Items of health interest

Puerto Rico – Hurricane Maria: A Health Risk Assessment 

Puerto Rico is in a race to prevent dangerous exposures to its residents. The potential hazards are infectious diseases from pathogens in sewage contaminated rivers and streams and poisoning from the twenty-four designated U.S. Environmental Protection Agency (EPA) superfund site floodwaters; EPA reports toxic chemicals, such as tetrachloroethene (PCE) and trichloroethene (TCE) are present.[i] These chemicals are considered probably carcinogenic and carcinogenic respectively.[ii] The Maria hurricane crisis response remains complicated by the absence of electricity for eighty percent of residents connected to the electrical grid and poor communications and road access in remote communities.[iii] Additionally, people may be suffering from treatable or preventable conditions because they may not know about the toxic or disease risks. 

Recent Federal Emergency Management Agency (FEMA) reports detail the current state of recovery on the island. According to the FEMA update of October 18, almost one million residents have not been restored to Puerto Rico Aqueduct and Sewer Authority potable water and only seven percent of the roads are open.[iv] While the military has provided helicopter transport for food and water into isolated communities and evacuation of ill/injured persons for medical care, many residents still do not receive sufficient life sustaining supplies. While cellular phone service has improved to fifty-eight percent customer access (as of October 7)[v] and facilitated the dissemination of emergency text messages, general warnings about the danger of contaminated water supplies may not address whether any specific water is safe for consumption.  Individual water sources must be tested to determine if they are potable. If there are few water supplies available, people may unintentionally choose to drink water of unknown purity. The movement of goods to repair homes is limited by the road access bottleneck. Damage to housing increases the risk of injury from poor living conditions and exposure to mosquito-borne disease, which is a constant concern in tropical environments. 

The hurricane that devastated Puerto Rico was the most severe storm to strike the island since hurricane San Filipe II in 1928 according to the U.S. National Weather Service.[vi] The fragility of Puerto Rican infrastructure, which is attributable to a lack of regular maintenance and other causes, also contributed significantly to the difficulty of recovery/restoration operations. Exposure to hazardous water can be prevented by comprehensive public messages cautioning residents to avoid consumption of water of unknown purity and increased supplies of bottled water. Hazards from living in unsafe living conditions can be mitigated by improving road access and supply delivery or temporary relocation of endangered residents. All possible efforts should be made help Puerto Rico recover from this calamitous hurricane.   

[i] U.S. Environmental Protection Agency, “Search for Superfund Sites Where You Live,” available at https://www.epa.gov/superfund/search-superfund-sites-where-you-live on October 22, 2017.   

[ii] U.S. Agency for Toxic Substances and Disease Registry, Toxic Substances Portal, available at https://www.atsdr.cdc.gov/toxfaqs/index.asp on October 22, 2017.   

[iii] U.S. Federal Emergency Management Agency, “Hurricane Maria- Maria Updates,” available at https://www.fema.gov/hurricane-maria?utm_source=hp_promo&utm_m on October 20, 2017   

[iv] U.S. Federal Emergency Management Agency, “Hurricane Maria- Maria Updates,” available at https://www.fema.gov/hurricane-maria?utm_source=hp_promo&utm_m on October 20, 2017   

[v] U.S. Federal Emergency Management Agency, “Overview of Federal Efforts to Prepare for and Respond to Hurricane Maria,” available at https://www.fema.gov/blog/2017-09-29/overview-federal-efforts-prepare-and-respond-hurricane-maria on October 22, 2017.   

[vi] U.S. National Weather Service, “Major Hurricane Maria: Wort hurricane in nearly 9- years for Puerto Rico,” available at http://www.weather.gov/media/sju/events/Maria/HurricaneMaria.pdf on October 22, 2017.    

Hurricane Maria and Puerto Rico – Health and Economic impacts  

Puerto Rico was devastated by hurricane Maria, which struck the island in September 2017. The major infrastructure systems, including electricity, transportation, and water purification/sewage treatment were heavily damaged and full restoration will take many months. Other infrastructure systems dependent on these infrastructures, such as communications and banking, will also be degraded for an extended period. Destruction of housing and disruption of communication, transportation, and electricity will have profound effects on the functioning of the island economy and the health of the population. The public health impact from the storm is expected to include increased incidence of infectious diseases, less effective management of chronic diseases, as well as a general degradation of health status. The loss of electricity and the resulting effects on water purification/sewage treatment and communications clearly demonstrates how major infrastructure systems are connected to each other and how some infrastructure systems are mutually dependent on other systems to function.  

The combination of damage to public and personal property indicates the recovery of Puerto Rico will be very expensive. The destruction caused by the hurricane is unprecedented. According to media reports 85 percent of the population continues to lack access to electrical power from the island’s grid, 40 percent lack access to clean water[i], and 80 percent[ii] of agriculture was destroyed. Communications, which are dependent on the availability of electricity, remain crippled and that continues to make comprehensive damage assessment and many banking services unavailable in remote areas. The challenges for the public health response are numerous. The damage to communications and transportation degrades the ability of public health authorities to monitor and mitigate the expected increase in infectious disease and to manage patients with treatment-dependent chronic diseases. The damage to a large percentage of residential dwellings means that many people are living outside, exposed to heat and mosquitoes. Mosquitoes are expected to flourish in the flood waters, raising the transmission risk of diseases such as dengue, chikungunya, and Zika, and placing additional stress on the limited health resources of battered communities. Typhoid disease may surge due to unavailability of sewage treatment and dependence on rivers and streams for drinking water. Road access to remote communities remains affected by debris-strewn roads and flooding. Transport of essential medications to treat prevalent diseases such as diabetes and heart disease remains limited and that, along with difficulties in distributing food supplies, is expected to have an adverse effect on older and sicker community members. The lack of access to electrical power could also affect food processing and storage, potentially leading to increased risks of food-borne disease. 

The crippling of communications outside the major cities is expected to limit the ability of public health authorities to quickly respond to individual health concerns. The advent of electronic medical records means that healthcare providers may not have access to the complete medical records of patients presenting for services outside of their customary treatment settings. Data collected by the Puerto Rican government indicates the three leading causes of death on the island are heart disease, cancer, and diabetes. All of these diseases are chronic and require continuing care. If records for past medical care are not available, the treatment may not be optimal because past test results can not inform treatment decisions. More generally, many more people may become dependent on access to public medical care. 

Restoration of infrastructure, housing, and the economy is likely to take a long time and many competing recovery priorities exist for the limited available resources. Electricity is an infrastructure that is essential to the functioning of other critical infrastructures and the inability to provide hospitals and other healthcare facilities with power increases the difficulty of treating acutely and chronically ill patients. Also, electricity supports infection control by supporting disinfection and it allows the laboratories to run diagnostic tests and clinicians to provide emergency services such as surgery. Lastly, chronic care services such as dialysis and breathing support and food safety resources are not available if there is no electricity. A reliable system of communication that covers the entire island is another important priority. Restoration of communications would facilitate public health surveillance and access to some banking services so health service institutions could pay staff salaries and purchase essential supplies. Individuals could buy goods to repair damaged houses. Although restoration of road transport can facilitate the movement of goods and personnel into areas where they are immediately needed, in the short term a logistics chain that quickly moves goods is another important priority. It would also make it possible to evacuate patients that require high–level care. Such a transportation system may be based on cargo helicopters until roads can be cleared and repaired. Restoration of water treatment facilities would provide one of the essential services that allows displaced persons to return to their homes and begin restoration activities. 

The recovery and associated needs assessments from hurricane Maria are in their earliest stages. Emergency response resources are arriving but the true scope of the disaster remains incompletely assessed. We do know the level of destruction is massive and people continue to suffer significant aftereffects. Formulation of a well-considered plan to reconstruct the lost infrastructure will ease the suffering of the Puerto Rican victims.  

Although the unemployment rate in Puerto Rico is twice the rate of the United States, many people on the island receive health insurance from their employer. The damage to industrial facilities will affect access to care for those who have lost jobs, the ability of the local government to fund public health services, and the ability of the economy to recover to pre-hurricane production activities. The level of devastation in Puerto Rico may also result in massive migration from Puerto Rico to the U.S. mainland as workers are displaced from their homes and employment. Since Puerto Ricans are U.S. citizens, they are free to relocate anywhere within the United States. Early estimates for restoration for electricity throughout the island are at a minimum many months and may require an entire year. In addition to residential destruction which will affect the ability of the workforce to live in the most severely affected areas, some of the important industrial facilities on the island, which include agriculture and pharmaceuticals, will experience significant disruption until the electrical grid is restored. The decline in economic production and the departure of workers could further destabilize Puerto Rico’s precarious economic condition. The government already faces a debt restructuring and an additional reduction in revenue would further compromise its ability to repay its creditors. It remains unknown how much money and time will be required to restore the economy, but Puerto Rico faces the simultaneous economic challenges of depopulation, and loss of economic production, and restoration of critical infrastructure as well as the health challenges of caring for a population living under difficult conditions.   

[i]  Oren Dorell, “Nearly 3 weeks after Hurricane Maria, distributing aid across Puerto Rico is a mess,” USA Today, October 9, 2017. Available at https://www.usatoday.com/story/news/world/2017/10/09/puerto-rico-aid-hurricane-maria/741739001/ on October 9, 2017.   

[ii] British Broadcasting Corporation (BBC), “Seven graphics that sum up Puerto Rico disaster,” October 2, 2017. Available at http://www.bbc.com/news/world-us-canada-41447184 on October 3, 2017.    

2017 avian influenza virus infection update – cases detected in humans and animals 

Both human and animal infections with the avian influenza continue to challenge countries around the world. In Taiwan and China, outbreaks of H5N6 an H7N9 respectively have caused significant economic losses among commercial bird flocks[i]. Additionally, China continues to experience human cases of H7N9 avian influenza with both fatalities and serious illness during 2017.[ii]  

Other outbreaks of reportable avian influenza, which include all highly pathogenic subtypes and all H5 and H7 subtypes, have been reported in Asian, African, North American, and European countries during 2017.[iii] The virus was detected in both domestic and wild birds. As in the past, the greatest risk for human avian influenza infection is from exposure to diseased domestic birds in settings such as live poultry markets or while slaughtering and preparing domestic birds for human consumption. The spread of reportable avian influenza viruses remains largely attributable to wild bird migration. The wild birds, which are generally not sickened by infection with the virus, can still shed the virus in their feces. Domestic birds become infected when they interact with wild birds, often by sharing outdoor water sources. 

The occurrence of reportable H5 and H7 subtype avian influenza virus and disease among domestic birds is especially concerning because of the risk of these subtypes mutating from low pathogenic viruses, which cause mild disease in domestic birds, to highly pathogenic viruses, which have high mortality among domestic birds. Notably, severe avian influenza virus disease in humans was generally associated only with infection with highly pathogenic viruses until several years ago. Beginning in 2013, humans infected with low pathogenic H7N9 subtype virus exhibited severe disease with significant mortality in China and this continues through 2017. 

Poultry is one of the most important animal based protein sources in the human diet worldwide. The confluence of husbandry practices that expose domestic birds to wild birds and slaughter/processing practices that expose humans to virus-laden aerosols suggests human and domestic bird cases of avian influenza infections will continue. Surveillance and monitoring will give public health authorities information that will help detect and respond to outbreaks that could lead, by virus mutation, to a human pandemic.    

[i] World Organization for Animal Health, “Update on avian influenza in animals (types H5 and H7) - OIE Situation Report for avian influenza (latest update: 18 September 2017),” available at http://www.oie.int/animal-health-in-the-world/update-on-avian-influenza/2017 on October 2, 2017.   [ii] World Health Organization, “Human infection with avian influenza A(H7N9) virus – China Disease outbreak news  13 September 2017,” available at http://who.int/csr/don/13-september-2017-ah7n9-china/en/ on October 2, 2017.   [iii] World Organization for Animal Health, “Update on avian influenza in animals (types H5 and H7) - OIE Situation Report for avian influenza (latest update: 18 September 2017),” available at http://www.oie.int/animal-health-in-the-world/update-on-avian-influenza/2017 on October 2, 2017.    

Community health centers provide the sole access to healthcare in many remote and underserved communities – they should be funded in full in the current federal budget

Community health centers are primary care health facilities that provide a wide range of medical, dental, and mental health services to underserved communities, especially in remote rural areas.[i] The federal funding for these facilities will end in March unless the U.S. Congress and President agree to provide the funding for the rest of fiscal 2018. The current opioid abuse epidemic and the severity of the seasonal flu epidemic are two urgent and ongoing health crises affecting communities lacking a robust health infrastructure and adequate numbers of healthcare providers. If funding is not restored to this program, many services for about 26 million people who may not have any other access to healthcare services will end. This would include substance abuse treatment for the impoverished areas most severely affected by the opioid crisis and preventive and acute care for the seasonal flu epidemic which has not yet reached its peak.

The U.S. Centers for Disease Control and prevention reports the current flu season is the worst in many years. Influenza related deaths have surpassed previous epidemic thresholds. While the virus remains susceptible to antiviral drug therapy, patients must first obtain a prescription from a healthcare provider. The number of opioid abuse related deaths continues to rise with the number for2016 exceeding the number for 2015. Effective addiction treatment requires both medical and mental health support services. Chronic disease is a complicating factor for many people suffering from both severe flu and substance abuse. Any interruptions in treatment may increase the risk of adverse outcomes. Federally funded community health centers are located in places where there are few opportunities for healthcare outside the facilities themselves, so residents who have health insurance and residents who can pay out-of-pocket are at a similar disadvantage as those who rely on community health centers to obtain low-cost or free health services.

Preventive care provides direct and indirect cost savings to the economy. The direct savings include effective management of chronic conditions and vaccination to prevent the spread of infectious disease. The indirect savings include reduced labor productivity losses from sick days and a reduction in disability due to chronic disease. Funding community health centers is a wise investment. If federal funds are not extended, many communities will lose access to the only health services available to them.

[i] Department of Health and Human Services, Health Resources and Services Administration, "Health Center Program,” August 2017, available at https://www.bphc.hrsa.gov/about/healthcenterfactsheet.pdf on February 1, 2018.

Delays in Puerto Rico hurricane recovery affect U.S. public health systems

The continuing crisis in Puerto Rico is affecting public health in the rest of the United States because of an unusually severe winter flu season and disruption of the supply chain of medical products manufactured on the island. Data from the U.S. Centers for Disease Control (CDC) and Prevention shows Influenza-like illness in every part of the United States except Hawaii is widespread.[i] According to a U.S. Food and Drug Administration (FDA) statement of January 4, intravenous saline solution shortages continue for the national healthcare system.[ii] These products are essential for the treatment of hospitalized patients suffering severe respiratory symptoms including influenza. Additionally, recent FDA testimony to Congress described 30 critical medical products either solely or primarily manufactured in Puerto Rico that were disrupted by hurricane Maria.[iii] Similarly, an FDA statement of October 20, 2017 reported Puerto Rico also manufactures a range of other medical goods including surgical instruments, cardiac pacemakers, insulin pumps, and pediatric/adult amino acid formula (for intravenous nutrition) among more than 1000 products.[iv] The 18,000 strong labor force in this sector is also affected by the destruction of housing and essential services like water purification.

Puerto Rico is an indispensable and essential component of the U.S. healthcare infrastructure and rapid hurricane recovery and reconstruction will benefit us all. As of December 27, the Department of Energy reported about 70 percent of Puerto Rico’s electricity has been restored.[v] As of mid-December, the U.S. Federal Emergency Management Agency (FEMA) reported about 14 percent of Puerto Rico still lacks potable water.[vi]

[i] U.S. Centers for Disease Control and Prevention, “FluView Weekly U.S. Influenza Surveillance Report - 2017-2018 Influenza Season Week 2 ending January 13, 2018,” available at https://www.cdc.gov/flu/weekly/index.htm  on January 22, 2018.

[ii] U.S. Food and Drug Administration, “FDA Statement:  Statement by FDA Commissioner Scott Gottlieb, M.D., update on recovery efforts in Puerto Rico, and continued efforts to mitigate IV saline and amino acid drug shortages,” January 4, 2018 available at https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm591391.htm on January 22, 2018.

[iii] U.S. Food and Drug Administration, “Testimony of Scott Gottlieb, M.D, Commissioner on Food and Drugs, before the Subcommittee on Oversight and Investigations, Committee on Commerce, U.S. House of Representatives,” October 24, 2017 available at https://www.fda.gov/NewsEvents/Testimony/ucm581757.htm  on January 22,2018. 

[iv] U.S. Food and Drug Administration, “FDA Statement Statement by FDA Commissioner Scott Gottlieb, M.D. on medical device manufacturing recovery in Puerto Rico,” October 20, 2018 available at https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm581436.htm on January 22, 2018.

[v] U.S. Department of Energy, Infrastructure Security and Energy Restoration, “Hurricanes Maria and Irma – December 27 Event Summary (Report 84), available at https://energy.gov/sites/prod/files/2017/12/f46/Hurricanes%20Maria%20and%20Irma%20Event%20Summary%20December%2027%2C%202017_2.pdf on January 22, 2017.

[vi] U.S. Federal Emergency Management Agency, “FEMA Hurricane Maria,” available at https://www.fema.gov/hurricane-maria on January 22, 2018.

Disease outbreak update

There is an outbreak of Lassa hemorrhagic fever in West Africa. It began with the detection of two separate cases in February 2017, one in Burkina Faso and one in Benin. Both cases were reported to the World Health Organization upon confirmation of the diagnosis. A case was detected in Togo and reported to WHO in early March 2017. The Nigeria Center for Disease Control reports an ongoing outbreak of Lassa since the beginning of 2017 affecting 10 states. None of this is remarkable since Lassa is endemic to the Nigeria and there is constant travel among border communities in Nigeria, Benin, Togo, and Burkina Faso. It is noteworthy, however, that the outbreak is being effectively managed locally with the epidemiological investigation conducted by health officials in the affected countries: Togo, Benin, Burkina Faso, and Nigeria, and the laboratory diagnoses were completed in local government facilities. 

Overall, there have been 239 contacts monitored and ongoing contact tracing is underway to identify persons who may be at risk for infection. This coordinated international response is the result of the January 2017 establishment of a multilateral African institution for disease control. The Africa Center for Disease Control (CDC) is a component of the African Union and collaborates on public health continent-wide. The creation of the African CDC also represents an enhancement of health capacity called for by the World Health Organization international health regulations (IHR). The improved capacity for local response will facilitate timely outbreak investigations and is especially important in circumstances where an international response would be hampered by difficulty in gaining access to affected areas.  

Black women and life expectancy

Recently reported findings on the health of several demographic groups in the United States have been concerning. Life expectancy for middle age white women and men, and black men declined during 2014- 2015.[i] An increased death rate from suicide and opioid abuse for middle age white women and men during 1999-2014 and a four month decline in life expectancy among all white Americans was noted in a 2016 report from the U.S. Surgeon General.[ii] Black women as a group, however, did not have a decline in life expectancy. 

Black women and men continue to experience health disparities based on race. For example, there remain differences in life expectancy between white women and black women as well as higher death rates for black women compared to white women for breast cancer. Racial disparities in health measures for black children compared to white children persist. 

Improvements in important social determinants of health, such as educational attainment, may play a role in the life expectancy findings.  The precise reasons for the absence of a decline in life expectancy for black women compared to white men and women of similar age is unclear. One finding of interest is a comparison of the percentage of black women completing post-secondary education compared to other race and gender cohorts.[iii] During 2012-2013, black females completed a higher percentage share of associates and bachelor’s degrees within their racial group compared to white males and white females. Sixty-seven percent of associate degrees and 65 percent of bachelor’s degrees completed by black students were granted to black women while 61 percent of associate degrees and 56 percent of bachelor’s degrees completed by white students were granted to white women. In addition, black women represented a higher percentage of completed post-secondary degrees than white, Hispanic, Asian, Pacific Islander, or American Indian/Alaskan native women. Black women have lower suicide rates than black men and all white persons as well as relatively low rates of crime, cigarette smoking, alcohol use, and illegal drug use.[iv] Higher education and avoidance of health damaging behaviors are associated with better health. 

Monitoring post-secondary degree completion for black women as well as life expectancy and death rates for all gender/racial cohorts over a longer period of time may clarify the explanation of the observed data. 

[i] Source: National Center for Health Statistics Data Brief No. 267, December 2016, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention National Center for Health Statistics Mortality in the United States, 2015 Jiaquan Xu, M.D., Sherry L. Murphy, B.S., Kenneth D. Kochanek, M.A., and Elizabeth Arias, Ph.D.   [ii] Source: U.S. Department of Health and Human Services (HHS), Office of the Surgeon General, Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, DC: HHS, November 2016   [iii] Source: U.S. Department of Education, National Center for Education Statistics. (2016), Status and Trends in the Education of Racial and Ethnic Groups 2016 (NCES 2016-007), Degrees Awarded    [iv] Source: Ann N Y Acad Sci. 2010 Feb; 1186: 69–101. doi: 10.1111/j.1749-6632.2009.05339.x