Puerto Rico Public Health Summit 2022

Introduction: A two-day music concert on December 10-11, 2021, attended by over 70,000 people, took place in Puerto Rico (PR) at an outdoor stadium. Attendees were required to wear masks and show proof of COVID-19 vaccination. At that time, positivity rate was 2.4% and ~80% of the eligible population was fully vaccinated.

Methods: The Department of Health (PRDOH) has a centralized surveillance system that includes updated information on cases to monitor main epidemiological indicators.

Results: On December 15, PRDOH observed an increase in positivity rates and incidence of cases. Community transmission levels escalated from moderate to high in two days. The first 176 cases directly associated with the concert were identified on December 14. In response, the PRDOH enhanced community awareness to encourage symptomatic persons and contacts to isolate or self-quarantine to prevent transmission. Testing capacity and surveillance efforts were scaled up. By December 19, PRDOH activated 27 testing sites, including 12 mass testing events. Concert attendees were encouraged to get tested and to isolate if tested positive. By December 22, positivity rate was 18.9% and 2,139 cases were associated to the concert.

Conclusion: SARS-CoV-2 spreads more easily indoors than outdoors. However, some of the benefits of being outdoors decrease when thousands of people are crowded together especially with the circulation of the Omicron variant. The high proportion of infections in this outbreak provides evidence for SARS-CoV-2 transmission in vaccinated individuals in an outdoor setting. Transmission was likely facilitated in this environment due to people in proximity for an extended time while dancing, breathing heavily, singing, and talking loudly which increases aerosol and droplets exposure. It is important to understand the epidemiological significance of super spread events in COVID-19 transmission and develop strategies to prepare for and respond to the surge of testing and treatment demands associated with a rapid increase in cases.

Melissa Marzán Rodríguez, DrPH

Puerto Rico Department of Health

Objective:The use of Remdesivir has become the principal source of treatment to attempt to decrease severity of disease and reducemortality.Therapy with Remdesivir advises doctors to monitor patients for renal impairment before and during treatment, and warns that the drug should not be initiated in patients with decreased renal function, eGFR < 30ml/min.Our objective is to determine if Remdesivir use is associated with Acute Kidney Injury in order to establish the safety profile of Remdesivir in current protocol use for COVID-19 Pneumonia. Methods:This is a retrospective study with 136 patients where we obtained data from Mayaguez Medical Center'sHER from March 2020 to March 2021. Results:The average age of those who received Remdesivir was 63.7 years. Of 136 patients, 55.1% (75) were men. The highest comorbidities were hypertension with 64.3% and Diabetes Mellitus with 41.4%. We obtained a statistically significant result in the percentage change in the creatinine value from baseline with an increase of 13.3% in the patients receiving Remdesivir.Conclusions:We were unable to prove that there is a relationship between the use of Remdesivir and the incidence of acute kidney injury. The only factor associated with acute kidney injury was age. The results obtained are compared with previous studies that show that there is still not enough evidence to determine a causal relationship between Remdesivir and acute kidney injury.

Glorymar López Garayua

Mayagüez Medical Center

Introduction: Primary prevention is a fundamental area for healthcare. Vaccination is an example of one of the tools for primary prevention help to fight disease. Thanks to vaccination effort, smallpox disease was globally eradicated in 1980. Today's world continues to face infectious diseases that endanger humanity. The COVID-19 pandemic and vaccination efforts are a worldwide topic of discussion. How society response to medical efforts could define the duration of the pandemic. The purpose of the study is to identify the reasons why patients refuse getting vaccinated, identify which population is most likely to not get vaccinated, and suggest ideas for vaccination promotion based on population interest. Methodology: The design of the study was cross-sectional. The sample size was 176 participants. Information was obtained from a created survey provided at public areas of the municipality of Mayaguez for 1 month during different hours of the day. Each participant was oriented and informed about study, providing verbal consent. Variables of the study were age, sex, municipality, vaccination status, reason for non-vaccination status, and vaccination education. The hypothesis is that people do not get vaccinated due to lack of information about vaccination benefits. Data obtained and tabulated was plotted using Microsoft excel sheet. Tables, graphs, and histograms were created to measure frequency of each variable. Results were divided by age range for analysis. Results: 176 surveys were answered from a population composed of 53% females and 46% males. The mean age was 35 years old. For tabulation purposes participants were divided in 5 age groups (21-26, 27-49, 50-65, 65-79, >80 years old). Most participants were from the municipality of Mayaguez with 51 participants, followed by Cabo Rojo with 14, Anasco with 12 and Aguadilla with 10 participants. From the study 152 participants reported been updated with their vaccines, and 73 participants reported an active communication with their physicians about vaccination. However, 98 participants reported that their physician has never talk about vaccination during their visits, representing a 55% of the sample. COVID19 is the most common vaccine reported in every age group, followed by shingles/chicken pox in the age group of 21-26 years; Hep B in the age group of 27-49; Influenza and Tdt in the age group of 50-64; influenza in the age group of 65-79 and >80 years old. The most common reason to refuse vaccination in each group was ignorance about vaccination regimen (21-26 years old and 65-79 years old) and vaccination side effect (27-64 years old). In general, participants reported that they would prefer to be educated about vaccinations by their physicians (32%) followed by social media (28%) and TV/radio (17%). The youngest age group prefer to be educated by social media (21-26 years old), meanwhile the rest of the population prefer the physician approach. Conclusion: At this date, Puerto Rico has a vaccination rate of 90% (people able to vaccine older than 12 y/o with one or more vaccine) of COVID-19. However, during the beginning of vaccination campaign the general population was hesitate toward vaccination. It took a joint of medical and government effort to achieve this goal. The take home message is patient physician communication still remain an important tool for education and primary prevention. Healthcare provider should be encouraged to speak about vaccination, and to explore new tools to reach a bigger population. In addition, government efforts could help impact the public health and society behavior.

José Rivera Sepulveda

Mayaguez Medical Center

The members of Red Panamericana de Bioética y Comunicación (RPBC), in association with Centro Latino de Bioética y Humanidades (CELABIH), have been invited to make interventions with frontline healthcare professionals in the context of the COVID-19 pandemic. At present, the authors have incorporated a multidisciplinary and multicultural perspective with strong components of health communication, psychology, and bioethics to help healthcare professionals who work with COVID-19 patients identify and manage burnout, compassion fatigue, and moral distress, and help employers and institutions create nurturing, caring and emotionally responsive work environments. An intervention program has been designed to address the burnout, moral distress, and compassion fatigue that stem from the significant cognitive, emotional, and physical demands of delivering healthcare services in clinical settings during the present pandemic.

In designing the program, healthcare professionals, healthcare employers, and administrative personnel were invited to two virtual round tables. The two-hour sessions with administrative personnel and healthcare employers explored their knowledge regarding current burnout, compassion fatigue and moral distress prevalence among healthcare professionals, whether they have been addressed in any way in their respective institutions, and their knowledge about evidence-based successful interventions to prevent and mitigate these conditions during the pandemic. Healthcare professionals on their round table were asked to narrate their experiences and, after being presented with information about burnout, compassion fatigue and moral distress, assessed their perception on these conditions in themselves and their professional setting. The information gathered from the administrator’s round table and the healthcare professionals’ narratives are analyzed using Qualitative Content Analysis and Narrative Analysis, respectively. The proposed presentation shares the insights gathered during the process of exploring the healthcare workers, as well as the administrators and human resources personnel perspectives, and the process of designing the program. Ultimately, this initiative will serve as a reference for future health emergencies.

Mirelsa Modestti, PhD

University of Puerto Rico, Medical Science Campus

Introduction: Transgender women (TGW), transgender men (TGM), and gender-non-confirming (GNC) experience more health disparities when compared to cisgender men and women. Limited studies have explored the needs for health and wellbeing among TGW, TGW, and GNC people in Puerto Rico (PR). A community assessment was conducted to understand how social determinants impact the health of TGW, TGW, and GNC people in PR. Methods: Data was collected through a culturally adapted survey completed online or in-person in 2020 by 212 TWG, TWM, and GNC individuals in PR. Participants were recruited online via social media outlets, mailing lists, and in-person through community collaborators. We collected sociodemographic data and perceived health needs. Descriptive analyses were conducted. Results: Nearly half of the sample was TGW (46.5%), 32.1% TGM, and 14.6% GNC. The average age was 38yo (SD=11.8; Range=16-73). Approximately 40% of the sample were unemployed, 57.6% had income under the poverty level, 66.6% had either a technical or college degree, and 28.2% had engaged in sex work. More than half had experienced discrimination when accessing healthcare (52.4%) and discrimination from healthcare providers (52.5%). Participants were asked to select a series of priorities that should be addressed to improve their wellbeing and expressed the need to create a safe and accessible primary care (66.4%) and work environment (79.3%). Conclusions: Findings reveal the need for structural interventions to eliminate barriers for health equity among TGW, TGW, and GNC people in PR. These interventions should have a multi-level approach that engages key stakeholders and community organizations to ensure sustainability. Potential interventions could include regulating sex work to improve work environments, providing training to healthcare providers, and providing incentives to employers to recruit and retain these populations.

Deve Mehta, BA; Carlos E. Rodríguez-Díaz, PhD, MPH

San Juan Bautista School of Medicine

Expanding and providing access to early detection through testing community-based strategies among socially vulnerable communities (SVC) are critical to reducing health dispari-ties related to the COVID-19 pandemic. The EpI-Net community-based intervention aimed at increasing COVID-19 testing uptake and prevention practices among SVC in Puerto Rico. We hypothesized that the integration of lay community leaders trained in COVID-19 prevention technology tools (EpI-Net) will result in increased COVID-19 testing uptake and prevention prac-tices among the targeted SVC in Puerto Rico. In partnership with Ponce Health Sciences Uni-versity RCMI Community Engagement Core (PHSU-RCMI-CEC), we developed a new commu-nity-based training focused on COVID-19 prevention strategies for SVC. The SVC were select-ed using an SVC index adapted for Puerto Rico population’s characteristics. This highly innova-tive and impactful study is co-led by epidemiologists and lay community leaders trained as health promotors. A total of 24 community leaders from socially vulnerable communities in Puer-to Rico have been completed the 4 community workshops. Pre and post assessments were completed as part of the health promotors training program. Preliminary results show: 1) high intervention retention levels of community leaders (91.7% retention rate); 2) an increase in community engagement strategies knowledge (85.8% vs 86.7%; p=0.48); 3) increase in COVID-19 prevention practices knowledge (68.2% vs 81.8%; p=0.03); and 4) increase in public health emergency management strategies (53.0% vs 75.5%; p<0.001). As an EpI-Net’s implementa-tion partners, community leaders have shown the importance of community capacity building as a key component for intervention’s feasibility and impact. Community engagement activities are essential to continue serving our communities over the COVID-19 response. This community-based training approach should be reproduced for other public health emergencies to assure cultural competence and relevance among communities who experienced health disparities.

Iris S. Martinez Torres

Ponce Health Sciences University

En marzo 2020, la Organización Mundial de la Salud declaró la pandemia de COVID-19. Se han implementado medidas de prevención para la reducción de contagios del virus SARS-CoV-2, siendo las pruebas de detección (PD) una estrategia de prevención indispensable en la contención del virus a nivel comunitario. Las PD permiten poder identificar los casos positivos que deben estar en aislamiento e identificar sus contactos cercanos para medidas de cuarentenas. Sin embargo, se ha podido documentar que, a dos años de la pandemia, todavía existen barreras para a hacerse las PD. Estas barreras traen consigo diferentes retos a la hora de prevenir y reducir la tasa de incidencia de SARS-CoV-2 en comunidades socialmente vulnerables (CSV). Se realizaron 27 entrevistas cualitativas a profundidad a líderes comunitarios de diferentes CSV del área sur de Puerto Rico entre los meses de marzo a diciembre de 2021. Las entrevistas se realizaron a través de la plataforma Zoom y fueron audio grabadas. Estas entrevistas fueron transcritas y se realizó un análisis contenido con tres jueces utilizando NVivo. Al analizarse las categorías de: conocimiento sobre COVID-19 (N=27) y acceso a pruebas de COVID-19 (N=25) se identificaron diversas barreras para PD en las CSV. Entre las razones mencionadas para no a hacerse las pruebas: 1) miedo a salir de sus casas y exponerse al SARS-CoV-2; 2) falta información sobre los tipos de pruebas; 3) proceso clínico para realizárselas; 4) proceso para solicitarlas; 5) acceso; 6) falta de iniciativas de salud a nivel comunitario, y 7) falta de transportación y redes de apoyo. Los resultados nos demuestran que ha dos años de la pandemia, continúan habiendo retos para que las personas se realicen las PD. Es necesario implementar estrategias de base comunitaria que sean relevantes para las CSV en emergencias de salud pública. Keywords: comunidades socialmente vulnerables, pruebas de detección, COVID-19, líderes comunitarios. Estudio apoyado: NIH RADxUP Project #46: 3R21MD013674-02S2.

Luis A. Arroyo-Andújar

Departamento de Salud Pública, Ponce Health Sciences University & Ponce Research Institute

Background & Objectives: Community outreach strategies have played a critical role in health initiatives aimed at reducing inequities around COVID-19. The PR-CEAL (Puerto Rico Community Engagement Alliance Against COVID-19 Disparities) aim to disseminate scientific-based COVID-19 related information and develop evidence-based strategies to promote vaccination and inclusion of Puerto Ricans in clinical studies. Methods: The PR-CEAL Community Outreach Group (COEG) developed a community survey tool for the assessment of needs related prevention and education of COVID-19, emergent topic related to COVID, and additional health concerns during the pandemic. Health promoters completed the questionnaire in 20 community engagement activities island wide in collaboration with community-based organizations (CBOs). A total of two phases of this survey were conducted. The first one was implemented in November. The second phase occurred in December, to include new booster vaccine recommendations. Results: A total of 289 participants were reached. During the first phase of the study, 94% of the participants received their initial dose of the COVID-19 vaccine. The second phase highlighted that more than 40% of the participants had received their booster vaccine dose. However, 89% of individuals who had not received the booster dose reported they are willing to receive it. Hypertension, diabetes, cholesterol, and asthma were the most prevalent health conditions reported by participants; with a higher percentage of comorbidities reported among women (63%) than men (51%). Bivariate analysis showed a significant higher rate of COVID-19 booster among women with comorbidities than men (pvalue= 0.063). Conclusions: These results suggest sex differences in booster vaccination. Information gathered in these community outreach activities can be used to strengthen future community engagement strategies. Efforts to develop targeted booster uptake education, added to reinforcement of the promotion of prevention screening practices for chronic disease and vaccination are needed concurrently with the COVID prevention efforts island wide.

Adriana Pons Calvo

Puerto Rico CEAL (La Alianza de Participación Comunitaria)

Molecular testing is an important tool at preventing and control the spread of COVID-19. Socially Vulnerable Communities (SVC) may experience structural challenges to access COVID-19 diagnostic tools. In order to increase access and uptake of COVID-19 molecular testing tools, a community-based intervention was developed for SVC in Puerto Rico. EpI-Net's community-based intervention aims to increasing access and uptake of COVID-19 molecular tests and prevention practices among SVC in Puerto Rico. A strategic COVID-19 testing campaign alongside community-based partnerships, “Clinica del Sur” mobile Unit with educational interventions (preventive measures, testing awareness, pre/post counseling) were conducted in selected communities to provide testing access. Since March 2021 to February 2022, EpiNet has impacted 6 municipalities (Juana Diaz, Santa Isabel, Ponce, Peñuelas, Guayanilla & Guánica) for a total of 21 testing sites within SVC. In terms of access, a total of 2,073 molecular tests has been performed since the implementation of EpINet intervention. Furthermore, a total of 21.6% (n=447) have access to a COVID-19 molecular testing for the first time. The 95% (n=1979) were linkage to prevention practices materials and 100% of positive cases (n=126) were linkage to case investigation and contact tracing programs. Community-based efforts are needed to overcome individual, community and structural testing-related barriers in a culturally relevant manner to reduce further health disparities due to COVID-19 among SVC. Community-based strategies are critical to increase COVID-19 molecular testing access and uptake among communities who experienced health disparities. Keywords: COVID 19, EpiNet, Testing campaigns, Molecular testing This study was supported by: NIH RADxUP Project #46: 3R21MD013674-02S2

Luisa Morales

Ponce Health Sciences University

Introduction In the United States, 6 in 10 adults have a chronic disease and 4 in 10 adults have two or more. Lack of access to health care exacerbates chronic conditions, as deterioration leads to significantly poor health outcomes. As technology advances, health care continues to lead growth by promoting innovative approaches that provide patients with better access to higher quality health care services that meet their medical and social needs using digital platforms. Hoy Health has developed the Remote Patient Monitoring (RPM) program to increase patient accessibility to timely health care evaluation. Methods Two simultaneous RPM data collection programs (Diabetes and Hypertension), observing the national standards established under the American Diabetes Association and the American Heart Association, under the sponsorship of Salud Integral de la Montaña (SIM). Results • Started on 9/9/2020 at six SIM Clinic. • Analyzed glucose and blood pressure RPM data showing improvement at individual, clinical site, and corporate levels during a 90-day period. • The Blood Glucose program showed initial improvement from 39 of 55 active patients; 10 of 18 time periods the day at clinical sites, arranged between Wake-up, Morning, Afternoon and Night; and 3 of 4 time periods for the overall organization, for a total of 71% improvement. • The Hypertension program showed initial improvement from 37 of 65 active patients; 6 of 17 time periods during the day at clinical sites, arranged between Wake-up, Morning, Afternoon and Night; and 4 of 4 time periods for the overall organization, for a total of 57% improvement. Conclusion In conclusion, this pilot has demonstrated that a combination of daily personal care (white glove), cost, technology, language, and cultural elements, completely dedicated to population health is a successful model form the promotion of optimum outcomes for minorities and underserved populations within their communities.

Mario Anglada Cortés, MBA

Hoy Health LLC

Introducción: La red de Centros 330 es la espina dorsal del sistema de salud primaria de Puerto Rico por lo que es sumamente importante estudiar el efecto de la pandemia del COVID19 sobre la prestación de servicios y las estrategias de adaptación implementadas para continuar operaciones. Los objetivos fueron identificar, medir y describir el efecto de la pandemia sobre la continuidad de las operaciones en los Centros 330, estabilidad financiera, estrategias implementadas, y por último, desarrollar recomendaciones para fortalecer la continuidad de operaciones de los Centros 330 para futuras emergencias. Métodos: Se utilizo una metodología de investigación mixta donde se combinó la perspectiva cuantitativa y cualitativa. Los Centros 330 enviaron datos de utilización de servicios, pacientes atendidos, personal, costos de operación e ingresos recibidos para los años 2018 al 2020. También se realizaron grupos focales y/o entrevistas en 7 de los Centros 330 con pacientes, miembros de la Junta de Directores y/o líderes comunitarios, personal clínico de los centros y con la gerencia alta. Luego se hizo una triangulación de los datos e información recopilada en ambos componentes. Resultados: Los Centros 330 demostraron una gran flexibilidad, adaptabilidad y capacidad innovativa durante la respuesta a la pandemia, y, los servicios de salud primarios prestados por los Centros 330 cumplieron un rol importante en asistir, apoyar y mitigar el impacto sobre la salud de miles de individuos, familias y comunidades vulnerables alrededor de toda la isla. Conclusiones: Aunque claramente queda mucho trabajo por hacer para superar este reto de salud pública, el momento actual ofrece una oportunidad para que líderes políticos locales y estatales utilicen la creatividad, las innovaciones, y las lecciones aprendidas de la respuesta a esta emergencia realizada por los Centros 330 para mantener y fortalecer un sistema de salud primario equitativo, resiliente y accesible en el futuro. Reconocimientos: Este estudio se realizó con el auspicio y apoyo de la Asociación de Salud Primaria de Puerto Rico (ASPPR) con fondos de HRSA (Health Resources and Services Administration).

Heriberto A. Marín Centeno, PhD

Escuela de Salud Pública, Recinto de Ciencias Medicas, Universidad de Puerto Rico

Background and Objectives: Responding to the growing urgent global mental health needs, we designed a model using syndemics approach plus design thinking principles, to create an interprofessional psychoeducational “culturally fluid”, adapted intervention for healthcare providers and other survivors of these catastrophic events. The “Tabonuco” (ta-bo-new-co), a native tree of Puerto Rico, that spreads its roots to connect, nourish and strengthen other trees, is the symbol for the model. The objectives of this project were: · Create a transdisciplinary model adapted to the vulnerabilities of health care providers and the community through health humanities and arts. · Provide participants with a theoretic, analytical, and documentary instrument on the psychosocial impact of disasters able to cause an important and lasting change. · Assess the impact of the intervention through measures of interaction, acceptability, and individual outcomes. Methods We combine evidence-based therapies with health humanities and arts to create briefing and debriefing scenarios, support well-being, create social connection, spark, and sustain change and communicate across differences. This 5-hour intervention has been implemented in Puerto Rico after two major hurricanes, earthquakes, political crisis, in the context of the COVID19 pandemics and, preparing for the long-term effects of this human experience. The model has demonstrated reliability and applicability to different scenarios and is aligned with several of the required competencies for health professionals through the continuum. Effectiveness and perceived benefits of the workshop were assessed through pre, and post workshop surveys based in the Kirkpatrick's Four-Level Training Evaluation Model. Results More than 30 online and onsite activities with cross-sector collaboration have been developed with almost 900 voluntary participants of diverse ethnoracial identities, population groups and backgrounds. Comparison of pre- and post-workshop data showed a statistically significant increase in participants' confidence in meeting all learning objectives. Participants positively commented on the interactive nature and received benefits of the workshop.

Leticia Ubiñas

Salud Inclusiva Inc.

Objectives Cancer is the 1st leading cause of death in Puerto Rico (PR, 2013), with 16,372 new cases and 5,185 deaths in 2015. Therefore, it is a major public health problem. For that reason, the purpose of this study is to show the cancer risk factors, preventive measures, and screening practices in a sub-population in Central-Eastern PR. The significance of this study is that the results may lead to the development of effective educational programs and a comprehensive cancer control program while verifying patients’ and medical care providers’ adherence and compliance with cancer clinical guidelines. Design This is an analysis for 2019, initial year for an annual descriptive cross-sectional questionnaire of risk factors, preventive measures, and screening practices for cancer in PR administered at a private hospital using a convenience sample of healthy and non-healthy adults. Results Out of 345 enrolled subjects in 2019 for the questionnaire, 342 completed the questionnaire, qualifying for this analysis: 71% females, with an average age of 55 years. Among other results, 57% had education beyond high school, 85% has never been diagnosed with cancer, 15% smoked tobacco products in the previous 30 days, and 7% has been vaccinated against Human Papilloma Virus. Meanwhile, among those 45-75 years old, 69% had a colonoscopy done every 10 years and among females 40-74 years old, 93% had a mammography done every 1-2 years. Conclusions Considering the limitations of this study (cross-sectional, single site, and recall bias), it provides important baseline data to reinforce and increase cancer knowledge about risk factors, preventive measures, and screening practices in the Puerto Rican population. This study takes particular interest now by 2 years into the COVID-19 pandemic and cancer risk factors management, preventive measures, and screening practices safely return to pre-COVID-19 pandemic levels. In addition, it is worth to be conducted again to assess for any changes and compare pre-COVID-19 pandemic and current COVID-19 pandemic times.

Wilfredo E. De Jesús-Monge, MD, MSc

Hospitales HIMA San Pablo

Luego de los huracanes Irma y María, en el 2019, la Comisión para la Prevención del Suicidio del Departamento de Salud inició el proyecto Prevención del suicidio en situaciones de desastre, el cual fue subvencionado por fondos de los Centros para el Control y Prevención de Enfermedades (CDC por sus siglas en inglés). Dicho proyecto buscaba ofrecer talleres presenciales de prevención de suicidio a través de toda la Isla para mejorar la respuesta jurisdiccional en otros desastres. La pandemia de COVID-19 supuso un reto inmenso para las actividades presenciales, lo que requirió una transformación tanto en la modalidad de los talleres como en la promoción de los mismos. Método: El proyecto utilizó talleres virtuales de prevención de suicidio dirigido a distintos grupos de interés a nivel de todo Puerto Rico. La promoción y adaptación del taller de manera virtual y el desarrollo de dos cursos en-línea se realizaron con el apoyo y asistencia técnica del Puerto Rico Public Health Trust. Resultados: Las actividades virtuales se realizaron en el periodo de noviembre 2020 a mayo 2021 y contaron con la participación de 3,254 personas, entre éstos profesionales de salud, empleados municipales y líderes comunitarios. Se logró la publicación de dos cursos en-línea libres de costo que siguen disponibles a través de la Academia Virtual del PR Trust. Conclusión: Los retos encarados en el contexto de la pandemia de COVID-19 requirieron una reformulación del proyecto sin precedentes que dejó huellas en el trabajo que se realiza desde la Comisión para la Prevención del Suicidio. Con actividades virtuales logramos robustecer el alcance de la sensibilización y concientización sobre la prevención del suicidio, maximizar los recursos disponibles, diseñar acercamientos educativos más efectivos según la población de interés y promover los servicios para la salud mental disponibles en la Isla. Reconocimiento: Este proyecto fue posible por el ‘Grant 6 NU90TP921946’ de los Centros para el Control y Prevención de Enfermedades.

Nayda I. Román Vázquez, PhD

Departamento de Salud de Puerto Rico

Despite COVID-19 testing initiatives in Puerto Rico (PR), not all of them are developed to meet the needs of vulnerable populations. EpI-Net is a community-based intervention that increases COVID-19 testing uptake and prevention practices among socially vulnerable communities (SVC) in PR. Interventions to increase access to diagnostic tests were developed considering SARS-CoV-2 transmission dynamics in the Puerto Rican population and the needs of the communities participating in the project. This study seeks to compare COVID-19 incidence outcomes (case rate and positivity rate) between SVC impacted by EpI-Net compare to island wide indicators. COVID-19 confirmed cases for PR were collected from the Department of Health official site. EpI-Net participants' data were collected at testing sites. Data was analyzed from April 12 to December 26, 2021. Overall, the average age for confirmed cases in the study period at population level was 34 years, while the average age for EpI-Net participants was 42 years. The highest weekly incidence in EpI-Net participants was recorded during the week of December 20-26, 202 with 3 new cases in EpI-Net per 100,000 people (8.9% positivity rate). For this same week, PR began to experience an incidence peak with 341 new cases per 100,000 people per week (15.6% positivity rate, p-value = 0.87). COVID-19 weekly incidence rates for EpI-Net demonstrated a close pattern to what was observed at the population level for the analyzed period, despite a difference in the average age of positive cases. EpI-Net continues working with underserved populations in PR to ensure their access to COVID-19 testing as a critical strategy for accelerating diagnostics and linkage to investigation systems and care treatments. Acknowledgment: Research reported in this Rapid Acceleration of Diagnostics – Underserved Populations (RADx-UP) publication was supported by the National Institutes of Health under Award Number 3R21MD013674-02S2, RADxUP Project #46: Epidemiologic Intelligence Network (EpI-Net) to promote COVID-19 testing and prevention practices among socially vulnerable communities in Puerto Rico. Keywords: Socially Vulnerable Communities, COVID-19 Testing, Community Transmission Levels, Prevention Strategies.

Kamalich Muniz-Rodríguez, DrPH, MPH

EpI-Net Project, Ponce Research Institute

Introduction: The COVID-19 pandemic has led to an increase in the conduction of treatment and vaccine trials. However, most participants include non-Hispanic Whites, which could lead to under representation of minority populations. We describe the interest, attitudes, and participation in COVID-19 related clinical trials in a sample of Hispanics living in Puerto Rico.

Methods: We analyzed data collected from an ongoing cross-sectional study that collected information of 193 individuals aged ≥ 21 years between November 2021 and February 2022. Information about demographics and participant’s experience, attitudes, and beliefs about participating in COVID-19 related clinical trials was collected through a telephone interview. This study was approved by the IRB MSC (A1810221).

Results: Median age of participants was 55 years, and 69.0% were women. Most had at least a high school degree (71.0%), an income ≥ $20,000 (62.0%), and private health insurance (52.0%). The majority of participants were vaccinated against COVID-19 (97.4%) and 64.3% had received the booster dose. Only 64.3% were aware of the availability of COVID-19 clinical trials. While 78.8% had thought that participating on a COVID-19 trial could be beneficial for their health, 72.8% were willing to participate in a trial to receive COVID-19 treatment if they become infected. Nonetheless, only 7.3% (n=14) had been invited to participate and 3.6% (n=7) had participated. Among them, the most commons reasons to participate in a COVID-19 trial were the importance of developing COVID-19 treatments and the need to return to normalcy. Reasons for refusal to participate in a trial included lack of enough information about the trial and fear about treatment safety.

Conclusion: Our study findings show that there is interest in participating in COVID-19 related clinical trials; however, more efforts are needed to raise awareness in order to improve the likelihood of participation among Hispanic populations.

Acknowledgments: NIMHD-1OT2HL161827

Jeslie M. Ramos-Cartagena, MS

Ponce Health Sciences University

Social determinants of health have a critical role in the disproportional impact of COVID-19 among socially vulnerable communities (SVC). This research aims to evaluate the relationship between CDC adapted Social Vulnerability Index for Puerto Rico and the Risk of Contagion to COVID-19. For this evaluation, we develop three indices. First, an adaptation of the CDC Social Vulnerability Index (SVI), defined as the limitation of people to respond favorably to social threats originated in their environment. Communities with low SVC are expected to have greater access to available resources to mitigate their social constraints. Then, the Epidemiological Vulnerability Index (EVI), which estimates the risk of Contagion to COVID-19; and, a composite of the two, that is, Epidemiological Social Vulnerability Index (ESVI) which, through Bayesian models, establishes the probability of risk of contagion given the level of Social Vulnerability. The SVI was categorized as High, Medium, Low, and the EVI as High and Low. A logistic regression test revealed that less vulnerable populations are 3.4 times (p-value = 0.026) more likely to be at risk of contagion. For example, the Ponce Health Region presents a crude probability of contagion of 25.3% and after Social Vulnerability adjustments: 4.5% (high), 10.3% (med), and 22.2% (low). The socially less vulnerable population in Puerto Rico can have more mobility increasing their chances of being exposed to SARS-CoV-2 and increasing their risk of contagion to COVID-19. It is important that SVC enhanced prevention practices, but implementation of public health strategies to address social determinants of health are needed to mitigate COVID-19 health disparities.

Keywords: social vulnerability index, Puerto Rico, risk of contagion, COVID-19.

Ángel Suárez-Rivera, Ruby Serrano

Public Health Program; Ponce Health Sciences University

Objective: The objective of this study is to assess the impact of COVID-19 pandemic worries (e.g., fear of contagion) and previous exposure to natural disasters (e.g., hurricanes) on Healthcare Workers (HCWs) mental health in Puerto Rico. Methods: Participants completed a self-administered online survey including items on sociodemographic information, working conditions, fears, and worries about the COVID-19 pandemic, past natural disasters experiences, and depressive symptoms and resilience. Logistic regressions models were performed to explain the relationship between depressive symptomatology and COVID-19 experiences and worries. Results: 40.9% (n=107) of the sample were classified as having some level (low to severe) of depressive symptomatology (PHQ-8 ≥5). Results reflect normal to high levels of psychological resilience (BRS; M=3.6, SD=0.7). Most participants responded that having experienced Hurricane Maria and the 2020 earthquakes made it “somewhat” (47.0%, n=94) to “much more” (15%, n=30) challenging to cope with emotions during the COVID-19 pandemic. A significant association was found between depressive symptomatology and psychological resilience (OR=0.44, 95% CI: 0.25-0.77). The odds of having depressive symptomatology were almost five times higher (OR=4.79, 95% CI: 1.71-13.44) among those who reported emotional coping difficulties during the pandemic after experiencing a natural disaster compared to those that did not, when adjusting for psychological resilience and residence region. Conclusions: HCWs in Puerto Rico reported low to severe levels of depressive symptomatology and normal to high psychological resilience. Despite high psychological resilience levels, HCWs who reported emotional coping difficulties due to previous disasters had almost five times the odds of developing depressive symptomatology.

Acknowledgments: Dr. Hernández-Torres is supported by the University of Rochester CTSA award number TL1 TR002000 from the National Center for Advancing Translational Sciences of the National Institutes of Health. Dr. Rivera-Segarra was supported by the National Institute of Mental Health under award R34MH120179. Dr. Ramos-Pibernus was supported by the National Cancer Institute under award 1R21CA233449. The content is solely the authors’ responsibility and does not necessarily represent the official views of the National Institutes of Health.

Ana Soto-Sánchez, BA

Ponce Health Sciences University

Background: As of February 27, 2022, the Puerto Rico Health Department has reported 266,559 COVID-19 confirmed cases and at least 1,002,631 (43.4%) persons eligible for the booster vaccine have not received it. The Puerto Rico (PR) COVID-19 Vaccine Uptake Study (PR-COVACUPS) will evaluate the efficacy of an educational intervention to reduce COVID-19 vaccine booster hesitancy and increase vaccine uptake in a vulnerable and socioeconomically disadvantaged population in Puerto Rico. We describe the development of a booklet, one of the educational components of the toolkit that will be used in the implementation of PR-COVACUPS.

Methods: A mixed-method approach was used to develop a low-literacy patient educational tool. In Phase 1, we performed a systematic content analysis of media coverage articles related to COVID-19 and government's vaccination guides. Phase 2 consisted of 11 interviews with key informants, health professionals of the UPR School of Medicine Outpatient Clinic, using a semi-structured and conversational guide that covered relevant constructs selected from the Consolidated Framework for Implementation Research. These key informants reviewed and provided feedback about the content and design of the educational booklet.

Results: The barriers identified by the key informant interviews and media content analysis were considered when designing the educational guide. A total of 16 emergent topics related to COVID-19 and the vaccine were included in the booklet. Themes included information about the development, efficacy, security, side effects, importance, access and eligibility of the vaccine booster, long-term effects of COVID-19, and strategies to detect misinformation. This consisted of no more than 4,426 words, with supplemental information included in a QRcode with videos by health professionals and students.

Conclusion: The phases implemented served as contributing resources to develop the educational toolkit intervention. We will conduct a randomized behavioral intervention with 386 individuals selected from patients receiving treatment at any of the institutions within the Puerto Rico Medical Center network to examine the toolkit's efficacy to address COVID-19 booster vaccination.

Acknowledgments: This research is supported by NIH Grant 3U54MD007600-35S.

Gabriella Torres Irizarry

University of Puerto Rico

Seaweed dermatitis is a rare type of irritant contact dermatitis that is typically seen in seabathers. It is commonly caused by Lyngbya majuscula, and, less commonly, by the Sargassum species and its toxicity. It is believed that Sargassum’s toxic agents disrupt the epidermis, recruit proinflammatory mediators and cause an inflammatory response. We herein report an unusual case of an 11-year-old boy with an urticarial, pruritic, hyperemic, and hyperthermic rash after sea bathing in a sargassum-filled beach. Skin lesions were only present in water-exposed skin. This rash is different from the few ones described in the literature, making this case unique. A diagnosis of seaweed dermatitis was made, caused by the sargassum species, and supportive treatment with steroids, and antihistamines ended in the resolution of the rash. Sargassum toxicity is becoming a relevant topic in the Caribbean due to massive rafts accumulating in water bodies, and the dermatological, neurocognitive, and constitutional effects that have been reported in the people exposed to it. Measures to prevent and raise awareness of this type of consequences, as a result of sea-bathing in Sargassum-filled water bodies, should be taken in order to minimize the incidence of cases. Further research in this topic is needed in order to deepen knowledge of this affliction along with its implications in human health.

Luisandrea Morales-Meléndez

miR Scientific Puerto Rico

Huntington’s Disease (HD) is an incurable, hereditary, neurodegenerative disorder characterized by involuntary movements, loss of cognitive function and personality changes. HD symptoms progressively worsen after the clinical diagnosis, resulting in death over 15-20 years. Worldwide HD affects an estimated 3-7 per 100,000 people of European ancestry, however, in Puerto Rico the HD prevalence is unknown. The Fundación Huntington Puerto Rico (FHPR) is a nonprofit organization with the mission to reduce health disparities and improve the quality of life of the people living with HD. When the FHPR was established in 2016, the HD community in Puerto Rico was an invisible and underserved population and our main objective became to identify all unknown cases of HD.

The research methodology consisted of educating and advocating about HD by the publication of articles in local newspapers, offering radio and TV interviews, conferences, and educating the healthcare professionals to become knowledgeable in HD. Once the families emerged, we performed home visits to obtain the sociodemographic information.

Our results show that we have identified and confirmed, through genetic testing or family history, 99 persons living with HD. In accordance with the autosomal inheritance of HD, 52% are male and 48% are females. We identified adult onset patients at early, middle and advanced disease stages and juvenile cases. We also have identified 253 people at risk of developing HD and created 31 pedigrees. These results represent 28.2% of the island (22 out of 78 municipalities). We conclude that, although it is premature to be established, the estimate reported in this study suggests a prevalence of 2 (1.68) per 100,000 people affected by HD, implying that the prevalence of HD in Puerto Rico might be similar to that reported worldwide.

These numbers are likely to be underestimated due to the limited quantity of municipalities examined. This work was supported by The Griffin Foundation and the Comisión Especial Conjunta de Fondos Legislativos para Impacto Comunitario.

Christian Gonzalez-Serrano

Fundación Huntington Puerto Rico

Introduction: On December of 2019, SARS-CoV-2 emerged as a new virus that spread around the world with no effective therapy or vaccine to improve or prevent clinical manifestations. At that time, only supportive care was used for patients. People with multiple high-risk conditions such as asthma, pregnancy, cardiovascular disease, hypertension, a body mass index (BMI) >25 and chronic lung diseases are more likely to develop severe COVID-19. Throughout the course of the pandemic, four anti-SARS-CoV-2 monoclonal antibodies products have received Emergency Use Authorizations (EUAs) from the Food and Drug Administration (FDA). Since 2020, the Puerto Rico Department of Health has successfully implemented monoclonal antibodies under EUA by establishing a therapeutics program.

Methods: Patients with a positive antigen or molecular COVID-19 test are identified using the local database called the Bioportal. COVID-19 positive cases within the first 7 to 10 days of symptoms onset are also referred to the PRDOH therapeutics program by epidemiologist, medical providers, and a call center. Patients are interview using a Spanish checklist that captures the patient’s profile and eligibility criteria.

Results: Between March 2021 and December 2021 around 3,902 patients received monoclonal antibody treatment in PR. The regions in which more patients accepted and received the monoclonal treatments were the Metropolitan and Mayaguez regions. Among the participants who accepted the treatment, the average age for females was 49 years old (SD=17) and for males 46 years old (SD=17). When assessing eligibility criteria’s, we found hypertension (44.5%), obesity (40.6%), and diabetes (33.4%) to be the most prevalent conditions among the treatment recipients.

Conclusion: Patient screening data suggest that monoclonal treatments are being administered to those who need it the most and in aliment with HHS guidelines. This has helped reduce complications among higher risk group. PRDH continues implementing strategies to address health literacy regarding COVID-19 therapies.

Mayra Boneta Soto, MPH, MT

CDC Foundation

Introduction: Pfizer-BioNTech COVID-19 vaccine received emergency use authorization by the USA Food and Drug Administration on December 11, 2020. The student body leadership of Universidad Central del Caribe (UCC) gathered to develop a university-based vaccination clinic under the guidance of diverse faculty mentors. The objective was to provide an interprofessional environment where different specialty programs facilitate community service and develop clinical, public health, ethics, and professionalism competencies during pandemics.

Methods: Multiple committees, ranging from education, logistics, volunteer, pharmacy, research and platform used: Vaxxineplus and PREIS, were developed to address every aspect of the clinic. As an academic institution, we acknowledge our obligation to offer truthful information about the vaccine to the community served, recognizing that misinformation will negatively impact public health promotion and disease prevention. The logistics committee established an operational plan for each clinic to fulfill the needs of each working station, updating them as clinic operations were implemented. The UCC community, including faculty and students, developed a sense of responsibility in aiding during the COVID-19 pandemic. The leaders assigned volunteers different tasks to fulfill the clinic’s priorities. The pharmacy committee had constant communication with volunteers and logistics committees to avoid vaccine shortages or overproduction.

Results: The clinic has administered a total of 20,511 adults and 86 pediatric doses. The clinic has been able to impact communities outside Bayamón, such as Loiza, Barrio Obrero, COSSAO (Utuado), Magüeyes (Dorado), among others. In addition, the research committee, along with second-year medical students, developed 16 projects to assess different themes regarding vaccination. To date the clinic is held twice a week with quality participant-centered service and strengthening student communication skills as its focus. Conclusion: Communication, changes, and improvements throughout the process are key to maintaining an adequate environment of operation to address the participants’ needs.

Jean A. Pérez Verdejo

Universidad Central del Caribe

Introduction: Prostate cancer (PCa) is the most common cancer, and the most common cause of cancer death among men in Puerto Rico, with a mortality rate 149% higher than in the mainland United States. Puerto Rico has a public health crisis that must be addressed to avoid catastrophic consequences among its population and the overall future of the Island. In 2019, miR Scientific pledged to bring an innovative solution to address the public health crisis of PCa on the Island.

Methods: A deliberate engagement model, Educate, Empower and Engage + I ( E3 + i), was deployed to align key stakeholders to produce a groundswell effort from prostate cancer survivors, healthcare providers, lawmakers, academia, scientists, and business leaders to pave a pathway to a healthier community and socioeconomic health equity. The E3 + i model’s foundation is to listen, research, inform and rally resources of like-minded individuals with a common goal of solving the current PCa public health crisis in PR.

Results: • MOU with ASES to address the underserved VITAL population to improve clinical and economic PCa outcomes • Clinical study conducted in PR to validate a noninvasive molecular screening tool for PCa • Holistic approach to patient care – engagement of entire medical spectrum • Government of PR proclaimed September as the PC Month to bring awareness of this issue in the community. • Academia and research – miR’s CEO as keynote during PRCCI ‘s 3rd Clinical Investigation Summit • PR urologist and PI invited to present at SUI in Dubai • PR Physician Executive selected to serve on global advisory council • Production of an award-winning short film FACES • Customer center in PR for bilingual markets • miR headquarters in Guaynabo

Conclusion: The E3 + i model has been widely embraced by Puerto Rican stakeholders and represents best-in-class model to address public health crises globally.

Arminda "Mindy" Figueroa

miR Scientific Puerto Rico

Background and Objectives: Behavioral and psychosocial barriers influencing COVID-19 booster vaccine uptake are a public health threat worldwide. As of February 24, 2022, 44.1% of the eligible population in Puerto Rico have not received the booster vaccine, highlighting ongoing challenges for its uptake in the archipelago. The PR COVID-19 Vaccine Uptake Study (PRCOVACUPS) aims to develop a behavioral intervention trial to evaluate the efficacy of an educational intervention to reduce COVID-19 booster vaccine hesitancy guided by the views of health professionals of the UPR School of Medicine Outpatient Clinics.

Methods: Zoom interviews with 11 health professionals were conducted using a semi-structured and conversational guide that covered relevant constructs selected from the Consolidated Framework for Implementation Research. Eligible health professionals, identified by the clinic medical director, were actively involved in managing patients during the COVID-19 pandemic.

Results: Health professionals expressed that the central patients’ barriers to booster vaccine hesitancy are: (1) concerns about their efficacy and safety, (2) fear of vaccine, (3) misinformation due to unreliable sources, (4) unawareness of new information regarding COVID-19 and corresponding booster doses, (5) problems of access to the vaccine, (6) distrust of the government, and (7) preexisting health conditions. Health care professionals outlined their patients' family beliefs and medical orientations as essential considerations in decision-making factors toward vaccination. Health professionals are aware of the importance of promoting and educating about vaccination but emphasize the need for a more active initiative to facilitate the vaccine and adequate education resources for the community.

Conclusion: Views from health professionals as part of these qualitative interviews served to identify potential predictors of vaccine hesitancy, which will be used to design and implement an educational intervention to reduce COVID-19 vaccine booster hesitancy in a vulnerable and economically disadvantaged community.

Acknowledgments: This research is supported by NIH Grant 3U54MD007600-35S.

Katherine Matos-Jiménez, MT

University of Puerto Rico - Medical Sciences Campus - Graduate School of Public Health

Psychological sequelae have been recognized as important elements of the burden of disease among caregivers of children with Zika virus prenatal exposure. Recognition of the impact of adverse experiences and biomarkers of toxic stress is important to identifying and preventing mental health problems with impact on child rearing practices and wellbeing. Our study explores social determinants of health (SDoH)-mediated stressors during COVID-19 that can put caregivers of vulnerable children at risk for mental health problems. Twenty-five Hispanic mothers of children with prenatal Zika exposure completed surveys assessing SDoH-mediated vulnerabilities, COVID-19 related stressors and the Impact of Event Scale (IES) to explore posttraumatic stress disorder (PTSD) symptomatology, and a sample for hair cortisol concentration (HCC) as a toxic stress biomarker. We used multivariable linear regression models to test the associations between stressors, IES, and HCC, adjusted for maternal age, education, and child sex. HCC was log-transformed in regression analyses due to a skewed distribution. The mean age of caregivers was 30 years, most have low education (76%), annual income below $15,000 (92%), and are unemployed (68%). COVID-19 stressors include difficulties obtaining healthcare services (32%), disruption of child education (88%) and specialized healthcare services (6/13, 46%), and food insecurity (40%). IES scores suggest that 60% of caregivers experienced PTSD symptomatology (score=33+). The median of HCC was 75.6 pg/mg. Adjusted linear regression models indicate that women with higher IES scores had significantly lower HCC (B=-1.11, SE=0.51, p=0.04), and those with children needing specialized healthcare services also had significantly lower HCC (B=-1.35, SE=0.49, p=0.01). Nevertheless, those with pandemic food insecurity had significantly higher HCC (B=1.01, SE=0.48, p=0.049). Dysregulation of the hypothalamic-pituitaryadrenal axis with a reduced response has been described in the presence of prolonged stressors, as compared to acute stressors. SDoH mediators can provide opportunities to prevent adverse mental health outcomes in child caregivers.

Luisa Alvarado-Domenech, MD

George Washington University-Milken Institute School of Public Health

Introduction: Feminization of poverty refers to the fact that poverty affects women and children more than men, and to those social, economic, judicial and cultural mechanisms and barriers that cause women and other feminized identities to be more exposed to impoverishment in quality of life. In 2014, it was estimated that for every 100 men in the poorest households there were 155.3 women, more than 50%. In 2015 the Institute of Statistics indicated that 43% of families were below the poverty level and that in households with female heads of family it was 60%. This paper intends to present the general panorama of poverty in general and describe the population of women, children, and adults under levels of poverty in P.R. Female-headed families, employment and education will be taken into consideration from a public health approach.

Method: Data was obtained from the PRCS. For its analysis, the Statistical Package for the Social Sciences (SPSS) program was used.

Results: In P.R., on a sample of 3,318,448, 44.2% of its population lives under poverty level. 46.0% of the women lives under poverty level. When analyzed by age, the ranges of 20-29 through 60-69 years old are the most affected by it. Households led by women, with no spouse present account for 70.4% with children under 18 years; and approximately 46.3% of women are employed. When considering “near poverty level”, women made up to 29.6% of the population, even with high school and college education.

Conclusions: Taking into consideration that women made up for most of the population under poverty level, with children under 18 and when considering “near the poverty level” they made up to 29.6% of the whole population. This is a public health issue affected by social determinants that can limit access to resources and services.

Francelis N. Báez Caraballo

University of Puerto Rico - Medical Science Campus and Institute of Statistics

Introduction: Nearly one-third of the eligible population in Puerto Rico (PR) has received a COVID-19 booster vaccine despite its importance in managing ongoing and emerging pandemic challenges. Beliefs towards COVID-19 booster vaccination may help understand booster acceptance among immunized individuals, but this remains unknown. This study examined the beliefs towards COVID-19 booster vaccination and acceptance among adults in PR.

Methods: Study participants were adults immunized against COVID-19 who completed the PR-CEAL online survey, framed by the Health Belief Model (HBM), from December 30, 2021, to January 28, 2022. Respondents were classified as booster vaccination acceptance (boosted or will get boosted as soon as possible) or booster vaccination refusal (no intent to get boosted or rather wait). Pearson χ2 test was used to compare the differences in booster vaccination acceptance across HBM constructs. Results: Mean (SD) age of the total sample (n=529) was 38.2 (14.5) years, 52.7% had some college education or were college graduates, and 73.3% were female. Most of the sample (90.7%) reported COVID-19 booster vaccination acceptance, and 9.3% refused booster vaccination. Immunized individuals refusing booster vaccination were less likely to perceive benefits of booster vaccination than those with booster acceptance: the booster decreases chances of getting COVID-19 or its complications (24.5% vs. 86.3%) and the booster decreases concerns about catching COVID-19 (12.2% vs. 79.8%). Additionally, individuals refusing booster vaccination were more likely to perceive barriers towards booster vaccination than those with booster vaccination acceptance: concerns about booster vaccine safety (81.6% vs. 37.9%), side effects (75.5% vs 37.7%), and efficacy (79.6% vs 41.0%).

Conclusion: Most adults reported COVID-19 booster vaccination acceptance despite concerns over its safety, side effects, and efficacy. However, public health campaigns need to target booster barriers and benefits to reduce booster vaccination refusal as new variants emerge in Puerto Rico.

Stephanie Cameron-Maldonado

PR-CEAL

Introduction: The Food and Drug Administration (FDA) has approved multiple products under an Emergency Use Authorization (EUA) for both inpatient and outpatient use to manage COVID-19 infections. These therapies have been an essential tool to prevent disease severity in patients with underlying medical conditions. The Office of the Chief Medical Officer (CMO) and the Office of Public Health Preparedness and Response (OPHPR) at the Puerto Rico Department of Health developed a medical countermeasures plan to ensure equal access to COVID-19 treatments. Factors affecting an individual’s access to care and regional positivity rates were considered during dispensing and expansion of operations. Since December 2020, PR has administered over 5,000 monoclonal treatments and over 2,000 antivirals courses have been dispensed.

Methods: The PR therapeutics program worked with providers across the island to augment capacity by providing trainings and facilitating over 10 culturally adapted protocols. Educational materials were disseminated via multiple channels. The CMO Team identified the locations for the treatments based on geography and population density. The GIS team developed maps positioning all antivirals and monoclonal sites, such as pharmacies, clinics, and hospitals throughout the island to ensure equal access. One fixed treatment site, located at the University Hospital, was implemented to link patients to treatment in a shorter time.

Results: Over 28 hospitals and clinics and 5 infusion centers are administering monoclonal antibodies in PR. Over 128 pharmacies distributed among 78 municipalities are dispensing COVID-19 antiviral therapies. The fixed treatment site has administered over 500 monoclonal treatments and has dispensed 59 oral antivirals.

Conclusion: Puerto Rico’s Department of Health has successfully implemented a therapeutics program that provides COVID-19 treatments throughout the island including Vieques. We are evaluating the possibility of expanding fixed treatment sites in all regions of the island. This operation model would allow patients to get tested, received medical evaluation, and treatment referrals at one location.

Diana Duran Lopez

CDC Foundation, Department of Health of Puerto Rico

Puerto Rico ha tenido una alta prevalencia de caries en infantes a edad temprana (47% a 53%). Este estudio evalúa la implementación de la Ley Núm. 63 de 2017 (Establece la entrega de un Certificado de Examen Oral en escuelas públicas y privadas para los grados K, 2do, 4to, 6to, 8vo y 10mo) y cuál ha sido el impacto en las reclamaciones de servicios de salud oral en el Plan de Salud del Gobierno. Mediante un análisis descriptivo se analizaron los datos del Sistema de Vigilancia de Reporte de Cumplimiento del Certificado de Examen Oral 2018-2022 y las reclamaciones realizadas al Plan de Salud del Gobierno durante el periodo 2016-2019. En el primer año escolar (2018-2019) de implementación de la Ley, 22.8% de los estudiantes entregaron el certificado, en 2019-2020 un 30%, en 2020-2021 un 24% y en 2021-2022 un 42%. Al comparar 2019 con 2016, el cambio porcentual más grande en reclamaciones de salud oral fue en la población impactada por la ley (5-16 años). En 2019 se registró un aumento en el porciento de beneficiarios entre las edades de 5 a 16 años que reportaron al menos una reclamación de servicios de salud oral. Los tres servicios preventivos con mayores reclamaciones entre la población de 5-16 años para el 2019 fueron: aplicación tópica de barniz de fluoruro (20.1%), profilaxis dental (14.4%) y evaluación oral periódica (13.6%). Tomando en cuenta los resultados de este estudio podemos establecer que la implementación de la Ley Núm. 63 de 2017 ha contribuido al aumento observado en las reclamaciones de servicios de salud oral en la población de 5 a 16 años comprobando así su efectividad. Por tal razón, es importante continuar monitoreando y promoviendo el cumplimiento de esta, así como desarrollando nuevos estudios que nos ayuden a establecer tendencias.

Alex Cabrera Serrano, MSc

Departamento de Salud de Puerto Rico

En Puerto Rico, el 50% de la población vive con una o más enfermedades crónicas. La emergencia de salud pública como consecuencia de la pandemia ocasionada por el SARS-COV2 ha provocado retos en el manejo de estas enfermedades, que aumentan el riesgo de complicaciones asociadas con el COVID-19. Según el Registro Demográfico, entre marzo y septiembre de 2020, las causas de muerte más documentadas asociadas a COVID-19 fueron enfermedades crónicas.

Ante este panorama, fue necesario desarrollar iniciativas educativas para concienciar sobre las complicaciones por COVID-19 en personas con enfermedades crónicas. La Secretaría de Salud Familiar, Servicios Integrados y Promoción de la Salud (SASFSIPS) solicitó y le fueron otorgados fondos bajo el Coronavirus Aid, Relief, and Economic Security (CARES) Act para el desarrollo e implementación de estrategias de comunicación en salud, como herramienta para informar sobre asuntos de salud y mantenerlos en la agenda pública. El fin de esta iniciativa era concienciar en torno a las complicaciones por COVID-19 en personas con condiciones crónicas.

Durante los meses de noviembre 2020 a marzo 2021, el equipo de trabajo desarrolló 65 materiales dirigidos a la población adulta relacionados con las enfermedades crónicas, estilos de vida y envejecimiento saludable. Se realizaron publicaciones en redes sociales, medios digitales, periódicos, billboards, radio, televisión y una página web. Se ofreció asistencia técnica a otras iniciativas de la respuesta a COVID-19 dentro del DS.

Estas iniciativas de comunicación en salud lograron un alcance masivo de personas en Puerto Rico mediante diversos medios. Se estima que más de 500,000 personas recibieron información sobre prevención y manejo de enfermedades crónicas en medio de la pandemia de COVID-19. Esta iniciativa estableció la base para el desarrollo de otros programas relacionados con la educación sobre enfermedades crónicas, específicamente en situaciones que aumentan el riesgo de complicaciones y muerte.

Yiselly M. Vázquez Guzmán, EdD, MPHE, CGG, CHES

Departamento de Salud de Puerto Rico

Introduction: Having an infant in the Neonatal Intensive Care Unit (NICU), is an unexpected and perhaps traumatic experience for most mothers, whose anxiety, depression, and perceived stress might be exacerbated by other life circumstances. The COVID-19 pandemic has changed our reality and mothers whose babies are admitted to the NICU are no exception. The purpose of this study is to evaluate the effects of the COVID-19 pandemic on these mother’s mental health symptoms.

Methods: The sample consisted of 63 mothers aged 18-41 (mean age 28.4 ± 5.95 years) with infants hospitalized to the NICU at the UPR Pediatric Hospital. During the months of January through December of 2021, mothers were voluntarily interviewed when the infants were between 1 to 8 weeks of age. They completed the State-Trait Anxiety Inventory (STAI-6), Patient Health Questionnaire (PHQ-9) to assess depressive symptoms; Parental Stressor Scale NICU (PSS:NICU), and a questionnaire evaluating parental COVID-19 related stress (Covid Scale 1) and how their experience in the NICU has been affected by the pandemic (Covid Scale 2).

Results: Mild, moderate and high symptoms of depression and perceived stress in the NICU were reported by 43% and 72% of the mothers, respectively. Additionally, 62% presented moderate and high anxiety symptoms. Pearson correlations were positively significant between anxiety and the Covid Scale 1 (r=.29, p<.01) and Covid Scale 2 (r=.36, p<.001).

Conclusion: Mothers reported higher anxiety as they experienced a higher impact of COVID-19 in their lives and as they perceived the NICU resources to control COVID-19 in the NICU as more disruptive. These results provide information about how important it is to explore the available support for mothers in and outside the NICU that can help them cope during the difficult times of having their babies admitted in the NICU, plus the COVID-19 pandemic.

Edmarie Sánchez Cintrón

University of Puerto Rico, Medical Sciences Campus

Adverse childhood experiences (ACEs) are associated with risk of mental health problems (MHPs) in adulthood. Resilience has been shown to be a protective factor for MHPs, however, there is little representation in the literature for Hispanic/Latinx adults. We examined the association between ACEs and resilience on MHPs among adults living in Puerto Rico.

Data were used from 931 participants (30-75 years) enrolled in the Puerto Rico Observational Study of Psychosocial, Environmental, and Chronic Disease Trends (PROSPECT). Trained interviewers conducted assessments using the Adverse Childhood Experience (ACE) Questionnaire, Center for Epidemiologic Studies Depression (CES-D) screener, Generalized Anxiety Disorder 7-item (GAD-7) screener, and Brief Resilience Scale (BRS). Multivariable logistic regression was used to evaluate the association between ACEs and depression and anxiety symptoms. After controlling for socio-demographic factors, we included resilience to assess effect modification. Our cross-sectional results suggest that the presence of at least one ACE is strongly associated with depressive and anxiety symptoms. In adults who reported resilience, the association was no longer significant in depressive symptoms, but was still present for anxiety symptoms (OR 1.74, 95% CI 1.15, 2.62). Further analysis showed that even among resilient adults, having an incarcerated household member was significantly associated with depressive and anxiety symptoms (OR 1.99, 95% CI 1.19, 3.33 and OR 2.82, 95% CI 1.70, 4.68, respectively), while sexual abuse was significantly associated with depressive symptoms (OR 1.58, 95% CI 1.03, 2.44).

Overall, resilience plays a protective role in the presence of ACEs for depressive symptoms. Resilience was not a protective factor for children exposed to an incarcerated household member or sexual abuse. ACEs impact mental health outcomes and may be mitigated by resilience. Interventions focused on strengthening individual and systemic resilience should be implemented to improve mental health.

This work was supported by the NHLBI grant (R01-HL143792) and NIMHD grant (R21-MD013650).

Almarely Berríos-Negrón

Ponce Health Sciences University

COVID-19 vaccination is significantly associated with a lower risk of SARS-CoV-2 infection, yet Puerto Ricans remain cynical. While initially vaccinating in high numbers here on the island, a considerable portion of the Puerto Rican population may experience vaccine hesitancy toward COVID-19 booster vaccines, which poses dangers to both the individual and their communities. Our study was designed to identify barriers to vaccination in the Puerto Rican population utilizing a multi-item questionnaire that was based on a comprehensive literature review and based on expert suggestions.

The questions were adapted from vaccine acceptance predictors identified in earlier general vaccine confidence studies. The survey was completed at the Centro de Vaccination at San Juan City Hospital between March and May 2021. We have included six hundred participants in this study. Results through descriptive analyses and multiple regression models revealed forty-three percent believe that vaccines are not safe. Forty-five percent believed their most important sources of information is the news or television. Thirty percent believe their single most important source for information is family and friends. The standout result from our questionnaire indicated that less than twenty percent of our participants gained information from their primary care physician or other healthcare professionals. This is a major cause of concern for the medical and scientific community in Puerto Rico requiring immediate intervention and constant monitoring. We must identify the vital gap missing in the communication between Doctors and their respective communities is crucial in the battle against misinformation and regaining the trust of the public here in Puerto Rico.

One of the unintended goals of this study was the introduction to creating a coalition of medical residents from all ACGME accredited residency programs to begin face to face conversations with communities. We must delivery up to date, high quality, evidenced based medical information to all of Puerto Rico.

There was no funding given for this study.

Akbar Khan, MD

San Juan City Hospital

Introduction: Nearly one-third of the eligible population in Puerto Rico (PR) has received a COVID-19 booster vaccine despite its importance in managing ongoing and emerging pandemic challenges. Beliefs towards COVID-19 booster vaccination may help understand booster acceptance among immunized individuals, but this remains unknown. This study examined the beliefs towards COVID-19 booster vaccination and acceptance among adults in PR.

Methods: Study participants were adults immunized against COVID-19 who completed the PR-CEAL online survey, framed by the Health Belief Model (HBM), from December 30, 2021, to January 28, 2022. Respondents were classified as booster vaccination acceptance (boosted or will get boosted as soon as possible) or booster vaccination refusal (no intent to get boosted or rather wait). Pearson χ2 test was used to compare the differences in booster vaccination acceptance across HBM constructs. Results: Mean (SD) age of the total sample (n=529) was 38.2 (14.5) years, 52.7% had some college education or were college graduates, and 73.3% were female. Most of the sample (90.7%) reported COVID-19 booster vaccination acceptance, and 9.3% refused booster vaccination. Immunized individuals refusing booster vaccination were less likely to perceive benefits of booster vaccination than those with booster acceptance: the booster decreases chances of getting COVID-19 or its complications (24.5% vs. 86.3%) and the booster decreases concerns about catching COVID-19 (12.2% vs. 79.8%). Additionally, individuals refusing booster vaccination were more likely to perceive barriers towards booster vaccination than those with booster vaccination acceptance: concerns about booster vaccine safety (81.6% vs. 37.9%), side effects (75.5% vs 37.7%), and efficacy (79.6% vs 41.0%).

Conclusion: Most adults reported COVID-19 booster vaccination acceptance despite concerns over its safety, side effects, and efficacy. However, public health campaigns need to target booster barriers and benefits to reduce booster vaccination refusal as new variants emerge in Puerto Rico. Acknowledgment: This work has been supported by OT2HL161827 from NIH-NHLBI.

Stephanie Cameron-Maldonado

PR-CEAL

Introduction: The purpose of this study is to observe if there is an increase between stool ova and parasite cases in the west side of Puerto Rico after the Hurricane Maria’s event.

Methods: A retrospective cross-sectional design study analyzed all the stool tests for ova and parasites from January 2015 to December 2019 performed at Mayaguez Medical Center were quantify. The variables of date, age, sex, municipality, and parasite were collected. Univariate analysis was performed to describe demographical and clinical variables. To define the characteristics of the sample the use distributions charts, central tendency and dispersion measures were used.

Result: From January 2015 to December 2019; 1,155 of stool tests of ova and parasites were performed at MMC. On the years 2015-2017 there were not positive samples. However, during 2018-2019 a total of 16 positive stools test were identified. The median age of the sample was 71.5 years old. A 60% were females and 40% were males. The municipally of Anasco has the highest frequency of positive cases of ova and parasite stool test. Strongyloides was the most prevalent parasite found on the sample with a 60.0%, specifically on the months of July and August.

Conclusion: There were a markedly increase on positive stool test of ova and parasite at MMC during the years 2018-2019. An important risk factor that could possibly triggered this observed increase in positive stool tests with parasites could be the impact of Hurricane Maria. However, the etiology of infection is not well established in this study.

No acknowledgement.

José Rivera-Sepulveda, MD

Mayaguez Medical Center

Introduction: Climate change increases the likelihood of multiple contemporaneous extreme weather events. Compounding hazards create cascading impacts through interconnected food, energy, and water (FEW) systems, with significant implications for community health and resilience.

Methods: This research is grounded in a community-based participatory research approach with 16 leaders of the rural community of Corcovada, Añasco, Puerto Rico. Utilizing a qualitative mixed-methods research design, inclusive of a two-day workshop, community walk, semistructured interviews, small group discussions, and individual reflections, we assessed how contemporaneous climate hazards interact with physical infrastructures and the effect the FEW security needs of residents with implications to health and wellbeing.

Results: Preliminary results demonstrate the key role of community leaders as public health promoters in their own community through their informal roles on various public health services including community health assessment and monitoring, education, and partnership mobilization. In addition, community leaders formally and informally identify public health threats while using their social capital to advance health resilience. In the context of compounded disasters and FEW insecurity over the last five years (2017-2022) Corcovada leadership for public health has the potential to serve as a model of community organization to ensure healthy communities in times of stress and shock including being an active player in the public health force.

Conclusions: The results of this community-based partnership will aid in the development of equitable public health policies and practices related to funding allocation and resource prioritization.

This project was funded through the Public Health Disaster Research Award Program based on work supported by the National Science Foundation (NSF Award #1635593) through supplemental funding from the Centers for Disease Control and Prevention (CDC).

Génesis Alvelo Colón, BA

University of Puerto Rico, School of Public Health

Introduction: To date, no studies have shown how access to safe drinking water is associated with beverage intake and abdominal obesity.

Methods: Cross-sectional data from 856 adults (30-75y) of the Puerto Rico Observational Study of Psychosocial, Environmental, and Chronic Disease Trends (PROSPECT) were used. Participants indicated the type of drinking water most used at home and preference factors (e.g., availability, appearance, cost, and taste). Sugar-sweetened beverages (SSBs) and water intake was assessed with a food-frequency questionnaire. Interviewers measured waist circumference; abdominal obesity was defined as >102cm in men and >88cm in women. Multivariable linear regression models tested associations between type and preference factors for water and water intake. Multivariable logistic regression models tested associations between beverage intake and abdominal obesity. Substitution analysis of water for SSBs was also performed.

Results: Most participants (61%) reported drinking bottled water, while 27% chose filtered tap water and 11% chose unfiltered tap water. Most participants (82%) did not think their tap water was clean/safe, while 63% disliked its taste. Participants that preferred bottled water to unfiltered tap water had higher water intake (mean±SE: 7.54±0.17 vs. 6.55±0.41 servings/d). Water intake was lower in participants that reported cost (6.66±0.23 vs. 7.76±0.16 servings/d), appearance (6.67±0.22 vs. 7.80±0.17 servings/d), and availability (6.57±0.20 vs. 8.06±0.18 servings/d) as preference factors than their counterparts. Taste or safety were not associated with water intake. SSBs or water intake were not associated with abdominal obesity. Substituting one serving of water for one serving of SSBs was associated with lower odds of abdominal obesity (OR=0.89; 95%CI: 0.79,0.98), with a significant association for substituting soda (OR=0.83; 95%CI: 0.74,0.93) and no association for substituting juice.

Conclusion: Measures to provide affordable, safe, and appealing drinking water may facilitate its intake, and its use as a substitute for SSBs, notably soda, may prevent abdominal obesity in PR adults.

Acknowledgement: PROSPECT was supported by the National Institutes of Health -National Heart Lung and Blood Institute (R01-HL143792 and K01-HL120951 to Josiemer Mattei), National Institutes of Health - National Institute on Minority Health and Health Disparities (R21-MD013650), and a Robert Wood Johnson Foundation Culture of Health Leaders Award (to Josiemer Mattei). Martha Tamez received training-grant support (T32 HL 098048).

Martha Tamez

Harvard T.H. Chan School of Public Health

Introduction: The capacity to recruit and retain the established number of participants in a research project pose serious threats to both internal and external validity of an observed outcome. As contributors to community informed solutions, we have persisted in our commitment to assess the effects of our multimodal intervention, in spite of ongoing external challenges. Methods: Here we describe the recruitment and retention strategies used in The Baby-Act Trial (BAT), a community-based lifestyle intervention study to promote physical activity, improve sleep and feeding practices in infants to prevent obesity early in life. BAT is a cluster-randomized controlled trial among 480 mother-infant’s dyads participating in the Puerto Rico WIC program.

Results: Engagement, recruitment and retention of enrolled BAT participants was accomplished through a strong partnership with the WIC program and a common goal to overcome adversity through continuing natural disasters and the COVID-19 pandemic. This partnership allowed the development of alternative means for engagement and support that benefited both institutions and program participants such as: facilitated access and communication with providers and other stakeholders, real time feedback on methods established to transition the WIC program to remote services, and continued access to current and projected programmatic changes. In times of workplace restrictions, we integrated artificial intelligence to schedule follow-up visits.

Results: We successfully recruited a revised sample size of 530 dyads, based on the interim analysis that showed a higher percentage of participants lost eligibility for WIC enrollment than expected (20.9%). Causes for loss of eligibility included obstetrical complications and premature delivery, among others. More significant, our resilience thus far has accomplished the retention of study participants, with only 6.2% of loss to follow up (for a total attrition rate of 27%). Our results demonstrate the importance of community-academic partnerships in the development of translatable evidence-based solutions.

Acknowledgements: The research release was supported by Award Number U54 MD007600 from the National Institute on Minority Health and Health Disparities. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Special thanks to Jeanette Canino and Milane Medina for achieving the recruitment of all the women who participated. Lastly, to all the participants who took their time and effort into making this possible. Keywords: COVID-19, Retention, Health Professionals.

Yari Valle Moro

University of Puerto Rico

El objetivo principal de esta presentación es acentuar la importancia de la preparación enfocada en las necesidades de la niñez y de la acción colectiva ante emergencias y desastres. Puerto Rico ha experimentado una serie de traumas que nos han afectado tanto a nivel individual como colectivo. Los huracanes Irma y María, los terremotos y la pandemia del COVID-19 han recrudecido las condiciones de pobreza, la limitación en el acceso a oportunidades y recursos y la vulnerabilidad de ciertas poblaciones, incluida la niñez.

A través de la iniciativa Resilient Children/Resilient Communities (RCRC), implementada desde el 2019 hasta el 2021 por el equipo del National Center for Disaster Preparedness de Columbia University - New York y esta servidora, se establecieron dos Coaliciones para la Resiliencia Comunitaria y se promovió la acción para trabajar colectivamente por el bienestar de la niñez. Las Coaliciones Comunitarias fueron establecidas una en la región de Mayagüez y otra en la región de Humacao. A través de estas Coaliciones se propulsaron planes de trabajo que tuvieron que ser ajustados con la llegada del COVID-19. Como resultado, se destaca una serie de webinars titulada Niños de PR y COVID-19: En la encrucijada de la pobreza y el desastre.

En esta serie se abordaron temas relacionados a política pública, comunicación estratégica de riesgos, alianzas comunitarias, educación, violencia doméstica, abuso infantil, salud mental y vivienda. También se hizo una Guía para los planes de emergencia en los Centros de Cuido y un módulo sobre Consideraciones básicas para el bienestar y seguridad de los niños y niñas en refugios de emergencia de Puerto Rico.

Este módulo aborda algunas de las brechas identificadas en la planificación y operación de refugios de emergencia. Además, se llevaron a cabo colaboraciones con otras entidades de Puerto Rico para difundir el mensaje y la importancia de trabajar estos temas. Todo esto, a la par con la implementación de los planes individuales de las coaliciones. En esta presentación se abundará en el proceso, los resultados, los retos y las lecciones aprendidas en los años que duró la iniciativa.

Yesenia Delgado Castillo, PhD.

Introduction: The American Academy of Pediatrics recommends breastfeeding as the gold standard for infant nutrition for minimum the first six months due to its multiple benefits. Lactation initiation rates have met national targets; however, goals for any lactation duration or exclusive breastfeeding have not been reached. Puerto Rico (PR) lacks data about factors leading to breastfeeding cessation. Furthermore, COVID-19 pandemic limited practices that promote breastfeeding, such as rooming in and community support systems. Nonetheless, mothers continue willing to breastfeed. Thus, a telehealth lactation support and educational program is suggested to help the University District Hospital ‘s (UDH) breastfeeding mothers. UDH is one of the principal institutions in PR that provides dignified care at the lowest cost possible to its population.

Methods: Ten mothers completed a needs assessment in UDH’s newborn care unit. Additionally, 14 mothers were recruited to complete a questionnaire about maternal and infant’s information, and mother’s initial lactation knowledge before discharge. Afterwards, they received an educational and follow-up intervention via telehealth. A descriptive analysis was performed. Participants are enrolled in an ongoing quality improvement project.

Results: Mean gestational age was 38 weeks. Only 29% breastfed immediately after delivery, all infants were eventually formula-fed after birth. All mothers planned to breastfeed at home, 43% exclusively. On follow-up, 75% were breastfeeding, 11% exclusively. Reported difficulties were decreased milk production, inverted nipple, latch problems, mastitis, laceration, and baby falling asleep before completing full feedings. Most mothers (58%) did not have breastfeeding support from a lactation specialist.

Conclusions: Mothers were confident to breastfeed their infants but encountered difficulties hindering their ability to breastfeed without support from a specialist. Telehealth is a feasible alternative for mothers to receive support, education, and clarification about lactation. A quality improvement project is implemented in UDH as a novel telehealth support program to maintain exclusive breastfeeding.

Claudia S. Morales Díaz

University of Puerto Rico