ABSTRACT
On 26 December 2004, a tsunami devastated the west coast of Thailand and caused 8457 injuries and 5395 deaths. Data were collected from 26 December 2004 to 31 January 2005 at four public hospitals to describe the character and treatment of wounds of 523 persons who were injured during tsunami and sought medical treatment. Wounds were contaminated with mud, sand, debris and sea water and had an infection rate of 66·5% (674/1013). Most wounds (45%) had poly‐microbial infection with gram‐negative rods such as Escherichia coli, Klebsiella pneumoniae, Proteus and Pseudomonas species. The risk of wound infection increased with size of the wound and presence of an open fracture. Infections occurred more frequently on the lower than upper trunk of the body. Early treatment with antibiotics was protective against wound infection. Many patients asked to have their wounds sutured so that they could return to their village to look for their families and to repair damage. This report suggests that wounds should be aggressively debrided and suturing postponed if possible. Patients should be given broad spectrum antibiotics to assist with wound healing.
Keywords: Disaster, Gram‐negative bacteria, Poly‐microbial, Thailand, Tsunami, Wound infection
BACKGROUND
On 26 December 2004, a major tsunami devastated coastal villages in 15 countries along the Indian Ocean. From the west coast of Southeast Asia to the east coast of Africa, approximately 214 000 people died, 34 000 were injured and at least 142 000 were missing (1). In Thailand, the tsunami caused 5395 deaths, 8457 injures and left 3113 people missing (2). Ranong, Pang‐nga, Phuket, Krabi, Trang and Satun were among the most affected provinces because these provinces have many popular beach resorts along the coast of the Indian Ocean and the tsunami struck during the tourist season.
Injury is a major health problem after disasters and wound infection can become a serious complication. After a mudslide in Thailand, 16·3% of affected people developed wound infections (P. Udompat, unpublished data). In a typhoon in the Philippines, wound infection was the fifth most common condition of survivors (3). After Hurricane Katrina in the USA, skin and wound infections were the most common complaints in emergency departments (4). Among the tsunami survivors who were repatriated to a hospital in Germany, multiple large flap lacerations were the most common injury (5). Here, we describe the occurrence of wound infections among survivors of the tsunami from a review of inpatient and outpatient data from government hospitals in the most affected provinces. We also followed up tsunami survivors in one hospital to describe and identify the risk factors for wound infection. Finally, we describe the type of treatment given in a post‐disaster situation. This study was conducted to understand why many people developed wound infections despite receiving treatment by medical personnel at public hospitals.
METHODS
On 29 December 2004, the Thai Ministry of Public Health implemented a surveillance system for diseases and injuries that might emerge after the tsunami. Health care workers recorded demographic information and the final diagnosis of each patient seen at government hospitals in the affected areas. The medical conditions included diarrhoeal diseases (acute diarrhoea, cholera, dysentery), respiratory diseases (influenza, pneumonia, aspirated pneumonia, measles), fever (acute febrile illness, typhoid fever, dengue, malaria), central nervous system infection (meningococcal meningitis) and other conditions such as hepatitis, wound infections, viral conjunctivitis, unknown death, sepsis and animal bites. Because wound infections was the second most common medical problem in the first few weeks after the tsunami (6), we conducted a survey to understand why so many wounds became infected.
Collection of data on wounds and wound treatment
A team of epidemiologists reviewed inpatient and outpatient records from four public hospitals in Phuket and Pang‐Nga Province areas that received the most damage by the tsunami. The hospitals were Takuapa Hospital (a general hospital with 177 beds in Pang‐nga Province) and the three government hospitals in Phuket Province: Vachira Phuket Hospital (a referral centre with 500 beds), Talang Hospital (a district hospital with 60 beds) and Patong Hospital (a district hospital with 30 beds). A person with a wound infection was defined as someone with a wound that occurred after the tsunami struck on 26 December and had at least one of the following clinical signs or symptoms around the wound site: pus or cloudy discharge; redness, pain and swelling; fever; black dead tissue (gangrene or myonecrosis); crepitus sign; or blisters or bleb. We also included any patient who had been diagnosed as wound infection by a doctor. The team abstracted demographic data, date of injury, type of treatment, date and time of treatment, characteristics of injuries, wound characteristics, day of onset of infection, bacterial isolations, treatment and outcome. We also interviewed key medical staff and nurses about wound management and wound care during the post‐tsunami period.
Informed consent was obtained on all people who were interviewed. The study protocol was exempt from an Institutional Review Board because this investigation was a response to a public health emergency.
Risk factors for wound infection
We evaluated risk factors for infection in the 146 tsunami victims who received care at Talang Hospital. We mailed a questionnaire that asked about signs and symptoms, whether they sought medical care for a wound infection and whether or not the wound(s) had improved. We also interviewed victims who lived in Talang district.
Wound management
We interviewed physicians and other medical staff who treated people with wound infections to describe the post‐tsunami treatment of wounds.
Laboratory methods
Medical staff who cared for the victims took samples from wounds and submitted samples to local hospital laboratories for culture of pathogenic bacteria. Prior to the tsunami, laboratories only cultured aerobic bacteria in wound specimens upon request. Anaerobic bacteria in wounds was routinely cultured a week after the tsunami. For aerobic bacteria culture, all samples from Vachira Phuket Hospital and Takuapa Hospital were processed at the hospitals' laboratory. Specimens from Talang and Patong Hospitals were sent to a regional laboratory centre in Phuket province and confirmed by National Institute of Health (NIH) Laboratory. Antimicrobial susceptibility testing was carried out on most of the isolates.
Statistical analysis
We used Epi Info software version 3·3 (US.CDC) to conduct univariate analysis, and to calculate prevalence ratios (PRs) and 95% confidence intervals (CIs) to compare factors purported to contribute wound infection between infected and non infected wounds. We compared the mean depth and length of wounds between infected and non infected wound using the Student's t‐test. Relative risk was calculated to determine the risk of wound infection among tsunami victims from Talang.
RESULTS
From the medical records, we identified 523 people with wound infections who received care at one of the four study hospitals from 26 December 2004 to 31 January 2005. Takuapa Hospital had the most people (205/523, 39·2%) followed by Vachira Phuket Hospital (176/523, 33·7%), Patong Hospital (98/523, 18·7%) and Talang Hospital (44/523, 8·4%). The 523 people had a total of 1013 wounds of which 66·5% (674/1013) became infected. The average age of a person with a wound infection was 37·3 years of which 32 (6·4%) were less than 15 years old; 149 (29·7%) were between 15 and 29 years old; 158 (31·5%) were between 30 and 44 years old; 116 (23·1%) were 45–59 years old; and 42 (8·4%) were 60 years or older. Most patients were from Thailand (64·8%, 328/506) followed by Germany (6·7%, 34/506), Myanmar (5·1%, 26/506), Sweden (5·1%, 26/506), England (2·8%, 14/506), Finland (2·6%, 13/506), France (2·4%, 12/506) and other countries (10·5%, 53/506).
Most (57·7%, 302/512) of the wounds occurred in the morning of the 26th and most infections occurred during the first 72 hours after the tsunami. The incidence of infection decreased as time passed (Figure 1). Symptoms and signs of wound infection included redness, swelling and pain at the wound site (69·3%, 355/512) purulent discharge (62·5%, 320/512), fever (36·9%, 189/512), wound gangrene (3·9%, 20/512) and a blister around the wound site (1·8%, 9/512). Lacerations were the most common type of wound (78·7%), followed by abrasions (14·4%) and open fracture (2·8%). The most common complication of the wound was cellulitis (60 cases) of which ten had necrotising fasciitis with two people going into shock. Sepsis was the most severe complication with two people progressing to septic shock and acute renal failure.
Figure 1.
Onset date of wound infection (n = 491).
The time of injury was assumed to be the time when the tsunami struck Phuket–at 9:00 am on 26 December 2004. Most people (76·5%, 309/404) received treatment on the first day following the tsunami. The medical records contained the time of treatment in only 194 of the 523 people with a wound infection. In this group, 44·3% (86/194) received wound treatment within 6 hours after the tsunami, 19·6% (38/194) received treatment between 6 and 12 hours, 8·8% (17/194) between 12 and 18 hours, 1·5% (3/194) between 18 and 24 hours and 25·8% (50/194) after 24 hours. Most of them (92·2%, 285/309) received treatment by medical personnel, whereas a few of them self‐treated their wounds (7·8%, 24/309).
Most cases (86·1%, 266/309) received antibiotic treatment at their first hospital visit. There were 215/523 (41·1%) cases with a surgical intervention which included wound debridement in 205/215 (95·3%) cases. There were 100/205 (48·8%) cases that required more than one treatment. Twelve patients had an amputation: seven had finger or toe amputation, four had leg amputation (two with above knee amputations, one with below knee amputation, one with a below knee on one leg and a through‐knee amputation on the other leg) and one with a pinna amputation.
Antibiotics given included: cloxacillin (279/ 475, 58·7%), metronidazole (227/475, 47·8%), third‐generation cephalosporin (163/475, 34·3%), quinolone (121/475, 25·5%) and amoxycillin and clavulanic acid (104/475, 21·9%). Most inpatients received a combination of antibiotics (246/285, 86·3%). The most commonly used were metronidazole (190/285, 66·7%), third‐generation cephalosporins (159/ 285, 55·8%) and Penicillins (amoxycillin+ clavulanicacid, ampicillin, or amoxycillin) (151/285, 53·0%), cloxacillin (150/285, 52·6%), aminoglycoside (91/285, 31·9%). Most outpatients received a single antibiotic (115/190 of available antibiotic data for outpatient, 60·5%) and the most frequently used antibiotic were cloxacillin (132/190, 69·5%), metronidazole (39/190, 20·5%), the quinolone group (39/190, 20·5%), clindamycin (32/190, 16·8%) and first‐generation cephalosporin (23/190, 12·1%).
Of the 523 people with a wound infection, 309 (59·1%) were hospitalised. The median length of hospital stay was 5 days (range 1–59 days). Among inpatients, 193 cases (193/309, 62·5%) improved and 114 (114/309, 36·9%) were evacuated or referred, 2 of whom ultimately died. Of those evacuated, 94 (94/ 114, 82·5%) were tourists who returned to their native countries for care. The two deaths were tourists who suffered multiple injuries and deep wounds at Phi‐Phi Island. They were rescued and transferred to Wachira Phuket hospital on 27 December 1 day after they were injured in the tsunami. One of them was on post‐renal transplant immunosuppressive treatment. There were 25 patients re‐admitted because of wound infection. Among the 214 treated as outpatients, 60·2% were noted to have improved, whereas 39·8% could not be followed up.
Our univariate analyses showed that infection was more prevalent in open wounds (PR = 1· 71; 95% CI: 1·48–1·98) as compared with abrasion, contusion and ecchymosis. Wounds on upper limbs were less likely to be infected than those of lower limbs (PR = 0· 86; 95% CI: 0·78–0·96). Infected wounds had greater mean of depths and mean of lengths than those of non infected wounds (Table 1).
Table 1.
Comparison of infected and non infected wounds among 523 people with 1013 wounds
| Wound characteristic | Infected wound, n = 674, n (%) | Uninfected wound, n = 339, n (%) | Prevalence ratio (95% CI) |
|---|---|---|---|
| Wound type | |||
| Laceration, penetration or avulsion | 558 (74·7) | 189 (25·3) | 1·71 (1·48–1·98) |
| Contusion, ecchymosis or abrasion | 116 (43·6) | 150 (56·4) | |
| Wound location | |||
| Upper trunk | 189 (60·0) | 126 (40·0) | 0·86 (0·78–0·96) |
| Lower trunk | 485 (69·5) | 213 (30·5) | |
| Wound depth and length | Compare means | ||
| Depth: Means | 1·0 cm (SD = 1· 4) | 0·4 cm (SD = 0· 6) | P < 0· 05 |
| Length: Means | 5·3 cm (SD = 5· 1) | 4·1 cm (SD = 4· 0) | P < 0· 05 |
The majority of the 146 tsunami victims who sought medical care at Talang Hospital were Thai (103/146, 70·5%). We followed up 81 people (84/146, 57·5%); information on 3 people was abstracted from referral books, 11 responded by mails and 70 were interviewed. Of those 84, 56 people (66·7, 1%) had a wound infection. Fractures with open wounds were one and half times higher risk of infection than other types of wounds (RR = 1· 5; 95% CI: 1·26–1·71). Receiving wound care on the first day after the tsunami seemed to be protective against infection (RR = 0· 7; 95% CI: 0·57–0·96) (Table 2).
Table 2.
Risk factors of wound infection among tsunami victims who received care at Talang Hospital
| Risk factors | Exposed | Non exposed | RR (95% CI) | ||||
|---|---|---|---|---|---|---|---|
| Infect | Not infect | AR* (%) | Infect | Not infect | AR* (%) | ||
| First aid on 26 Dec | 42 | 23 | 64·6 | 14 | 2 | 87·5 | 0·7 (0·57–0·96) |
| Having open wound | 28 | 9 | 75·7 | 28 | 16 | 63·6 | 1·2 (0·89–1·59) |
| Having open fracture | 3 | 0 | 100·0 | 53 | 25 | 67·9 | 1·5 (1·26–1·71) |
| Having abrasion wound | 36 | 19 | 65·5 | 20 | 6 | 76·9 | 0·9 (0·64–1·13) |
| Having stab wound | 7 | 1 | 87·5 | 49 | 24 | 67·1 | 1·3 (0·96–1·77) |
| Having associated injury | 11 | 6 | 64·7 | 45 | 19 | 70·3 | 0·9 (0·63–1·35) |
| Direct effect by tsunami | 47 | 20 | 70·1 | 3 | 3 | 50·0 | 1·4 (0·62–3·17) |
| Suturing open wound on first day | 10 | 5 | 66·7 | 11 | 4 | 73·3 | 0·9 (0·57–1·46) |
AR* = attack rate; number of cases exposed to risk factor
Wound cultures
Wound cultures were obtained from 92 patients (62·4% were hospitalised); 75 (75/92, 81·5%) cases were culture positive. The results showed mixed organisms (43·5%) and single organism (38%). Most isolates were gram‐negative bacteria (Table 3). In 12 cases, marine organisms such as Aeromonas hydrophilla and Vibrio alginolyticus were identified. Patients with marine organisms isolated from their wound infection had relatively mild symptoms. Of the 13 specimens sent for anaerobic culture only one was positive; Clostridium perfingens was found. Antibiotic susceptibility testing was not performed routinely, thus results are not available on every isolate (Table 4).
Table 3.
Wound culture results (n = 155 organisms)
| Bacteria cultured from wound | Frequency | Percent |
|---|---|---|
| Escherichia coli | 26 | 16·8 |
| Klebsiella pneumoniae | 19 | 12·3 |
| Staphylococcus aureus | 18 | 11·6 |
| Proteus vulgaris | 14 | 9·0 |
| Pseudomonas aeruginosa | 14 | 9·0 |
| Proteus mirabilis | 9 | 5·8 |
| Enterobacter spp. | 7 | 4·5 |
| Klebsiella ozaenae | 6 | 3·9 |
| Enterobactor aerogenes | 6 | 3·9 |
| Enterobacter cloacae | 6 | 3·9 |
The following bacteria were recovered in less than 2·0% of the cultures: Edwardsiella tarda, Aeromonas claviae, Vibro alginolyticus, S. epidermidis, Klebsiella oxytoca, Acinitobactor spp., Xanthomonas spp., Streptococcus gr.D, Shewanella alga, Serratia marcescens, Pseudomonas putrefaciens, Providecia rettgui, Prevotella sp., Morganella morganii, Klebsiella rhinoscleromatis, Clostridium perfringens, Citrobactor farmanii, Alcagenes spp., Aeromonas hydrophila, Acinetobacter lwoffii, Acinetobacter caviae.
Table 4.
Drug susceptibility results of the most commonly isolated pathogens
| Antibiotics † | Escherichia coli | Klebsiella pneumoniae | Staphylococcus aureus | Psuedomonas aeruginosa | Proteus sp. |
|---|---|---|---|---|---|
| Amikacin | 14/14(100) | 14/14(100) | – | 7/8(87·5) | 14/14(100) |
| Gentamicin | 17/17(100) | 12/12(100) | 2/2(100) | 8/9(88·9) | 15/15(100) |
| Ciprofloxacin | 4/4(100) | 1/1(100) | 2/3(66·7) | 5/6(83·3) | 3/3(100) |
| Ceftazidime | 10/10(100) | 6/6(100) | – | 5/6(83·3) | 8/8(100) |
| Cefazolin | 8/10(80) | 13/13(100) | 1/1(100) | 5/5(100) | 14/14(100) |
| Cefotaxime | 11/11(100) | 11/11(100) | – | 3/7(42·9) | 15/15(100) |
| Oxacillin | – | – | 8/12(66·7) | – | – |
| Amoxy + clavulanic acid | 6/9(66·7) | 9/12(75) | 4/9(44·4) | 1/1(100) | 10/12(83·3) |
| Vancomycin | – | – | 9/11(81·8) | – | – |
| Imipenam | 12/12(100) | 13/13(100) | 1/1(100) | 5/5(100) | – |
| TMX‐SMZ | 12/18(66·7) | 10/10(100) | 4/4(100) | 2/8(25) | 13/15(86·7) |
†Different denominators because of antibiotic susceptibility was not carried out on every isolate.
Initially wound cultures were based upon the judgement of the treating physician. Doctors used clinical judgements for requesting anaerobic cultures on wounds. About 1 week after the tsunami, the Ministry of Public Health recommended wound culture for everyone and provided culture transport media.
Interviews with the medical staff
Immediately after the tsunami, the hospital staff were overwhelmed by many people seeking care and by responding to their personal tragedies. We interviewed four physicians and four nurses who cared for tsunami victims immediately after the tsunami. They said that most of the wounds were severely contaminated, not only with sea water, but also with foreign bodies such as debris, sand and mud. One said ’some open wounds were sutured to stop bleeding and some patients requested suturing because they wanted to go back to find their families'. Another remarked that ’many patients who had primary closure of wound on December 26, returned to the hospital with an infection at the site of their wound a few days after that. It seemed as sand and other debris were still inside some of the wounds'. Figure 2 is a typical example of such a wound.
Figure 2.
Typical time series of an infected wound (1) first presented at the hospital, (2) after removal of sutures, (3) after wound extension (Picture credits: Wound care team, Vachira Phuket Hospital).
DISCUSSION
A wound infection was the second most common health problem among the survivors of the 2004 tsunami. In the 523 people in this study, wounds occurred just after impact of the tsunami and became infected within 72 hours. Wounds were typically contaminated with debris, sand, mud, sea water and in some instances sewage. Infections were more likely to occur in open wounds than an abrasion, contusion or ecchymosis, on a lower extremity than the upper extremity and were longer and deeper in length than non infected wounds. These characteristics are similar to those reported by other researchers of the 2004 tsunami (7) as well as war wounds (8).
Wounds associated with the tsunami were commonly infected with gram‐negative organisms commonly found in human and animal faeces. This is in contrast to wounds not associated with a tsunami that are typically infected with Staphylococci (9). The infecting bacteria are compatible with other studies of post‐tsunami wound infections: a private hospital in Thailand reported that K. pneumoniae was present in 24·2% of the cultures, E. coli in 18·9% and Proteus spp. in 15·8% 8, 10. A study of patients repatriated to Europe recovered similar pathogens but these bacteria had a higher level of antibiotic resistance. One reason is that most of these patients were treated with antibiotics in Thailand and the remaining bacteria may be the resistant strains. In a study of wound infection among repatriated German citizens, the isolates (Psuedomonas, Enterobacteriae, Aeromonas spp.) showed higher antibiotic resistance than in Thailand (6). Similarly, a Swedish study reported gram‐negative bacilli (Psuedomonas aeruginosa, E.coli, Proteus spp, Klebsiella spp.) with greater antibiotic resistance (11). Findings also included some rare species such as Myroides odoratus, Sphingomonas paucimobilis and Bergeyella zoohelcum. Additional case reports from other sources described Burkholderia pseudomallei in wound infection among Finish travelers (12). Tetanus wound infections occurred in Indonesia but tetanus is rare in Thailand because tetanus toxoid has been given to all children since 1977 10, 13.
Even though antibiotic susceptibility was not carried out on every isolate, some patterns were similar to those in the National Antimicrobial Surveillance System in southern Thailand, 2003 (14). These surveillance data found that P. aeruginosa shows considerable antibiotic resistance: 91·9% susceptible to amikacin, 83·3% to gentamicin, 84·5% to ceftazidime, 89·1% to ciprofloxacin, 95·0% to imipenam, 1·0% to cotrimoxazole. Our own findings did show a higher percentage of antibiotic susceptibility for E. Coli, K. pneumoniae compared with the surveillance data.
The study limitations included missing data because of incomplete or no medical records. Some patients received medical treatment in the hospital but the staff did not make a copy of the records for the patient. Our study does not represent all tsunami victims because only government hospitals were included in the study which probably over‐represents Thais. The evacuation policy encouraged foreigners to return home as soon as possible unless urgent medical care was needed. Despite government support, wound culture and antimicrobial testing of the isolates were not routinely performed because of the turmoil after the disaster. Therefore, our investigation could not determine the frequency of organisms that requires special culture media. Infection with other organisms such as fungi, as reported among Sweden victims (15) and mycobacteria (16), would not have been detected, and our knowledge about anaerobic infection is incomplete.
On 2 January 2005, in response to the large amount of infection wounds, Vachira Phuket Hospital established a program to treat wound infections based upon articles by Falanga and Sibbald 17, 18. The program was called Wound Bed Preparation and consisted of the methods for debridement to remove devitalised tissue, reduction of bacteria in the wound and managing the exudate. They established a wound care team composed of a surgeon, an infection control nurse, surgical nurses and outpatient department nurses. Nurses were trained to collect specimens and provide care for the wounds. Every day the team monitored patients with wound infections.
RECOMMENDATIONS
Wound treatment following a tsunami poses challenges for health care providers and hospitals. In the days immediately after the tsunami, treatment depended on having sufficient health care workers and medial supplies. Heavy contamination with microbes and debris is expected and aggressive cleaning and debridement seems particularly important 6, 19. Early suturing is not advisable because sutured wounds often became infected and required revision. We recommend delaying in primary suturing of open or deep wounds and close follow‐up of the patient to detect early signs of wound infection. Therapy for post‐tsunami patients with wounds should include broad spectrum antibiotics for gram‐negative bacteria and poly‐microbial infections. Marine organisms (Aeromonas spp., Vibrio spp.) or other unusual pathogens that might exist in environmental setting such as fungi, Mycobacterium spp. or Burkholderia pseudomallei (especially in endemic areas) should be included in differential diagnosis for wound infection 20, 21. Establishing a wound care team should be considered to standardise the method of wound care.
Health education is the keystone in successful wound care and be provided to both health care providers and patients with wounds. Based on our interviews with health care providers, health care workers should have information on the potential challenges and managing of patients in a disaster. Education on wound care at home and the signs to seek the assistance of a doctor can help patients better manage wound infections. Finally, post‐tsunami surveillance should include wound infections to evaluate the scope and magnitude of wound infections–an important and preventable health problem.
Acknowledgements
We thank the wound care team of Vachira Phuket Hospital; the registration unit staff of Takuapa Hospital; nurses, epidemiological and administration staff at Talang and Patong Hospitals, Muang, Talang and Patong districts; Takuapa and Siriroj Hospitals; all Thai epidemiological staff who conducted active surveillance during the study period; the Regional laboratory centre at Phuket and Pang‐nga provinces; and Bacteria laboratory National Institute of Health. We also thank Dr Rungrueng Kitphati, Dr Lakkana Thaikreu, Dr Tippawan Nagachinta, Dr Yonjua Laosiritaworn, Dr Rapeepan Dejpichai, Dr Panithee Thammawijya, Dr Asadong Wannachak, Dr Chakarat Pittayawonganon, Dr Worawit Kittisakronnakorn, Mrs Pannarai Samitsuwan, Mrs Somkid Kongyu, Miss Nipapan Sarit‐apichai and Miss Suttanan Sutchana. The authors also thank Kim Porter, Hjordis Foy and Alden Henderson for reviewing and preparing this article for publication.
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