Evaluation of self-collected nasal, urine, and saliva samples for molecular detection of SARS-CoV-2 using an EUA approved RT-PCR assay and a laboratory developed LAMP SARS-CoV-2 test.

As the SARS-CoV-2 virus spread throughout the world, millions of positive cases of COVID-19 were registered and, even though there are millions of people already vaccinated against SARS-CoV-2, a large part of the global population remains vulnerable to contracting the virus. Massive nasopharyngeal sample collection in Puerto Rico at the beginning of the pandemic was limited by the scarcity of trained personnel and testing sites. To increase SARS-CoV-2 molecular testing availability, we evaluated the diagnostic accuracy of self-collected nasal, saliva, and urine samples using the TaqPath reverse transcription polymerase chain reaction (RT-PCR) COVID-19 kit to detect SARS-CoV-2. We also created a colorimetric loop-mediated isothermal amplification (LAMP) laboratory developed test (LDT) to detect SARS-CoV-2, as another strategy to increase the availability of molecular testing in community-based laboratories. Automated RNA extraction was performed in the KingFisher Flex instrument, followed by PCR quantification of SARS-CoV-2 on the 7500 Fast Dx RT-PCR using the TaqPath RT-PCR COVID-19 molecular test. Data was interpreted by the COVID-19 Interpretive Software from Applied Biosystems and statistically analyzed with Cohen's kappa coefficient (k). Cohen's kappa coefficient (k) for paired nasal and saliva samples showed moderate agreement (0.52). Saliva samples exhibited a higher viral load. We also observed 90% concordance between LifeGene-Biomarks' SARS-CoV-2 Rapid Colorimetric LAMP LDT and the TaqPath RT-PCR COVID-19 test. Our results suggest that self-collected saliva is superior to nasal and urine samples for COVID-19 testing. The results also suggest that the colorimetric LAMP LDT is a rapid alternative to RT-PCR tests for the detection of SARS-CoV-2. This test can be easily implemented in clinics, hospitals, the workplace, and at home; optimizing the surveillance and collection process, which helps mitigate global public health and socioeconomic upheaval caused by airborne pandemics.

Assessment of Covid-19 vaccine confidence among healthcare personnel in the safety-net sector in the United States and Puerto Rico.

BACKGROUND: This study aimed to assess COVID-19 vaccine confidence among healthcare personnel in the safety net sector of the United States and Puerto Rico. This study aimed to examine the extent to which increased knowledge and positive attitudes toward COVID-19 vaccine safety and efficacy were associated with healthcare workers' COVID-19 vaccination status and their recommendation of the vaccine to all patients. METHODS: Online survey data were collected from health care workers working in Free and Charitable Clinics across the United States and Federally Qualified Health Centers in Puerto Rico. The survey consisted of 62 questions covering various demographic measures and constructs related to healthcare workers' vaccination status, beliefs, and recommendations for COVID-19 vaccination. Statistical analyses, including multivariate analysis, were conducted to identify the factors associated with the COVID-19 vaccine status and recommendations among healthcare personnel. RESULTS: Among the 2273 respondents, 93% reported being vaccinated against COVID-19. The analysis revealed that respondents who believed that COVID-19 vaccines were efficacious and safe were three times more likely to be vaccinated and twice as likely to recommend them to all their patients. Respondents who believed they had received adequate information about COVID-19 vaccination were 10 times more likely to be vaccinated and four times more likely to recommend it to all their patients. CONCLUSIONS: The study results indicate that healthcare workers' confidence in COVID-19 vaccines is closely tied to their level of knowledge, positive beliefs, and attitudes about vaccine safety and efficacy. The study emphasizes the significance of healthcare workers feeling well informed and confident in their knowledge to recommend the vaccine to their patients. These findings have important implications for the development of strategies to boost COVID-19 vaccine confidence among healthcare workers and increase vaccine uptake among patients.

Sentinel Enhanced Dengue Surveillance System - Puerto Rico, 2012-2022.

Problem/Condition: Dengue is the most prevalent mosquitoborne viral illness worldwide and is endemic in Puerto Rico. Dengue's clinical spectrum can range from mild, undifferentiated febrile illness to hemorrhagic manifestations, shock, multiorgan failure, and death in severe cases. The disease presentation is nonspecific; therefore, various other illnesses (e.g., arboviral and respiratory pathogens) can cause similar clinical symptoms. Enhanced surveillance is necessary to determine disease prevalence, to characterize the epidemiology of severe disease, and to evaluate diagnostic and treatment practices to improve patient outcomes. The Sentinel Enhanced Dengue Surveillance System (SEDSS) was established to monitor trends of dengue and dengue-like acute febrile illnesses (AFIs), characterize the clinical course of disease, and serve as an early warning system for viral infections with epidemic potential. Reporting Period: May 2012-December 2022. Description of System: SEDSS conducts enhanced surveillance for dengue and other relevant AFIs in Puerto Rico. This report includes aggregated data collected from May 2012 through December 2022. SEDSS was launched in May 2012 with patients with AFIs from five health care facilities enrolled. The facilities included two emergency departments in tertiary acute care hospitals in the San Juan-Caguas-Guaynabo metropolitan area and Ponce, two secondary acute care hospitals in Carolina and Guayama, and one outpatient acute care clinic in Ponce. Patients arriving at any SEDSS site were eligible for enrollment if they reported having fever within the past 7 days. During the Zika epidemic (June 2016-June 2018), patients were eligible for enrollment if they had either rash and conjunctivitis, rash and arthralgia, or fever. Eligibility was expanded in April 2020 to include reported cough or shortness of breath within the past 14 days. Blood, urine, nasopharyngeal, and oropharyngeal specimens were collected at enrollment from all participants who consented. Diagnostic testing for dengue virus (DENV) serotypes 1-4, chikungunya virus, Zika virus, influenza A and B viruses, SARS-CoV-2, and five other respiratory viruses was performed by the CDC laboratory in San Juan. Results: During May 2012-December 2022, a total of 43,608 participants with diagnosed AFI were enrolled in SEDSS; a majority of participants (45.0%) were from Ponce. During the surveillance period, there were 1,432 confirmed or probable cases of dengue, 2,293 confirmed or probable cases of chikungunya, and 1,918 confirmed or probable cases of Zika. The epidemic curves of the three arboviruses indicate dengue is endemic; outbreaks of chikungunya and Zika were sporadic, with case counts peaking in late 2014 and 2016, respectively. The majority of commonly identified respiratory pathogens were influenza A virus (3,756), SARS-CoV-2 (1,586), human adenovirus (1,550), respiratory syncytial virus (1,489), influenza B virus (1,430), and human parainfluenza virus type 1 or 3 (1,401). A total of 5,502 participants had confirmed or probable arbovirus infection, 11,922 had confirmed respiratory virus infection, and 26,503 had AFI without any of the arboviruses or respiratory viruses examined. Interpretation: Dengue is endemic in Puerto Rico; however, incidence rates varied widely during the reporting period, with the last notable outbreak occurring during 2012-2013. DENV-1 was the predominant virus during the surveillance period; sporadic cases of DENV-4 also were reported. Puerto Rico experienced large outbreaks of chikungunya that peaked in 2014 and of Zika that peaked in 2016; few cases of both viruses have been reported since. Influenza A and respiratory syncytial virus seasonality patterns are distinct, with respiratory syncytial virus incidence typically reaching its annual peak a few weeks before influenza A. The emergence of SARS-CoV-2 led to a reduction in the circulation of other acute respiratory viruses. Public Health Action: SEDSS is the only site-based enhanced surveillance system designed to gather information on AFI cases in Puerto Rico. This report illustrates that SEDSS can be adapted to detect dengue, Zika, chikungunya, COVID-19, and influenza outbreaks, along with other seasonal acute respiratory viruses, underscoring the importance of recognizing signs and symptoms of relevant diseases and understanding transmission dynamics among these viruses. This report also describes fluctuations in disease incidence, highlighting the value of active surveillance, testing for a panel of acute respiratory viruses, and the importance of flexible and responsive surveillance systems in addressing evolving public health challenges. Various vector control strategies and vaccines are being considered or implemented in Puerto Rico, and data from ongoing trials and SEDSS might be integrated to better understand epidemiologic factors underlying transmission and risk mitigation approaches. Data from SEDSS might guide sampling strategies and implementation of future trials to prevent arbovirus transmission, particularly during the expansion of SEDSS throughout the island to improve geographic representation.

Plasma Proteins Associated with COVID-19 Severity in Puerto Rico.

Viral strains, age, and host factors are associated with variable immune responses against SARS-CoV-2 and disease severity. Puerto Ricans have a genetic mixture of races: European, African, and Native American. We hypothesized that unique host proteins/pathways are associated with COVID-19 disease severity in Puerto Rico. Following IRB approval, a total of 95 unvaccinated men and women aged 21-71 years old were recruited in Puerto Rico from 2020-2021. Plasma samples were collected from COVID-19-positive subjects (n = 39) and COVID-19-negative individuals (n = 56) during acute disease. COVID-19-positive individuals were stratified based on symptomatology as follows: mild (n = 18), moderate (n = 13), and severe (n = 8). Quantitative proteomics was performed in plasma samples using tandem mass tag (TMT) labeling. Labeled peptides were subjected to LC/MS/MS and analyzed by Proteome Discoverer (version 2.5), Limma software (version 3.41.15), and Ingenuity Pathways Analysis (IPA, version 22.0.2). Cytokines were quantified using a human cytokine array. Proteomics analyses of severely affected COVID-19-positive individuals revealed 58 differentially expressed proteins. Cadherin-13, which participates in synaptogenesis, was downregulated in severe patients and validated by ELISA. Cytokine immunoassay showed that TNF-α levels decreased with disease severity. This study uncovers potential host predictors of COVID-19 severity and new avenues for treatment in Puerto Ricans.

"It didn't hurt me": patients' and providers' perspectives on unsupervised take-home doses, drug diversion, and overdose risks in the provision of medication for opioid use disorder during COVID-19 in San Juan, Puerto Rico.

BACKGROUND: During the COVID-19 pandemic, clinics offering medication for opioid use disorder (MOUD) needed to rapidly introduce unsupervised take-home dosing, while relapsing patients and patients unable to enter treatment faced increased risks of fentanyl-related overdose deaths and other drug-related harms. Based on a qualitative study of people who inject drugs (PWID) receiving MOUD treatment and MOUD staff in Puerto Rico, this paper documents the lived experiences of patients and providers during this period and the risk perceptions and management strategies to address substance misuse and drug diversion attributable to unsupervised take-home-dose delivery. METHODS: In-depth qualitative interviews were conducted with patients (N = 25) and staff (N = 25) in two clinics providing MOUD in San Juan, Puerto Rico, during 2022. Patients and staff were receiving or providing treatment during the pandemic, and patients reported injection drug use during the past thirty days. RESULTS: Patients were overwhelmingly male (84%), unmarried (72%), and unemployed (52%), with almost half (44%) injecting one to three times a day. Mean time in treatment was 7 years. Staff had a mean age of 46 years with more than half of the sample (63%) female. The majority of patients believed that unsupervised take-home dosing had no significant effect on their treatment adherence or engagement. In contrast, providers expressed concerns over the potential for drug diversion and possible increased risks of patient attrition, overdose episodes, and poor treatment outcomes. CONCLUSION: This study underscores the importance of insider perspectives on harm-reduction changes in policy implemented during a health crisis. Of note is the finding that staff disagreed among themselves regarding the potential harms of diversion and changes in drug testing protocols. These different perspectives are important to address so that future pandemic policies are successfully designed and implemented. Our study also illuminates disagreement in risk assessments between patients and providers. This suggests that preparation for emergency treatment plans requires enhanced communication with patients to match treatments to the context of lived experience.

Investigating SARS-CoV-2 Incidence and Morbidity in Ponce, Puerto Rico: Protocol and Baseline Results From a Community Cohort Study.

BACKGROUND: A better understanding of SARS-CoV-2 infection risk among Hispanic and Latino populations and in low-resource settings in the United States is needed to inform control efforts and strategies to improve health equity. Puerto Rico has a high poverty rate and other population characteristics associated with increased vulnerability to COVID-19, and there are limited data to date to determine community incidence. OBJECTIVE: This study describes the protocol and baseline seroprevalence of SARS-CoV-2 in a prospective community-based cohort study (COPA COVID-19 [COCOVID] study) to investigate SARS-CoV-2 infection incidence and morbidity in Ponce, Puerto Rico. METHODS: In June 2020, we implemented the COCOVID study within the Communities Organized to Prevent Arboviruses project platform among residents of 15 communities in Ponce, Puerto Rico, aged 1 year or older. Weekly, participants answered questionnaires on acute symptoms and preventive behaviors and provided anterior nasal swab samples for SARS-CoV-2 polymerase chain reaction testing; additional anterior nasal swabs were collected for expedited polymerase chain reaction testing from participants that reported 1 or more COVID-19-like symptoms. At enrollment and every 6 months during follow-up, participants answered more comprehensive questionnaires and provided venous blood samples for multiantigen SARS-CoV-2 immunoglobulin G antibody testing (an indicator of seroprevalence). Weekly follow-up activities concluded in April 2022 and 6-month follow-up visits concluded in August 2022. Primary study outcome measures include SARS-CoV-2 infection incidence and seroprevalence, relative risk of SARS-CoV-2 infection by participant characteristics, SARS-CoV-2 household attack rate, and COVID-19 illness characteristics and outcomes. In this study, we describe the characteristics of COCOVID participants overall and by SARS-CoV-2 seroprevalence status at baseline. RESULTS: We enrolled a total of 1030 participants from 388 households. Relative to the general populations of Ponce and Puerto Rico, our cohort overrepresented middle-income households, employed and middle-aged adults, and older children (P<.001). Almost all participants (1021/1025, 99.61%) identified as Latino/a, 17.07% (175/1025) had annual household incomes less than US $10,000, and 45.66% (463/1014) reported 1 or more chronic medical conditions. Baseline SARS-CoV-2 seroprevalence was low (16/1030, 1.55%) overall and increased significantly with later study enrollment time (P=.003). CONCLUSIONS: The COCOVID study will provide a valuable opportunity to better estimate the burden of SARS-CoV-2 and associated risk factors in a primarily Hispanic or Latino population, assess the limitations of surveillance, and inform mitigation measures in Puerto Rico and other similar populations. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/53837.

The Use of Therapy Dogs in the Pediatric COVID-19 Vaccination at the University of Puerto Rico Medical Sciences Campus.

Pet ownership and therapy dogs as companion animals and emotional support have potential health benefits. We report the experiences at a COVID-19 vaccination center after authorizing children's vaccines. When the Pfizer-BioNTech vaccine for children aged 5 to 11 years was authorized for emergency use, we adapted the center's space to receive children, adding cartoon posters and balloons and using children's adhesive bandages, among others. Located at a Campus with six health professional schools, medical students dressed as storybook or movie characters. Children were asked to make drawings during the post vaccination observation period. We incorporated therapy dogs as part of our strategy for a child-friendly center during vaccination activities. Parents expressed that the COVID-19 immunization seemed to be better accepted by children as the dogs in the center entertained them. Many children were in close contact with the dogs while receiving the shots, caressing them, or having the small dogs on their laps. Children's drawings reflected colors, flowers, families, images of happiness, dogs with their names, their own pets, and superhero characters. There were no negative images of syringes, injections, or germs. To our knowledge, this was the only vaccine center in Puerto Rico that implemented therapy dogs as a strategy to create a friendly environment for COVID 19 immunization efforts targeted for children. Based on this experience, we encourage the use of therapy dogs in other immunization activities and will further gather prospective data in the future.

Ensuring Community Engagement in Disease Surveillance: The Municipal Case Investigation and Contact Tracing System for COVID-19 in Puerto Rico.

Objectives. To describe the implementation of a novel disease surveillance model in Puerto Rico, the Municipal Case Investigation and Contact Tracing System for COVID-19, established during the pandemic as the primary response. Methods. We analyzed data from July 2020 to June 2021, including all COVID-19 cases reported by public and private laboratories in Puerto Rico to describe the accomplishments and limitations of the surveillance. Results. During the first year, the system was successfully implemented in all Puerto Rican municipalities, collecting data on more than 132 000 confirmed COVID-19 cases. It improved case investigation coverage, reduced laboratory reporting times, and facilitated community engagement for ongoing response enhancements. Conclusions. Surveillance systems of this scale were new to Puerto Rico's Health System, and there was a steep learning and improvement curve. This approach enabled tailored health education, equitable distribution of testing and treatments, and surveillance by educational institutions. Public Health Implications. Near-real-time epidemiological data publication promoted trust, education, and evidence-based policymaking. (Am J Public Health. 2024;114(S1):S96-S102. https://doi.org/10.2105/AJPH.2023.307493).

COVID-19 Information, Trust, and Risk Perception Across Diverse Communities in the United States: Initial Findings from a Multistate Community Engagement Alliance (CEAL).

Objectives. To provide initial findings from Community Engagement Alliance (CEAL), a multistate effort funded by the National Institutes of Health, to conduct urgent community-engaged research and outreach focused on COVID-19 awareness, education, and evidence-based response. Methods. We collected survey data (November 2020-November 2022) from 21 CEAL teams from 29 state and regional CEAL sites spanning 19 US states, the District of Columbia, and Puerto Rico, which covered priority populations served and trusted sources of information about COVID-19, including prevention behaviors, vaccination, and clinical trials. Results. A disproportionate number of respondents were Latino (45%) or Black (40%). There was considerable variability between CEAL sites regarding trusted sources of information, COVID-19 prevention, and COVID-19 vaccination. For example, more respondents (70%) reported health care providers as a trusted source of COVID-19 information than any other source (ranging from 6% to 87% by site). Conclusions. CEAL rapidly developed novel infrastructure to engage academic, public health, and community organizations to address COVID-19's impacts on underserved communities. CEAL provides an example of how to respond in future public health emergencies to quickly promote trustworthy, evidence-based information in ways that advance health equity. (Am J Public Health. 2024;114(S1):S112-S123. https://doi.org/10.2105/AJPH.2023.307504).

Mental Health Among Puerto Rican Adolescents Living in the United States During the COVID-19 Pandemic.

OBJECTIVES: The present study examined how different family level (family financial stress, family violence) and individual (food insecurity, gender, race) determinants of health were associated with mental health among Puerto Rican adolescents living in the U.S. during the COVID-19 pandemic. METHOD: A sample consisting of 119 Puerto Rican adolescents, aged 13 to 17, was collected via Qualtrics Panels between November 2020 and January 2021. We examined the association between family financial stress experienced during the pandemic and psychological distress. We also evaluated whether the association between family financial stress and psychological distress was moderated by family violence, food insecurity, and the participant's gender and race. RESULTS: Findings showed that food insecurity positively predicted psychological distress. Results also showed that participants' race moderated the association between family financial stress and psychological distress. Specifically, we found that while there was a significant positive association between family financial stress and psychological distress among Puerto Rican adolescents who identified as a racial minority, this association was nonsignificant among White Puerto Rican adolescents. CONCLUSION: Our research highlights the significant role of COVID-19 related family financial stress and food insecurity on Puerto Rican adolescents' poor mental health during the COVID-19 pandemic.

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.

Mental Health Referrals Among Medicare Advantage Enrollees Receiving Home-Based Annual Wellness Visits in Puerto Rico During the COVID-19 Pandemic.

Annual Wellness Visits (AWV) promote preventive care for older adults, yet uptake remains low. To increase AWVs, a Medicare Advantage (MA) plan in Puerto Rico contracted a medical group to provide home-based AWVs during the last quarter of 2020. Using data from 464 visits, we conducted descriptive and multivariable analysis to profile patient characteristics and identify predictors of mental health referrals. We found that 87% of patients had multiple chronic conditions, 75% were taking more than 5 medications, and the odds of a mental health referral were higher for those who also had a nutrition-related condition (AOR = 5.05, CI95: 1.76-11.88), diabetes (AOR = 3.34, CI95: 1.18-7.58), or an additional reported uncontrolled health issue (AOR = 28.18, CI95: 8.96-70.59). This strategy helped one MA plan reach high-need patients, but coordination of follow-up care is needed to ensure patients receive recommended services.

Compliance with Influenza Vaccination and Cervical, Breast, and Colorectal Cancer Screening in a Sample of Women in Puerto Rico: Community Engagement Efforts from PR-CEAL.

OBJECTIVE: There are an estimated 5,570 yearly cancer deaths in Puerto Rico. Breast and colorectal are the most common malignancies among Puerto Rican women. Therefore, prevention and early detection of these cancer types are critical to reducing morbidity and mortality. This study assessed whether women who received the influenza vaccine had increased adherence to cervical, breast, and colorectal cancer screening. METHODS: The Puerto Rico Community Engagement Alliance (PR-CEAL) against COVID-19 Disparities team attended community outreach events throughout Puerto Rico and completed a face-to-face survey among women 18 years or older. The survey gathered demographic information and adherence to influenza vaccination and cervical, breast, and colorectal screening in the past year. The initial sample included 400 women, of whom 347 met the age inclusion criteria (21-74 years). Chi-square tests were used to compare cancer screening adherence according to influenza vaccination status. A p-value <0.05 was considered statistically significant. RESULTS: Of all participants, 47.0% received the influenza vaccine in the past year. Cancer screening rates among vaccinated and non-vaccinated women were as follows: 64.5% vs. and 13.0% vs. 8.0% for colorectal cancer (p-value=0.19). CONCLUSION: Adherence to cervical, breast, and colorectal cancer screening in the past year did not differ by influenza vaccination status. Influenza vaccination appointments may therefore represent a missed opportunity to promote preventative cancer screening in Puerto Rico.

A Closer Look at Indirect Causes of Death After Hurricane Maria Using a Semiparametric Model.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic as well as other recent natural emergencies have put the spotlight on emergency planning. One important aspect is that natural disasters or emergencies often lead to indirect deaths, and studying the behavior of indirect deaths during emergencies can guide emergency planning. While many studies have suggested many indirect deaths in Puerto Rico due to Hurricane Maria; the specific causes of these deaths have not been carefully studied. METHODS: In this study, we use a semiparametric model and mortality data to evaluate cause of death trends. Our model adjusts for cause of death effect potentially varying over time while also inferring on how long excess deaths occurred. RESULTS: From September 2017 to March 2018, after adjusting for intra-annual variability and population displacement, we find evidence of significant excess deaths due to Alzheimer's/Parkinson, heart disease, sepsis, diabetes, renal failure, and pneumonia and influenza. CONCLUSIONS: In contrast, for the same time period we find no evidence of significant excess deaths due to cancer, hypertension, respiratory diseases, cerebrovascular disease, suicide, homicide, falling accidents, and traffic accidents.

Examining Global Crises: Extracting Insights From the COVID-19 Pandemic and Natural Disasters to Develop a Robust Emergency Diabetic Retinopathy Strategy for Puerto Rico.

In this critical analysis, we investigate the profound impact of natural disasters and pandemics on the care and adherence to treating diabetic retinopathy, a severe complication of diabetes requiring continuous monitoring and treatment to prevent vision loss. Our study also sheds light on the social and economic context of Puerto Rico, emphasizing recent emergency events that have exacerbated existing public health challenges. Through a comprehensive review of relevant literature from PubMed, Google Scholar, and the George Washington University Himmelfarb Health Sciences Library database, we identified 31 pertinent articles out of 45 evaluated, focusing on the effects of these crises on healthcare delivery, diabetic retinopathy screening, and treatment. The evidence strongly indicates that during such emergencies, barriers to healthcare escalate, leading to significant treatment delays and a reduction in diabetic retinopathy screening and diagnosis, ultimately resulting in deteriorated visual outcomes. Thus, our review underscores the urgent need for the development of effective emergency plans tailored specifically to diabetic retinopathy, particularly in Puerto Rico, where diabetes prevalence and its complications are notably higher. Such plans should not only incorporate established emergency measures but also harness emerging technological advances in the field of ophthalmology to ensure optimal preparedness for future pandemics and natural disasters.

Breast and Colorectal Cancer Screening Utilization after Hurricane María and the COVID-19 Pandemic in Puerto Rico.

Puerto Rico (PR) has faced environmental and public health challenges that could have significantly affected cancer screening access. Using administrative claims data from PR's Medicaid population, this study assessed trends in colorectal and breast cancer screening from 2016 to 2021, the impact of disasters in screening, and the absolute deficit in screening due to the pandemic. The monthly rates of claims were analyzed using Poisson regression. Significant reductions in breast and colorectal cancer screening utilization were observed. The colorectal cancer screening rate in 2017 was 77% lower a month after Hurricanes Irma and María [RRadj: 0.23; 95% CI: 0.20, 0.25] compared to the same time period in 2016. Breast cancer screening dropped 50% in November 2017 compared to November 2016 [RRadj: 0.50; 95% CI: 0.47, 0.54]. Prospectively, a recovery in utilization has been observed only for breast cancer screening. The results revealed that cancer screening utilization substantially declined after environmental disasters and the pandemic. These findings have potentially severe long-term implications for cancer health disparities and mortality in PR.

COVID-19 Vaccine Booster Hesitancy among Hispanic Adults: A Cross-Sectional Study from the Puerto Rico Community Engagement Alliance against COVID-19 Disparities (PR-CEAL).

Hispanic/Latino communities have suffered a disproportionate burden of the COVID-19 pandemic. Although Puerto Rico has one of the highest COVID-19 primary series vaccination rates nationwide, this estimate contrasts with the reported booster doses' low uptake. This study aimed to assess health belief correlates of COVID-19 vaccine booster uptake. Using a convenience sampling approach, the Puerto Rico-Community Engagement Alliance (PR-CEAL) conducted a cross-sectional study where 787 participants were recruited using online and in-person strategies between December 2021 and February 2022. Participants were adults 18 years or older, Spanish-speaking, and residents of Puerto Rico. The Health Belief Model was used to evaluate attitudes and beliefs. A total of 784 participants were used in this analysis. Adjusted Poisson regression models were used to estimate prevalence ratios (PR) and 95% confidence intervals (CI) of booster refusal. Overall, 22% of participants refused the vaccine booster or had not gotten it yet. Adjusted models showed that (i) participants who disagreed that getting the booster dose either made them feel less worried about COVID-19 or (ii) felt that the vaccine decreased their chances of getting COVID-19 presented higher booster-refusal prevalence ratios (PR = 4.20, 95% CI: 3.00, 5.90; PR = 3.70, 95% CI: 2.64, 5.18). Moreover, participants that (iii) reported having concerns for booster side effects [PR = 2.47; 95% CI = 1.73, 3.51], (iv) booster efficacy [PR = 2.50; 95% CI = 1.75, 3.58], and (v) booster safety [PR = 2.80; 95% CI = 1.96, 3.99] were significantly more likely to refuse the booster. In conclusion, booster vaccination refusal was associated with lower perceived vaccine benefits and greater barriers among adults in Puerto Rico. These results informed the development of PR-CEAL's targeted community outreach strategies and public health campaigns to increase booster vaccine uptake.

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.

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 who underwent a comprehensive visual evaluation between 2018 and 2021 at the Inter American Eye Institute in Puerto Rico was performed. The spherical equivalent pre- and post-lockdown was 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 years, with 50.3% male and 49.7% female children. The mean spherical equivalent for the right and left eyes was similar ( r = 0.93, P ≤ .001). A significant difference in the mean spherical equivalent was found pre- and post- lockdown (0.22 ± 0.59 D, t800 = 10.44, P ≤ .001). A myopic shift post-lockdown was significant for all ages except those in the 7- (0.13 ± 0.79 D, t28 = 0.84, P = .40) and 8-year-old range (0.12 ± 0.65 D, t40 = 1.22, P = .23), respectively. No significant change was found between sexes before (0.16 ± 0.12 D; t799 = 1.38, P = .16) and after (0.15 ± 0.13 D; t799 = 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.

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.