Deaths due to bacterial disease in Puerto Rico were marked by Hurricane Maria

Puerto Rico's own records list as many cases of bacterial leptospirosis that officials should have declared an "epidemic" or "epidemic" after Hurricane Maria instead of deny that one to seven medical experts who reviewed unpublished data for CNN and the Centro de Periodismo Investigativo (CPI).

A Puerto Rican Mortality Database – which CNN and CPI have pursued the Island's Demographic Register to obtain – lists 26 deaths in six months Hurricane Maria, which clinicians have qualified "caused" by leptospirosis, a bacterial disease that spreads in water and soil, especially as a result of storms. According to the analysis of federal files, this is more than double the number of deaths recorded in Puerto Rico the previous year.

"Twenty-six deaths attributed to leptospirosis – this is extraordinary," said Dr. Joseph Vinetz of Medicine at the University of California at San Diego and an expert on the disease, who said examined the data. The numbers are huge.

The Puerto Rico Department of Health attributed only four leptospirosis deaths to Hurricane Maria until June 22, when it added two more after CNN and CPI about the 26 death. Officials argued that the timing was related to laboratory tests and not to journalists' questions.

Lab tests typically take weeks, not months, the experts said.

The two additional deaths were not added 64. A spokeswoman for the Ministry of Public Security, who determines the number of victims of the storm, said the government would not adjust the number until the researchers he recruited at George Washington University completed the review. ] The toll of the victims of Hurricane Maria was the subject of close scrutiny following investigations conducted by CNN, ICC and others. In May, a New England Journal of Medicine study estimated, according to interviews, that 793 to 8,498 people had died for reasons related to Hurricane Maria, many of which were due to lack of services, like electricity, after the storm. 19659004] The mortality database does not indicate whether cases have been confirmed by lab tests related to leptospirosis. It only shows if "leptospirosis" was written on a death certificate. But CNN and CPI investigated two suspected deaths from leptospirosis that were not recorded in the official death toll from Hurricane Maria and appeared, based on interviews with families, neighbors and doctors, be tied to the storm. Both men were first-aiders or volunteers who spent a lot of time in the flood waters, where the disease spreads.

One of the men, Daniel L. Vick, a 31-year-old Cayey's father, tested positive for leptospirosis. a local laboratory, according to his doctor. His medical records, provided by his family, show that he was hospitalized for "fever / chills," "nausea / vomiting" and "diarrhea," which, according to doctors, is consistent with the disease. Before his third and last hospitalization, family members and neighbors said that he had been seen coming out of his home with yellowish, yellowed skin – another sign of leptospirosis.

Her mother does not understand why her death is not counted. "Maybe the government thought that the more people died, the worse it went, that it meant that they had done a bad job in responding to this tragedy," Margarita Rodriguez said. "It's incomprehensible, it seems like they're not doing it.The only thing they care about is their image."

Leptospirosis is very rarely fatal and can be treated with antibiotics currents. It is mainly carried in the urine of rats and other animals. It can be ingested in drinking water or absorbed by cuts in the skin. None of the men CNN and CPI investigated were given gloves, boots, or prophylactic antibiotics, according to their families. According to experts, these simple measures can help prevent leptospirosis diseases in people working in the water.

In general, epidemiologists have stated that deaths occurring closer to the hurricane of September 20, 2017 were more related to the storm than those of 2018 The 26 deaths labeled "leptospirosis" in the Puerto Rico data are occurred between September 24, 2017 and March 6, 2018. The majority of these deaths – 21 – occurred before December 31st.

In comparison, there were 11 deaths from leptospirosis. Puerto Rico the previous year, according to mortality data from Centers for Disease Control and Prevention (CDC) analyzed for CNN and CPI by an independent demographer.

Puerto Rican authorities say they only count deaths from leptospirosis if the diseases were confirmed. by CDC tests and if deaths occurred between September 20th, the day of the storm and October 20th.

Vick's death occurred on October 19, a day before this cut. It is not known whether his death was analyzed by CDC tests because the officials refused to comment on specific cases.

Vinetz, of the UCSD, has termed the delay of one month indefensible because it may take three weeks for leptospirosis symptoms to appear. and because the cleaning of hurricanes – and the potential for exposure to leptospirosis that goes with it – has continued for weeks.

"This is not justified," he said. "It's probably too restrictive and this underestimates the numbers … I think it's more likely that no, it's a political decision." Asked by CNN and CPI why so much more of deaths labeled with leptospirosis appear in Puerto Rico's death records that have been publicly acknowledged as related to the storm, Dr. Carmen Deseda, Puerto Rico's state epidemiologist "Doctors do not always have access to complete records, and labs may still be waiting. "

Authorities investigate 26 cases in death records, Deseda

.

Several data sources suggest that An "epidemic" or "epidemic" of leptospirosis occurred as a result of Hurricane Maria – but the Puerto Rican authorities will not call it that way.

On Friday, the Centers for Disease Control and Prevention (CDC) ap relied on its own statistics on leptospirosis deaths on the Caribbean island under the Freedom of Information Act of the United States. The internal CDC document lists 17 "confirmed and probable" post-hurricane deaths in which laboratory tests show that leptospirosis was a factor – plus 25 other "suspected" leptospirosis deaths that required additional laboratory confirmation.

In addition to deaths The Puerto Rico Department of Health told CNN and CPI that 57 cases of leptospirosis were laboratory-confirmed in 2017, 54 of which after Hurricane Maria, which struck the 20 September. and quadrupling confirmed illnesses in the previous two years, according to the figures provided. Comparing months, the peak is even sharper – with 31 confirmed diseases in October 2017 compared with four the previous year; and 16 cases of illness in November 2017, sixteen times more than the only confirmed disease in November 2016.

There is no internationally established threshold for reporting an "epidemic" or "epidemic" of leptospirosis, according to epidemiologists, many of whom use these terms. almost interchangeable. The CDC generally defines an epidemic as "an increase, often sudden, in the number of cases of an illness greater than what is normally expected in this population in this area". Epidemics often refer to "a more limited geographical area," says the CDC.

Puerto Rican health officials cited conflicting thresholds that they believe are needed to declare a leptospirosis epidemic. In November, Puerto Rico's secretary of health, Dr. Rafael Rodríguez Mercado, told a local radio journalist that "200 cases a week" were needed to make this statement. Dr. Cruz María Nazario Delgado, a professor and epidemiologist at the University of Puerto Rico's Medical Sciences Campus, told CNN and CPI that the measure is "a lot of nonsense". (Monday, Rodríguez Mercado told CNN and CPI interview.)

In an interview with CNN and CPI on June 25, Deseda, the Puerto Rico state epidemiologist, said officials should see a "double" increase in cases of reporting an outbreak.

After CNN and CPI questioned these inconsistencies, Deseda issued a statement by a spokesperson paraphrasing the definition of an epidemic or epidemic – and adding that it was not necessary Is not appropriate to compare the number of diseases after the storm to previous years. She said the officials were more actively looking for Leptospirosis diseases after Hurricane Maria and that they were doing it using different diagnostic tests, she said. The double threshold of an epidemic has been reached – if not exceeded – due to the fact that laboratory-confirmed diseases have more than doubled after Hurricane Maria.

Another way to evaluate data from the Ministry of Health would be the two "confirmed" and "probable" diseases of leptospirosis, according to experts. Both are at least partially confirmed by laboratory tests. Looking at the numbers in this way, there is at least a "double" increase when comparing October or November 2016 to 2017, but a little less than twice the number of diseases – 1.6 times – when compared to the same period of time. we compare the year 2016 to the following year. ] Deseda told CNN and CPI on June 25 that the Puerto Rico health department did not have access to its own lab tests after the severe storm and that the basic data needed to declare an outbreak was unclear. Were not available. "Leptospirosis is one of those diseases where it's very difficult to declare an epidemic," said Deseda, "because at that time, there was no test we could do to validate or confirm the cases … It took three or four weeks to send samples (to the CDC) because of the heavy impact of the hurricane – and the devastating impact on our communications and our power supply

"Our laboratory was not ready to collect samples. How could we declare an epidemic if we did not have that number (of confirmed cases) at that time? "

Authorities responded to emergencies," she said, warning the public about the dangers of flooding with antibiotics and advising doctors to treat the signs of leptospirosis as if the disease had occurred. produced, even though laboratory tests were not readily available.

On October 22, Public Affairs Secretary Ramon Rosario Cortes told reporters "But obviously," he added, "we all do the ads as if it was a health emergency. "

" The evidence is just irrefutable "

Seven experts – five epidemiologists and two doctors specializing in related diseases – have told CNN and CPI that Puerto Rico's mortality database and its own figures for confirmed leptospirosis diseases suggest "epidemic" and "epidemic" labels are important, according to public health experts because they can trigger increased disease surveillance and more vigorous efforts to prevent infection. They also help the public deal with the seriousness of the situation and take the warnings seriously, which can lead to disease prevention and better treatment, experts say. control of the situation – do not hide the situation, "said Nazario, the professor and epidemiologist of the campus of the University of Puerto Rico's medical sciences.The officials, she said, had reason to believe that 39, there was a significant number of cases of leptospirosis after Hurricane Maria.

Leptospirosis cases should have been classified as an epidemic, added Nazario, adding that it is surprising that "Disclaimer "That's something that happened last year." Puerto Rican health officials had enough information to declare an outbreak even before CDC tests were made available to them. , she said.

"The Ministry of Health was not doing its job." epidemic, "said Dr. Albert Icksang Ko, professor and chair of the Department of Microbial Disease Epidemiology School of Public Health Yale.

"The epidemic of leptospirosis that occurred after Hurricane Maria and the associated deaths were predictable," he said. "Disasters, whether they happen in Puerto Rico or anywhere in the world, are triggers or drivers of leptospirosis … It really highlights the challenges we have in solving the public health problems of leptospirosis in Puerto Rico ". "This information should have been public and I'm surprised you had to go on to get this information."

"The real question is" why? ", Said Dr. Lemuel Martinez, an infectious disease specialist in Manati, Puerto Rico. "If they had the data, why did not they say [an epidemic] at that time? … It's not a question of opinion." The data is there. would they refuse? "

The numbers are staggering, said Vinetz, the UCSD professor. "The evidence is just irrefutable that something is happening – something important is going on," he said. "It's taboo not to call it an epidemic or an epidemic."

Several experts pointed out that leptospirosis is under-researched. Doctors often miss or poorly diagnose the disease, which has symptoms reflecting other diseases such as influenza and dengue, including "fever, headache, chills, muscle aches, vomiting / diarrhea, cough, conjunctival suffusion , jaundice and sometimes rash ". the CDC says. Untreated, according to the CDC, a person "could develop kidney damage, meningitis, liver failure and respiratory distress."

Other experts saying that an epidemic or epidemic should have been declared were: Jonas Brant, professor and epidemiologist at the University of Brasilia; Dr. Melissa Marzán Rodríguez, Epidemiologist and Professor of Infectious Diseases at Ponce Health Sciences University, Puerto Rico; and Claudia Muñoz-Zanzi, an epidemiologist at the School of Public Health at the University of Minnesota, who said it was the "definition" of an epidemic.

"We need to raise awareness about leptospirosis and these epidemics. the need to do more research to detect these outbreaks as soon as possible "and to say how best to respond, said Muñoz-Zanzi." Without [public officials] declaring outbreaks, we can not do that because we n & # We do not have the data we need to make these recommendations. "

Worldwide, the disease is estimated to be over 1 million Two additional experts said that an outbreak could have been declared – but would not go so far as to say that it should have been declared by the Puerto Rican authorities without better baseline data and without understanding exactly what the authorities did, and I did not know it at that

Dr. Brenda Rivera García, a former state epidemiologist in Puerto Rico, said that there is clear basic data available for officials to judge whether an outbreak is occurring. is produced. In fact, she said, there has been a significant increase in cases in a short period of time – but she does not know if the Department of Health has all the information needed to declare an epidemic

CNN and CPI investigated a total of four deaths labeled in government data as having been linked to leptospirosis that were not recorded in the death toll caused by Hurricane Maria.

After interviewing relatives and neighbors, In reviewing hospital records, at least two of these un-identified deaths appeared to be related to Hurricane Maria, based on criteria set by the CDC for deaths caused by disasters.

At least one case seemed to have nothing to do with the storm.

A. Sanchez Vazquez, 58, was hospitalized before Hurricane Maria, according to Ana Sanchez, his sister. He died four days after the passage of Hurricane Maria. Because he was sick before the arrival of Hurricane Maria, Ana Sanchez does not consider his death as a storm.

In Bayamon, a suburb of San Juan, the capital of Puerto Rico, Ricardo A. Cotto Rodriguez, 48, known in his neighborhood for his humor and for being the fanatic water boy for the Vaqueros, the local basketball team, died on November 17, records show. Relatives told CNN that Cotto was mostly bedridden after the storm and that his bed sores were infected.

He was hospitalized after falling and he got stuck in the shower, when there was no electricity in the area. Gilberto Rodriguez Quiñones, his cousin, said that his death seems to have been linked to Hurricane Maria because of this fall, which, according to him, occurred in the dark without power. But it was not clear how he could have contracted a waterborne illness.

The government database lists "Leptospirosis", "Chronic Skin Ulcer" and "Obesity" among contributors to Cotto's death. His death certificate indicates that leptospirosis "probably" contributed

. In two other cases, however, family members and neighbors described circumstances that health professionals consider compatible with leptospirosis

. They also did not receive gloves, boots or prophylactic antibiotics, according to experts, which according to public health experts could be used.

Deseda, the state's epidemiologist, said that aid workers had received preventive help. Officials have made the risks of leptospirosis sufficiently known, she said, and antibiotics are available in hospitals. When she insisted, she did not clearly indicate whether the drugs were being used preventively.

She defended Puerto Rico's efforts to warn the public of the disease, saying that she appeared on television and radio warning people to stay away from the contaminated waters. places where the urine of rats and other animals could be found.

Martinez, the doctor in Manati, Puerto Rico, said the health department's communications about leptospirosis were "almost non-existent, at best." said: "It shocked me"

In Toa Baja, Luis Diaz Garcia, 55, told CNN and CPI that his younger brother, Ramon, had been injured. Diaz Garcia, 52, was generally healthy before the storm. He suddenly became ill and then disappeared after spending weeks volunteering with cleanup efforts, said Luis Diaz. The family spent a month in agony, not knowing what had happened before a relative contacted the San Juan Bureau of Forensic Sciences. The database shows that the death of Ramon Diaz was examined on October 26 by the Bureau of Forensic Sciences, who did not perform an autopsy.

"Leptospirosis" is among the contributors to his death in the registers. we that he had a strange color, that he looked yellowish, "said Luis Diaz. "They asked if he had hepatitis, and we said," No, he was healthy. "

Martinez, the infectious disease specialist, said that yellow skin is a clear sign of leptospirosis, especially when it accompanies acute fever after a storm." one becomes yellow after a hurricane, that is leptospirosis unless proven otherwise, "he said.

The Bureau of Forensic Sciences of Puerto Rico is allowed to classify deaths related to hurricanes. Ramon Diaz does not appear on the list of 64 hurricane victims in Puerto Rico.

Ramon Diaz did not have any identification on him when he went to At the hospital, said his brother, the forensic doctors told Luis Diaz that if the family had not contacted them, his body would have been cremated in a few days and remained unidentified, he told CNN and at CPI

"He was cool to everyone. He would help anyone who needed it, "said Luis Diaz of his brother, one of 13 brothers and sisters." This guy would put you to sleep while talking and telling jokes! "

Ramon Diaz was living with him At the moment of the storm, said Luis Diaz.The room of Ramon Diaz is now empty.The blades of a fan are still on the floor.A clock that has not worked for years is hanging on the wall, stuck right after 4 pm A mattress is wrinkled in the corner.

Luis Diaz has trouble understanding why his brother is not counted.

"I do not know what to tell you," says he, seeming stifled by the question.

He keeps his brother's ashes in a box on the kitchen counter

'He sacrificed himself'

Daniel L. Vick, the Cayey's young father, is also unaccounted for.

Loved the beach, karaoke nights and watching his 7-year-old salsa dance, a pa Sseed her days after Hurricane Maria to cross the floods to help the neighbors as an employee of the city of Cayey, said the family. His death on October 19, which Puerto Rico's death records describe as "caused" by "leptospirosis," is not considered a hurricane death.

The doctor who certified his death, Dr. Julio Garcia at the Centro Medico Menonita of Cayey, He told CNN and CPI that a local laboratory test indicated that he was suffering from leptospirosis.

Prior to his third and last hospitalization, family members and neighbors stated that he had been seen coming out of his home with jaundice. Margarita Rodriguez said her son was in "perfect health" before the storm.

Authorities declined to comment on the death of Vick or Diaz beyond saying that they had not been officially classified as being related to Hurricane Maria. One of the two cases – either Vick or Diaz – has been confirmed by laboratory tests as having been caused by leptospirosis, said Deseda. She declined, however, to say which of the two, adding that laboratory-confirmed death from leptospirosis was not considered hurricane-related because of the date on which it occurred. .

Rodriguez said that she begged her son to stay alive. 19659004] "You must be strong," she recalls, telling her son at the hospital. "We need you here – for your daughter, for your wife and to continue to help your community – we need you here."

"You could see tears running down his face" Health would intubate her, pushing a tube into her airways so she could continue to breathe, she said in an interview. "You could see by looking into his eyes that he did not want to close his eyes – let himself go."

"He sacrificed himself," she added. "He gave it all … He should be considered a hero."

"I just want him to be remembered," she says.

Margarita Rodriguez will remember her son as a shy, kind, caring and considerate man. a man who loved his family and loved his job, who rarely put himself in the honor but whose value was measured by everything he did quietly to help others, especially after Maria

His widow , Ingrid Nieves García, 29, her shoes in an impromptu public memorial for the victims of Hurricane Maria on the Puerto Rican Capitol of San Juan

In early June, people have deposited thousands of empty shoes near the steps to represent countless victims

. was important "because I've never had the space or the moment to say goodbye in his funeral.It was not my place to do it at the time," she said to CNN and CPI. "I think the moment I brought her shoes (to the memorial), which was the last thing I left her, helped me let me go, say goodbye. After his death, a psychologist told Daniel Vick's daughter that her father was in heaven, an angel watching over her – that God needed that he be up there with him, his "Maybe later "said a neighbor," she will understand what happened ".

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