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Introduction
On August 25, 2017, Hurricane Harvey made landfall as a Category 4 hurricane near Corpus Christi, Texas (USA).1–3 Over the next five days, 51 inches of rain – more than 27 trillion gallons – fell in Texas and Louisiana (USA) leading to a 500-year flooding event (ie, a flood with a 1-in-500 chance of occurring in a single year).1,3 Nearly 150,000 residents were forced out of flooded homes, while tens of thousands were stranded by major disruptions due to flooded roadways (which led to more than 30,000 water rescues), and damaged infrastructure that left 336,000 without power.1–3 Hurricane Harvey-associated inland flooding caused significant disruptions in medical care, including among residents with chronic kidney disease.4 Dialysis care requires clean water, access to specialized equipment, and electricity, all of which can be compromised during a natural disaster.5 In the City of Houston (Texas USA) alone, more than 150 hemodialysis centers and 6,700 hemodialysis patients were at risk of negative health outcomes as the result of the storm’s impacts.4
In a non-disaster setting, between five percent and nine percent of US hemodialysis patients miss at least one dialysis session per month. However, after a major hurricane, 44% of hemodialysis patients miss at least one dialysis session.6–9 Missed dialysis sessions have been associated with an increased incidence of mortality, hypertensive emergencies, fluid overload, respiratory failure, electrolyte imbalance, and hospital admissions.7,10–12 In a study of missed dialysis sessions and hospitalizations among 386 hemodialysis patients exposed to Hurricane Katrina (2005),9 17% of hemodialysis patients missed at least three sessions and the percentage of hemodialysis sessions missed after the storm was five-to-seven-times pre-hurricane levels.
Systems related to dialysis treatment were improved in response to Hurricane Katrina, with many dialysis centers making advanced preparations, such as providing early treatment and adding generators to facilities. However, Hurricane Sandy (2012) exposed additional problems with the continuity of care for end stage renal disease (ESRD) patients. During Hurricane Sandy, many dialysis facilities closed in preparation for the storm and remained closed after the storm, which affected much of the Mid-Atlantic and Northeastern US. In some cases, patients received dialysis treatments a day early in anticipation of Hurricane Sandy’s landfall.5 However, dialysis facility closures during...