Restoring Immunization Services Provided by the Vaccines for Children Program in Puerto Rico After Hurricanes Irma and Maria, 2017-2019.

CONTEXT: In September 2017, Hurricanes Irma and Maria impacted Puerto Rico, causing significant disruption of immunization services and vaccine losses due to widespread infrastructure and electrical grid damage and resulting cold chain failures. OBJECTIVE: To describe posthurricane efforts undertaken to restore and strengthen immunization services provided by Puerto Rico's federally funded Vaccines for Children (VFC) Program, a network of clinics that provide vaccines to eligible children. DESIGN: Historical records were reviewed to characterize Puerto Rico's prehurricane immunization system. Site visits to assess VFC clinic posthurricane operational status were conducted by the Puerto Rico Department of Health, working with the Centers for Disease Control and Prevention and other partners. Infrastructure repair and acquisition of backup generators, temperature data loggers, and replacement vaccines were carried out to restore operations. RESULTS: Prior to the hurricanes, 224 VFC clinics throughout the island provided immunizations. An initial assessment 10 days after Hurricane Maria showed that only 11 (5%) of the clinics were operational. Reasons included ongoing power outages; difficulties in obtaining generator fuel; equipment or facility damage; and damaged vaccines. The VFC clinics were restored incrementally; 123 (55%) were operational by December 2017, 193 (86%) by May 2018, and 204 (91%) by May 2019. Long-term recovery activities are underway and focus on strengthening Puerto Rico's immunization system to withstand future disasters, including improving backup power systems. CONCLUSION: Through coordinated efforts of the Puerto Rico Department of Health, the Centers for Disease Control and Prevention, and other partners, the operational status of VFC clinics posthurricanes was assessed and operations restored. Emergency plans for vaccine storage and handling, which called for alternative vaccine storage locations and backup generators, were inadequate to address disasters of the magnitude of Hurricanes Irma and Maria; such plans need to consider the possibility of large-scale disasters that result in long-term power outages.

Lessons from the reestablishment of Public Health Laboratory activities in Puerto Rico after Hurricane Maria.

Public Health Laboratories (PHLs) in Puerto Rico did not escape the devastation caused by Hurricane Maria. We implemented a quality management system (QMS) approach to systematically reestablish laboratory testing, after evaluating structural and functional damage. PHLs were inoperable immediately after the storm. Our QMS-based approach began in October 2017, ended in May 2018, and resulted in the reestablishment of 92% of baseline laboratory testing capacity. Here, we share lessons learned from the historic recovery of the largest United States' jurisdiction to lose its PHL capacity, and provide broadly applicable tools for other jurisdictions to enhance preparedness for public health emergencies.

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.

Effect of maternal antibody on immunogenicity of hepatitis A vaccine in infants.

OBJECTIVE: To determine the effect of maternal antibody on hepatitis A vaccine immunogenicity in infants. Study design Infants of mothers negative for antibody to hepatitis A virus (anti-HAV; group 1) were administered hepatitis A vaccine at 2, 4, and 6 months of age, and infants of anti-HAV-positive mothers were randomized to receive either hepatitis A vaccine (group 2) or hepatitis B vaccine (group 3) on the same schedule. Group 3 infants subsequently received hepatitis A vaccine at 8 and 10 months of age. RESULTS: At 15 months of age, 100% of infants in group 1, 93% in group 2, and 92% in group 3 had protective levels of antibody. However, there were significant differences in the geometric mean concentration (GMC) of anti-HAV between groups. Group 1 GMC was 231 mIU/mL, compared with 85 mIU/mL for group 2 and 84 mIU/mL for group 3 (P<.001, group 1 vs group 3). CONCLUSIONS: Passively acquired maternal anti-HAV resulted in a significantly lower final antibody response when infants were administered hepatitis A vaccine at 2, 4, and 6 months of age or at 8 and 10 months of age.

Characterization of hepatitis D virus genotype III among Yucpa Indians in Venezuela.

The complete genome sequences of hepatitis D virus (HDV) strains isolated from three Yucpa Amerindians in Venezuela were determined and found to be genotype III. Comparison of these three genotype III sequences demonstrated the presence of a hypervariable region containing numerous substitutions, insertions/deletions and a highly conserved region containing the self-cleavage domains, which have been reported previously for genotypes I and II. Amino acid changes within the first 90 amino acids of the hepatitis D antigen (HDAg) were found in the genotype III sequences, while the remainder of the HDAg-coding sequence was conserved. The secondary structure for the RNA-editing site differed between genotypes I and III. It was concluded that the serious delta hepatitis outbreaks characterized epidemiologically in the Yucpa Amerindians were caused by HDV genotype III isolates that were related to HDV genotype III isolates from other regions of South America.

Characterization of hepatitis B virus genotypes among Yucpa Indians in Venezuela.

The complete genome sequences of hepatitis B virus (HBV) from 12 HBV-infected Yucpa Indians of Venezuela, a group with highly endemic HBV, were amplified and sequenced. The 12 isolates were closely related to each other, with 98.6-100% nucleotide identity. A phylogenetic tree based on the complete genome indicated clearly that they were genotype F. Three individuals had evidence of infection with two different HBV deletion mutants. In two individuals, a three amino acid deletion was identified just prior to the 'a' determinant loop of the S region. A third individual was infected with virus that contained a complete core reading frame and a population that contained a deletion in the middle of the core region. These results indicate that genotype F HBV is present in the Venezuelan Yucpa Amerindians and the complete genome sequence allowed the identification of two unique deletion mutants in a limited set of samples.

Manejo médico de la exposición al virus de la hepatitis B / Medical treatment of the hepatitis B virus exposure

Se hace un revisión de los conocimientos actuales sobre el tratamiento en el caso de una probable exposición al virus de la hepatitis B. Se presenta la pormenorización de las diferentes clases de exposición así como la indicación y dosificación de la inmunoglobulina específica y de la vacuna anti-hepatitis B. Esta revisión tiene como fundamento las recomendaciones deL CDC de Atlanta y de la Organización Mundial de la Salud

Epidemiología de la infección por el virus de la hepatitis B en dos poblaciones del departamento del Magdalena / Epidemiology of the hepatitis B virus infection in two villages in the Magdalena Department

Durante 1989 se llevó a cabo una encuesta de seroprevalencia de infección por el virus de la hepatitis B (VHB) en dos poblaciones del departamento del Magdalena (costa norte de Colombia): Cerro Azul y Varela, las cuales presentaban historia reciente de casos de hepatitis fulminante (HF) causada por co y sobre infección del virus de la hepatitis Delta (VHD) en portadores del antígeno de superficie del VHB (HBsAg). De acuerdo con los resultados obtenidos, en la población con mayor número de casos fulminantes, Cerro Azul, la infección por VHB empieza desde la infancia temprana, probablemente por transmisión horizontal y alrededor de los 15 años, ya la mitad de la población ha sido infectada por VHB. En ella los principales factores asociados con la infección fueron: la carencia de un sistema de disposición de excretas, el hacinamiento y el antecedente de algún familiar muerto por hepatitis. En la segunda población, Varela, menos afectada por la hepatitis fulminante, la infección por VHB ocurre a edades más tardias: desde los 15 años en adelante y alrededor de los 30 años, la mitad de la población ha sido infectada por este virus. En ella los factores que hellamos asociados a la infección por VHB son; el sexo masculino, la carencia de un sistema de eliminación de excretas, el antecedente de transfusión sanguínea y la aplicación de medicamentos parenterales ambulatorios

Infarto del miocardio no fatal y habito de fumar en mujeres de Cali, Colombia / No fatal myocardial infarction and the habit of smoking in women of Cali, Colombia

Del archivo de historias clinicas del Hospital Universitario del Valle en Cali, Colombia, se seleccionaron 100 casos de infarto de miocardio no fatal en mujeres ocurridos durante los anos 1977 a 1981, y 100 controles con el fin de establecer si existia relacion entre el habito de fumar y la aparicion del infarto. En el momento del infarto, 31% de los casos tenian el habito de fumar contra 18% de los controles (P < 0.10) pero otros factores de confusion como la historia de hipertension arterial y la historia de angina fueron tambien mas frecuentes en los casos. El porcentaje de riesgo atribuible al habito de fumar fue 50.9 y el riesgo relativo, 2.04; la historia de hipertension arterial y la historia de angina tuvieron un porcentaje atribuible y un riesgo relativo mayores. Los antecedentes de diabetes y de hipercolesterolemia no mostraron significancia. A diferencia de otros estudios, el uso de anticonceptivos mostro un riesgo relativo muy bajo