Zika in Puerto Rico, 2016-2017: I Perspectives on the Social Crisis and Health Care Concerns.

The social reaction to the Zika epidemic in Puerto Rico reached a confrontational climax regarding aerial fumigation with an organophosphate insecticide. The public drama has obscured multiple simultaneous controversies. This and a companion paper, based mostly on print and digital news reports, provide a context and description of the major controversies and examine the outcomes and their lessons for the protection of the public's health. Part I describes the social and sanitary environment, the first three months of the epidemic, and the debates related to religious, demographic, economic, political, and health care concerns.

Zika in Puerto Rico, 2016-2017: II Perspectives on Epidemic Surveillance and Control, Health Communication, Outcomes and Lessons.

The social reaction to the Zika epidemic in Puerto Rico reached a confrontational climax regarding aerial fumigation with an organophosphate insecticide. The public drama has obscured multiple simultaneous controversies. This and a companion paper, based mostly on print and digital news reports, provide a context and description of the major controversies and examine the outcomes and their lessons for the protection of the public's health. Part II covers the questions on disease surveillance (what is going on?); health communication and epidemic control (what is an epidemic? is there a way to control an epidemic transmitted by Aedes aegypti?), and the outcomes and lessons from the debates.

The Work of US Public Health Service Officers in Puerto Rico, 1898-1919.

The history of the US Public Health Service (PHS) is usually presented in terms of diseases or discoveries; this article examines twenty years' activity in one location. When the United States invaded Puerto Rico in 1898, the Marine Hospital Service (now PHS) took responsibility for foreign quarantine, inspection of immigrants, and medical care for merchant seamen. Its officers evaluated the sanitary conditions of port cities, helped reorganize local disease surveillance and control, and investigated endemic diseases (e.g., hookworm-related anemia) and epidemics (e.g., bubonic plague). After World War I and pandemic influenza, and the greater self-government allowed Puerto Rico by Congress in 1917, PHS officers withdrew from routine local sanitary actions. A narrow geographic focus (Puerto Rico), to examine PHS activity over time (1898 to 1919) provides a richer picture of the agency's impact, and reveals how the sum of disease control activities affected the development of an area's health status and institutions. The duties and, importantly, the personal initiatives of PHS officers in Puerto Rico, such as WW King, produced lasting impact on scientific institutions and administrative, professional, and health care practices.

Unlicensed to Prescribe Herbs: A Chinese Healer - Médico Chino - in Puerto Rico, 1851-1853.

In Puerto Rico and Cuba, the phrase "can't be saved even by the Chinese physician" ("no lo salva ni el médico chino") indicates a person with an incurable disease. The documents at the Archivo General de Puerto Rico include three requests for a medical license from a Chinese immigrant, Juan de Dios Sian (Lin Hua Cheng). Despite lacking legal credentials, he used herbal therapies to treat chronically ill persons in Ponce, San Juan and Mayaguez from 1851 to 1853. Before arriving in Ponce he had spent four years in Cuba, where he is again found by 1865. Sian's petitions show that Puerto Rico, like Cuba, experienced a widely known "médico chino." The anecdote reminds us of important issues in our medical and social history: Asiatic immigration (earlier, larger and more diverse than usually considered), access to care (and its limitations), and the long history of herbal medicine in Oriental and Western cultures. Elements of this story, such as the eagerness for new treatments among patients who have derived no benefit from standard therapy, the ethics of medical licensing, the impotence of licensing agencies and the toleration of authorities regarding an unorthodox but popular healer, exemplify dilemmas that accompany medical practice at all times.

Francisco Guerra (1916-2011), medical historian for the world and Puerto Rico.

This brief celebration of the work of Francisco Guerra (1916-2011) highlights his role as mentor for an international community, his study of local events in the context of global developments, and his contributions to the understanding of the medical history of Puerto Rico. A selective review of Francisco Guerra's methods and publications shows that his principal works are characterized by their vast scope and exhaustive coverage of ancient and modern published sources, coupled with clarity and conciseness of exposition. At least eight of his books (presented here) provide important information on events and personalities in Puerto Rico up to about 1940. Guerra, through his clinical experience, profound scholarship, and personal contacts, recovered the local medical developments of peripheral areas and incorporated them to a global context.

Measles, Malnutrition and Mortality: Puerto Rico, 1917-1918.

OBJECTIVE: Recent measles outbreaks in the United States and Europe have highlighted the threat of the disease. We studied the 1917-1918 epidemic in Puerto Rico to better understand the social and place-specific risk factors and severity of such crises. METHODS: We reviewed medical and government reports, newspapers and private contemporary documents. RESULTS: The epidemic developed over two years, encompassed the Island, and caused nearly 2,000 deaths among more than 9,000 registered cases (with much underreporting). During the first six months, 59% of fatalities were children under 2 years of age. Officials recognized poor nutrition and living conditions as an important determinant of epidemic severity. Responses came from different social sectors before the central government mobilized to help. In San Juan, Catholic and Protestant churches and philanthropic women from both Spanish and Englishlanguage communities joined to provide free milk to needy children and create a temporary Infants' Hospital. Despite food scarcity and wartime conditions, central and municipal governments established hospitals and milk stations. CONCLUSION: Studies that examine the impact of reemerging diseases in a time and place-specific context look at disease severity together with the socioeconomic conditions of patients and health care systems. This type of investigation also suggests avenues into the history of pediatrics, the use of epidemiologic methods, the utility of historical statistics, nutritional history, and the history of disaster response. Historical and recent outbreaks show the need for health care professionals and public health systems to be prepared to confront measles epidemics.

Use of an enhanced surveillance system for encephalitis and aseptic meningitis for the detection of neurologic manifestations of dengue in Puerto Rico, 2003.

Dengue infection has been implicated as a cause of neurologic manifestations since the beginning of the 20th century. An enhanced surveillance system for encephalitis and aseptic meningitis developed by the Puerto Rico Department of Health in collaboration with the Dengue Branch, Centers for Disease Control and Prevention, identified eleven laboratory positive dengue patients presenting with neurologic manifestations in 2003. Anti-dengue IgM antibody was detected in serum of eight patients and in cerebrospinal fluid of one patient. DENV-2 and DENV-3 were isolated from the serum of one patient each. All patients were negative for serologic markers of West Nile Virus and St. Louis encephalitis. Nine (82%) of the 11 patients had symptoms compatible with encephalitis. Their median age was 46 years (range: 9 months - 82 years) and five were males. Symptoms included severe headache, seizures, altered mental status, confusion, and coma. A motor disorder (upper extremities weakness and Guillain Barré Syndrome, respectively) occurred in two additional patients. Most patients recovered but there were two fatalities. Neurologic manifestations of dengue were rarely reported in Puerto Rico until the institution of enhanced surveillance, which resulted in the recognition of severe and fatal cases.

Dengue-related deaths in Puerto Rico, 1992-1996: diagnosis and clinical alarm signals.

BACKGROUND: Dengue, although endemic in Puerto Rico, is often not mentioned in the death certificates of decedents with laboratory results positive for dengue. Because confirmatory results are usually not available during hospitalization, we examined the utility of 2 instruments for diagnosis on the basis of clinical findings: the definition of dengue hemorrhagic fever (DHF) and the publicized (but unevaluated) clinical alarm signals for impending dengue shock. METHODS: We studied data from all patients with laboratory test results positive for dengue who died (23 patients) and from the 8 patients whose death certificates listed dengue as a cause of death but whose laboratory test results were negative for dengue in Puerto Rico from 1992 through 1996. We examined hospital records to determine whether the clinical criteria for DHF were fulfilled and evaluated the incidence and timing of clinical alarm signals (intense, sustained abdominal pain; persistent vomiting; sudden change from fever to hypothermia; and marked restlessness or lethargy) and the hematocrit/hemoglobin ratio as an indicator of hemoconcentration. RESULTS: A similar proportion of patients with laboratory test results positive for dengue (18 [78%] of 23) and negative for dengue (6 [75%] of 8) fulfilled the criteria for DHF. Clinical alarm signals were found only among patients with laboratory test results positive for dengue and were usually noted on the day that the patient's condition deteriorated. The hematocrit/hemoglobin ratio identified 1 (6%) of 16 patients with dengue who had significant hemoconcentration. Important comorbidities were present in 16 (70%) of the patients with laboratory test results positive for dengue and in 4 (50%) of the patients with dengue-related deaths with laboratory test results negative for dengue. CONCLUSIONS: Dengue-related deaths in Puerto Rico often occur in patients with comorbidities. Among such patients, the DHF definition and the hematocrit/hemoglobin ratio were not useful in identifying patients with laboratory test results positive for dengue. In contrast, the clinical alarm signals for shock supported the dengue diagnosis and should alert clinicians to the severity of the disease.

Severe dengue: the need for new case definitions.

Dengue fever imposes a societal burden that is difficult to measure because of the disease's non-specific symptoms and the lack of easily applied case definitions for its more severe manifestations. An efficacy trial of a tetravalent vaccine is expected in the near future, but only one of the severe dengue syndromes-the continuum of dengue haemorrhagic fever and dengue shock syndrome-is well defined. One of the results of the focus on dengue haemorrhagic fever is the false perception of low disease burden in the Americas, which is an obstacle to the mobilisation of political and economic resources to fight the disease. Three improvements are necessary to standardise the dengue haemorrhagic fever definition and to allow it to do well in different populations: (1) redefine the threshold for thrombocytopenia, (2) clarify the standard practice and value of the tourniquet test, and (3) incorporate a criterion to measure intravenous fluid replacement. In addition, for an accurate estimation of dengue burden, locally appropriate definitions of severe dengue must be devised and standardised so they will be considered valid in the global research community.

Risk factors for infection during a dengue-1 outbreak in Maui, Hawaii, 2001.

Autochthonous dengue virus transmission, last identified in the state of Hawaii in 1945, was detected again in 2001. A seroepidemiological survey in a high-incidence community (Nahiku) and a nearby low-incidence community (Hana Subdivision) was implemented. The two communities studied differed in median household size (two vs. four persons), median lot size (2.8 vs. 0.8acres), proportion of households with mosquito larvae (81 vs. 28%) and incidence of recent infection (39% [28/72] vs. 1% [1/131]). The average number of reported anti-mosquito actions by residents of both locations remained low, and approximately 50% (42/80) of the inspected houses had larvae, evidencing the need for more effective community mosquito control. Logistic regression analysis of risk factors for infection in Nahiku identified residing in properties with birds in the house or yard as significantly associated with infection (odds ratio 7.0, 95% CI 1.7-28.5), probably as an indicator of unspecified environmental characteristics that were attractive to the vector. We documented that nearly 40% of Nahiku residents had acquired dengue locally in 2001 and that undetected dengue outbreaks had occurred in Hawaii. Our data suggest that ecological characteristics may help Hawaii health officials identify communities at increased risk of dengue infection.

Medical examiner samples: a source for dengue surveillance.

Post-mortem medical examiner samples may be useful for sentinel surveillance of disorders usually detected by antibody determinations on specimens from ill patients or from surveys. We found anti-dengue IgM positivity in 3% (23/780) and anti-dengue IgG positivity in 77% (597/777) of sera obtained at the Puerto Rico medical examiner (Institute of Forensic Sciences) in December 2000, April 2001, and October 2001. This approach may be a useful alternative for estimating the population prevalence of serologic markers for dengue and other infectious diseases.

Assessment of dengue risk in relief workers in Puerto Rico after Hurricane Georges, 1998.

Health risk assessment is important in the safe deployment of workers to tropical areas. We monitored dengue incidence in 204 of 222 North American relief workers visiting Puerto Rico after Hurricane Georges and during a dengue epidemic in 1998. We recorded information regarding participants' living conditions and any illness they experienced from arrival to 2 weeks after their departure. Virus isolation, polymerase chain reaction, and serological tests for anti-dengue immunoglobulin (Ig) M and IgG antibodies were used to diagnose dengue infection by means of departure and follow-up serum specimens. Among respondents, 82% (164 of 199) reported mosquito bites, 97% (156 of 161) reported having insect repellent available, and 41% (79 of 195) reported using repellent every day. Twelve participants reported a mild denguelike illness. No participants had laboratory evidence of dengue infection after 1.8 person-years of assessable exposure to areas with dengue transmission (upper 95% confidence limit of 1.67 cases per person-year). The risk of acquiring dengue among relief workers in this study appears low, possibly as a result of protective factors. Travelers to dengue-endemic areas should continue to be advised to protect themselves against mosquito bites.

The reappearance of dengue-3 and a subsequent dengue-4 and dengue-1 epidemic in Puerto Rico in 1998.

In January 1998, dengue-3 (DEN)-3 (group III genotype) was detected in Puerto Rico after an absence of 20 years. Public health officials intensified education efforts to promote community participation in dengue control. Virologic surveillance revealed an unexpected paradox: DEN-4 and DEN-1 produced a large epidemic overlaying the DEN-3 epidemic. In 1998 there were 17,000 reported cases of dengue (4.8/1,000 persons), and among all virus isolations (n = 960), DEN-4 (419, 43.6%), DEN-1 (337, 35.1%), and DEN-2 (143, 14.9%) were detected much more frequently than DEN-3 (61, 6%). Age group-specific attack rates were highest for persons 10-19 years old, followed by infants less than a year of age. Nineteen fatal cases (median = 37 years old, range = 8 months to 90 years) had a positive laboratory diagnosis of dengue. Among DEN-3 cases no fatalities were documented, 50 were hospitalized, and 10 of 48 (21%) fulfilled the criteria for dengue hemorrhagic fever (four had primary infections and six had secondary infections). During 1999, DEN-3 became the predominant serotype isolated (182 of 310 isolations, 59%). The reappearance of DEN-3 and its subsequent circulation from 1999 to 2001 produced no changes in dengue incidence that could have been detected in the absence of virologic surveillance.

Community-based dengue prevention programs in Puerto Rico: impact on knowledge, behavior, and residential mosquito infestation.

Dengue is a major health burden in Puerto Rico. Televised public service announcements and posters, elementary and pre-school educational programs, and an exhibit at the Children's Museum in Old San Juan were evaluated separately using knowledge and practices surveys administered to children and their parents, surveys of house lots for larval container habitats, focus groups, and interviews with program organizers and participants. Exposure to the programs was associated with increased dengue-related knowledge, increased proportion of tires protected from rain, decreased proportion of water storage containers positive for mosquito larvae, and increased indoor use of aerosol insecticides. Exposure to the elementary school program was associated with slightly lower indices of residential mosquito infestation. The programs have resulted in high levels of awareness, some behavior change, and limited change in larval indices. Greater emphasis on the skills necessary for community members to keep containers free of mosquito larvae would increase program effectiveness.

Risk factors for infection during a severe dengue outbreak in El Salvador in 2000.

In 2000, El Salvador experienced a large dengue-2 virus epidemic with many severe cases. A seroepidemiologic survey was conducted in 106 randomly selected households (501 residents) in an affected community (Las Pampitas). The frequency of recent infection, documented by the presence of IgM antibodies or high-titer IgG antibodies to dengue virus, was estimated to be 9.8% (95% confidence interval [CI] = 5.8-13.7), of which at least 44% were secondary infections. The number of containers positive for Aedes mosquito larvae or pupae per 100 premises (Breteau Index) was 62 and the frequency of positive premises (House Index) was 36%; 33% (35 of 106) of the informants reported having taken action against mosquito larval habitats and 82% (87 of 106) reported having taken actions against adult mosquitoes. Recent infection was associated with the presence in the home environment of mosquito infested discarded cans (odds ratio [OR] = 4.30, 95% CI = 2.54-7.28), infested discarded plastic containers (OR = 3.98, 95% CI = 1.05-15.05), and discarded tire casings (OR = 2.57, 95% CI = 1.09-6.04). The population attributable fractions associated with these factors were 4%, 13%, and 31%, respectively. Our data suggest that targeted community cleanup campaigns, particularly those directed at discarded tires and solid waste, are likely to have the greatest impact on reducing the risk of dengue infection.

[The real philanthropic expedition of the smallpox vaccine: monarchy and modernity in 1803]. / La real Expedición filantrópica de la Vacuna de viruela: monarquía y modernidad en 1803.

Smallpox resulted in the death of 30 % of those who acquired it, so the preventive method discovered by Edward Jenner (London, 1798) spread very quickly. At the request in 1803 of Carlos IV, king of Spain, his government evaluated offers to carry smallpox vaccine to the colonies. The selected proposal, by doctor Francisco Xavier de Balmis, sought to take the lymph to America and Asia in a chain of arm to arm vaccination of foundlings. The Expedition set sail from Corunna on November 30, 1803, stopped in the Canary Isles, Puerto Rico, and Venezuela and after Caracas (1804) split in two groups. Balmis led some members of the Expedition to Cuba and Mexico. For the trip to the Philippines, in 1805, parents lent their children in exchange for economic compensation and the promise that the boys would be returned home. The Expedition returned to Mexico in August, 1807, but Balmis separately took vaccine to China and returned to Spain. Another contingent of the Expedition, under vice-director José Salvany, took vaccine to what we know as Colombia, Ecuador, Peru and Bolivia. His assistant Manuel Grajales reached the Chilean Patagonia in 1811. This article also comments on three principal themes - the institutional management of the scientific project, the conflicts that characterized its course, and the children's experience. The Vaccine Expedition was a brave and humanitarian endeavor, but also an extraordinary sanitary and administrative success. It was not until the twentieth century that a global eradication campaign eliminated smallpox in the world.

The world's first immunization campaign: the Spanish Smallpox Vaccine Expedition, 1803-1813.

SUMMARY: Smallpox produced the death of up to thirty percent of those infected, so Jenner's preventive method spread quickly. The Spanish government designed and supported a ten-year effort to carry smallpox vaccine to its American and Asian territories in a chain of arm-to-arm vaccination of children. An expedition directed by Doctor Francisco Xavier de Balmis sailed from Corunna in November 1803, stopping in the Canary Islands, Puerto Rico, and Venezuela. Balmis led a subexpedition to Cuba, Mexico, and the Philippines; his assistants returned to Mexico in 1807, while Balmis took vaccine to China and returned to Spain (and again to Mexico, 1810-13). Vice-director José Salvany and his staff took vaccine to present-day Colombia, Ecuador, Peru, Bolivia, and Chilean Patagonia. The Spanish Royal Philanthropic Vaccine Expedition shows the first attempts to solve questions still important for the introduction of new immunizations--professionalization in public health, technology transfer, protection of research subjects, and evaluation of vaccine efficacy, safety, and cost.

[How to respond to a dengue epidemic: overview and experience in Puerto Rico]. / Cómo responder a una epidemia de dengue: visión global y experiencia en Puerto Rico.

Dengue, a viral disease transmitted by mosquitoes, is endemic and frequently epidemic in many tropical countries. Because low-incidence periods vary in length, it is difficult to know in advance when an epidemic will occur. Response efforts, despite being logical, have been counter-productive at times. Furthermore, experience has demonstrated that dengue epidemics last a long time, making it important that government control efforts be sustainable while they last. This article describes priority activities requiring attention in order to minimize the impact of dengue epidemics. Such activities, which in many cases can be adapted to combat other types of epidemics as well, are as follows: (1) establishment of an inter-sectoral action committee, (2) formalization of an emergency action plan, (3) epidemiologic surveillance, (4) diagnostic laboratory testing, (5) mosquito control, (6) protection of sources of employment and special populations, (7) patient care, (8) education of medical personnel, (9) research, and (10) transparency before the mass media. The best way to reduce the ravaging effects of dengue epidemics is to anticipate their emergence so that infection can be prevented and steps can be taken to protect the ill. Relying on improvisation to solve all the problems that arise in moments of crisis is inefficient and reckless.

Dengue fever, Hawaii, 2001-2002.

Autochthonous dengue infections were last reported in Hawaii in 1944. In September 2001, the Hawaii Department of Health was notified of an unusual febrile illness in a resident with no travel history; dengue fever was confirmed. During the investigation, 1,644 persons with locally acquired denguelike illness were evaluated, and 122 (7%) laboratory-positive dengue infections were identified; dengue virus serotype 1 was isolated from 15 patients. No cases of dengue hemorrhagic fever or shock syndrome were reported. In 3 instances autochthonous infections were linked to a person who reported denguelike illness after travel to French Polynesia. Phylogenetic analyses showed the Hawaiian isolates were closely associated with contemporaneous isolates from Tahiti. Aedes albopictus was present in all communities surveyed on Oahu, Maui, Molokai, and Kauai; no Ae. aegypti were found. This outbreak underscores the importance of maintaining surveillance and control of potential disease vectors even in the absence of an imminent disease threat.