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| Cases of the virus are expected to rise on the island in coming months.
And that raises the likelihood of transfer to the mainland. |
March 1, 2016 - PUERTO RICO - Zika has landed forcefully in America, in one of its poorest and most
vulnerable corners, a debt-ridden territory lacking a functioning
health-care system, window screens and even a spray that works against
the mosquitoes spreading the virus in homes, workplaces, schools and
parks.
There are 117 confirmed cases of the virus in Puerto Rico,
four times the number at the end of January. The island territory,
which has a population of 3.5 million people, is “by far the most
affected area” in the United States, Tom Frieden, director of the
Centers for Disease Control and Prevention (CDC), said Friday. The
number will almost certainly rise sharply in coming weeks, making it
ever more likely that the virus will spread to the continental United
States.
Dozens of flights move daily between San Juan and Orlando,
Washington, New York and other major cities on the mainland. Cruise
ships stop here as part of their Caribbean tours. College students will
soon head here on spring break.
The growing outbreak has laid
bare how deeply Puerto Rico’s debt crisis has cut public programs,
including basic health and environmental control services needed to
fight the virus. Most homes and public schools — and even some medical
facilities — don’t have window screens. A specialist in birth defects at
Puerto Rico’s top hospital has trouble obtaining basic supplies, such
as toner for his office printer. There are hundreds of abandoned houses —
not only in low- and middle-income neighborhoods but also in gated
communities — because owners have fled to the mainland as a result of
the economic crisis.
 |
At dusk, health department workers spray
permethrin in the middle-class neighborhood of Riveras de Cupey in San
Juan, Puerto Rico. The government is beefing
up anti-mosquito measures
as the Zika virus spreads through the island. (Allison Shelley for The
Washington Post) |
Experts say urgent action is needed before mosquitoes reach their peak
with the start of the rainy season in April. Experts from the CDC
estimate that 700,000 people — about 20 percent of the population —
could be infected across the island by the end of the year, based on
previous outbreaks of dengue and chikungunya, related viral diseases.
In
response, the CDC has sent 30 experts from its Atlanta headquarters and
elsewhere to Puerto Rico, adding to the 70 CDC staff members based here
who usually work on dengue fever but now are focusing on Zika. Frieden
is expected to visit soon. President Obama’s $1.9 billion emergency Zika
request to Congress includes $250 million for Puerto Rico.
“I
don’t think we’re going to be able to stop the Zika outbreak,” said
Steve Waterman, chief of the CDC’s dengue branch, located on the city’s
west side. “There will be a substantial Zika outbreak that will peak in
the summer and fall. It’s likely that thousands of pregnant women will
be exposed and infected, so that’s why our efforts are focused on
protecting as many pregnant women as possible.”
Five of the 117
confirmed cases involve pregnant women. And unlike in the continental
United
States, where cases are the result of infected travelers to Latin
America and elsewhere bringing the virus back home, almost all the
cases in Puerto Rico involve people bitten here by infected
Aedes aegypti mosquitoes, which also spreads dengue fever and chikungunya.
Because of the suspected link between Zika and potentially devastating
birth defects, authorities are focusing on protecting as many pregnant
women as possible. That includes 4,000 expectant mothers living in parts
of the island where mosquitoes are spreading the virus. That’s more
than one-third of Puerto Rico — primarily San Juan, the northeast and
the southern coast.
Only the CDC and Puerto Rico’s health department
labs can perform the special Zika testing. The labs expect to run
100,000 tests over the year for pregnant women, five times as many as
they handle now, Waterman said. Determining whether someone is infected
is complicated because most people don’t show symptoms. It’s also hard
for tests to easily differentiate between dengue and Zika infections.
On
Monday, authorities in Puerto Rico began distributing free Zika
prevention kits to pregnant women that were created by the CDC and the
CDC Foundation. The kits include information and tools to help them
reduce risk of infection and include repellent, products that kill
mosquito larvae, and condoms.
Mosquitoes have ample breeding
grounds here. In the Villa Palmeras cemetery in barrio Obrero, a
low-income neighborhood in northeastern San Juan, virtually all of the
thousands of graves have built-in flower stands where water, and
mosquito larvae, collect. There are 109 cemeteries across Puerto Rico
and thousands of flower holders.
Mosquito larvae also flourish
underground, in water meters and vent pipes of septic tanks, which
contain more water than elsewhere in the United States, said Roberto
Barrera, a CDC entomologist.
And then there are the mountains of used
tires, which mosquitoes flock to, said Johnny Rullan, a former health
secretary who is helping the government eliminate breeding sites. Puerto
Rico has accumulated more used tires than anywhere else in the United
States, experts said. In the past three weeks, temporary collection
centers have received more than 561,000 tires.
 |
Elwin Moran, 26, helps pile used tires at a
former shoe factory in Humacao, Puerto Rico. The Humacao environmental
board is
collecting abandoned tires from neighborhoods. (Allison Shelley
for The Washington Post) |
‘Part of living on the island’
Perhaps the most difficult challenge is
changing people’s attitudes and behavior about an ever-present pest
that is as much a part of life here as steamy weather and graceful old
banyan trees.
“What can I say, it’s part of living on the
island,” said José Fernandez, a supervisor at a tire collection center
in Humacao, in the southeast.
Emeris Canales Morales, 27, a
single mother who is 23 weeks pregnant, lives in a home that overlooks a
small cemetery on one side and a fetid canal on the other. Plastic
bottles and other trash collect along the banks of the canal. Her
windows have no screens. In December, the mosquitoes were biting so hard
that she woke up with red welts covering her arms.
At a prenatal
clinic for high-risk pregnancies at San Juan’s University Hospital at
the Puerto Rico Medical Center, she was among the first to sign up for
free Zika screening for women in their first and second trimesters.
 |
Tourists visit two of Puerto Rico’s most famous
landmarks — Fort San Felipe del Morro fortress and Santa Maria
Magdalena de Pazzis cemetery.
Mosquitoes thrive in wet conditions, such
as cemeteries. (Allison Shelley for The Washington Post) |
She
won’t know the results for at least another week. Her first two
pregnancies ended in miscarriages because of complications from
diabetes. She is hoping for the best this time.
“I haven’t had
the fever or the red eyes or the rash,” said Canales, who lives in
Loiza, a northeast community that is one of the island’s poorest areas.
But even for pregnant women, it’s hard to stay vigilant against the mosquito.
“When
there was chikungunya, we joked about it until everyone had it,” she
said. “Until people have the sickness, nobody in Loiza will take it
seriously.”
Said Brenda Rivera, chief epidemiologist for Puerto
Rico’s health department: “Controlling Zika is going to be a daunting
task.” The department is coordinating the island’s response to the
public health emergency.
 |
Entomologist Roberto Barrea examines materials
at a lab where his team breeds thousands of mosquitoes for research at
the CDC’s dengue branch in San Juan.
(Allison Shelley for The Washington
Post) |
Poor and unprepared
Women
in Puerto Rico give birth to about 33,000 babies a year. The island has
one of the highest teenage birth rates in the United States, and many
public high schools have no window screens. The government is estimating
how much it would cost to add screens, said Grace Santana, chief of
staff to Gov. Alejandro Javier GarcÃa Padilla.
Nearly half of
Puerto Rico lives below the poverty line. The thousands of pastel-hued
public housing projects that dot the island don’t have air conditioning.
Residents don’t have window screens, in part because they can’t afford
them, but also because they don’t want to block the breeze. Adding
screens to those homes would cost about $70 million, said Santana.
At
dusk on a recent day, a maroon pickup truck drove through the streets
in the middle-class neighborhood of Riveras de Cupey, in San Juan’s
south, spraying permethrin, a commonly used insecticide, from a machine
mounted on the back.
But
Aedes aegypti mosquitoes already
have developed resistance to permethrin in some parts of Puerto Rico,
said Audrey Lenhart, a CDC research entomologist. She is testing which
insecticides are most effective, something that was never done before.
“The
Puerto Rican government doesn’t really have a well-developed vector
control and surveillance program,” she said, referring to basic programs
to eliminate insects, birds and other vectors that transmit disease.
CDC
teams are helping authorities rebuild mosquito control programs, expand
testing, and monitor and track thousands of pregnant women and their
babies. They also are working with U.S. companies to provide window
screens for women’s homes, and to bring to market a CDC-invented trap
that could be a potent and cheap way to snare and kill adult mosquitoes.
For
doctors such as Alberto De La Vega, an expert in high-risk pregnancies
at the University Hospital in San Juan, Zika is one of many serious
concerns. He worries that additional Zika testing will create huge
demands on an already burdened health system.
“We’re having
problems getting supplies, but we have to uphold U.S. standards,” he
said. He has modern ultrasound equipment, but he pays out of his own
pocket for the paper sheets that cover exam room beds.
He tells his patients they need to remove standing water and wear repellent.
“What
we can do as physicians is very little,” he said. “By the time we
identify problems with the fetus, it’s usually well into the second
trimester, and by then it’s too late.”
‘I’m going to have the baby’
The
new mystery disease has infected Zulmarys Molina Paredes, 29. She’s one
of the five pregnant women with a confirmed Zika diagnosis. But at 16
weeks in her pregnancy, an ultrasound shows her baby developing
normally.
Molina and her 2-year-old son, Marco, live in Humacao
in a peach-colored public housing project with her mother, aunt and
brother. She is the sole breadwinner. She thinks she became infected at
the private university where she works as an admissions officer, during
tours of the campus. The campus has an artificial lake surrounded by
trees full of mosquitoes.
Her headaches began Feb. 5. The following Monday, she looked in the mirror and was stunned.
“I was starting to put on my makeup and realized I was covered in a rash,” she said. “I got really scared.”
The
emergency room doctor sent Molina’s blood to be tested. Nine days
later, she was told her test was positive for Zika. But the doctor also
said scientists didn’t know how often women with Zika infections have
babies with birth defects such as microcephaly, where they are born with
abnormally small heads.
Given the uncertainty, she is choosing
to believe — and to pray — that everything will be fine. An
amniocentesis is scheduled for next week. More ultrasounds will follow.
“I
don’t care what happens. I’m going to have the baby,” Molina said. “I
have faith that she’s going to be fine.” Her due date is Aug. 6. She
will name her daughter Michaela. -
Washington Post.
