Puerto Rico Department Of Health Research Articles

1790. Characteristics of Patients with Mpox Treated with Tecovirimat during the 2022 Outbreak in Puerto Rico

Abstract Background In June 2022, the first case of Mpox, was diagnosed in Puerto Rico, followed by a sharp increase in cases that peaked in August 2022. In total, 108 cases were confirmed during this period. Throughout this time period, Tecovirimat (Tpoxx) was already available upon request to the Puerto Rico Department of Health (PRDoH). In this report we aim to describe the clinical characteristics and outcomes of all the patients in Puerto Rico who received Tecovirimat. Methods A cross sectional study was conducted to describe clinical and epidemiological profile of Mpox patients who received Tecovirimat. We use the data collected from our institution (PRDoH), who was responsible for the approval, delivery and monitoring of Tecovirimat prescription during the outbreak. The analysis period ranges from August 2022 to November 2022. Univariate analysis was conducted, including the median and percentage, to provide a summary of the distribution of the variables of interest. Results We present the clinical characteristics of 27 male patients who received Tecovirimat for a diagnosis of Mpox during the outbreak in Puerto Rico. Most patients were treated during August and September (85%), followed by October and November 2022 (15%). Most received treatment in outpatient settings at private clinics (63%) followed by government clinics (37%). Of the patients that required Tecovirimat, 67% had human immunodeficiency virus (HIV) and the median age was 32 years. Prior immunization with smallpox vaccine was reported by two patients, while 70% were not immunized and the immunization status of 22% was unknown. The most common indications for Tecovirimat prescription were genital structure involvement (67%), severe pain (37%), oral cavity involvement (22%), proctitis (19%), and immunosuppression (11%). Only two patients received Tecovirimat while admitted to an acute care setting. No severe adverse events or deaths were reported among these patients, and there were no suspected cases of Tecovirimat resistance. Conclusion This study provides relevant clinical information on the use of Tecovirimat in patients with Mpox during the outbreak in Puerto Rico. These findings may have important implications for the clinical management of future outbreaks of Mpox and other related infections. Disclosures Iris Cardona Gerena, MD, Valneva: Honoraria

Abstract A096: Stakeholders’ perceptions on the impact of the COVID-19 pandemic on the implementation of the HPV vaccine school-entry requirement in Puerto Rico

Abstract Background: The human papillomavirus (HPV) vaccine is a cancer prevention tool, yet vaccination coverage among adolescents remains suboptimal in the United States. Research shows significant disparate incidence and mortality rates of HPV-related cancers in Puerto Rico (PR). In 2018, the PR Department of Health (DOH) enacted an HPV vaccine school-entry requirement for adolescents 11 to 12 years old, and on August 2020 extended the requirement to include adolescents up to 16 years old. Amid the COVID-19 pandemic in the US, during March-August 2020, national data showed that HPV vaccine uptake rates decreased about 75%. Public health measures, such as stay-at-home orders, may have caused this decline by limiting access to preventive services. Our study explored, using a qualitative assessment, the impact of the COVID-19 pandemic on the implementation of the HPV vaccine school-entry requirement in PR. Methods: We conducted 26 interviews with stakeholders from schools, DOH employees, Department of education staff, health providers, and community-based organizations from 08/2021-03/2022. Interviews were recorded and transcribed in Spanish. Data were analyzed using applied thematic techniques by two trained coders using Atlas-ti 8. We discussed eight of these interviews among the team to identify major barriers related to the HPV school-entry implementation during the pandemic. Results: Our analysis identified the following preliminary emergent themes including: (1) lockdown limitations and access barriers to the vaccine and (2) shifting immunization priorities. Most participants noted that the March 2020 lockdown limited parents’ ability to get their kids vaccinated and for schools to monitor the vaccine requirements; however, as vaccination centers and schools re-opened, gradually, vaccination processes increased. Participants described how during the pandemic, public health agencies prioritized the COVID-19 vaccine missing other vaccines that are required for school-entry, including the HPV vaccine. Discussion: Continuation of the implementation of the HPV vaccine school-entry requirement was challenging during early stages of the pandemic due to public health measures enacted to stop the spread of COVID-19. Moreover, once the COVID-19 vaccine was available, public heath vaccination priorities shifted. Nonetheless these barriers, efforts to increase HPV vaccine to pre-pandemic rates should continue, including providing educational support to parents, increase vaccine promotion, and creating community collaborations. As new guidelines recommend COVID-19 boosters, for everyone ages 5 years and older, this opportunity could serve to vaccinate against HPV as part of the bundling implementation of the HPV vaccine school-entry requirement. Citation Format: Coralia Vázquez-Otero, Diana T. Medina-Laabes, Derick Pérez-Guzmán, Olga L. Díaz-Miranda, VOCES PR, Vivian Colón-Lopez. Stakeholders’ perceptions on the impact of the COVID-19 pandemic on the implementation of the HPV vaccine school-entry requirement in Puerto Rico [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr A096.

Abstract D072: Challenges providing gynecologic cancer care for women in Puerto Rico after the impact of Hurricanes Irma and Maria: Findings from key informant interviews

Abstract Introduction: Cancer patients are among the most vulnerable populations in the aftermath of natural disasters. Proper delivery and continuity of cancer care is a top priority of medical management after a disaster. On September 2017, Hurricanes Irma and María impacted Puerto Rico (PR), causing major disruption in essential services. Using key informant (KI) interviews, this study documents the experiences and responses of providers/organizations involved in the delivery of gynecologic oncology care in PR. Methods: We conducted 23 KI interviews from organizations in different parts of the island. KIs included providers (gynecologist oncologists, hematologist oncologists, surgeons, radiologists, oncologists, obstetrics and gynecologists), nonprofit organizations (vice-presidents and personnel of the American Cancer Society [ACS] of PR), cancer care facilities (vice-presidents and personnel of public and private hospitals and clinics), and government agencies (Auxiliary Secretary of the PR Department of Health and Government personnel). The interviews addressed problems encountered in their clinics/organizations in the aftermath of the hurricanes, perceived stressors and risks of patients, and recommendations for future preparedness efforts. Results: All clinics/organizations took some preparedness measures but did not have an updated emergency protocol to follow. Most of the physicians prepared by protecting the clinics and calling patients to reschedule surgeries and follow-up visits. All KIs experienced in their clinics/organizations disruption of telecommunications; potable water, and electric power after the hurricanes. They confronted challenges in finding essential supplies like fuel for electricity generators, oxygen, and chemotherapy drugs. The oncologists implemented an emergency collaboration network to share services, medical supplies, and other essential medications needed for the care of patients. Some of them expressed that treatments, such as radiotherapy, were delayed because the equipment required a stable source of energy and cooling temperatures. Organizations such the ACS helped moved patients to the United States so that they did not have to interrupt their cancer treatment; many of these patients had to come back as they were not able to get services there. Even the largest hospitals in PR, including those in the most populous cities, confronted serious problems of communication with the government and FEMA. Conclusion: Although interruptions and delays in services occurred, all the KIs interviewed mentioned to have given the best effort to try to prevent patients from interrupting their treatment. One of the biggest obstacles to provide oncology treatment was the lack of effective communication between agencies. These results guided the topic areas that will be assessed in the subsequent quantitative phase of this NCI sponsored project, and the development of a disaster management plan for cancer patients in PR. NCI Grant #R21CA239457. Citation Format: Sandra I. García-Camacho, Mirza Rivera, William Calo, Pablo Mendez, Guillermo Tortolero-Luna, Yanina Bernhardt-Utz, Astrid Diaz-Quiñones, Vanessa Patricia Gomez-Vargas, Sharee Umpierre-Catinchi, Istoni DaLuz-Santana, Ana Ortiz. Challenges providing gynecologic cancer care for women in Puerto Rico after the impact of Hurricanes Irma and Maria: Findings from key informant interviews [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr D072.

Using the Collaborative Requirements Development Methodology to Build Laboratory Capacity for Timely Diagnosis During the Zika Epidemic in Puerto Rico.

In 2016, Puerto Rico became the focal point of the Zika epidemic, with more than 36 000 laboratory-confirmed cases before August. The Puerto Rico Department of Health (PRDH) responded by providing tests to symptomatic and asymptomatic pregnant women. The increased demand for Zika testing placed unprecedented strain on the laboratory capacity and information management processes used within the PRDH. The PRDH recognized the need to have an updated informatics system that securely manages, stores, and transmits digital data. The Centers for Disease Control and Prevention funded the Public Health Informatics Institute to collaborate with the PRDH to assess and improve the informatics capability to respond to the ongoing Zika virus transmission in Puerto Rico. The team employed a 4-component approach to assess the informatics system and improve the information management processes for laboratory testing and reporting of arboviral diseases (Zika, chikungunya, and dengue). The method consisted of a (1) needs assessment, (2) business process analysis and requirements definition, (3) vendor analysis, and (4) solution implementation. The needs assessment determined that the PRDH's procedures for arbovirus testing and reporting were highly complex and paper-based and thus did not maximize the use of existing technology. The solution was to build a Web portal. The business process analysis yielded information to create a map of the flow of specimens, an arbovirus context diagram, and more than 200 requirements. The requirements identified in this process guided the design and creation of the Web portal. This report describes the process to build a Web portal to enhance laboratory testing and electronic reporting of Zika cases during the 2016 epidemic in Puerto Rico. We demonstrate the utility of applying the Collaborative Requirements Development Methodology, a proven informatics method, to the development of a Web portal for managing arboviruses in a health department.

Promoting Compliance with Regulations that Support BF Initiation in the Hospital's Settings

NEED: Promote compliance with local Regulations that Support BF Initiation in the Hospital's Settings to increase ever-breastfed prevalence Method: Administrative Order336, approved on March 2015, requires hospitals in Puerto Rico(PR) to adopt some of the baby friendly steps that support breastfeeding (BF) initiation in the hospital so as to receive certification to operate from the PR Department of Health(DOH). The implementations of these steps are recommended as best practices proven to help improve BF initiation in the hospital setting. This Order …

Initial Public Health Laboratory Response After Hurricane Maria - Puerto Rico, 2017.

Hurricane Maria made landfall in Puerto Rico on September 20, 2017, causing major damage to infrastructure and severely limiting access to potable water, electric power, transportation, and communications. Public services that were affected included operations of the Puerto Rico Department of Health (PRDOH), which provides critical laboratory testing and surveillance for diseases and other health hazards. PRDOH requested assistance from CDC for the restoration of laboratory infrastructure, surveillance capacity, and diagnostic testing for selected priority diseases, including influenza, rabies, leptospirosis, salmonellosis, and tuberculosis. PRDOH, CDC, and the Association of Public Health Laboratories (APHL) collaborated to conduct rapid needs assessments and, with assistance from the CDC Foundation, implement a temporary transport system for shipping samples from Puerto Rico to the continental United States for surveillance and diagnostic and confirmatory testing. This report describes the initial laboratory emergency response and engagement efforts among federal, state, and nongovernmental partners to reestablish public health laboratory services severely affected by Hurricane Maria. The implementation of a sample transport system allowed Puerto Rico to reinitiate priority infectious disease surveillance and laboratory testing for patient and public health interventions, while awaiting the rebuilding and reinstatement of PRDOH laboratory services.

Abstract C03: Randomized controlled trial to increase anal cancer clinical trial recruitment among persons living with HIV/AIDS in Puerto Rico: Methodology and baseline assessment

Abstract Introduction: Anal cancer is more frequent among people living with HIV/AIDS (PLWHA), with incidence rates increasing among PLWHA despite effective HIV treatments. This highlights the need for effective anal cancer screening guidelines. As part of the development of such guidelines for anal cancer prevention, participation and retention in clinical trials (CT) is pivotal. Previous studies showed lower participation of Hispanics in cancer-related CT among PLWHA. We are conducting a randomized controlled trial (RCT) aimed to test the effectiveness of an educational intervention in recruiting PLWHA in one of the anal cancer-related CT of the AIDS Malignancy Consortium (AMC) being conducted in Puerto Rico (PR), the Anal Cancer Prevention Study (ANCHOR). This work describes the methodology of this study and baseline characteristics of study participants. Methods: A collaboration in the development of an educational linear video for anal cancer was conducted in 2015 between UC Davis Comprehensive Cancer Center and the University of Puerto Rico (UPR) Comprehensive Cancer Center. As a result, a RCT is being conducted at the 9 immunology/STI clinics of the PR Department of Health, to test the effectiveness of this audiovisual intervention in increasing: (1) HIV/AIDS patients' knowledge of anal cancer and CT; (2) favorable attitudes towards CT; and (3) willingness to participate in ANCHOR, a CT aimed to developing anal cancer screening and treatment guidelines for PLWHA. Our RCT is expected to recruit 308 PLWHA aged ≤ 35 years, that receive HIV care at these clinics, and that have not participated in any cancer CT or have been diagnosed with any cancer type in their lifetime. The randomization of this study is at the clinic level, in which we randomly allocated each clinic to either: the intervention group (receiving the audiovisual educational intervention focused on CT and anal cancer screening) or the control group (receiving a standard CT recruitment education). Participants who agree to participate complete an informed consent, a baseline survey, and an initial contact survey through a face-to-face computer-based interview. Participants are followed-up at 2-weeks (by phone) and 3-months (at the clinic) in order to assess changes in willingness to participate in anal cancer CT and to determine if the participant has called, been screened, or been enrolled into an AMC CT. Results: As of Mid-June 2016, 134 patients had been screened, 125 (93%) PLWHA were eligible, and 124 of them (99%) agreed to participate in the study. Of the recruited participants, the mean age was 55±10 years, 60% were men, 56% had ≤12 years of education, and 96% had an annual family income ≤ $35,000. Close to half (44%) of the participants reported never having heard about CT, while most (84%) could not correctly identify the definition of a CT. Although 98% of participants thought that participating in an anal cancer CT could be beneficial for their health, 91% had never heard of a high-resolution anoscopy (HRA) and 26% were not interested in participating in a CT that used HRA. Among those not interested in participating in a CT that used HRA, the most common reasons reported were: lack of information provided about the study (87%), and fear to the procedure (6%). Conclusions: Preliminary data at the baseline interview showed a high willingness of PLWHA to participate in anal cancer CT; however, there is a lack of knowledge about anal cancer CT and CT in general. The methodology developed as well as the information obtained will be necessary to develop specific strategies to increase knowledge and awareness about anal cancer and anal cancer CT among PLWHA and promote the advance of RCT for cancer prevention among PLWHA. Citation Format: Vivian Colon-Lopez, Omar Valentin-Rivera, Marievelisse Soto-Salgado, Darilyn Rivera, Julie H. Dang, DA Letran, Moon Jr Chen, Ana Patricia Ortiz. Randomized controlled trial to increase anal cancer clinical trial recruitment among persons living with HIV/AIDS in Puerto Rico: Methodology and baseline assessment. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr C03.

Human Rabies — Puerto Rico, 2015

On December 1, 2015, the Puerto Rico Department of Health (PRDH) was notified by a local hospital of a suspected human rabies case. The previous evening, a Puerto Rican man aged 54 years arrived at the emergency department with fever, difficulty swallowing, hand paresthesia, cough, and chest tightness. The next morning the patient left against medical advice but returned to the emergency department in the afternoon with worsening symptoms. The patient's wife reported that he had been bitten by a mongoose during the first week of October, but had not sought care for the bite. While being transferred to the intensive care unit, the patient went into cardiac arrest and died. On December 3, rabies was confirmed from specimens collected during autopsy. PRDH conducted an initial rapid risk assessment, and five family members were started on rabies postexposure prophylaxis (PEP).

Incidence of Zika Virus Disease by Age and Sex - Puerto Rico, November 1, 2015-October 20, 2016.

Zika virus is a flavivirus transmitted primarily by Aedes species mosquitoes; symptoms of infection include rash, arthralgia, fever, and conjunctivitis.*,† Zika virus infection during pregnancy can cause microcephaly and other serious brain anomalies (1), and in rare cases, Zika virus infection has been associated with Guillain-Barré syndrome (2) and severe thrombocytopenia (3). This report describes the incidence of reported symptomatic Zika virus disease in the U.S. territory of Puerto Rico by age and sex. During November 1, 2015-October 20, 2016, 62,500 suspected Zika virus disease cases were reported to the Puerto Rico Department of Health (PRDH); 29,345 (47%) were confirmed by reverse transcription-polymerase chain reaction (RT-PCR) testing, or were presumptively diagnosed based on serological testing. The highest incidence among confirmed or presumptive cases occurred among persons aged 20-29 years (1,150 cases per 100,000 residents). Among 28,219 (96.2%) nonpregnant patients with confirmed or presumptive Zika virus disease, incidence was higher among women (936 per 100,000 population) than men (576 per 100,000) for all age groups ≥20 years, and the majority (61%) of reported Zika virus disease cases occurred in females. Among suspected Zika virus disease cases in nonpregnant adults aged ≥40 years, the percentage that tested positive among females (52%) was higher than that among males (47%) (p<0.01). Reasons for the higher incidence of Zika virus disease among women aged ≥20 years are not known; serosurveys of persons living near confirmed Zika virus disease cases might help to elucidate these findings. Residents of and travelers to Puerto Rico should remove or cover standing water, practice mosquito abatement, employ mosquito bite avoidance behaviors, take precautions to reduce the risk for sexual transmission, and seek medical care for any acute illness with rash or fever.

Use of Household Cluster Investigations to Identify Factors Associated with Chikungunya Virus Infection and Frequency of Case Reporting in Puerto Rico.

BackgroundChikungunya virus (CHIKV) is transmitted by Aedes species mosquitoes and is the cause of an acute febrile illness characterized by potentially debilitating arthralgia. After emerging in the Caribbean in late 2013, the first locally-acquired case reported to public health authorities in Puerto Rico occurred in May 2014. During June–August 2014, household-based cluster investigations were conducted to identify factors associated with infection, development of disease, and case reporting.Methodology/Principal FindingsResidents of households within a 50-meter radius of the residence of laboratory-positive chikungunya cases that had been reported to Puerto Rico Department of Health (PRDH) were offered participation in the investigation. Participants provided a serum specimen and answered a questionnaire that collected information on demographic factors, household characteristics, recent illnesses, healthcare seeking behaviors, and clinical diagnoses. Current CHIKV infection was identified by rRT-PCR, and recent CHIKV infection was defined by detection of either anti-CHIKV IgM or IgG antibody. Among 250 participants, 74 (30%) had evidence of CHIKV infection, including 12 (5%) with current and 62 (25%) with recent CHIKV infection. All specimens from patients with CHIKV infection that were collected within four days, two weeks, and three weeks of illness onset were positive by RT-PCR, IgM ELISA, and IgG ELISA, respectively. Reporting an acute illness in the prior three months was strongly associated with CHIKV infection (adjusted odds ratio [aOR] = 21.6, 95% confidence interval [CI]: 9.24–50.3). Use of air conditioning (aOR = 0.50, 95% CI = 0.3–0.9) and citronella candles (aOR = 0.4, 95% CI = 0.1–0.9) were associated with protection from CHIKV infection. Multivariable analysis indicated that arthralgia (aOR = 51.8, 95% CI = 3.8–700.8) and skin rash (aOR = 14.2, 95% CI = 2.4–84.7) were strongly associated with CHIKV infection. Hierarchical cluster analysis of signs and symptoms reported by CHIKV-infected participants demonstrated that fever, arthralgia, myalgia, headache, and chills tended to occur simultaneously. Rate of symptomatic CHIKV infection (defined by arthralgia with fever or skin rash) was 62.5%. Excluding index case-patients, 22 (63%) participants with symptomatic CHIKV infection sought medical care, of which 5 (23%) were diagnosed with chikungunya and 2 (9%) were reported to PRDH.Conclusions/SignificanceThis investigation revealed high rates of CHIKV infection among household members and neighbors of chikungunya patients, and that behavioral interventions such as use of air conditioning were associated with prevention of CHIKV infection. Nearly two-thirds of patients with symptomatic CHIKV infection sought medical care, of which less than one-quarter were reportedly diagnosed with chikungunya and one-in-ten were reported to public health authorities. These findings emphasize the need for point-of-care rapid diagnostic tests to optimize identification and reporting of chikungunya patients.

Guillain-Barré Syndrome During Ongoing Zika Virus Transmission - Puerto Rico, January 1-July 31, 2016.

Guillain-Barré syndrome (GBS) is a postinfectious autoimmune disorder characterized by bilateral flaccid limb weakness attributable to peripheral nerve damage (1). Increased GBS incidence has been reported in countries with local transmission of Zika virus, a flavivirus transmitted primarily by certain Aedes species mosquitoes (2). In Puerto Rico, three arthropod-borne viruses (arboviruses) are currently circulating: Zika, dengue, and chikungunya. The first locally acquired Zika virus infection in Puerto Rico was reported in December 2015 (3). In February 2016, the Puerto Rico Department of Health (PRDH), with assistance from CDC, implemented the GBS Passive Surveillance System (GBPSS) to identify new cases of suspected GBS (4). Fifty-six suspected cases of GBS with onset of neurologic signs during January 1-July 31, 2016, were identified. Thirty-four (61%) patients had evidence of Zika virus or flavivirus infection; the median age of these patients was 55 years (range=21-88 years), and 20 (59%) patients were female. These 34 patients were residents of seven of eight PRDH public health regions. All 34 patients were hospitalized and treated with intravenous immunoglobulin G (IVIg), the standard treatment for GBS; 21 (62%) required intensive care unit admission, including 12 (35%) who required endotracheal intubation and mechanical ventilation. One patient died of septic shock after treatment for GBS. Additionally, 26 cases of neurologic conditions other than GBS were reported through GBPSS, including seven (27%) in patients with evidence of Zika virus or flavivirus infection. Residents of and travelers to Puerto Rico and countries with active Zika virus transmission should follow recommendations for prevention of Zika virus infections.* Persons with signs or symptoms consistent with GBS should promptly seek medical attention. Health care providers in areas with ongoing local transmission seeing patients with neurologic illnesses should consider GBS and report suspected cases to public health authorities.

Update: Ongoing Zika Virus Transmission - Puerto Rico, November 1, 2015-July 7, 2016.

Zika virus is a flavivirus transmitted primarily by Aedes aegypti and Aedes albopictus mosquitoes, and infection can be asymptomatic or result in an acute febrile illness with rash (1). Zika virus infection during pregnancy is a cause of microcephaly and other severe birth defects (2). Infection has also been associated with Guillain-Barré syndrome (GBS) (3) and severe thrombocytopenia (4,5). In December 2015, the Puerto Rico Department of Health (PRDH) reported the first locally acquired case of Zika virus infection. This report provides an update to the epidemiology of and public health response to ongoing Zika virus transmission in Puerto Rico (6,7). A confirmed case of Zika virus infection is defined as a positive result for Zika virus testing by reverse transcription-polymerase chain reaction (RT-PCR) for Zika virus in a blood or urine specimen. A presumptive case is defined as a positive result by Zika virus immunoglobulin M (IgM) enzyme-linked immunosorbent assay (MAC-ELISA)* and a negative result by dengue virus IgM ELISA, or a positive test result by Zika IgM MAC-ELISA in a pregnant woman. An unspecified flavivirus case is defined as positive or equivocal results for both Zika and dengue virus by IgM ELISA. During November 1, 2015-July 7, 2016, a total of 23,487 persons were evaluated by PRDH and CDC Dengue Branch for Zika virus infection, including asymptomatic pregnant women and persons with signs or symptoms consistent with Zika virus disease or suspected GBS; 5,582 (24%) confirmed and presumptive Zika virus cases were identified. Persons with Zika virus infection were residents of 77 (99%) of Puerto Rico's 78 municipalities. During 2016, the percentage of positive Zika virus infection cases among symptomatic males and nonpregnant females who were tested increased from 14% in February to 64% in June. Among 9,343 pregnant women tested, 672 had confirmed or presumptive Zika virus infection, including 441 (66%) symptomatic women and 231 (34%) asymptomatic women. One patient died after developing severe thrombocytopenia (4). Evidence of Zika virus infection or recent unspecified flavivirus infection was detected in 21 patients with confirmed GBS. The widespread outbreak and accelerating increase in the number of cases in Puerto Rico warrants intensified vector control and personal protective behaviors to prevent new infections, particularly among pregnant women.

Update: Ongoing Zika Virus Transmission - Puerto Rico, November 1, 2015-April 14, 2016.

Zika virus is a flavivirus transmitted primarily by Aedes species mosquitoes, and symptoms of infection can include rash, fever, arthralgia, and conjunctivitis (1).* Zika virus infection during pregnancy is a cause of microcephaly and other severe brain defects (2). Infection has also been associated with Guillain-Barré syndrome (3). In December 2015, Puerto Rico became the first U.S. jurisdiction to report local transmission of Zika virus, with the index patient reporting symptom onset on November 23, 2015 (4). This report provides an update to the epidemiology of and public health response to ongoing Zika virus transmission in Puerto Rico. During November 1, 2015-April 14, 2016, a total of 6,157 specimens from suspected Zika virus-infected patients were evaluated by the Puerto Rico Department of Health (PRDH) and CDC Dengue Branch (which is located in San Juan, Puerto Rico), and 683 (11%) had laboratory evidence of current or recent Zika virus infection by one or more tests: reverse transcription-polymerase chain reaction (RT-PCR) or immunoglobulin M (IgM) enzyme-linked immunosorbent assay (ELISA). Zika virus-infected patients resided in 50 (64%) of 78 municipalities in Puerto Rico. Median age was 34 years (range=35 days-89 years). The most frequently reported signs and symptoms were rash (74%), myalgia (68%), headache (63%), fever (63%), and arthralgia (63%). There were 65 (10%) symptomatic pregnant women who tested positive by RT-PCR or IgM ELISA. A total of 17 (2%) patients required hospitalization, including 5 (1%) patients with suspected Guillain-Barré syndrome. One (<1%) patient died after developing severe thrombocytopenia. The public health response to the outbreak has included increased laboratory capacity to test for Zika virus infection (including blood donor screening), implementation of enhanced surveillance systems, and prevention activities focused on pregnant women. Vector control activities include indoor and outdoor residual spraying and reduction of mosquito breeding environments focused around pregnant women's homes. Residents of and travelers to Puerto Rico should continue to employ mosquito bite avoidance behaviors, take precautions to reduce the risk for sexual transmission (5), and seek medical care for any acute illness with rash or fever.

Chikungunya Cases Identified Through Passive Surveillance and Household Investigations—Puerto Rico, May 5-August 12, 2014

Chikungunya and dengue are mosquito-borne, viral, acute febrile illnesses that can be difficult to distinguish clinically. Whereas dengue is endemic in many countries in the Caribbean and the Americas, the first locally acquired chikungunya case in the Western Hemisphere was reported from the Caribbean island of St. Martin in December 2013 and was soon followed by cases in many parts of the region. In January 2014, the Puerto Rico Department of Health (PRDH) and CDC initiated chikungunya surveillance by building on an existing passive dengue surveillance system. To assess the extent of chikungunya in Puerto Rico, the severity of illnesses, and the health care-seeking behaviors of residents, PRDH and CDC analyzed data from passive surveillance and investigations conducted around the households of laboratory-positive chikungunya patients. Passive surveillance indicated that the first locally acquired, laboratory-positive chikungunya case in Puerto Rico was in a patient with illness onset on May 5, 2014. By August 12, a total of 10,201 suspected chikungunya cases (282 per 100,000 residents) had been reported. Specimens from 2,910 suspected cases were tested, and 1,975 (68%) were positive for chikungunya virus (CHIKV) infection. Four deaths were reported. The household investigations found that, of 250 participants, 70 (28%) tested positive for current or recent CHIKV infection, including 59 (84%) who reported illness within the preceding 3 months. Of 25 laboratory-positive participants that sought medical care, five (20%) were diagnosed with chikungunya and two (8%) were reported to PRDH. These investigative efforts indicated that chikungunya cases were underrecognized and underreported, prompting PRDH to conduct information campaigns to increase knowledge of the disease among health care professionals and the public. PRDH and CDC recommended that health care providers manage suspected chikungunya cases as they do dengue because of the similarities in symptoms and increased risk for complications in dengue patients that are not appropriately managed. Residents of and travelers to the tropics can minimize their risk for both chikungunya and dengue by taking standard measures to avoid mosquito bites.

Detection of West Nile Virus in Blood Donations—Puerto Rico, 2007

In the United States, West Nile virus (WNV) was first detected in humans in 1999; it subsequently spread to countries of Central and South America and the Caribbean. WNV is a mosquito-borne virus that produces potentially serious clinical disease, particularly among persons aged > or =50 years. Transmission by routes other than mosquito bites, including blood transfusion, transplacental infection, organ transplant, and possibly breast milk, also have been reported. On July 19, 2007, the American Red Cross in Puerto Rico notified the Puerto Rico Department of Health (PRDH) of three persons whose blood donations were positive for WNV by nucleic acid-amplification test (NAT) screening. These three donors had the first confirmed human WNV infections detected in Puerto Rico. In response, PRDH and CDC conducted in-depth interviews of the blood donors. This report describes these human infections and other recent surveillance for transmission of WNV in Puerto Rico. Detection of WNV infections in human blood donors indicates that heightened clinician awareness, ongoing surveillance, and educational activities are needed to monitor and assess the public health threat posed by WNV in Puerto Rico.

From the Center of Disease Control and Prevention. Pregnancy in perinatally HIV-infected adolescents and young adults--Puerto Rico, 2002.

Since the introduction of highly active antiretroviral (ARV) therapy in the United States in the mid-1990s the life expectancy of U.S. children who were infected perinatally with human immunodeficiency virus (HIV) has increased substantially. As a result the number of perinatally HIV-infected females in the United States who are becoming both sexually active and pregnant is increasing. During August 1998– May 2002 a total of 10 pregnancies were identified among eight perinatally HIV-infected adolescents and young adults in Puerto Rico; in April 2002 the Puerto Rico Department of Health (PRDOH) asked CDC to assist in assessing such pregnancies. This report describes these pregnancies and discusses factors associated with sexual activity and pregnancy. The findings suggest that increasing numbers of pregnancies will occur among perinatally HIV-infected adolescents and young adults and that appropriately tailored reproductive health interventions should be developed. (excerpt)

Pregnancy in Perinatally HIV-Infected Adolescents and Young Adults-Puerto Rico, 2002

Since the introduction of highly active antiretroviral (ARV) therapy in the United States in the mid-1990s, the life expectancy of U.S. children who were infected perinatally with human immunodeficiency virus (HIV) has increased substantially. As a result, the number of perinatally HIV-infected females in the United States who are becoming both sexually active and pregnant is increasing. During August 1998-May 2002, a total of 10 pregnancies were identified among eight perinatally HIV-infected adolescents and young adults in Puerto Rico; in April 2002, the Puerto Rico Department of Health (PRDOH) asked CDC to assist in assessing such pregnancies. This report describes these pregnancies and discusses factors associated with sexual activity and pregnancy. The findings suggest that increasing numbers of pregnancies will occur among perinatally HIV-infected adolescents and young adults and that appropriately tailored reproductive health interventions should be developed.