of mosquito-linked illnesses thus far this year, they can take some time to appear.

Researchers noted a more than two-fold increase in cases of West Nile virus in parts of Louisiana and Mississippi in 2006, one year after Hurricane Katrina devastated the region. Most individuals infected with the virus develop a fever and other symptoms that run a self-limiting course, but one out of every 150 infected individuals will develop serious illness that can be fatal.

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Mold and Pollution

Mold growth can cause serious problems in the aftermath of a hurricane. In flooded homes, fungus usually develops within 24 to 48 hours and remediation is costly.

Mold exposure can be particularly harmful for individuals with lung conditions, such as asthma or chronic obstructive pulmonary disease (COPD), and evidence suggests people can develop allergy symptoms to mold in the wake of catastrophic flooding. Following Hurricane Katrina, 78% of children tested in one study had allergies to mold, compared with the typical rate of 50% in other major urban areas.

Toxic pollutants are another concern.

Damaged petrochemical refineries and other industrial facilities in and around the Houston area accidentally released millions of tons of airborne emissions after Harvey hit in Texas, according to The New York Times.

Despite reassurances from the Environmental Protection Agency that residents were not in any immediate danger, Elena Craft, a senior health scientist at the environmental Defense Fund, told the newspaper that the pollution contained “cancer-causing compounds, like benzene and butadiene” and said her group is “very concerned about people’s long-term health in the area.”

In Puerto Rico, meanwhile, thirsty and desperate residents with no access to clean drinking water have reportedly been filling up jugs with water from wells at a federally designated hazardous waste site contaminated with toxic industrial chemicals like tetrachloroethylene and trichloroethylene, a known carcinogen.

Mental Anguish

Natural disasters don’t just take a physical toll on people—they take a mental one, too.

One study found that a third of the adult survivors of Hurricane Katrina suffered from some form of storm-related mental distress, such as depression, anxiety, and post-traumatic stress disorder (PTSD), and nearly 40% of children tracked in the study were were diagnosed with a mental disorder after the storm.

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It’s not just survivors who are impacted. First responders and recovery workers who are separated from their own loved ones for long periods of time can develop mental fatigue.

The psychological burden will be even greater in places like Puerto Rico, where recovery is lagging. At least nine people have died by suicide since the storm, according to the Latin Times, and residents are overwhelmed by the disaster that has left so many homeless and jobless and struggling to survive.

Amy Keller, BSN, RN
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