PT  - JOURNAL ARTICLE
AU  - Rolando J. Acosta
AU  - Rafael A. Irizarry
TI  - Post-Hurricane Vital Statistics Expose Fragility of Puerto Rico’s Health System
AID  - 10.1101/407874
DP  - 2018 Jan 01
TA  - bioRxiv
PG  - 407874
4099  - http://biorxiv.org/content/early/2018/09/18/407874.short
4100  - http://biorxiv.org/content/early/2018/09/18/407874.full
AB  - Importance Hurricane Maria made landfall in Puerto Rico on September 20, 2017. As recently as May of this year (2018), the official death count was 64. After a study describing a household survey reported a much higher death count estimate, as well as evidence of population displacement, extensive loss of services, and a prolonged death rate the government released death registry data. These newly released data will permit a better understanding of the effects of this hurricane.Objective Provide a detailed description of the effects on mortality of Hurricane Maria and compare to other hurricanes.Design We fit a statistical model to mortality data that accounts for seasonal and non-hurricane related yearly effects. We then estimated the deviation from the expected death rate as a function of time.Setting We fit this model to 1985-2018 Puerto Rico daily data, which includes the dates of hurricanes Hugo, Georges, and Maria, 2015-2018 Florida daily data, which includes the dates of Hurricane Irma, 2002-2004 Louisiana monthly data, which includes the date of Hurricane Katrina, and 2000-2016 New Jersey monthly data, which includes the date of Hurricane Sandy.Results We find a prolonged increase in death rate after Maria and Katrina, lasting at least 207 and 125 days, resulting in excess deaths estimates of 3,400 (95% CI, 3,100-3,700), and 1,800 (95% CI, 1,600-2100) respectively, showing that Maria had a more long term damaging impact. Surprisingly, we also find that in 1998, Georges had a comparable impact to Katrina’s with a prolonged increase of 106 days resulting in 1,400 (95% CI, 1,200-1,700) excess deaths. For Hurricane Maria, we find sharp increases in a small number of causes of deaths, including diseases of the circulatory, endocrine and respiratory system, as well as bacterial infections and suicides.Conclusion and Relevance Our analysis suggests that since at least 1998, Puerto Rico’s health system has been in a precarious state. Without a substantial intervention, it appears that if hit with another strong hurricane, Puerto Ricans will suffer the unnecessary death of hundreds of its citizens.Key Points Question: How does the effect of Hurricane Maria on mortality in Puerto Rico compare to the effect of other hurricanes in Puerto Rico and other United States jurisdictions?Findings: We estimate about 3,000 excess deaths after Maria, a higher toll than Katrina. Only other comparable effect was after Georges, also in Puerto Rico. For Georges and Maria, we observe a prolonged death rate increase of more than 10% lasting several months. The causes of death that increased after Maria are consistent with a collapsed health systemMeaning: Puerto Rico’s health system does not appear to be ready to withstand another strong hurricane.