The LA-HRH interviewed Dr. Stephen Murphy, PhD, about the challenges of the 2020 Hurricane Season coinciding with the COVID-19 pandemic. Dr. Murphy is an Assistant Professor at Tulane University School of Public Health & Tropical Medicine; Department of Environmental Health Sciences; and Program Director of the MPH degree in Disaster Management. His expertise includes emergency management and public health emergency preparedness and response.
June 1 marked the beginning of the Atlantic Hurricane Season. What should residents of coastal and geographic areas threatened by hurricanes be doing?
Murphy: Beyond what is typical in hurricane planning, everyone should remember the unique needs, such as disinfectants, soap, sanitizer, masks, and gloves posed by Covid-19 when refreshing their hurricane kits and plans. Residents should examine evacuation plans and have multiple destinations if possible. Also understand what an accelerated timeline would do to your individual family plan (e.g., consider fueling vehicle earlier, be ready to leave earlier, and have different routes for each potential destination). Pay attention to authorities throughout hurricane season and heed their warnings.
Stocking supplies, whether for an evacuation or shelter-in-place strategy, however, can be an equity issue. Low income populations might have greater needs, fewer locations to procure these resources, or even fewer financial resources to meet those needs. Jurisdictions and response organizations, including stakeholders and volunteer organizations active in disasters, should continue, and increase when possible, their strong support to these groups as part of preparedness planning.
Given the concerns regarding the Covid-19 pandemic and increasing cases in some areas, residents may feel reluctant to evacuate. Should this be a factor in decision-making for individual residents?
Murphy: Bottom line – no, people should not allow this to interfere with decisions. Depending on the storm forecasts (trajectory, speed, strength, rainfall, etc), coastal and even more in-land areas have difficult decisions which are more complex than normal, but the overarching message remains the same for residents – get out of harm’s way. If you live in an area susceptible to storms or are ordered to evacuate, do not let Covid-19 influence your decision in any way to get out of the storm’s path and impact zone. If there is a major hurricane bearing down on your city, the magnitude of that hurricane is a much greater, immediate risk to life than the spread of a pandemic.
What should public health emergency response leaders prioritize in preparation for sheltering residents during these unprecedented times of multiple threats?
Murphy: Shelter locations and operations are challenging without Covid-19. Factor Covid-19 into the situation and you’ve created a complex environment to navigate.
In many areas, such as in New Orleans, the pandemic response included establishing an alternative treatment facility (ATF), which in NOLA is at the convention center. Many jurisdictions and states operationalized these ATFs for various reasons and with specific strategies, but the bottom line remains to decompress the hospitals – period. The ATF in New Orleans has largely been serving as a recovery center to give hospitals the flexibility to receive more emergent Covid-19 cases. As patients come off mechanical ventilators, for example, the hospitals re-triage patients and those no longer in need of immediate acute care are transported to the ATF. Thankfully, at the moment and for several consecutive weeks, NOLA has been experiencing reduced Covid-19 patient loads, but the ATF remains a regional asset for the surrounding jurisdictions given the threat of increased cases alone but also in concert with the arrival of hurricane season.
In the event of a hurricane, coastal area leadership should consider, among others: Could the current ATF operations expand as needed to accommodate additional Covid-19 patients or expand to absorb a larger patient load depending on the mission and scope of practice operating at the ATF? Maybe the scope of practice at an ATF is modified to provide additional capacity or receive broader ranges of acuity of Covid-19 patients.
Setting up shelters for vulnerable and/or electric-dependent populations during low-level storms not resulting in mandatory evacuation orders is going to potentially be different as well. It is important for planners in hurricane-prone cities to explore locations where they can set up an easily modifiable, general population shelter. Planners should consider expanding the existing number of shelter locations so (a) they have existing agreements when the time arises, and (b) to provide the recommended physical distancing element needed for Covid-19. A single shelter might not meet basic protective measures for the pandemic and planners should assess this – and assess it now. Earlier in the pandemic, many hotels were vacant but now that most of the Gulf Coast has reopened those options are less available. Regardless of where the shelter operates, emergency planners/operators need to ‘de-densify’ congregate shelters open for evacuation as soon as possible.
Given the unique challenges posed by hurricane sheltering and Covid-19, are there specific assessments emergency planners should consider at shelter locations?
Murphy: Several small tweaks to typical assessments can serve as helpful reminders in the current climate.
Do facilities have the space to safely shelter residents with physical distancing in mind? Has the layout actually been considered and mapped out to ensure sleeping cots are not too closely positioned to one another? For example, a staggered, head-to-toe arrangement has been proposed as helpful in reducing exposure to neighboring respirations.
What is known about the facility’s air exchange capacity? Does the facility owner know the specification of the system? Who can assess this at a shelter?
Recent evidence, one of which was published in the CDC’s Emerging Infectious Diseases, suggests that either poor ventilation and/or a poorly functioning HVAC system can lead to an increased transmission risk for restaurant patrons seated in varying proximity to an infected individual. Research continues to focus on particulate transmission and their actual infectivity. We still do not fully understand the infectious dose required to make us sick. And we now know, in some favorable conditions, COVID-19 can spread by traveling longer distances than previously considered and remain in the ambient air in small particles called aerosols. And while we do not yet know the infectivity of these particulates, evidence suggests that small particles (aerosols) pose increased risk in areas lacking proper, adequate ventilation or ones with poor air exchange. Further, while we have not yet confirmed transmission via air-conditioning systems, a congregate sheltering strategy in a poorly ventilated facility might be problematic and ill-advised. You have to ask yourself – When was the last time you visited a gymnasium or large assembly hall – typical large spaces used in shelter strategies – where you felt it was well ventilated?
How would you attempt to minimize this risk at a shelter facility?
Murphy: The hierarchy of controls approach is a logical starting point – Elimination (of the SARS-CoV-2 virus in this case), Engineering Controls, Administrative Controls, and finally PPE. It may be helpful for local planning teams to recruit environmental health experts and/or certified industrial hygienists to help recognize and implement stronger control strategies or solutions.
Engineering controls that consider air exchange and ventilation are critical. Steps to reduce risks include increasing the amount of outside air being introduced to interior spaces and increasing the air exchange rates inside facilities. Two functions of air-conditioning systems can help prevent the spread of Covid-19: Ventilation (fresh air coming into the building from outside) and filtration (process of removing small particles from the air). Properly functioning systems used in most commercial and public buildings do both to some degree and by doing so help limit risk of aerosol transmission of Covid-19. It is important that this technical aspect is understood by facility and shelter operations staff
Administrative controls should consider the placement of various operations within a shelter (e.g., food services, sleeping areas) related to any possible air exchange or fan installation. If attempting to increase air movement and reduce stagnant air, consider those upwind and downwind. For example, do not place well, non-symptomatic shelterees downwind of an isolated area for shelterees experiencing mild symptoms. In addition, do not place symptomatic shelterees (if your protocols include co-locating them, even temporarily, with well shelterees) next to air vents or near air filtration systems if the filtration utilized at the facility is poor or substandard.
Consider if interior spaces within the facility could be utilized for protecting more susceptible shelterees. For example, shelter elderly individuals in interior office rooms completely separated from the congregate shelter operations in an attempt to eliminate the exposure risk or drastically reduce it. Other considerations are having on exits and entrances close enough to each other that someone can keep a constant eye on both, but far enough apart so people don’t cross paths.
PPE, such as face masks, work to reduce the large droplets which are a significant source of transmission. Face masks should be worn at all times and leadership should ensure shelters have adequate supplies of face masks.
Would you recommend that responding agencies try to test evacuees at shelters for Covid-19?
Murphy: Testing remains challenging—not enough, specificity and sensitivity concerns, turnaround time, etc. If you could possibly have some sort of test kit at shelters, that would be great, but it will still likely take time for the results to come back. As far as lab-confirmed, symptomatic patients, or others not yet confirmed, but exhibiting Covid-like symptoms, you don’t want them next to air vents, potentially blowing aerosols and particles across the facility, and you do not want them near the air filtration if the filtration utilized at the facility is poor or substandard. A few environmental health scientists or industrial hygienists would be a great asset to consider for your planning teams in such an instance.
Is there anything else that we didn’t specifically cover that you think is critical to address?
Murphy: One of the most essential things often overlooked if the health of your providers and public health practitioners – their physical, mental, and emotional health. They’re invaluable assets and remain our lifeline. They have been going non-stop for a long time. I am concerned not only about physical health and protection from infection, but also the burnout rate and compassion fatigue. There should be a focused effort to cycle them off and get some much needed – and deserved – down time. Hospitals should bring in mental health experts to assist as needed. Not only is that burnout based on their daily jobs, but for many the lack of childcare, schools, camps, etc. has been exhausting mentally, making sure children are okay and taken care of, all while performing essential duties at the highest levels during chaotic times. Having some way to take care of frontline providers is necessary because they’re our lifeline.