More Deaths in Puerto Rico than Announced During the Pandemic

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Deaths in Puerto Rico have increased over the past three months despite the few COVID-19 losses reported on the island and the drop in fatalities from accidents and crimes due to quarantine confinement, as compared to 2019, the Center for Investigative Journalism (CPI, in Spanish) found.

This, contrary to what was publicly said by Health Secretary Lorenzo González Feliciano and by the director of the Demographic Registry, Wanda Llovet the first week of May when the Department of Health sent the media the data on the deaths of March and April, without making the distinction that they were still significantly incomplete.

On May 5, Secretary González Feliciano said in the Jugando Pelota Dura television program that deaths for the month of April totaled 1,750, “when typically in Puerto Rico we  have 2,500 deaths per month.”

“How do you explain that? Possibly with the reduction in crime, the decrease in other conditions, but what has been done in Puerto Rico has resulted in a significant impact on the absolute number of deaths,” he continued in reference to the Government of Puerto Rico’s COVID-19 contention measures.

But the numbers have significantly changed since then and as of this Wednesday, June 10, the death toll for April already totaled 2,358 deaths, or 608 more deaths than those the Secretary mentioned.

In statements to El Nuevo Día newspaper, Llovet had also said that total deaths for the months of March and April did not reflect an increase compared to last year. Although she acknowledged that the figure could change, she did not clarify that at least close to a third of the cases were missing due to the time it takes the tract of documentation on the deceased.

After not answering questions the CPI sent Monday about his statements on deaths in Puerto Rico and the inconsistencies in the figures on the Puerto Rico government COVID-19 dashboard, on Wednesday, the Health Secretary held a press conference to announce changes to this platform.

From now on, it will not report total combined deaths linked to COVID-19 as it had until Thursday, but will report deaths confirmed and suspected by molecular testing, separately, including those with positive serologic test results.

“That was the number we had at the time,” said González Feliciano to justify his initial statement, and went on to explain on this occasion that, “typically” you have to wait at least 30 days after the end of the month to have an accurate number.

However, he insisted that it was valid to use the data at that time “because that is the number that existed and the number that was reported,” and minimized the fact of the increase in deaths in Puerto Rico during the pandemic period.

“The increase is not extraordinary and can’t be attributed to COVID either,” he said. However, he acknowledged that one of the things that is being discussed globally regarding COVID-19 is the issue of excess deaths, which still have no explanation.

Although an in-depth analysis of the increase detected by CPI has not yet been done, preliminary data from the cases processed by the Bureau of Forensic Sciences (NCF, in Spanish) point to a significant increase in sudden deaths at home, instead of in hospitals, which were almost vacant during that period, and causes of death that have been associated with heart disease.

The difficulties with information and underreporting in deaths during the COVID-19 pandemic have been evident in different parts of the world since the pandemic began in December in Wuhan, China, due to factors such as limitations and advances in knowledge about the virus, deficiencies in data collection and reporting processes, protocols that have been used to perform the tests, and availability and effectiveness of diagnostic tests. The underreporting of deaths due to these factors has already been documented in the United States and other countries such as Chile, which revised its estimate of victims on Sunday, adding another 653 fatalities.

Three infectologists consulted by the CPI were not surprised by the finding and said an increase in deaths during the pandemic, despite low censuses in hospitals, has several possible explanations.

Dr. Armando Torres, from the Mennonite Health System, emphasized that much about the behavior of the virus and about the effectiveness of tests — both molecular and serological — has been learned on the go and medical personnel have had to make adjustments. One of the most important factors, he said, is the timing or moment when the test is done. Depending on this, the chances of false negatives increase — that is, infected people who do not test positive.

At least seven studies reveal that the molecular test, or PCR, which detects the presence of the active virus, is highly accurate during the first eight days after exposure to the virus, but its sensitivity drops markedly after the ninth day, Torres said. Symptoms in COVID-19 patients begin on day five, so there is a three-day window for testing with an optimal result. In contrast, the effectiveness of the serological test — which is not diagnostic, but detects antibodies — is higher  as of the 14th day of exposure, he added.

Besides these limitations there are difficulties such as the molecular test sampling, as well as the fact that the virus eventually moves from the nose to embed itself in internal organs such as the lungs, and the quality of the test brands, Torres said, noting that some tests that the Federal Food and Drug Administration (FDA) initially gave fast-track approval to, eventually proved to be ineffective.

“All these variables can cause the test to show a false negative. There are many factors,” Torres said, emphasizing that if only one test can be done, it must be the molecular one.

The MD explained that infectologists use four criteria to diagnose COVID-19: symptoms; labs and X-Rays; molecular testing; and the serological test. If a patient shows the first three criteria compatible with COVID-19, but shows a negative result in the molecular test, or if the test could not be done, the doctor’s judgment prevails and his position is that this case must be identified as suspicious or possible COVID-19 and must be counted, according to the Centers for Disease Control and Prevention guidelines (CDC).

His colleague and infectious diseases doctor from San Juan’s Auxilio Mutuo Hospital, Miguel Colón, said that he would require that a patient test positive for the two types of antibodies in the serological test (IGM and IGG) and die from a stroke, heart disease, or viral pneumonia, for example, to associate the death with the virus if the molecular test is negative.

Colón acknowledged that there are differences and debate among infectious disease doctors as to which deaths should be associated with COVID-19 and which should not. Given these differences, the Department of Health and the Puerto Rico Infectious Diseases Society developed a document called COVID-19 Diagnostic Guidelines on May 29, but the CPI learned that there is no consensus on them, and they are not mandatory.

However, both doctors pointed out that there must be COVID-19 deaths not associated with respiratory problems since the virus also produces a severe inflammatory reaction that affects other organs of the body and produces complications of the heart and brain, in addition to attacking the lungs and respiratory system.

“From the experience with influenza, we have seen that it is a disease that produces generalized or systemic inflammation, that affects other organs besides the lungs, and one of the most affected systems is the cardiovascular system. There have been arrests, fatal arrhythmias, strokes. Many, many deaths from inflammation, and the same may be happening with coronaviruses. The ability to induce inflammation by COVID-19 is three to four times higher than influenza,” said Torres.

He explained that this can happen without the patient developing the entire spectrum of symptoms and without being tested fo COVID-19. In other words, without anyone noticing the possible relation.

Meanwhile, Colón said that, in his experience, heart complications have been more severe than respiratory complications among the COVID-19 patients he has treated. He also said that the increase in general mortality in Puerto Rico may have to do with the deterioration of chronic patients during the two months of quarantine in which the Government closed elective medical services and patients did not go to the hospital afraid of the virus.

“Patients were terrified of going to the hospitals,” he said.

The president of the Infectious Diseases Society, Dr. Lemuel Martínez, agreed that this is a possible explanation, as well as undiagnosed COVID-19 cases to a lesser degree. He said it is important to analyze the data and, if the excess deaths are correlated to the quarantine period, they must be associated, even if indirectly, to the virus.

“What killed them, the heart attack or COVID?” he asked rhetorically. “Those deaths must be related to COVID because it has an effect, and this data must be considered to develop a better response in case we receive a second COVID-19 wave,” he said.

Another factor that may have had an impact in the unexplained deaths are the inconsistencies Puerto Rico hospitals have exhibited in carrying out molecular tests. According to CPI sources, relatively few tests have been done at hospitals since the beginning of the pandemic, most have been done solely  to hospitalized patients, due to the lack of availability of the tests, the costs and low reimbursement rates by medical plans, and the way in which private emergency rooms work.

Martínez recognized these limitations and explained that between 80% and 85% of the patients with symptoms compatible with COVID-19 who go to emergency rooms with symptoms are not hospitalized because they do not have criteria, that is, their symptoms are not severe enough and the international guidelines  say their recovery is best at home.

As soon as the patient leaves the hospital, with instructions to get tested, the facility loses contact and it is up to the Puerto Rico Department of Health or their primary doctor, if they have one, to follow up on them.

For this reason and given the scant amount of molecular tests that have been done in Puerto Rico, the Society brought to Secretary González Feliciano’s attention the need both to develop guidelines to educate doctors and for the Department of Health to help hospitals financially so they can set up the expensive infrastructure needed to process the tests and be able to do more of them. They also argued that there is an urgent need to regulate health insurance rates and reimbursements for PCR tests and the new diagnostic technologies that continue to emerge, at least during the emergency.

“That’s why we met with the Secretary again to convey the message that it’s time to turn to tests that detect the virus directly and to other technologies,” he said, referring to the need to de-emphasize the use of serological tests that the Government of Puerto Rico has insisted upon. Although the response was good, they still have had no feedback on the economic and rate issues.

As for the deaths officially attributed to COVID-19 in Puerto Rico, there is also a large discrepancy between the data that the Puerto Rico Department of Health shows on its dashboard and that of the Registry, a branch of that same agency.

On Wednesday, June 10, the Department of Health dashboard — partially fed by the Registry — had 143 deaths from COVID-19; 80 attributed to the medical records on the death certificates that the Registry processed. Meanwhile, the update of the database that the Registry delivered to the CPI on May 22, almost three weeks earlier, has 111 cases.

In other words, the Registry’s older data, included in the database, has 32 more deaths than that of the dashboard that is supposed to be updated daily, when it should be the other way around. When asked about the reason for the discrepancy, González Feliciano argued this Tuesday that the change in the way data is presented, which has recently been implemented, will reduce the cases of confirmed deaths to 56, making the gap narrow 25 deaths. Nonetheless, the discrepancy prevails.

The 63 cases of deaths from COVID-19 on the dashboard — which on Thursday will become the 56 diagnosed with molecular testing — are the only ones that have been documented with confirmatory tests, according to the Department of Health, and that figure has remained unchanged since May 31.

Poverty indicators related to COVID deaths in Puerto Rico

The data in the Registry base — which is the only one available with demographic information — shows that fatal victims of the novel virus are mainly people with low education and low incomes. Seventy five percent of the 111 cases of COVID-19 deaths do not have a college degree, and 62% have a high school diploma or a lower level of education. Likewise, 41% did not complete high school, which is almost twice as many people as those that don’t have an academic degree in Puerto Rico: 24.5%, according to the 2019 Community Survey.

Regarding the gender of the deceased, 58% are men and 42% are women. This proportion is inverse to the distribution of the population in Puerto Rico, but in line with the global trend of COVID-19 where men are dying more than women.

According to a preliminary investigation by Dr. Julio C. Hernández, professor and researcher at the University of Puerto Rico’s Mayagüez Campus (RUM), where he evaluated the socioeconomic factors associated with deaths from COVID-19, the largest group affected were the unemployed, with 28% of deaths associated with the virus.

The percentage increases among those employed in sectors such as manufacturing, retail, wholesale, professional services, educational services, and health and public administration, “seem to generate increases in the probability of deaths from COVID-19,” the researcher said.

The manufacturing industry had 18.36% of deaths from COVID-19, and the remaining industries had 7% each, despite the fact that they remained almost closed during the months analyzed.

His research, based on the Demographic Registry’s data delivered to the CPI crossed with data from the Census American Community Survey, also initially reveals that factors such as “the percentage of the population below the poverty line and the percentage of households with incomes between $10,000 and $15,000 [a year] seem to increase the probability of COVID-19 deaths occurring.”

This is a socio-economic segment with great challenges in which a family of three at this income level does not qualify to receive government aid such as Nutritional Assistance Program (PAN, in Spanish) and the Government of Puerto Rico’s public health insurance.

On the contrary, families with even lower incomes, but who receive PAN program benefits and qualify for the public health insurance, are less likely to die from COVID-19, Hernández found.

Deaths on the rise in Puerto Rico

Regarding the increase in total deaths in Puerto Rico since March, -not only those attributed to COVID-19- as of Wednesday of this week, the Demographic Registry reported through the dashboard a total of 2,719 deaths for March, 2,358 for April, and 2,270 for May, a month that must still have less than half of the cases entered in the system. In comparison, there were 2,534 in March, 2,325 in April, and 2,489 in May in 2019.

The demographic and cause of death information available comes from the Demographic Registry’s Puerto Rico Mortality Database, that the CPI obtained through a lawsuit, which contains information on all the deaths that have occurred on the island, the causes of death and the demographic data of the deceased.

Documentation management process among doctors, the Forensic Science Bureau (NCF), funeral agents and the subsequent review and entry of data by Registry employees takes two weeks in most cases, and more than two weeks in 29% of cases, as Llovet told the CPI, so the number of deaths recorded in April and, particularly in May, are still incomplete.

Although González Feliciano and Llovet are aware of how long the death registration process takes, the first week of May, they both used a significantly incomplete figure for April, which at that time reflected 1,711 deaths, to say that deaths in Puerto Rico had dropped compared to 2019. The death figure for April was already at 2,358 on Wednesday, exceeding that of 2019, and it continues to increase every day with the entry of cases that are still being processed.

The information provided by officials, coupled with the low counts in hospitals, gave the false impression that the pandemic was under control and was used to instill confidence and justify the reopening of most of the island’s economic sectors including construction, shopping malls, restaurants and hairdressers. Gov. Wanda Vázquez Garced ordered the reopening also against the recommendations of her own Medical Task Force.

Dr. Mark Grabowsky, an epidemiologist who has worked at CDC, the US National Institutes of Health (NIH) and the World Health Organization (WHO), said Monday in a virtual workshop with journalists that Puerto Rico failed to comply with the White House recommendations for the reopening that, through the CDC, recommended having two consecutive weeks of drops in infections before reopening. He said that he was concerned that the island may see a rebound in cases like states that have done the same such as Florida and Texas.

“What we are seeing is that Puerto Rico never experienced the sustained 14-day drop. It’s worrisome. What we’re seeing is worrying,” said Grabowsky about the island’s contagion curve.

A preliminary analysis the CPI ran on the data that the NCF provided, shows there was a 35% increase in March in sudden deaths in homes, and a 48% increase in deaths from heart disease, compared to 2019. There were five deaths from cerebrovascular complications and one from pneumonia, when the previous year the NCF did not record any deaths at home from these causes.

The trend continued in April, with a 41% increase in at-home deaths, a 27% increase in heart-related causes and an 86% increase in cerebrovascular deaths. In addition, there were three deaths from pneumonia, when in 2019 there were none. A study published May 27 in health journal “The Lancet” found a significant increase in deaths from heart attacks outside hospitals in Paris during the pandemic and said the change could be partially related to infection with the virus, but also to quarantine measures and adjustments in the health system due to the pandemic.

“The trend has continued. I’m seeing a consecutive increase in March and April,” NCF Commissioner María Conte told the CPI, saying that although the figure for May was also high, she cannot yet confirm it reflects an increase, as the comparative data for 2019 — which has to be recreated — is not available.

On the possible reasons for the increase in at-home deaths, Conte said she agrees with the appreciation of doctors and hospitals that it could be due to unattended chronic conditions during the quarantine, but pointed out that this is a reasonable, unscientific conclusion.

“Nothing is conclusive so far because there’s not much data,” Conte said.

So far, the Department of Health has left it up to each doctor and hospital to establish their own criteria when determining who is tested and who is not, and what type of test is done. The agency itself has faced serious difficulties in efficiently performing and reporting the tests. The CPI has consulted half a dozen experts who deal with COVID-19 cases on a daily basis in hospitals and found that every institution and almost every doctor has their own understanding of when to test and when to attribute a death to COVID-19.

“There is no protocol,” Dr. Andrés Juliá Beltrán, epidemiologist in charge of contact tracing in the Municipality of Yauco said.

He said in an interview that he has seen “everything” so far: Hospitals that perform only the serological test; others that only run the molecular test; some that do both; and others that have not performed any on patients who, in his opinion, should have been tested.

He also said that he’s had a negative experience with the way the Puerto Rico Department of Health has handled data on COVID-19 because of the long time it takes to disclose positive results in its dashboard, particularly in the case of molecular tests. In one of his cases,the Department of Health showed the result sent April 28 on May 28, exactly one month later.

Another inconsistency in the Department of Health’s data is that numbers do not match those of municipalities that have established their own contact tracing programs, given the central government’s inability to execute this strategy. Dr. Juliá argued that the numbers of those infected in Yauco and all the towns that have established programs in collaboration with the Puerto Rico Health Trust are higher than those published by the Department.

“Epidemiologically speaking, the data from the Department of Health is of little use. If it was useful, the municipalities wouldn’t be implementing their own tracing program,” he said. The agency is in the process of delivering federal funds directly to 30 municipalities that want to establish their own tracing programs, he added.

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