New York State, New York City, New Jersey, Puerto Rico, and the US Virgin Islands' Health Department Experiences Promoting Health Equity During the Initial COVID-19 Omicron Variant Period, 2021-2022.

In this case study, we aim to understand how health departments in 5 US jurisdictions addressed health inequities and implemented strategies to reach populations disproportionately affected by COVID-19 during the initial Omicron variant period. We used qualitative methods to examine health department experiences during the initial Omicron surge, from November 2021 to April 2022, assessing successful interventions, barriers, and lessons learned from efforts to promote health equity. Our findings indicate that government leadership supported prioritizing health equity from the beginning of the pandemic, seeing it as a need and vital part of the response framework. All jurisdictions acknowledged the historical trauma and distrust of the government. Health departments found that collaborating and communicating with trusted community leaders helped mitigate public distrust. Having partnerships, resources, and infrastructure in place before the pandemic facilitated the establishment of equity-focused COVID-19 response activities. Finally, misinformation about COVID-19 was a challenge for all jurisdictions. Addressing the needs of diverse populations involves community-informed decisionmaking, diversity of thought, and delivery measures that are tailored to the community. It is imperative to expand efforts to reduce and eliminate health inequities to ensure that individuals and communities recover equitably from the effects of COVID-19.

Sociodemographic Differences in COVID-19 Pandemic Experiences Among Families in the United States.

Importance: Few population-based studies in the US collected individual-level data from families during the COVID-19 pandemic. Objective: To examine differences in COVID-19 pandemic-related experiences in a large sociodemographically diverse sample of children and caregivers. Design, Setting, and Participants: The Environmental influences on Child Health Outcomes (ECHO) multi-cohort consortium is an ongoing study that brings together 64 individual cohorts with participants (24 757 children and 31 700 caregivers in this study) in all 50 US states and Puerto Rico. Participants who completed the ECHO COVID-19 survey between April 2020 and March 2022 were included in this cross-sectional analysis. Data were analyzed from July 2021 to September 2022. Main Outcomes and Measures: Exposures of interest were caregiver education level, child life stage (infant, preschool, middle childhood, and adolescent), and urban or rural (population <50 000) residence. Dependent variables included COVID-19 infection status and testing; disruptions to school, child care, and health care; financial hardships; and remote work. Outcomes were examined separately in logistic regression models mutually adjusted for exposures of interest and race, ethnicity, US Census division, sex, and survey administration date. Results: Analyses included 14 646 children (mean [SD] age, 7.1 [4.4] years; 7120 [49%] female) and 13 644 caregivers (mean [SD] age, 37.6 [7.2] years; 13 381 [98%] female). Caregivers were racially (3% Asian; 16% Black; 12% multiple race; 63% White) and ethnically (19% Hispanic) diverse and comparable with the US population. Less than high school education (vs master's degree or more) was associated with more challenges accessing COVID-19 tests (adjusted odds ratio [aOR], 1.88; 95% CI, 1.06-1.58), lower odds of working remotely (aOR, 0.04; 95% CI, 0.03-0.07), and more food access concerns (aOR, 4.14; 95% CI, 3.20-5.36). Compared with other age groups, young children (age 1 to 5 years) were least likely to receive support from schools during school closures, and their caregivers were most likely to have challenges arranging childcare and concerns about work impacts. Rural caregivers were less likely to rank health concerns (aOR, 0.77; 95% CI, 0.69-0.86) and social distancing (aOR, 0.82; 95% CI, 0.73-0.91) as top stressors compared with urban caregivers. Conclusions: Findings in this cohort study of US families highlighted pandemic-related burdens faced by families with lower socioeconomic status and young children. Populations more vulnerable to public health crises should be prioritized in recovery efforts and future planning.

Attitudes and perceptions toward the COVID-19 risk-mitigation strategies among racially and ethnically diverse older adults in the United States and Puerto Rico: a qualitative study.

OBJECTIVES: There is limited qualitative research investigating how risk-mitigation strategies during the COVID-19 pandemic impacted the lives of diverse older adults, who met criteria for mild to severe generalized anxiety or depression and minor to moderate disability. This study aims to address this gap by examining how racially and ethnically diverse older adults with at least mild mental health symptoms and minor physical disability in the United States and Puerto Rico adapted to guidelines during COVID-19. It aims to inform the medical community and policymakers of potential threats to these older adults' well-being given the COVID-19 burden. DESIGN: Based on descriptive qualitative inquiry and phenomenological perspectives, we conducted semi-structured interviews over the phone with a racially and ethnically diverse sample of older (age 60+), predominantly minoritized adults (N = 100) in four states and territories across the United States and Puerto Rico in 2021. Interviews were recorded, coded, and analyzed using a thematic analysis approach. RESULTS: Findings centered on five themes: (1) Previous experiences with the healthcare system and cultural beliefs related to trust and distrust led to mixed attitudes toward COVID-19 risk-mitigation strategies; (2) Compliance with COVID-19 mitigation strategies ensured safety and addressed fear of illness; (3) Compliance led to isolation due to interrupted social relations; (4) Isolation and disrupted social networks negatively impacted mental health and finances, and (5) Coping strategies and embracing support reduced the effects of social isolation. CONCLUSION: This study underscores the importance of increasing support and social connectedness during a pandemic and beyond to ensure the well-being of older adults in racially and ethnically diverse communities. It highlights the resiliency of older adults in identifying strategies to cope with negative impacts. We recommend safeguarding economic security through policy efforts toward financial safety nets during health crises and collaborative approaches with community-based organizations to mitigate social isolation.

Refractive Error Changes Due to COVID-19 Pandemic Confinement in Children From Puerto Rico: A Retrospective Study.

SIGNIFICANCE: The progression of myopia increased in children after the pandemic confinement. A myopic shift in the refractive error of the Hispanic population was found regardless of the refractive status of the school-aged children studied. PURPOSE: This study aimed to evaluate the refractive error in Puerto Rican children before and after the COVID-19 pandemic. We were interested in whether there was a significant change in refractive error attributed to online learning during the pandemic lockdown. METHODS: A retrospective record review of children aged 7 to 18 years that underwent a comprehensive visual evaluation between 2018 and 2021 at the Inter American Eye Institute in Puerto Rico. The spherical equivalent pre- and post-lockdown were compared. The study excluded the best corrected visual acuities worse than 20/40, any corneal or retinal disease, and amblyopia. RESULTS: In total, 801 records were included in this study. The mean age was 12.7 ± 3.2, with (50.3%) males and (49.7%) females. The mean spherical equivalent for the right and left eyes was similar (r = .93, P ≤ .001). A significant difference in the mean spherical equivalent was found pre and post-lockdown (0.22 ± 0.59 D, t(800) = 10.44 P ≤ .001). A myopic shift post-lockdown was significant for all ages except those in the seven (0.13 ± 0.79 D, t(28) = 0.84, P = .40) and 8-year-old range (0.12 ± 0.65 D, t(40) = 1.22, P = .23), respectively. No significant change was found between genders pre (0.16 ± 0.12 D; t(799) = 1.38, P = .16) and post (0.15 ± 0.13 D; t(799) = 1.19 P = .23) confinement. CONCLUSIONS: The current study revealed a significant myopic shift in Hispanic school-aged children as a result of the pandemic confinement.

Challenges Accessing Food, Water, Healthcare Services, and Medications During the COVID-19 Pandemic Among Adults in Puerto Rico and Their Association with Self-Rated Health: Assessments of PR-CEAL.

BACKGROUND: The COVID-19 pandemic created challenges in accessing food, water, medications, and healthcare services some of which are linked with lower self-rated health (SRH). These challenges have already been documented in the US, but it remains unknown how the pandemic affected access to food, water, medications and healthcare services, and how these challenges relate to SRH in this group, a population experiencing profound health disparities and limited resources prior to the pandemic. OBJECTIVE: To assess associations between challenges accessing food, water, healthcare, and medications during the COVID-19 pandemic and SRH among adults in Puerto Rico. METHODS: Cross-sectional analysis of Puerto Rico-CEAL. Adults (>18 years; n=582) completed an online survey (December 30, 2021-February 8, 2022). Presence of each challenge during the past 30 days was measured and analyzed individually and combined (0, 1, >2). SRH (rated from poor-excellent) was measured before and at pandemic. Change in SRH was calculated. Adjusted Poisson models with robust variance errors estimated prevalence ratios (PR). RESULTS: Experiencing food, water, medication, and healthcare challenges (vs. not) were associated with pandemic fair-poor SRH (PR=1.44, 95%CI=1.06-1.97; PR=1.59, 95%CI=1.15-2.18; PR=1.38, 95%CI=1.05-1.81; and PR=1.56,9 5%CI=1.15-2.12, respectively). Experiencing 2+ challenges (vs. none) was associated with pandemic fair-poor SRH (PR=1.77, 95%CI=1.22-2.55). Additionally, experiencing food, medication, and healthcare challenges (vs. not) was associated with decreased SRH (PR=1.35, 95%CI=1.08-1.69; PR=1.24, 95%CI=1.01-1.51; and PR=1.25, 95%CI=1.01-1.54, respectively), as well as experiencing 2+ challenges (vs. none; PR =1.49, 95%CI=1.15-1.92). CONCLUSION: Challenges accessing food, water, medications, and healthcare services during the pandemic were associated with fair-poor SRH and decreased SRH in Puerto Rico. Public health policy should ensure access to basic needs.

Mental health impact of the COVID-19 pandemic in perinatal women living in Puerto Rico.

BACKGROUND: Studies have reported an increase in mental health disorders during the perinatal period as a result of the COVID-19 pandemic and the quarantine restrictions imposed. The effects of untreated maternal mental health have an adverse impact on the mother, the development of the baby, and the family system. Determinants of health, recent natural disasters, and disparities in perinatal care that impact perinatal women in Puerto Rico place them at a higher risk of mental health difficulties. AIM: It is therefore, of extreme importance, to evaluate the effect that the COVID-19 pandemic has had on this vulnerable population. DESIGN: This is a cross-sectional observational study that interviewed 100 women in the perinatal period during the COVID-19 lockdown measures in Puerto Rico. Participants completed the Spanish version of the COVID-19 Perinatal Experiences (COPE-IS) questionnaire and assessments of clinical depression (PHQ-9) and anxiety (GAD-7). RESULTS: The prevalence of moderate to severe risk of depression in this sample is 14%, while 17% showed clinical signs of anxiety. Concerns about social impact and the quarantine mandate were the most common stressors reported. Additionally, our sample reported concerns about the impact the pandemic would have on future employment and finances. CONCLUSION: Perinatal women showed significantly higher prevalence of depression and anxiety during the COVID -19 pandemic when compared to the mental health prevalence of the general population pre-pandemic in Puerto Rico. The concerns identified during the pandemic provide information on the importance of a biopsychosocial approach to perinatal mental health care.

Community Forums as Amplifiers of Communities' Voices: Isolated Communities in Puerto Rico.

Social determinants of health contribute to health disparities and inequities. We conducted a community forum on the topic of isolation with the objectives of (1) identifying and prioritizing key health-related issues needing attention in isolated communities in Puerto Rico; (2) developing strategies in terms of Policies, Programs, and Practices to address the community priorities we identified. We used the triangulation method for qualitative data, integrating the Colorado State University's Tri-ethnic Center Model and the Delphi Technique for a better understanding of community health needs and priorities. The five community health-related priorities identified in the community forum were: (1) access to health services (physical and mental); (2) older adults; (3) access to basic services; (4) preparedness for future disasters/emergencies; and (5) COVID-19 and access to vaccination. The Alliance Leaders and Advisory Boards understand that we will work with the priorities of preparedness for future natural disasters/emergencies and COVID-19 and access to vaccination. Fifteen strategies were developed for these priorities and were grouped into five areas that require more attention in order to reduce health disparities. Isolated communities in Puerto Rico present an intersectionality of factors that affect a wide range of health-related risks and outcomes.

Understanding the Impact of the COVID-19 Pandemic on the Prenatal Care of a Group of Pregnant Hispanic Women living in Puerto Rico.

OBJECTIVE: To understand the impact of the COVID-19 pandemic on the prenatal care of pregnant Hispanic women living in Puerto Rico. METHODS: This was a cross-sectional study. The participants' profiles were determined through an online questionnaire to analyze COVID-19 related behaviors and experiences. RESULTS: Our sample comprised 131 women with an average age of 28 years (±5.3 years). Most of the population was pregnant at the time of the interview (74.8%; n = 98), and the rest were in their post-partum period. Overall, 46.5% (n = 61) of the patients indicated that their prenatal care did not change during the pandemic. In addition, 92.50% (n = 111) reported not altering their plans for breastfeeding their babies. Overall, 77.86% of the participants reported feeling scared or overwhelmed due to the current pandemic, and 97% agreed that COVID testing should be performed as a screening method in all pregnant females. CONCLUSION: Our findings describe the characteristics of pregnant Hispanic females living in Puerto Rico. The majority reported adhering adequately to their health services, with few or no changes in their prenatal care.

Age-Related Differences in Anxiety and Depression Diagnosis among Adults in Puerto Rico during the COVID-19 Pandemic.

Residents of Puerto Rico bear a significant burden of mental health disorders, which the COVID-19 pandemic may have exacerbated. However, age-specific data on these disorders during the pandemic in Puerto Rico are scarce. This study evaluated age-related differences in the self-reported diagnosis of depression and anxiety among adults ≥18 years residing in Puerto Rico during the pandemic. An anonymous online survey was administered from December 2020 to February 2021 via Google Forms to measure self-reported sociodemographic and behavioral characteristics and physician-diagnosed mental health disorders. Multivariable logistic regression models were conducted for each self-reported mental health diagnosis after adjusting for sex, education, income, marital status, chronic diseases, and smoking. Out of 1945 adults, 50% were aged 40 years and over. Nearly 24% of responders self-reported an anxiety diagnosis, whereas 15.9% reported depression. Compared to individuals 50 years and over, those 18-29 y, 30-39 y, and 40-49 y had significantly higher odds of an anxiety diagnosis (OR = 1.84, 95% CI = 1.34-2.55; OR = 1.50, 95% CI = 1.09-2.07; and OR = 1.37, 95% CI = 1.01-1.87, respectively). However, no association between age and depression diagnosis was found. Despite anxiety and depression being frequent disorders during the pandemic in this sample, younger adults bear a higher burden of anxiety. Further research is needed to allocate appropriate mental health resources during emergencies according to population subgroups.

Epidemiological intelligence community network intervention: a community response for COVID-19 community transmission.

BACKGROUND: Expanding and providing access to early detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) through testing community-based strategies among socially vulnerable communities (SVC) are critical to reducing health disparities. The Epidemiological Intelligence Community Network (EpI-Net) community-based intervention sought to increase coronavirus 2019 (COVID-19) testing uptake and prevention practices among SVC in Puerto Rico (PR). We evaluated EpI-Net's community leaders' capacity-building component by assessing pre-post COVID-19 public health workshops' tests' score changes and satisfaction among trained community leaders. METHODS: A total of 24 community leaders from SVC in PR have completed four community workshops. Pre- and post-assessments were completed as part of the health promotors training program to evaluate participants' tests score changes and satisfaction outcomes. RESULTS: Preliminary results showed: (1) high intervention retention levels of community leaders (85.7% acceptance rate); (2) change in post-test scores for community engagement strategies (p = 0.012); (3) change in post-test educational scores in COVID-19 prevention practices (p = 0.014); and (4) a change in scores in public health emergency management strategies (p < 0.001). CONCLUSIONS: The overall workshop satisfaction was 99.6%. Community leaders have shown the importance of community capacity building as a key component for intervention feasibility and impact. TRIAL REGISTRATION: Our study was retrospectively registered under the ClinicalTrial.gov ID NCT04910542.

Dengue vaccine acceptability before and after the availability of COVID-19 vaccines in Puerto Rico.

Dengue is a growing public health threat, causing approximately 400 million infections annually. In June 2021, the Advisory Committee on Immunization Practices recommended the first dengue vaccine (CYD-TDV) for children aged 9-16 years with a previous dengue infection, living in endemic areas, such as Puerto Rico (PR). As the COVID-19 pandemic affected vaccine intention worldwide, we assessed dengue vaccine intention before (pre-COVID) and after (post-COVID) COVID-19 vaccine availability among participants enrolled in the Communities Organized to Prevent Arboviruses (COPA) cohort to prepare for dengue vaccine implementation in PR. We used logistic regression models to evaluate changes in dengue vaccine intention by interview timing and participant characteristics. Among 2,513 participants pre-COVID, 2,512 answered the dengue vaccine intention question for themselves, and 1,564 answered relative to their children. Post-COVID, dengue vaccine intention in adults increased for themselves from 73.4% to 84.5% (adjusted odds ratio (aOR) = 2.27, 95%CI: 1.90-2.71) and relative to their children from 75.6% to 85.5% (aOR = 2.21, 95%CI: 1.75-2.78). Among all participants, groups with higher dengue vaccine intention included those who reported previous year influenza vaccine uptake and those who reported being frequently bitten by mosquitos, compared to those who did not. Adult males were also more likely to intend to vaccinate themselves than females. Respondents who were employed or in school were less likely to intend to vaccinate compared to those who were not working. The primary reasons for vaccine hesitancy were concerns with side effects and not believing in vaccines, which should be considered during educational strategies prior to dengue vaccine implementation. In general, dengue vaccine intention is high in PR and has increased after COVID-19 vaccine availability, potentially due to increased awareness of vaccine importance during the COVID-19 pandemic.

The impact of the Covid-19 pandemic and previous natural disasters on the mental health of healthcare workers in Puerto Rico.

The objective of this study was to assess the impact of COVID-19 pandemic worries (e.g., fear of contagion) and previous exposure to natural disasters (e.g., hurricanes) on Healthcare Workers (HCWs) mental health in Puerto Rico. Participants completed a self-administered online survey including items on sociodemographic information, working conditions, fears, and worries about the COVID-19 pandemic, past natural disaster experiences, depressive symptoms, and resilience. Logistic regressions models were performed to explain the relationship between depressive symptomatology and COVID-19 experiences and worries. 40.9% (n = 107) of the sample were classified as having some level (mild to severe) of depressive symptomatology (PHQ-8 ≥5). Results reflect normal to high levels of psychological resilience (BRS; M = 3.7, SD = 0.7). A significant association was found between depressive symptomatology and psychological resilience (OR = 0.44, 95% CI: 0.25-0.77). The odds of having depressive symptomatology were almost five times higher (OR = 4.79, 95% CI: 1.71-13.44) among those who reported emotional coping difficulties during the pandemic after experiencing a natural disaster compared to those that did not, when adjusting for psychological resilience and residence region. Despite normal to high psychological resilience levels, HCWs who reported emotional coping difficulties due to previous disasters were at risk of developing depressive symptomatology. Results suggest interventions to address the mental health of HCWs could benefit from considering other individual and environmental factors beyond resilience. Findings could inform future interventions to promote HCWs' well-being before, during, and after a natural disaster or pandemic outbreak.

Surveillance for Violent Deaths - National Violent Death Reporting System, 48 States, the District of Columbia, and Puerto Rico, 2020.

Problem/Condition: In 2020, approximately 71,000 persons died of violence-related injuries in the United States. This report summarizes data from CDC's National Violent Death Reporting System (NVDRS) on violent deaths that occurred in 48 states, the District of Columbia, and Puerto Rico in 2020. Results are reported by sex, age group, race and ethnicity, method of injury, type of location where the injury occurred, circumstances of injury, and other selected characteristics. Period Covered: 2020. Description of System: NVDRS collects data regarding violent deaths obtained from death certificates, coroner and medical examiner records, and law enforcement reports. This report includes data collected for violent deaths that occurred in 2020. Data were collected from 48 states (all states with exception of Florida and Hawaii), the District of Columbia, and Puerto Rico. Forty-six states had statewide data, two additional states had data from counties representing a subset of their population (35 California counties, representing 71% of its population, and four Texas counties, representing 39% of its population), and the District of Columbia and Puerto Rico had jurisdiction-wide data. NVDRS collates information for each violent death and links deaths that are related (e.g., multiple homicides, homicide followed by suicide, or multiple suicides) into a single incident. Results: For 2020, NVDRS collected information on 64,388 fatal incidents involving 66,017 deaths that occurred in 48 states (46 states collecting statewide data, 35 California counties, and four Texas counties), and the District of Columbia. In addition, information was collected for 729 fatal incidents involving 790 deaths in Puerto Rico. Data for Puerto Rico were analyzed separately. Of the 66,017 deaths, the majority (58.4%) were suicides, followed by homicides (31.3%), deaths of undetermined intent (8.2%), legal intervention deaths (1.3%) (i.e., deaths caused by law enforcement and other persons with legal authority to use deadly force acting in the line of duty, excluding legal executions), and unintentional firearm deaths (<1.0%). The term "legal intervention" is a classification incorporated into the International Classification of Diseases, Tenth Revision, and does not denote the lawfulness or legality of the circumstances surrounding a death caused by law enforcement.Demographic patterns and circumstances varied by manner of death. The suicide rate was higher for males than for females. Across all age groups, the suicide rate was highest among adults aged ≥85 years. In addition, non-Hispanic American Indian or Alaska Native (AI/AN) persons had the highest suicide rates among all racial and ethnic groups. Among both males and females, the most common method of injury for suicide was a firearm. Among all suicide victims, when circumstances were known, suicide was most often preceded by a mental health, intimate partner, or physical health problem or by a recent or impending crisis during the previous or upcoming 2 weeks. The homicide rate was higher for males than for females. Among all homicide victims, the homicide rate was highest among persons aged 20-24 years compared with other age groups. Non-Hispanic Black (Black) males experienced the highest homicide rate of any racial or ethnic group. Among all homicide victims, the most common method of injury was a firearm. When the relationship between a homicide victim and a suspect was known, the suspect was most frequently an acquaintance or friend for male victims and a current or former intimate partner for female victims. Homicide most often was precipitated by an argument or conflict, occurred in conjunction with another crime, or, for female victims, was related to intimate partner violence. Nearly all victims of legal intervention deaths were male, and the legal intervention death rate was highest among men aged 35-44 years. The legal intervention death rate was highest among AI/AN males, followed by Black males. A firearm was used in the majority of legal intervention deaths. When a specific type of crime was known to have precipitated a legal intervention death, the type of crime was most frequently assault or homicide. When circumstances were known, the three most frequent circumstances reported for legal intervention deaths were as follows: the victim's death was precipitated by another crime, the victim used a weapon in the incident, and the victim had a substance use problem (other than alcohol use).Other causes of death included unintentional firearm deaths and deaths of undetermined intent. Unintentional firearm deaths were most frequently experienced by males, non-Hispanic White (White) persons, and persons aged 15-24 years. These deaths most frequently occurred while the shooter was playing with a firearm and were precipitated by a person unintentionally pulling the trigger. The rate of deaths of undetermined intent was highest among males, particularly among AI/AN and Black males, and among adults aged 30-54 years. Poisoning was the most common method of injury in deaths of undetermined intent, and opioids were detected in nearly 80% of decedents tested for those substances. Interpretation: This report provides a detailed summary of data from NVDRS on violent deaths that occurred in 2020. The suicide rate was highest among AI/AN and White males, whereas the homicide rate was highest among Black male victims. Intimate partner violence precipitated a large proportion of homicides for females. Mental health problems, intimate partner problems, interpersonal conflicts, and acute life stressors were primary circumstances for multiple types of violent death. Public Health Action: Violence is preventable, and states and communities can use data to guide public health action. NVDRS data are used to monitor the occurrence of violence-related fatal injuries and assist public health authorities in developing, implementing, and evaluating programs, policies, and practices to reduce and prevent violent deaths. For example, the Colorado Violent Death Reporting System (VDRS), Kentucky VDRS, and Oregon VDRS have used their VDRS data to guide suicide prevention efforts and generate reports highlighting where additional focus is needed. In Colorado, VDRS data were used to examine the increased risk for suicide among first and last responders in the state. Kentucky VDRS used local data to highlight how psychological and social effects of the COVID-19 pandemic might increase risk for suicide, particularly among vulnerable populations. Oregon VDRS used their data to develop a publicly available data dashboard displaying firearm mortality trends and rates in support of the state's firearm safety campaign. Similarly, states participating in NVDRS have used their VDRS data to examine homicide in their state. Illinois VDRS, for example, found that state budget cuts were associated with notable increases in homicides among youths in Chicago. With an increase of participating states and jurisdictions, this report marks progress toward providing nationally representative data.

Attitudes towards HPV and COVID school-entry policies among adults living in Puerto Rico.

Prior to the COVID pandemic, Puerto Rico (PR) had one of the highest Human Papillomavirus (HPV) vaccine rates in the United States. The COVID pandemic and administration of COVID vaccines might have impacted attitudes toward HPV vaccination. This study compared attitudes toward HPV and COVID vaccines with respect to school-entry policies among adults living in PR. A convenience sample of 222 adults (≥21 years old) completed an online survey from November 2021 to January 2022. Participants answered questions about HPV and COVID vaccines, attitudes toward vaccination policies for school-entry, and perceptions of sources of information. We assessed the magnitude of association between the agreement of school-entry policies for COVID and HPV vaccination by estimating the prevalence ratio (PRadjusted) with 95% Confidence Intervals (95% CI). The most trusted source of information for HPV and COVID vaccines were healthcare providers (42% and 17%, respectively) and the CDC (35% and 55%, respectively), while the least trusted were social media (40% and 39%, respectively), and friends and family (23% n = 47, and 17% n = 33, respectively). Most participants agreed that HPV (76% n = 156) and COVID vaccines (69% n = 136) should be a school-entry requirement. Agreement with school policy requiring COVID vaccination was significantly associated with agreement of school policy requiring HPV vaccination (PRadjusted:1.96; 95% CI:1.48-2.61) after controlling for potential confounders. Adults living in PR have an overall positive attitude about mandatory HPV and COVID vaccination school-entry policies, which are interrelated. Further research should elucidate the implications of the COVID pandemic on HPV vaccine attitudes and adherence rates.

SARS-CoV-2 Omicron Replacement of Delta as Predominant Variant, Puerto Rico.

We reconstructed the SARS-CoV-2 epidemic caused by Omicron variant in Puerto Rico by sampling genomes collected during October 2021-May 2022. Our study revealed that Omicron BA.1 emerged and replaced Delta as the predominant variant in December 2021. Increased transmission rates and a dynamic landscape of Omicron sublineage infections followed.

Emergency powers, anti-corruption, and policy failures during the COVID-19 pandemic in Puerto Rico.

This paper explores how the use of emergency powers by the US and Puerto Rican governments exacerbated the impact of the COVID-19 pandemic and manufactured the conditions for furthering the multilayered economic, legal, political, and humanitarian crisis affecting Puerto Rico since 2006. The paper discusses three cases. First, it examines how the multiple declarations of the state of emergency, and its constant renewals, produced contradictory public health policies. Since the start of the COVID-19 pandemic in March 2020, the Puerto Rican government has issued over 90 executive orders aimed at addressing the emergency, producing an unclear, contradictory, and unequal emergency management policy. Second, the paper focuses on the impact of the passing of Law 35 on April 5, 2020, which imposed severe penalties on those who disobeyed executive orders. As a result, hundreds of Puerto Ricans were arrested, fined, and incarcerated for violating the issued order. Third, the paper studies how, citing the presence of corruption, the Puerto Rican government implemented anti-corruption and anti-fraud policies that made it more difficult for those most in need of it-mainly poor and racialized individuals, as well as immigrants and working women-to access Pandemic Unemployment Assistance. Thus, the paper argues that emergency policies designed to address the pandemic, punitive governance, and anti-corruption and anti-fraud policies undermined Puerto Rico's capacity to handle the pandemic, exacerbated its impact, and created an unequal recovery scenario.

"The Drug Sellers Were Better Organized than the Government": A Qualitative Study of Participants' Views of Drug Markets during COVID-19 and Other Big Events.

"Big events", such as wars, economic crises, pandemics, or natural disasters, affect the risk environment in which people use drugs. While the impact of big events on injection risk behaviors and access to drug-treatment services is well documented, less is known about the effects of big events on drug markets. Based on self-reporting data on drug availability among people who use drugs (PWUD) in the aftermath of Hurricane Maria in Puerto Rico and during the COVID-19 lockdown in a Midwestern US state, this study aims to document the effects of big events on drug markets. Qualitative data on the effects of Hurricane Maria on drug markets are based on participants' self-reporting (N = 31). Data collection started after the hurricane and ended in 2020. Data on changes to the drug supply during the COVID-19 lockdown were collected based on semi-structured interviews with PWUD (N = 40) in a Midwestern US state. Findings show that while the drug markets might have initially been affected by big events, most effects were temporary. Drug availability, pricing, and quality might have suffered some initial fluctuations but stabilized as the drug markets absorbed the initial shocks caused by the hurricane and the lockdown measures. In preparation for increasingly more frequent and virulent pandemics and natural disasters, health infrastructures should be strengthened to prevent not only overdose episodes and deaths but also drug-related harms.

Short- and mid-term outcomes in systemic lupus erythematosus patients presenting with disease exacerbation after SARS-CoV-2 mRNA vaccination: A cohort study from Puerto Rico.

OBJECTIVE: To determine if SARS-CoV-2 mRNA vaccination has an impact on the clinical course of systemic lupus erythematosus (SLE). METHODS: Puerto Ricans with SLE who received mRNA COVID-19 vaccines were studied. Demographic parameters, clinical manifestations, disease activity (per Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), disease damage (per Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index), emergency room visits, hospitalizations, and pharmacologic therapy were determined. Baseline variables (prior to vaccination) were compared between patients with and without exacerbation after SARS-CoV-2 vaccination. Among those with exacerbation, clinical outcomes were determined up to 1 year after vaccination. RESULTS: Of the entire cohort (n = 247), 14 (5.7%) had post-vaccination exacerbations. Photosensitivity, oral ulcers, anti-Ro antibodies, higher SLEDAI score, and corticosteroids exposure were associated with post-vaccination flares. Among those with post-vaccination flares, 10 (71.4%) had major organ involvement. No significant differences were observed for mean SLEDAI scores, emergency room visits, hospitalizations, disease damage, and exposure to immunosuppressive drugs before and after SARS-CoV-2 mRNA vaccination. At 12 months of follow-up, all patients were fully controlled without evidence of active disease. CONCLUSION: In our group of SLE patients, 5.7% had a disease flare after SARS-CoV-2 mRNA vaccination. Most had exacerbations involving major organs/systems. Mucocutaneous manifestations, anti-Ro antibodies, disease activity, and corticosteroids were associated with flares. Awareness of these factors and the possibility of a major lupus flare after vaccination with COVD-19 vaccines is critical to provide timely and effective therapy.

Searching for the 'Trigger': An ethnographic analysis of parental beliefs regarding autism causation and vaccination in Puerto Rico.

This study examines the personal beliefs held by parents of autistic children in Puerto Rico regarding the cause of their child's autism and how these beliefs may influence parental vaccination decision-making. This study seeks to contribute towards diversifying the autism literature by focusing on an autism community living in a relatively lower income, resource-deficit context. These findings expand our understandings of how parents of autistic children may perceive vaccines and how these perceptions are informed by various sources of knowledge. This ethnographic research study was conducted between May 2017 and August 2019. Methods included 350+ hours of participant-observation and semi-structured interviewing of 35 Puerto Rican parents of autistic children. 32 of these 35 parents interviewed believed autism to be the result of genetic risks that are 'triggered' by an unknown environmental factor. Suggested 'triggers' included various environmental contaminants and vaccinations. The subject of vaccination came up in every interview; 18 interviewed parents did not believe vaccines 'triggered' autism, 3 parents attributed their child's autism entirely to vaccines, while 14 considered vaccines to be one of several possible 'triggers'. It is important to note that no parents interviewed perceived vaccinations to be inherently or universally harmful. Rather, they perceived vaccinations to be one of many possible 'triggers' for a child predisposed to develop autism. In some cases, this perception prompted parents to oppose mandatory vaccination policies on the island. Parents shared nuanced, complex understandings of autism causation that may carry implications for COVID-19 vaccine uptake within the Puerto Rican autistic community.

Solving Problems Due to Hurricane Maria and COVID-19: CT Trends in Puerto Rico Before, During, and Beyond Public Health Crises.

Our objective was to evaluate the impact of recent public health crises on radiology CT services in Puerto Rico. We gathered and analyzed CT statistics from 2 of Puerto Rico's major private hospital groups and obtained monthly data from January 2016 to March 2021. We quantified short- and long-term impacts of Hurricane Maria (September 2016-August 2017, September 2017-August 2018, September 2018-August 2019) and COVID-19 (April 2019-March 2020, April 2020-March 2021) by calculating month-to-month and year-to-year percentage differences for each hospital and all hospitals combined for the dates leading up to, in the immediate aftermath, and following these major events. Despite short-term effects throughout September from Hurricane Maria, there were no noticeable year-to-year differences in the total number of CT studies performed. Both March and April 2020 highlighted the instantaneous impact caused by COVID-19; these months contributed less than 6% of the total yearly scans performed between April 2019 and March 2020 and April 2020-March 2021 for all the hospitals individually. Hurricane Maria exerted a short-term impact on CT studies performed throughout September 2017. COVID-19 also demonstrated immediate yet prolonged effects on the number of CT studies performed with all 3 hospitals reporting decreases between a full pandemic year and the year prior. Our results support fortifying medical and societal infrastructure to better prepare for future natural and public health disasters, particularly in Puerto Rico and similarly resourced areas, to maintain steady, if somewhat diminished, radiology services such as CT for regular and emergency purposes.