The Honorable Morgan Griffith

Vice Chairman

United States House of Representatives

Energy and Commerce Committee

Subcommittee on Oversight and Investigations

2022 Rayburn House Office Building

Washington, DC 20515

The Honorable Diana DeGette

Ranking Member

United States House of Representatives

Energy and Commerce Committee

Subcommittee on Oversight and Investigations

2111 Rayburn House Office Building

Washington, DC 20515

Dear Vice Chairman Griffith and Ranking Member DeGette:

On behalf of the Infectious Diseases Society of America (IDSA) and the HIV Medicine Association (HIVMA), thank you for scheduling the October 24 hearing, “Examining HHS’s Public Health Preparedness for and Response to the 2017 Hurricane Season.”

IDSA represents more than 11,000 physicians, scientists and other health care professionals who specialize in infectious diseases. Housed within IDSA, HIVMA is an organization of more than 5,000 clinicians and researchers who are working on the front lines of the HIV epidemic.

We are writing to share with you our concerns regarding the areas recently affected by hurricanes, including information on the potential infectious diseases risks posed by hurricanes. We appreciate that the House has taken action to pass $36.5 billion in emergency hurricane and the fire aid. We hope the Senate will quickly follow suit, permitting the dispersal of the funding to address urgent health needs and rebuild the health care and public health infrastructure in areas devastated by recent hurricanes.

The need is particularly acute in Puerto Rico and the U.S. Virgin Islands. Key infectious disease considerations in the aftermath of a hurricane include access to clean water, medicines and medical supplies; vaccination and hand hygiene, particularly in crowded shelters; vector -borne diseases such as Zika; and mold -related illnesses. In addition, because Puerto Rico locally manufactures many medications, we are deeply concerned that the severe impact of Hurricane Maria could lead to drug shortages for critical medicines, including for HIV and cancer, exacerbating already troubling antimicrobial drug shortages throughout the country.

Access to clean drinking water and food safety are of paramount importance. Without electricity to power refrigeration, the risk of food spoilage and foodborne illness increases. With water supplies still not restored and sewerage systems disrupted to many affected areas, individuals may turn to rivers, springs or other ad hoc water sources. This approach, along with the presence of floodwaters, increases the risk of illness caused by waterborne pathogens such as cholera, non-cholera vibrios (such as Vibrio vulnificus) non-tuberculosis mycobacteria, and Legionella. Already at least one death has been confirmed from leptospirosis, a disease that can be spread in water contaminated by the urine of an infected animal, and scores of illnesses and several additional deaths are being investigated as suspected cases. These concerns underscore the need to rebuild and repair basic infrastructure to ensure access to safe food, clean water and sanitation, and to mount education campaigns for health care workers and the public.

Health care facilities are also in urgent need of support. In many facilities, lack of electricity, saline, medicines and other supplies are significantly hampering patient care and impeding infection control efforts.

For people living with HIV, maintaining continuous access to medications is critical to prevent treatment disruptions that could lead to disease progression, life -threatening illness, and treatment resistance. When people with HIV have “undetectable virus” while on effective HIV treatments, HIV is not transmitted to others, but access must be continuous to be effective. Therefore interruptions in drug access also are likely to be associated with outbreaks of new HIV infections. There are more than 17,000 people living with HIV in Puerto Rico and 550 living in the U.S. Virgin Islands. The Department of Health and Human Services (HHS), the Centers for Medicare and Medicaid Services (CMS), as well as the Health Resources and Services Administration (HRSA) and its HIV/AIDS Bureau must work closely with these jurisdictions to provide them with the greatest amount of flexibility to ensure the medical needs of individuals with HIV are met for those who remain on the island and those who evacuate to the states.

Conditions in crowded shelters and severely damaged homes and health care facilities can greatly increase the spread of infection, making hand hygiene and immunizations even more important. We strongly support HHS efforts to deliver influenza vaccinations to impacted areas and encourage the subcommittee to further assess with HHS any additional vaccination needs and plans to meet them. Crowded conditions can precipitate outbreaks of common vaccine-preventable diseases. We also note that ensuring optimal immunization rates before a disaster strikes is an important strategy to mitigate the spread of disease and lessen the burden of disaster response.

We are also concerned that persistent, standing water from flooding may contribute to increased mosquito breeding. Further, loss of housing leads individuals to spend longer periods of time outdoors, increasing the risk of mosquito-borne illnesses, including West Nile Virus and Zika. As individuals return to damaged homes, mold-related illnesses such as severe asthma might be seen.

Finally, we enc ourage the subcommittee and HHS to assess the impact of Hurricane Maria on the supply of medications that were manufactured in Puerto Rico. Two manufacturers of critical components of frequently prescribed HIV regimens have plants in Puerto Rico and shortages of these medications could have devastating consequences for individuals with HIV both in Puerto Rico and across the mainland, in addition to fueling a rise in new HIV infections. As you may know, antimicrobial drug shortages have persisted throughout the US for the last several years. A 2016 survey conducted by the IDSA Emerging Infections Network found that 70% of responding physicians faced an antimicrobial drug shortage in the previous 2 years, and 73% of those stated that the shortage negatively im pacted the care of their patients. Most common adverse effects included use of broader spectrum antimicrobials (75%), use of more expensive therapy (58%) and use of less effective treatment (45%). We urge the Subcommittee to work with HHS on strategies to limit any worsening of drug shortages that may be caused by the impact of Hurricane Maria.

We look forward to working with you to address the urgent needs of those devastated by recent hurricanes and to strengthen future preparedness efforts. Thank you for your attention to these important issues.


Paul G. Auwaerter, MD, MBA, FIDSA

President, IDSA

Melanie Thompson, MD

Chair, HIVMA

Click here to read the original letter.

Click here for more about the aftermath of the hurricanes in Puerto Rico.