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\begin{document}

\title{A call for individualized evacuation strategy for floods: a case report
of secondary surgical site infection in a post-surgery breast cancer
patient in Fukushima, Japan, following Typhoon Hagibis in 2019}



\author[1]{Akihiko Ozaki}%
\author[1]{Yoshiaki Kanemoto}%
\author[1]{Masahiro Wada}%
\author[1]{Tomohiro Kurokawa}%
\author[2]{Ayumu Kawamoto}%
\author[1]{Toyoaki Sawano}%
\author[3]{Divya Bhandari}%
\author[4]{Masaharu Tsubokura}%
\author[1]{Tetsuya Tanimoto}%
\author[1]{Tomozo Ejiri}%
\author[1]{Norio Kanzaki}%
\affil[1]{Jyoban Hospital of Tokiwa Foundation}%
\affil[2]{University of Szeged Faculty of Medicine}%
\affil[3]{The University of Tokyo Graduate School of Medicine Faculty of Medicine}%
\affil[4]{Fukushima Medical University School of Medicine}%


\vspace{-1em}



  
  \date{May 20, 2024}


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\selectlanguage{english}
\begin{abstract}
Cancer patients, particularly those post-surgery, are prone to skin
infection following immersion in flood waters. We reported secondary
surgical site infection in a postoperative 80-year-old post-operation
breast cancer patient affected by Typhoon Hagibis. Individualized
responses based on individual and environmental risks are crucial to
alleviate the damage of disasters.%
\end{abstract}%



\sloppy


\textbf{Clinical Case Reports, Case Report}

\textbf{Title:}

A call for individualized evacuation strategy for floods: a case report
of secondary surgical site infection in a post-surgery breast cancer
patient in Fukushima, Japan, following Typhoon Hagibis in 2019

\textbf{Authors:}

Akihiko Ozaki\textsuperscript{1}, Yoshiaki Kanemoto\textsuperscript{2},
Masahiro Wada\textsuperscript{1,3}, Tomohiro
Kurokawa\textsuperscript{2}, Ayumu Kawamoto\textsuperscript{4}, Toyoaki
Sawano\textsuperscript{5,6}, Divya Bhandari\textsuperscript{7}, Masaharu
Tsubokura\textsuperscript{6}, Tetsuya Tanimoto\textsuperscript{8},
Tomozo Ejiri\textsuperscript{2}, Norio Kanzaki\textsuperscript{2}

\textbf{Affiliations:}

\textsuperscript{1} Department of Breast Surgery, Jyoban Hospital of
Tokiwa Foundation, Iwaki, Fukushima, Japan

\textsuperscript{2} Department of Surgery, Jyoban Hospital of Tokiwa
Foundation, Iwaki, Fukushima, Japan

\textsuperscript{3} Department of Breast Surgery, Sano Kosei General
Hospital, Sano, Tochigi, Japan

\textsuperscript{4} Faculty of Medicine, University of Szeged, Szeged,
Hungary

\textsuperscript{5} Department of Surgery,~Sendai City Medical Center,
Sendai Open Hospital, Sendai, Miyagi, Japan.

\textsuperscript{6} Department of Radiation Health Management, Fukushima
Medical University School of Medicine, Iwaki, Fukushima, Japan

\textsuperscript{7} Community and Global Health, Graduate School of
Medicine, the University of Tokyo, Tokyo, Japan

\textsuperscript{8} Department of Internal Medicine, Jyoban Hospital of
Tokiwa Foundation, Iwaki, Fukushima, Japan

\textbf{Corresponding author:}

Akihiko Ozaki, MD, PhD

Department of Breast Surgery, Jyoban Hospital of Tokiwa Foundation, 57
Kaminodai, Jyoban-Kamiyunaga-Yamachi, Iwaki, Fukushima, Japan.

Email address: aozaki-tky@umin.ac.jp.

Telephone: 81-244-22-3181

Fax: 81-244-22---8853

\textbf{Funding:} None available

\textbf{Abstract:}

Cancer patients, particularly those post-surgery, are prone to skin
infection following immersion in flood waters. We reported secondary
surgical site infection in a postoperative 80-year-old post-operation
breast cancer patient affected by Typhoon Hagibis. Individualized
responses based on individual and environmental risks are crucial to
alleviate the damage of disasters.

\textbf{Key words}

Breast Neoplasms; Japan; Climate Change; Cyclonic Storms; Floods

\textbf{Key Clinical Message}

Recognition of Individual and environmental risks is crucial to
alleviate the damage of disasters. In particular, an awareness of the
flood risks in patients' residences is important for patients and their
healthcare professionals.

\textbf{Introduction}

Flood frequency has been increasing globally due to climate
change.\textsuperscript{1} When flood water submerges residential
districts, it is affected by sewage and can easily cause skin infections
in the affected population.\textsuperscript{2} When considering
populations vulnerable to skin infections following flooding, the risk
may be higher in post-surgery cancer patients than the general
population because the immune systems of cancer patients are
suppressed\textsuperscript{3} and they are particularly compromised
after chemotherapy, radiotherapy, or
surgery.\textsuperscript{2}Incisional wounds are especially susceptible
to surgical site infections. However, little information is available
concerning measures to prevent such infections among these populations
following floods.

Typhoon Hagibis, which occurred on October 6, 2019 and landed on Japan's
main island on October 12, 2029, killed approximately one hundred
citizens and caused various other injuries.\textsuperscript{4} These
damages occurred although typhoon warnings had been repeatedly
disseminated in various media outlets beforehand. This typhoon was a
Category 5 (the highest according to the Saffir-Simpson Hurricane Wind
Scale) and was one of few severe disasters that required government
support in its recovery. Given this context, we present a post-operative
breast cancer patient who was affected by flood water caused by Typhoon
Hagibis in order to plan specific measures to ensure the safety of
cancer patients from flood damage in the future.

\textbf{Case description}

An 80-year old patient living with her son-in-law and grandson in Iwaki
City, Fukushima, with chronic renal diseases of unknown cause, found a
lump on the top of her right nipple and initially visited her primary
physician in March 2019. She was then referred to our breast surgery
outpatient office on June 17, 2019 after several consultation
cancellations. An in-depth diagnostic workup confirmed cancer of the
right breast with anatomical clinical stage of cT2N0M0 StageIIA. We
carried out mastectomy, sentinel lymph node biopsy with a positive lymph
node metastasis, and subsequent axillary resection on September 25,
2019. The postoperative condition was stable, and she was discharged on
October 11, 2019, which was the day before Typhoon Hagibis hit Iwaki
City (post-operative day 16). Although she was advised to stay in the
hospital until the typhoon passed by the city, she insisted on discharge
that day.

At midnight on October 12, 2019, the typhoon heavily hit the city and
destroyed 5,927 residences and 3,111 non-residential buildings,
submerged 5,721 buildings, and killed 12 people. Her single-story
residence was located 13 meters above sea level and only 100 meters away
from the embarkments running along the Natsui River. The flood hazard
map that estimates areas that would be submerged by floods with a scale
of once in one thousand years is open access on the municipality website
and clearly showed that her residence would become submerged up to 5 to
10 meters high due to overflow of the nearby Natui River. This occurred
because the typhoon destroyed several of the river's embarkments at
12:30am on October 13, 2019. While Iwaki City issued an evacuation order
for those living around the river at 9:40pm on October 12, 2019, she
reportedly did not evacuate from her residence because she was not aware
of that warning. The flood water submerged her residence soon after the
destruction of embarkments when she was asleep. The water level rapidly
reached approximately two meters high, and she managed to survive by
climbing on furniture her son-in-law piled up for her. Despite her
efforts to cover her wound, it was immersed by contaminated flood water.
The water smelled rotten, probably because of sewage that overflowed
from the sewers, given that scattered manhole covers were observed
around her residence the next day.

On October 13, 2019, she complained of appetite loss and visited our
emergency department the next day (October 14, 2019). On physical
examination, she was afebrile and her surgical site was not apparently
infected, but she was hospitalized due to appetite loss and destruction
of her residence. After admission, her surgical site gradually became
red, swollen, and edematous, highly suggestive of secondary infection.
On October 16, we inserted a drainage tube into the surgical wound and
started administration of cefazolin 1g three times per day. We failed to
take a culture of the fluid sample. Further discussion revealed that she
had not carefully read the flood hazard map before the typhoon. Her
condition gradually improved and she was discharged on November 5, 2019.
After discharge, she abandoned her original residence because of
persistent smells and moved to a nearby apartment building following
several relocations.

\textbf{Discussion}

This case describes a skin infection in a postoperative breast cancer
patient due to an immersion of surgical site with contaminated flood
water following Typhoon Hagibis. Her discharge took place on the day
before the typhoon hit Iwaki City, and she had characteristics that
would make her vulnerable to floods, such as advanced age, breast
cancer, and post-operative status. In this regard, we believe that there
might have been some room for interventions to prevent her from
incurring such severe flood damage.

Of note, a flood hazard map covering areas that would be submerged in
floods was open access and widely available in Iwaki City. In Japan,
local municipalities usually publish flood hazard maps on its website
and on paper for community distribution. Further, the Geospatial
Information Authority in Japan, similar to the Federal Emergency
Management Agency in the United States and Ministry of Environment in
France, prepares a website called ``\emph{Kasaneru (Superimposing)
Hazard Map} {[}in Japanese{]}'' where people can freely evaluate risks
of flooding and landslides in basically any location in Japan. According
to a municipality-based hazard map, her neighborhood was designated as a
flood-prone area, while the hospital was not. Following Typhoon Hagibis,
the patient's neighbors were all affected by flooding, but the hospital
only incurred minor ceiling water leakage.

If we healthcare professionals had understood the information from the
flood hazard map beforehand, we could have given her more appropriate
advice when she wished to be discharged the day before the typhoon hit
the city. Specifically, we could have more strongly persuaded her to
stay at the hospital to prevent potential harm. Further, even when she
declined our suggestion, we could have alternatively advised her to
evacuate to residences of family members or friends living outside the
flooding areas. Needless to say, some medical institutions exist in
flood-prone areas, and this approach cannot always be generalizable.

For all residents including cancer patients, as is a lesson from this
case, it is important to know whether their residences are located in
flood-prone areas in ordinary times, but this may not be enough to
guarantee a safe evacuation in situations when flood damage is
anticipated. People are easily affected by normalcy bias, which is a
tendency to consider that they themselves will not be affected by
disasters or crises.\textsuperscript{5,6} In this regard, it is unclear
whether people can successfully evacuate just because they were aware of
the warning in a timely fashion. Rather, they may have been affected by
normalcy bias, and somehow considered that they would not be affected by
the flood. It is not always easy to overcome normalcy bias, but informal
and formal support and ordinary-time preparedness would help people
avoid this inherent mental tendency.\textsuperscript{6}

Every natural disaster including and beyond flood is unique. In this
respect, lessons gained from one disaster are not directly applicable to
another. For instance, dozens of people died in floodwater in Kumamoto,
Japan in July 2020. The damage was not caused by typhoons, but by a
seasonal rain front, and it was obviously more difficult to predict the
occurrence, timing, and potential locations than those of typhoons.
Nonetheless, our ongoing mission is a continuous accumulation of
evidence of any kind of health issue related to flooding to establish
effective countermeasures to safeguard the health and well-being of
cancer patients and other citizens.

In conclusion, we reported a case of secondary surgical site infection
in a postoperative breast cancer patient affected by Typhoon Hagibis.
Individualized responses based on individual and environmental risks are
crucial to alleviate damage from disasters. In particular, an awareness
of flood risks in patients' residences are important for patients and
their healthcare professionals.

\textbf{Conflict of interest} : Akihiko Ozaki receives personal fees
from MNES Inc, outside the submitted work. Also, Tetuya Tanimoto
receives personal fees from MNES Inc, and Bionics co., ltd. outside the
submitted work.

\textbf{Ethical approval} : Written informed consent was obtained from
the patient for publication of this case report and any accompanying
images.

\textbf{Funding information:} None

\textbf{Acknowledgements:} None

\textbf{Author Contribution:} AO wrote the manuscript. All authors
conceptualized and designed the case report, and revised the paper. All
authors read and approved the final manuscript.

References

1. Hirabayashi Y, Mahendran R, Koirala S, et al. Global flood risk under
climate change. Nature Climate Change 2013;3:816-21.

2. Alderman K, Turner LR, Tong S. Floods and human health: a systematic
review. Environ Int 2012;47:37-47.

3. Whiteside TL. Immune suppression in cancer: effects on immune cells,
mechanisms and future therapeutic intervention. Semin Cancer Biol
2006;16:3-15.

4. Ozaki A, Kanemoto Y, Morita T, et al. Nail Wound and Cellulitis
Following Typhoon Hagibis in Fukushima, Japan. Disaster Med Public
Health Prep 2020:1-3.

5. Ozaki A, Leppold C, Sawano T, et al. Social isolation and cancer
management - advanced rectal cancer with patient delay following the
2011 triple disaster in Fukushima, Japan: a case report. J Med Case Rep
2017;11:138.

6. Ozaki A, Leppold C, Tsubokura M, et al. Social isolation and cancer
management after the 2011 triple disaster in Fukushima, Japan: A case
report of breast cancer with patient and provider delay. Medicine
(Baltimore) 2016;95:e4027.

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