Date: Mon 16 Oct 2017
From: Lemuel Martinez
<lemuelmartinez.md@outlook.com> [edited]

As Puerto Rico enters its 4th week post Hurricane Maria [20 Sep 2017], most hospitals continue to be powered only by electric generators and some of them have intermittently collapsed. As the hospitals systems continue to be in a fragile condition, cases suspicious for leptospirosis continue to present on the island.

Leptospirosis is endemic in Puerto Rico and its initial symptoms are almost identical to dengue, which is also endemic in the island. Hurricane seasons in Puerto Rico (from May to November) are very rainy, which promote a rise in mosquito and consequently dengue cases. An increase in cases of leptospirosis is also perceived during this rainy period.

This season, unfortunately Hurricane Maria hit the island causing flooding and destruction. This, along the continued cleaning efforts, has exposed many people to possible contaminated environments. The cases of suspected leptospirosis were first documented 1-2 weeks after the hurricane, which is compatible with the bacteria incubation period.

This 1st wave of cases should be the biggest, but as cleaning, reconstruction efforts, and seasonal rains continue, further exposure is expected. Leptospirosis definitive diagnosis in Puerto Rico continues to be a challenge, and even more during this historic moment. Although physicians are maintaining a high index of suspicion and low threshold to give antibiotics in clinically compatible cases, many symptomatic patients could be missed.

The only commercial laboratory test available to us is IgM. This is an indirect test and depends on the host immune response, not the bacteria. In the clinical practice, it is common to care for patients with leptospirosis that, even when having Weil syndrome [dysfunction of the kidneys and liver, abnormal enlargement of the liver (hepatomegaly), persistent yellowing of the skin, mucous membranes, and whites of the eyes (jaundice), and/or alterations in consciousness], have the initial IgM test result falsely negative.

The CDC has a PCR test for reference testing, but having to ship samples is hard at this moment, plus communications for test results are unstable and limited. It is clear that we need direct leptospirosis tests done in the local hospitals, and since many institutions already have PCR capabilities, it should not be difficult to habilitate our equipment if we are given the primers.

So far, in institutions were procalcitonin levels are done, what we have noticed is marked elevation of plasma procalcitonin levels, making it an interesting marker to monitor in cases of suspected leptospirosis. Further research and experience will tell if it could be used as an initial test to attempt to differentiate potential leptospirosis cases from dengue or influenza.

Further access to leptospira PCR and possibly point of care procalcitonin could aid to better diagnose patients in Puerto Rico during catastrophic events like Hurricane Maria.
----------------------------------
Lemuel Martinez, MD Vice-President
Infectious Diseases Society of Puerto Rico practicing in the Manata­ municipality Puerto Rico USA
lemuelmartinez.md@outlook.com
=====================
[Outbreaks of leptospirosis frequently follow heavy rainfall and flooding with fresh water. Parts of Puerto Rico saw more than 30 inches (76.2 cm) of rain and subsequent flooding with recent Hurricane Maria. A map showing the estimated rainfall across Puerto Rico with this hurricane is available at <https://twitter.com/NWSSanJuan/status/910983698597777409/photo/1?ref_src=twsrc%5Etfw&ref_url>.

Manata­, where Dr Martinez practices, is a municipality with a population of 43 772 residents in 2011, about 51 km (31.7 mi) west of San Juan, Puerto Rico, on the northern coast and is part of the San Juan-Caguas-Guaynabo Metropolitan Statistical Area.

Manata­ is in an area that received 16-20 inches of rainfall during Hurricane Maria
(<https://twitter.com/NWSSanJuan/status/910983698597777409/photo/1?ref_src=twsrc%5Etfw&ref_url>). - ProMED Mod.ML]

[A HealthMap/ProMED-mail map can be accessed at: <http://healthmap.org/promed/p/192>.]
Date: Thu 12 Oct 2017
Source: Center for Infectious Disease Research and Policy (CIDRAP) [edited]
<http://www.cidrap.umn.edu/news-perspective/2017/10/groups-warn-infectious-disease-threats-puerto-rico>

After Hurricane Maria hit Puerto Rico on 20 Sep [2017], the island lost power and experienced extensive flooding, leaving thousands homeless and without access to routine medical care. Now, as the waters recede, the Infectious Diseases Society of America (ISDA) is warning that the US territory faces public health threats that need to be countered by immediate funding and aid from the US government.

Underscoring worries about disease threats, local officials are reporting leptospirosis infections and deaths in people affected by the storm.

"We appreciate that the Trump administration has requested USD 29 billion in disaster relief funds and request congress act swiftly, at a minimum, to approve this level of much-needed support," said IDSA president Paul Auwaerter, MD, in a statement published with Melanie Thompson, MD, chair of the HIV Medicine Association (HIVMA) yesterday [11 Oct 2017, <http://www.idsociety.org/News_and_Publications/IDSA_News_Releases/2017/Pages/Puerto_Rico_and_U_S__Virgin_Islands_Need_Urgent_Aid_Now_to_Avert_Public_Health_Crises.aspx>]. "Additional resources will likely be needed, and we are pleased that federal agencies are assessing additional needs."

"Indeed, Puerto Ricans and U.S. Virgin Islanders are U.S. citizens and expect the same federal aid and support during natural disasters as the rest of the United States," wrote Carmen D. Zorilla, MD, an obstetrician from Puerto Rico who penned a perspective piece published in the New England Journal of Medicine yesterday [11 Oct 2017, <http://www.nejm.org/doi/full/10.1056/NEJMp1713196>].

Zorilla said every one of Puerto Rico's 3.4 million citizens have been touched by the hurricane, and 16 days after the storm, only 9.2% of people had power, and 54% had access to drinking water.

As an obstetrician-gynecologist on the faculty of the University of Puerto Rico School of Medicine, Zorilla stayed on the 18th floor of a maternity ward during the hurricane to help deliver babies and offer care to pregnant women. She said that the standing water and heavy flooding could bring more Zika, dengue, and chikungunya epidemics to the island.

"The impact of this disaster on morbidity, survival, adherence to treatments, and medical complications has yet to be documented," Zorilla said.

The IDSA named "waterborne pathogens, the spread of infections in crowded shelters, food-borne illnesses, mosquito-borne infections and mold-related illnesses," as a few of the immediate areas of concern for Puerto Ricans. Moreover, the hurricane has jeopardized access to medicines for patients with HIV and tuberculosis, as well as antibiotics, oral hydration solutions, and other basic first aid care.

In an update yesterday [11 Oct 2017], the US Environmental Protection Agency (EPA) said there are reports of residents obtaining, or trying to obtain, drinking water from hazardous waste "Superfund" sites in Puerto Rico [<https://www.epa.gov/newsreleases/epa-hurricane-maria-update-wednesday-october-11th>]. It also added that raw sewage continues to be released into waterways and can be expected to continue until repairs are made and power is restored.

According to the Associated Press (AP), Ricardo Rossello, governor of Puerto Rico, said at a news conference yesterday [11 Oct 2017] that 4 people had died and 10 were sickened with leptospirosis, a bacterial illness spread through contact with contaminated animal urine or contact with the urine via water, soil, or other means [<https://www.nytimes.com/aponline/2017/10/11/world/americas/ap-cb-hurricane-maria-puerto-rico.html?_r=0>].

The disease can be spread when people drink water contaminated with animal urine or feces, and, without treatment, complications can develop, including kidney damage, meningitis, liver failure, or respiratory distress.

According to the AP, many Puerto Ricans have taken to drinking from local streams because water has been shut off for the last 2 weeks.

To date, the AP said 45 deaths in Puerto Rico have been blamed on Hurricane Maria.  [Byline: Stephanie Soucheray]
====================
[Leptospirosis is a zoonotic spirochetal infection that occurs worldwide and is transmitted to humans by exposure to soil or fresh water contaminated with the urine of wild and domestic animals (including dogs, cattle, swine, and especially rodents) that are chronically infected with pathogenic _Leptospira_. _Leptospira_ may survive in contaminated fresh water or moist soil for weeks to months. Outbreaks of leptospirosis frequently follow heavy rainfall, flooding with fresh water, and increasing rodent numbers.

Parts of Puerto Rico saw more than 30 inches of rain and consequent flooding with recent Hurricane Maria. A map showing the estimated rainfall across Puerto Rico with this hurricane is available at <https://twitter.com/NWSSanJuan/status/910983698597777409/photo/1?ref_src=twsrc%5Etfw&ref_url>.

With continued absence of potable water, inadequate sanitation, and flooding in the streets for a large proportion of the population in Puerto Rico, food- and water-borne diseases, like leptospirosis, will be a major problem. - ProMED Mod.ML]

[A HealthMap/ProMED-mail map can be accessed at:
<http://healthmap.org/promed/p/192>.]
Date: Wed 11 Oct 2017, 2:25 PM EDT
Source: New York Times [edited]
<https://www.nytimes.com/aponline/2017/10/11/world/americas/ap-cb-hurricane-maria-puerto-rico.html>

A total of 4 deaths in Hurricane Maria's aftermath are being investigated as possible cases of a disease spread by animals' urine [leptospirosis], Puerto Rico's governor said [Wed 11 Oct 2017] amid concerns about islanders' exposure to contaminated water. A total of 10 people have come down with suspected cases of leptospirosis, Gov. Ricardo Rossello said at a news conference. On a U.S. territory where a 3rd of customers remain without running water 3 weeks after the hurricane, some became ill after turning to local streams to relieve their thirst.

A 61-year-old bus driver, took a drink from a stream near his concrete home on a hillside in Canovanas a week after the [20 Sep 2017] storm. He then developed a fever, his skin turned yellow and within a week, he died at a hospital in Carolina, according to his widow. Dr. Juan Santiago said [the patient] was among 5 patients who came in his emergency clinic last week with similar symptoms after drinking from streams in Canovanas and Loíza.

The water was still not running at [the patient's] house this week, but [his widow], said she and her family were drinking only bottled water, including some delivered by the town. Her husband was the only one who drank from the stream, she said. As many as 45 deaths in Puerto Rico have been blamed on Hurricane Maria, which tore across the island with 150 mph (240 kph) winds.

Currently 90 percent of the island is still without power and the government says it hopes to have electricity restored completely by March [2018]. Leptospirosis is not uncommon in the tropics, particularly after heavy rains or floods. Rossello said the symptoms can be confused with those of other illnesses, including dengue, and the Centers for Disease Control and Prevention was helping to investigate.

Two of the deaths were in Bayamon, and one each in Carolina and Mayaguez. Other patients have been receiving treatment with antibiotics. Rossello said that fliers with instructions on how to disinfect water will be sent to mayors for distribution with food supplies in towns across Puerto Rico. "For people that have access to internet and have access to printers, be good citizens and help us distribute this information," Rossello said.  The Health Department and the U.S. military also will be distributing pills to purify water, he said.
=====================
[San Juan is the capital of Puerto Rico and its largest city by population (395 326 residents) located on the northeast coast (<https://en.wikipedia.org/wiki/San_Juan,_Puerto_Rico>). Canóvanas is a town with a population of 47 648 residents, located 15 mi (24 km) east of San Juan (<https://en.wikipedia.org/wiki/Canóvanas,_Puerto_Rico>).

Loaza is a town with a population of 30 060 residents, on the northeast coast of Puerto Rico, 23 mi (37 km) north of Canóvanas (<https://en.wikipedia.org/wiki/Lo%C3%ADza,_Puerto_Rico>). Carolina is Puerto Rico's 3rd largest city (176 762 residents), located immediately east of San Juan and 4.3 mi (7 km) west of Canavanas (<https://en.wikipedia.org/wiki/Carolina,_Puerto_Rico>).

Bayamon, the 2nd largest city (239 116 residents), is located about 19 km southwest of San Juan (<https://en.wikipedia.org/wiki/Bayamón,_Puerto_Rico>); all these towns are part of the San Juan-Caguas-Guaynabo Metropolitan Statistical Area. Mayaguez is the 8th largest (89 080) on the western coast of Puerto Rico (<https://en.wikipedia.org/wiki/Mayagüez,_Puerto_Rico>).

A map of Puerto Rico showing the location of these towns can be found at
<http://www.puertorico.com/map/>.

Leptospirosis is a zoonotic spirochetal infection that occurs worldwide and is transmitted to humans by exposure to soil or fresh water contaminated with the urine of wild and domestic animals (including dogs, cattle, swine, and especially rodents) that are chronically infected with pathogenic _Leptospira_. _Leptospira_ may survive in contaminated fresh water or moist soil for weeks to months.

Outbreaks of leptospirosis frequently follow heavy rainfall, flooding with fresh water, and increasing rodent numbers. Parts of Puerto Rico saw more than 30 inches of rain and subsequent flooding with recent Hurricane Maria.

A map showing the estimated rainfall across Puerto Rico with this hurricane is available at
<https://twitter.com/NWSSanJuan/status/910983698597777409/photo/1?ref_src=twsrc%5Etfw&ref_url>. - ProMED Mod.ML]
Date: Sat, 23 Sep 2017 10:26:59 +0200
By Hector RETAMAL and Edgardo RODRIGUEZ

San Juan, Sept 23, 2017 (AFP) - Some 70,000 people have been ordered to evacuate their homes after a rain-swollen dam in Puerto Rico failed in the latest disaster caused by Hurricane Maria.  With the death toll from the storm at 33 across the Caribbean, the National Weather Service office in capital San Juan Friday issued a flash flood warning for people living along the Guajataca River and said the 1920s earthen dam was in danger of collapsing altogether.   "All Areas surrounding the Guajataca River should evacuate NOW. Their lives are in DANGER!," the service said in a tweet.

Flooding has already begun downstream, it said.   Shortly thereafter, Governor Ricardo Rossello issued an order for some 70,000 people living in the area in the northwest of the island to get out.   According to the newspaper El Vocero, Public Safety Secretary Hector Pesquera said a drain that normally releases a stream of water from the dam in a controlled fashion had broken.

Instead the busted drain sent water gushing down a ramp-style conduit, eventually washing away huge chunks of soil from the grassy green slope of the dam, according to video on the WeatherNation website.    However the flash flood warning was only due to last until 0600 GMT, the weather service said, suggesting that the river waters were receding.  Puerto Rico was already battling dangerous floods after Hurricane Maria ravaged the island early Wednesday. Rescuers raced against time to reach trapped residents.    Rossello has called Maria the most devastating storm in a century after it destroyed the US territory's electricity and telecommunications infrastructure.

Rossello told CNN the island is lacking communications and the preliminary assessment at this point is 13 fatalities. "Right now our efforts are to make sure we have everybody safe, that we can rescue people. Our efforts have already produced almost 700 rescues so we're clearly focused on that."   The National Hurricane Center said some areas in Puerto Rico could see 40 inches (more than a meter) of rain from Maria, and Rossello warned of dangerous mudslides brought on by the deluge.   "We have a lot of flooding, we have reports of complete devastation of vulnerable housing. Of course it's still raining over here."

- Coming home -
Maria has been blamed for at least 33 deaths, including 15 in Dominica, three in Haiti and two in Guadeloupe.   After lamenting that Puerto Rico had been "absolutely obliterated" by Maria, US President Donald Trump spoke with Governor Rossello Thursday night and promised to speed up relief efforts.   The northern town of Toa Baja was one of the worst devastated areas -- first ravaged by gusts of more than 200 kilometers per hour, then inundated after the island's largest river, La Plata, overflowed.

Many residents did not evacuate on time, while others say they never heard the warning sirens. Some were returning home after several days away, to clear the heavy mud left by the floodwaters from their homes and start the process of rebuilding.   Marisol Rosario, a 55-year-old housewife who had fled with her husband, said she was forced by the winds to leave their dog behind. "I thought I would find him dead, but he managed to climb on top of the furniture and survive," she said tearfully.

- Network crippled -
The torrential rain had turned some roads into muddy brown rivers, impassable to all but the largest of vehicles.   Toppled trees, street signs and power cables were strewn across roads that were also littered with debris.

Puerto Rico's electricity network has been crippled by the storm and engineers say it could take months for power to be fully restored.   The local electricity board has promised that their priority will be to restore power to hospitals, water treatment plants and pumping stations.   Brock Long, who heads the US federal government's emergency management agency FEMA, said that ships carrying millions of meals and bottled water were trying to dock as the island's ports are slowly reopened.

After devastating Puerto Rico, the storm headed west toward the Dominican Republic where it damaged nearly 5,000 homes and caused more than 18,000 people to evacuate, according to a statement by the office of president Danilo Medina.   As of Friday night, Maria was a Category Three hurricane with winds of 125 miles per hour (205 kilometers per hour), churning in the sea some 365 miles east of the central Bahamas.

Heavy rains and high winds began hitting the archipelago on Thursday afternoon.   The government opened new shelters after several buildings which had been used during Hurricane Irma earlier this month were damaged and authorities feared they might not hold up under another fierce storm.   Maria previously tore through several Caribbean islands, claiming the highest toll on Dominica, which has a population of around 72,000 and has been largely cut off from the outside world.
Date: Wed, 20 Sep 2017 17:21:48 +0200
By Hector RETAMAL and Edgardo RODRIGUEZ

San Juan, Sept 20, 2017 (AFP) - Hurricane Maria slammed into Puerto Rico on Wednesday, cutting power on most of the US territory as terrified residents hunkered down in the face of the island's worst storm in living memory.   After leaving a deadly trail of destruction on a string of smaller Caribbean islands, Maria made landfall on Puerto Rico's southeast coast around daybreak, packing winds of around 150 miles per hour (240 kilometers per hour).   "The wind sounds like a woman screaming at the top of her lungs!" photographer and storm chaser Mike Theiss wrote on Twitter, sheltering in a safe room in the eye of the storm.   "We are getting absolutely hammered right now," he added, posting pictures of walls collapsing in a local restaurant.

Many of the most vulnerable of Puerto Rico's 3.5 million residents took cover in the 500 shelters set up around the island, with officials warning of life-threatening floods.   "As we anticipated, this is the most devastating storm in a century or in modern history," said Puerto Rico governor Ricardo Rossello.   "We have many fronts of danger, not only flooding regions, which we have plenty here in Puerto Rico, coastal lines where the surge is coming," Rossello told CNN.   "Also we have mudslide potential and vulnerable housing -- we are talking wooden housing and so forth."   Although engineers had managed to restore power to most of the island after the recent Hurricane Irma, Rossello said around 60 percent of Puerto Rico had again been blacked out.

Brock Long, who heads the US federal government's emergency agency FEMA, warned it could take some days for power to be restored on Puerto Rico and the smaller US Virgin Islands which have also been badly hit by Maria.   "Because of the nature of the geography of the islands, it's a logistical challenge so it will be a frustrating event to get the power back on," said Long.   "We are well positioned. We have more assets on the islands than before Irma hit. We have 3,200 staff members in the islands collectively. We have multiple days' worth of commodities, meals, water, and other things ready to go."   Maria made landfall as a Category Four storm on the five-point Saffir-Simpson scale, packing winds of 150 mph (240 kph).   - Virgin Islands misery -   The US and British Virgin Islands -- still struggling to recover from the devastation of Irma -- are also on alert, along with the Turks and Caicos Islands and parts of the Dominican Republic.

Maria has already torn through several Caribbean islands, leaving two people dead in the French territory of Guadeloupe and causing major damage on the independent island of Dominica.   In the US Virgin Islands, locals reported horizontal rain and trees swirling in the wind.   "Very violent and intense right now as we have just begun to experience hurricane force winds," said 31-year-old Coral Megahy, hunkered down on St Croix island.   "We can hear debris banging on the aluminium windows as well."   In Guadeloupe, one person was killed by a falling tree as Maria hit, while another died on the seafront.   At least two more are missing after their boat sank off the French territory, while some 40 percent of households in the archipelago of 400,000 were without power.

- Dominica devastation -
Communications to Dominica have been largely cut, and its airports and ports have been closed.   But an advisor to Prime Minister Roosevelt Skerrit, who spoke to the premier by satellite phone, painted a picture of devastation on an island that is home to around 73,000 people.   "Many buildings serving as shelters lost roofs, which means that a very urgent need now is tarpaulins and other roofing materials," Hartley Henry said in a statement.   Reports from rural communities spoke of a "total destruction of homes, some roadways and crops," added Henry.   While there have been reports of a handful of deaths on Dominica, Henry said it was too early to give a figure.   There had been fears that Maria could wreak fresh havoc on islands that were already flattened by Category 5 hurricane Irma earlier in the month.

Reports suggested St Martin, a French-Dutch island that was among the most severely hit by Irma with 14 dead, had escaped the worst this time around.   Britain, France and the Netherlands had boosted resources in their Caribbean territories ahead of Maria, after heavy criticism of poor preparations for Irma.   All three European countries have increased their troop deployments to the region after complaints of looting and lawlessness after Irma.   French President Emmanuel Macron told the UN General Assembly in New York that the lethal sequence of hurricanes -- Irma and Maria came after Harvey blasted through Texas -- was "one of the direct consequences of global warming."   The French leader is pushing US President Donald Trump to reverse his decision to pull out of the 2015 Paris climate accord, which triggered an international outcry.
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