Reprinted from North Carolina Health News

OCRACOKE — Despite being a business leader in a busy tourist town, Cheryl Ballance sometimes has had to tell summer guests not to come to Ocracoke.

“Sometimes, we’d get calls from people who said they were nine months pregnant with a high-risk pregnancy, wanting to know if we had resources for them,” Ballance said. “I’d tell them, ‘Oh, you really need to look at the map.’”

Ballance, the longtime head of the Ocracoke Health Center has seen and heard it all from tourists and from the thousand-or-so year-round residents on the 13-mile long island, which lies south of Hatteras Island on the Outer Banks.

The health center is an important place on the island’s map, as it’s the only place to get consistent health services. The center does not turn anyone away, insured or not.

Supplementing the remote island’s health care is Gail Covington, a mobile nurse practitioner, who provides services in homes on Ocracoke and Hatteras islands, and who does not take insurance.

“On a summer holiday weekend, we have this blossom of you know, maybe 10,000 people who show up,” Ballance said. ”I think it’s probably like seven to 8,000 during the week.”

Despite the center’s importance to the life of Ocracoke, the past few years have been challenging financially. Ballance said she’s making a go of it, but it’s difficult to keep providing high quality care on a shrinking health care dollar in one of the most remote and sparsely populated parts of the state.

Seasonal work, year-round expenses

One issue for Ballance is about a third of her patients are uninsured, even as they work two, three, even four gigs at a time during tourist season, when there’s work to be had.

“The people who support this whole resort are people who are only employed, if they’re lucky, somewhat in April, May, June, July, August, and if we don’t have hurricanes September and October,” she said. “Then by November, everything is closed.”

“They’re making a year’s worth of income during that five to six month period.”

Some workers do leave the island in winter, Ballance said. Maybe “they have a friend that lives out in the mountains, ‘Can you come up here for three weeks, we’re really busy, you can help us at ski lodge?’”

But for many people on the island, funds begin to dwindle in the lean months of the late winter, especially as unemployment checks peter out.

It’s something familiar to Erin O’Neal, the clinic’s chief operating officer, who used to work in restaurants when she’d come home from school.

“Anybody who’s waiting tables, and you got a lot of that, or cleaning rooms, aren’t a high hourly rate, their unemployment is gonna be the lowest,” O’Neal said, noting how the law changed to shorten the number of weeks someone can draw an unemployment check.

“And if there was a storm, and they drew on their unemployment during that time, they’ve already used part of their weeks before they’ve even gone out with their season. So it’s an even longer extended period of time with no income, it’s really hard for people.”

The flip side is that winters give the clinic’s doctor, Erin Baker, time to dig in to problems.

“In the summertime, she’s clipping those visits for the residents,“ because the clinic is hopping, Ballance said. “But she spends a lot of time, time you’re never going to get anywhere else … in the winter.”

Getting away has a cost

The isolation that tourists crave also poses challenges for the locals.

When Vince O’Neal was a kid on Ocracoke, his only medical encounters were with the school nurse or his grandmother, a midwife who delivered the island’s babies for decades. That was before the clinic started in 1981.

“We did not have any kind of medical services here until that clinic was built,” said the 59-year-old restaurant owner, and, by his reckoning, eighth-generation Ocracoker.

Otherwise, it was off the island to the doctor, a trip that could take hours, or even a whole day.

Access to emergency care from Ocracoke has gotten better over the years.

There are always emergency medical technicians on the island and helicopter service to Vidant Medical Center in Greenville or to the Outer Banks Hospital in Nags Head, but there’s no pharmacy and no lab.

Getting off the island takes hours by ferry to the mainland and then to the nearest hospital or an hourlong ferry ride to Hatteras from the northern end of the island and another 90 minutes from there to Nags Head.

So much depends on the ferry. If the weather turns stormy or foggy, the ferries don’t run. Even when they do, getting to a specialist off the island or to the dentist can mean getting up at 3:30 a.m. to get the 5 a.m. Hatteras ferry run.

Prescriptions? They come by courier from Hatteras every afternoon.

But if a tourist gets a stingray barb in their foot or a severe sunburn, the center is where they turn.

This story is provided courtesy of North Carolina Health News, a website covering health and environmental news in North Carolina. Coastal Review Online is partnering with North Carolina Health News to provide readers with more environmental and lifestyle stories of interest about our coast.

Reprinted from North Carolina Health News

MOREHEAD CITY — When Brett Froelich saw Hurricane Florence taking aim at the North Carolina coast, he saw an opportunity.

So, even as Florence’s winds were screaming past the University of North Carolina Institute of Marine Sciences where he is an associate professor, Froelich was planning on how to get test kits out to physicians and other health care providers who would be providing care after the storm.

Froelich studies the kinds of bacteria that are present in water stirred up by hurricane winds and surges. The target of his current research is a species of the nasty pathogen known as vibrio, which is in the family of bacteria that includes cholera.

“We’re not too worried about cholera. We have excellent sanitation and things like that,” he said reassuringly. “What we are worried about are a couple of other species, Vibrio vulnificus and Vibrio parahaemolyticus.”

Those two species of vibrio live in shellfish and also in the waters that host other shellfish. People who eat raw shellfish inoculated with either of these bacteria can get pretty sick.

The Centers for Disease Control and Prevention estimates between 52,000 and 80,000 cases of food poisoning each year are attributable to vibrio.

But another problem is when people come in contact with either of the vibrio species through an open wound.

“Say they cut themselves on a rock, or they poke their finger while baiting a hook or something like that and some of the salt water gets in there,” he said. “The bacteria can then get into that wound and cause a life-threatening infection.”

During Hurricane Katrina, there were 22 confirmed cases of Vibrio vulnificus-based wound infections, said Froelich’s colleague, Rachel Noble, a professor at IMS.

“There were five deaths that happened from those,” she said.

Dangerous floodwaters

Vibrio infections happen more often in summer months when the water is warm and the bacteria are able to multiply. The good news is that the bacteria are very susceptible to treatment if a person with a red and oozing wound receives treatment early.

“If a patient were to come in, and they say, ‘Look, I got cut and it looks infected,’ and the doctor gave them antibiotics they’d probably be fine,” he said. “But if they got infected, and then think, ‘Well, let me sleep on it and see how it looks tomorrow,’ the next day it might be too late.”

V. vulnificus left untreated has a 50 percent fatality rate.

“That’s even with aggressive medical treatment, which usually involves intravenous antibiotics, amputation of infected limbs and things like that,” Froelich said.

That’s what happened to a Wilmington man, who died after cutting his leg during hurricane cleanup and getting floodwater into the wound. He died on September 25 after having his infected leg amputated.

NC Health News could not confirm that V. vulnificus was the cause of his infection, but New Hanover County deputy health director David Howard said the pathogen is a big concern for his department. His agency put out a press release on the 25th warning local residents about the risk of vibrio.

Howard said if people “have to come in contact with floodwater, say cleaning up the house, wear boots or waders, gloves.”

In 2017, 64 people in North Carolina were reported to have acquired vibrio infections, five of them were V. vulnificus, but Froelich believes that number might be higher, and that’s why he saw an opportunity in Florence.

Marine bacterial infections inland

When a patient shows up at a doctor’s office with an angry, infected wound, most of the time, the doctor won’t culture the bacteria that are in the wound but will simply give antibiotics. The good news is that vibrio is very responsive to antibiotics and will easily get killed off.

But Froelich wants to get the doctors near the coast and inland to culture those wounds in the wake of Florence to get a better idea of the prevalence of these infections.

“The storm surge pushed water up the estuary and up the river, bringing with it that salty water,” Froelich said. “When the water is less salty that (vibrio) can proliferate, but they also require some salt. So they can’t survive in fresh water.

“If you go way up into the river, normally all the way up to New Bern, you wouldn’t find these things at all. But with the storm surge, it pushed the salt water that far up and extends the risk way upriver.”

Even as Florence was dumping rain on the coast, he scrambled to assemble kits containing sterile swabs, culture media, instructions, gloves and a consent form. Then he drove around, distributing the kits to providers as far inland as New Bern.

Froelich worried that people are at risk further inland who might think they’re safe from encountering coastal pathogens. He said that the large storm surges extend the places that vibrio can be found and places not normally considered a risk area now are.

“People who are just walking through standing water [there] might have a wound or get a wound and then these bacteria can infect them without them ever having gone into the coastal waters,” he said. “Basically, people who are technically on land can get a marine bacterial infection.”

He said the vibrio can enter a wound as small as an ant or mosquito bite.

“Little cuts you didn’t know you had, ones you can’t even see, that’s all it takes,” he said.

Long lasting

What makes vibrio even more of a horror movie pathogen is its persistence. Froelich explained that if soil containing vibrio dries up, it enters what’s called a “viable but non-culturable state.”

“It essentially just really, really, really slows down its metabolism to almost nothing and then once conditions improve, that is to say, enough water, enough salt and then the temperature is right, they come back out,” he said. “Because they grow so fast, they can double every 20 minutes and can react like that to changing conditions.”

He said in his lab they had an old test tube sitting in the back on the shelf, forgotten for close to 20 years.

“When we got to it, the tube was nothing but dried-up salt crystals. We took that, added water to it, shook it up, got them to grow,” he said.

There is one upside: fully salty ocean water isn’t as welcoming to vibrio, so, as coastal waters flush out the fresh water coming downstream, the risk on beaches diminishes. As of this weekend, most precautions on the ocean side of the state’s barrier islands have been lifted. But people who wade in brackish, part-salty water will have to continue to be on guard.

This story is provided courtesy of North Carolina Health News, a website covering health and environmental news in North Carolina. Coastal Review Online is partnering with North Carolina Health News to provide readers with more environmental and lifestyle stories of interest about our coast.

Reprinted from N.C. Health News

WILMINGTON — Thick black smoke hovered in the autumn skies over Wilmington 153 years ago this week. Carts collecting dead bodies trundled over the roads and uncollected rubbish produced a stench that permeated the city.

Gravediggers at Oakdale Cemetery, just outside of town, buried at least a dozen bodies a day. Half of the city’s 10,000 residents had fled to the homes of friends and relatives. But the ones without means or a destination huddled behind to wait out the plague, along with those who served them as physicians, caregivers and tenders of the dead.

During the end of the week of Oct. 17, 1862, 453 Wilmingtonians came down with yellow fever. The following week, 111 died, making it the most deadly week of the epidemic.

Overall, between late August and the first frost in November, 1,505 people contracted the disease; of those, 654 died.

Yellow fever, a “hemorrhagic” fever, similar to the Ebola virus disease, starts innocuously with a fever, chills and diarrhea. But within days, bleeding in the gastrointestinal tract produces black diarrhea and vomit, along with abdominal pain, as can Ebola. In the final throes, patients begin to bleed from the gums, nose and bowels.

The similarities between yellow fever and Ebola have not been lost on David Rice, the New Hanover County health director, who on occasion leads groups of people on tours through Oakdale cemetery. He is also an amateur historian of health care in North Carolina.

Rice said he thought about the panic, fear, superstition and stigma that accompanied the arrival of yellow fever as he’s prepared his community last year for the possibility of a case of Ebola.

Entire Families Killed

Rice said no one is really sure how the yellow fever epidemic started. It might have arrived on a blockade runner or another ship with a sick crew. As the city was also in the throes of the Civil War, many whispered that Union soldiers had snuck a sick patient into the city – a 19^th-century accusation of bioterrorism.

What is certain is that the summer of 1862 had been rainy, leaving many ponds and flooded areas where yellow fever carrying mosquitoes could breed. But at that time, people were unaware that this was how the disease spread. Food was scarce because of the war, people were undernourished and many of those usually tasked with keeping the streets cleaned and encroaching water at bay were off fighting.

Some stayed behind, and their job became one of collecting bodies, as recorded by epidemic survivor John Dillard Bellamy, who was 8 years old at the time.

“I recollect, well, having stood in our home on Market and Fifth Streets, watching wagon-loads of corpses go by to Oakdale Cemetery,” he said.

Those manning the “death carts” retrieved bodies from the terrified families of the deceased, said Eric Kozen, superintendent of Oakdale. At the time, people did not know how yellow fever was transmitted and did not want to keep the bodies inside their homes, for fear of contagion, so bodies were left by the side of the road. Whole families died, one after the other.

For more than 400 of those bodies, their final resting place was a mass burial ground on a high point in Oakdale.

“As bodies were being brought here to the cemetery, we were receiving anywhere from about 10 to 15 a day during the height of the epidemic,” along with those who died of other causes, Kozen said.

They were not mass burials, with a one pit receiving dozens of bodies; instead, they were methodically done in 28 rows, each 20 to 30 yards long. One is simply marked “children.”

“The husband would die; he would be buried in a certain gravesite. His wife would pass, sometimes three days later. They would open that same grave, bury her with him. Children would follow thereafter. So we actually had up to four or five people being buried in the same grave in a month’s time frame,” Kozen said. “It would wipe out entire families.”

In the push to get bodies interred, few gravestones were erected. Instead, what remains is a field punctuated by stately oaks, camellias and azaleas, and, since Kozen’s arrival, thousands of daffodils in the spring.

“It was pretty scary stuff,” Kozen said. No one knew how the disease got around or the best way to handle the sick and the dead.

“That’s where that whole public fear came in, and that’s why cemeteries were developed on the edges of towns.”

Fallen Caregivers

As with the Ebola epidemic, many health care workers who fought yellow fever became victims. They’re also buried at Oakdale, along with those they cared for.

The brilliant Dr. James Henderson Dickson reported the very first cases of yellow fever on Sept. 17, 1862 to state officials.

“Since Tuesday the 9th, I have seen five cases of the disease,” he wrote. “Of these, two have died, one is discharged as a convalescent, and two are still under treatment with doubtful prospects.”

Dickson’s friend John Lamb Pritchard, pastor of First Baptist Church, asked Dickson whether he should visit a sick patient. From an account read by Rice, Dickson told his friend, “‘I reckon you will have to do as I do. It is like war, we must have to take our chances. You will have to go and see many during their illness.’”

Rice read from an account of Dickson’s final patient visit. The doctor stood in the door, propping himself up on the doorposts as he advised his patient.

“‘I cannot come in. I have the fever now,’” Rice read.

By the end of September, Dickson was dead.

Rev. Pritchard sent his family from town, but remained to tend to his remaining flock. Rice read from his diary, where he wrote, “‘Must a minister fly from disease and danger and leave poor people to suffer for want of attention? Did the Saviour ever draw back?’”

Pritchard too died of yellow fever, along with his colleague Robert Drane, the rector of St. James Episcopal. Drane’s sister, who remained to help him, died as well.

“Someone asked, why did they remain?” Rice said. “Well, we have duties; we can’t abandon our duties.”

One of those who stayed was Phineas Fanning, who supervised collection of the dead, provided “subsistence for the destitute who could not flee” and oversaw protection of abandoned property. Fanning also took over operations of the cemetery after the superintendent, James Quigley, died in the middle of the epidemic. Rice said Fanning himself was left destitute by the end of the Civil War.

Echoes Sound Today

The epidemic served to galvanize many of Wilmington’s leaders to work against a repeat of the horror.

Physician Thomas Fanning Wood survived because he was away, serving as a Confederate surgeon. Rice noted that Wood lost his wife and family to infectious disease and “he saw injury and illness, and he didn’t want our communities facing that in the future.”

Now Wood is known as the “father of public health” in North Carolina.

“He went back and forth to the legislature begging them to start the public-health movement, and they finally gave in to him because he was so persistent,” Rice said, noting that the General Assembly gave Wood a mere $100 to get the state’s public-health service started.

Rice has quipped that public health remains underfunded.

Another Confederate surgeon, Solomon Sampson Satchwell, became the first president of the N.C. Medical Society. Wood started the N.C. Medical Journal.

And although Rice does tours of the cemetery for the Friends of Oakdale, his day job has had him consumed with Ebola preparedness for weeks in the fall of 2014. He said he had numerous panicked calls about Ebola to his office.

But he expressed greater concern for rabies in his area than Ebola. And he urged people on the tour to get vaccinated against the flu.

Every generation, it seems, has a dread disease to be faced by patients, caregivers and the public, he said.

“It’s the same as yellow fever. You have to learn about the diseases, you have to contain them, you have to stop them.… Same thing with Ebola; you have to educate and contain,” he said.

To prepare, Rice recently convened all local officials who might have had anything to do with Ebola response, from airports and ports to schools to hospitals. He also convened a media-education session.

“My thought is that we haven’t had to respond to a hurricane, let’s respond to a hurricane-like condition called Ebola,” he said.

And Rice said the historian in him was continually making connections between Ebola and yellow fever.

“If you don’t visit the history of what has occurred, you’re apt to repeat it,” he said. “We try to make those connections from the past so we can better serve in the future.”

To Learn More

• Oakdale Cemetery, the oldest rural cemetery in North Carolina
• City of the Dead: Wilmington’s Yellow Fever Epidemic

This story was reprinted from N.C. Health News

RALEIGH — The seasons are getting ready to change, and with the shortening days will come the sight of flocks of ducks and geese flying south for the winter.

But some in North Carolina are dreading the arrival of our feathered winter residents. For the most part, those are poultry farmers who’ve watched a highly pathogenic form of avian influenza, or bird flu, devastate farms in the Midwestern U.S.

The disease has required the culling of millions of chickens, turkeys and ducks, driving farms into financial peril, affecting the nation’s egg supply and increasing the prices of chicken and eggs.

“We’re literally one flyway away” from the disease, State Veterinarian Doug Meckes told farmers who gathered recently at the annual Food Safety Summit, hosted by state Agriculture Commissioner Steve Troxler at the state fairgrounds in Raleigh.

Poultry experts believe the disease has been carried to farms large and small by wild migrating birds. For the past three months, those birds have been congregating in summer breeding grounds far to the north, passing the disease around. As birds return south from Canada and Alaska, they could very well bring the disease with them.

And while high pathogenic avian influenza, or HPAI, is not a human health issue per se, spread of the disease could affect the supply of meat and eggs and kill poultry on both large farms and in backyards.

“We’re talking about food availability, and how the high path [HPAI] could impact that food availability,” Troxler said. He recounted how his department fielded calls from the military during the Midwest outbreak this spring asking for help finding eggs.

“Well, no, we can’t help you find them, because they’re not out there,” he said. “We’ve seen them taken out in the Midwest. Egg prices could rise again; there could be a shortage of eggs.

“I do know that the U.S. is importing eggs now for the first time in a long, long time.”

And officials at the Centers for Disease Control and Prevention are keeping an eye on these outbreaks, just to make sure they don’t make the jump from birds to humans.

Averting the First Sneeze

Troxler said he’s serious about avoiding the arrival of HPAI in North Carolina, where poultry is a $34 billion a year industry. The coastal plain is one of the areas in the state where commercial  poultry farms are concentrated. All poultry shows in the state have been banned for the year and the State Fair in October will not have any fowl on display, according to Brian Long, a spokesman for the state Department of Agriculture and Consumer Services.

“We just cannot afford to risk the movement of poultry after they have come together and back to different geographic locations and are potentially moving this virus,” Meckes said.

He said the evidence is strong that the disease was introduced in Minnesota, Iowa and Wisconsin by migrating waterfowl that carried the virus and pooped it out. It was then carried on the wind.

“But as the virus began to build up in commercial operations, the human factor became a great component of the virus spread,” Meckes said. “People moving from farm to farm without the appropriate change of clothing, without appropriate decontamination and disinfection of their vehicles.”

In prior outbreaks, the spread of infection was traced to virus carried on the tires of trucks from affected farms that then infected other farmers’ trucks in the parking lots of feed stores.

A single case of HPAI can rip through a chicken house within a day or two, sickening or killing many of the animals.

Veterinarian Ben Meade from the U.S. Department of Agriculture’s Animal and Plant Health Inspection Service told the group that vaccines aren’t a good choice for stopping the spread of this disease. He explained that as with human flu vaccines, avian flu viruses change frequently, and it can be hard to create the right vaccine in time to stop an outbreak.

“There is a vaccine, but it’s not very good,” Meade said. He also pointed out that many international trading partners won’t buy vaccine-treated poultry for up to a year.

Between 30 and 40 percent of U.S. poultry is for the export market, Meade said.

Large and Small

The Department of Agriculture and Consumer Services has also asked people with backyard flocks to register their birds, a move some birders view with suspicion.

“If you don’t tell the fire department where you are, how can you get help?” Troxler asked, by way of analogy. “And then if you don’t like government, and the fire department happens to be part of government, are you going to sit in the house and burn up?”

He said his department is “pro people having backyard flocks. We just want to make sure that birds don’t die.”

“We had a lady call in, and she said, ‘I’ve got a pet rooster, and he’s old and he stays in the kitchen with me most of the time. He loves to watch things on the Internet,’” Troxler recounted. She wanted to know if her single bird needed to be registered. “We said, ‘Yes, ma’am; we want to make sure Chester is alive.’”

Meckes said agricultural officials were not going to confiscate anyone’s birds

“We just want to know where birds are,” he said, should the disease come this way.

Meckes also said that in the event of an outbreak, part of the containment strategy is to restrict movement of birds in or out of an area; in effect, a quarantine. That also means that farms raising chickens will not be able to raise more birds for months as they disinfect their chicken houses.

Mass Killing

Meckes showed grim images of poultry houses in Minnesota, where North Carolina teams arrived in April to help agriculture officials control widespread outbreaks. To kill the birds, response teams pump tens of thousands of gallons of firefighting foam into the poultry houses. The birds suffocate within minutes.

He said on the first weekend the teams arrived, they went straight to the world’s largest turkey farm: “2.54 miles of turkey houses, 12 houses.” Within days, the North Carolina teams had “depopulated” 305,000 from that one farm, first culling them and then composting them.

It’s the concentration of animals that concerns some agricultural experts, in part because putting together all those birds increases the death toll when diseases strike.

“When you put large numbers of birds in one place, disease is more of a concern,” said Scott Marlow, an agronomist who heads the Rural Advancement Foundation International, based in Pittsboro. “Just like when kids go back to school, the illnesses run through them quickly and they bring home the illness.”

Marlow also voiced concern for the contract farmers who grow the birds for large producers such as Tyson and Perdue.

“We’re very concerned about the multiple levels of losses the contract producers face,” Marlow said in an interview after the summit. “There are the costs of disposing of animals killed, and of being quarantined and facing weeks and months out of production. Those contractors have loans taken out to run these farms. You get (HPAI) in your farm, it could mean the loss of income, the loss of farms, the loss of homes.”

Requirements from the USDA and the International Organization for Animal Health call for cleaning and disinfecting regimens that could take a chicken house out of production for as long as six months.