Atypical death trends during the pandemic have gone unnoticed, but expert analysis begins to identify the keys as to why they occurred and what lessons they hold for the immediate future.
Six months after the government reported the arrival of COVID-19 in Puerto Rico, more than 600 people have officially died from the disease but, in addition, hundreds have died from other causes that have gone unnoticed and that could be directly or indirectly linked to the pandemic.
These excess deaths have been masked in the total mortality figure due to the sharp drop that has been registered in deaths due to crimes, accidents, and trauma on the island. The Department of Health (DS, in Spanish) has been using so far the monthly death toll number on the island to monitor the status of COVID-19, without detailing the significant changes in deaths from specific causes.
These deaths, identified as deaths in excess of those that regularly occur in Puerto Rico, happened mainly during the period of the initial strict lockdown that the government of Puerto Rico implemented between March and April, and were focused on chronic conditions that have been associated as high risk for the virus, according to an investigation by the Center for Investigative Journalism (CPI, in Spanish) that included mortality data and interviews with more than a dozen experts. The data analysis was conducted in a joint effort with Dr. Ángeles Rodríguez Rosario, infectologist and epidemiologist, and Dr. Juan Carlos Orengo, epidemiologist, and was consulted and validated by other specialists in biostatistics, epidemiology and medicine.
The investigation also shows that at the same time, deaths from causes external to the body — that is, from homicides, traffic accidents, falls and suicides, among others — dropped dramatically.
When the drop in these external deaths is deducted, in March and April there were more than 400 additional deaths above average, and they were attributed mainly to chronic diseases such as pneumonia, diabetes, metabolic disorders, hypertension, heart disease and Alzheimer’s. These excess deaths include 99 that were identified as COVID-19 during that period. When looking at the deaths from January to August, excess deaths from all causes increase, and coupled with those attributed to COVID-19, they exceed 1,000 deaths. This is twice the number of deaths that the government officially recognizes as from coronavirus.
CPI asked Secretary of Health Lorenzo González Feliciano if Puerto Rico’s Department of Health had done a general mortality analysis during the pandemic, and he answered that the agency had “prioritized COVID-19 mortality analisis”.
“The analysis of general mortality in Puerto Rico for this period will be shared later”, he added.
Nonetheless, Dr. González Feliciano recognized that excess deaths in March and April in endocrine, circulatory, nervous and respiratory causes are possibly linked to the pandemic.
“It’s likely that the increase may be associated with the COVID-19 pandemic and it’s even possible that part of the population that had these conditions was affected by the lockdown, when many health facilities weren’t providing outpatient services and follow-up appointments. On the other hand, it’s likely that some people won’t visit a hospital or health facilities for fear of contracting COVID-19.”
The first death identified as a suspect by COVID-19 in Puerto Rico occurred on March 17, and it was a 54-year-old man with diabetes, a resident of the Luis Llorens Torres public housing complex in San Juan, the CPI found. This was five days before the death of the Italian tourist that for months the government identified as the first case to arrive on the island. The data indicates that the virus had been present in Puerto Rico, at least since February, considering the incubation period.
Those who died from COVID-19 in Puerto Rico, according to data from the Demographic Registry (DR), are mostly men (60%) with an average 72 years of age. To date, the youngest person who has died is a 13-year-old girl, also a resident of a public housing project, in Caguas in the central region of the island.
The highest mortality rates from the virus are mainly in small and poor municipalities in Puerto Rico. Furthermore, 43% of all deaths happened disproportionately in rural areas of the island, even though only 6.4% of homes are located in these regions. Both data are indicative that socioeconomic inequality has possibly been a determining factor in mortality from the virus, experts consulted by the CPI said.
The largest municipalities, which concentrate the island’s labor and economic activity, also showed high rates, which exceed 20 deaths per 100,000 inhabitants. These towns, which include San Juan, Bayamón, Guaynabo and Mayagüez, registered the highest number of deaths.
For its analysis, the CPI used the Puerto Rico mortality database obtained in a lawsuit against the Demographics Registry (DR) and compared the months of January to June 2020 with the average of the previous five years. The figures are conservative given that the DR data are still preliminary, and because the exercise included the first half of 2018, a period in which the island was still experiencing excessive mortality due to the aftermath of Hurricane María. If that period were excluded, as the U.S. Center for Disease Protection and Control (CDC) has done, the excess mortality would be 30 deaths in addition to the 400.
The trends of excess deaths detected by the CPI began in February, increased in March and April, under certain conditions in May as well, and decreased in June, as did COVID-19. In July, August and so far in September, infections and deaths from the virus soared, approaching 500 deaths. It is unknown whether the trend of excess deaths from other causes followed the same pattern because the registry of causes of death is still incomplete for that period. With incomplete data, the CDC has already identified a significant amount of excess deaths on the island for August.
Specifically, statistically significant increases were found in causes of death from diseases linked to the body’s circulatory, endocrine, nervous and respiratory systems. In the case of the circulatory system, there were increases in deaths from heart attacks, vascular diseases and hypertension. In the endocrine system, it was diabetes and metabolic diseases; in respiratory diseases, it was pneumonia; in the nervous system, Alzheimer’s.
The data analysis highlights an increase of 13% in deaths of people at home and of 43% in older adults in nursing homes. Of those, only two deaths in nursing homes and long-term care centers, and three deaths in residences, were attributed to COVID-19 from March to May. The government began testing in nursing homes in late April.
Secretary González Feliciano said that his agency has also documented an increase in deaths at both places, residential homes and nursing homes, but from March up until August and compared only to 2019. They have seen a 15% spike at nursing homes and at 10% at homes. He said this trend “has to be studied in greater depth”.
The findings of the CPI and a team of experts coincided with what clinicians in the concerned medical specialties who have seen many of the trends on the ground among their patients, as they said in an interview with the CPI. They also confirmed the suspicions of independent epidemiologists, who said they had been taking note of atypical and worrisome trends during the pandemic, despite the limitations of the data that have been published by the DS.
The causes of the excess
One of the clinical professionals consulted was Infectologist Miguel Colón Pérez, practicing at the Auxilio Mutuo and Ashford Presbyterian Community Hospital in San Juan. The doctor, who said he had seen “too many” patients with COVID-19 so far this year, said that in his opinion, the increase in mortality identified by the CPI responds to a combination of factors that includes undiagnosed cases of COVID -19, the impact of fear and anxiety on patient health, the closure of medical offices due to the strict lockdown ordered by Gov. Wanda Vázquez Garced and complications from unattended chronic conditions.
“This increase in mortality is definitely very indicative that many of these patients could have been infected with COVID, but there was no way to diagnose them because we did not have the molecular tests to make that diagnosis,” Dr. Colón Pérez said.
The infectious disease specialist also noted that, in retrospect, he believes that the virus arrived in Puerto Rico possibly in early 2020 or late 2019, long before the government identified the first case in March. The Secretary of Health at that time, Rafael Rodríguez Mercado, said that COVID-19 would not reach Puerto Rico because the island did not have direct flights from China. However, according to the Flight Aware database, there were four weekly direct flights from Spain, a country that had a strong early epidemic of the virus.
Deaths from endocrine, nutritional and metabolic causes in Puerto Rico also began to increase as of February with an almost 11% spike, compared to the average from 2015 to 2019.
It’s now known that the causes that showed significant increases in the CPI analysis are clinically linked to the virus, an understanding that the scientific community did not have in the first months of the pandemic, said Colón Pérez. Today, COVID-19 is known to produce a severe inflammatory effect that affects virtually all essential organs in the human body.
The doctor explained that the new coronavirus (SARS-CoV-2) is a thrombotic, which forms clots in the arteries and veins, and therefore affects the vascular system, aggravating hypertension and causing heart attacks and brain aneurysms. He also argued that the disease’s greatest mortality issue is the inflammation it produces, the so-called cytokine storm, and the inflammatory process that causes diabetic and obese patients to get out of control and attack the nervous system. Finally, the virus targets the lung, because it contains receptors that capture it, causing severe damage.
“There’s no doubt that the lockdown, with the closure of medical offices, prevented many people from following their regular health regime of taking medications and following up with their primary doctors. Number two, the hospitals were emptied, patients and their families didn’t want to come to the hospitals because they thought they were going to be infected with the virus,” Colón Pérez added.
Pneumologist Luis Nieves Garrastegui also considered that the excess of deaths of almost 16% from respiratory problems and 57% from pneumonia in March, was multifactorial. In his view, it responded to COVID-19 cases that were undetected or classified incorrectly, and to patients who stopped going to their doctors.
“There wasn’t enough evidence and many of the cases that we can say that we saw clinically may have had the condition and we didn’t know it,” he said.
Chronic obstructive pulmonary disease (COPD) patients weren’t going to the doctor’s office. They got there two or three months later, already “in such bad shape,” including some with complicated pneumonia, that they died.
“That happened many times, and those patients were actually the ones who greatly increased morbidity and mortality,” said Nieves Garrastegui. Morbidity refers to the number of people who fall ill in a population, and mortality is the number of people who die.
Another factor that has greatly affected patients with respiratory conditions is anxiety, the pulmonologist said, indicating that this disorder also affects recovered COVID-19 patients.
“There are patients that by just hearing a bell ring or something they unconsciously remember the ventilator and they get panic attacks, they get fatigued when they are [physically] fine. In other words, there’s a connection between the lung, anxiety and post-traumatic stress from being intubated in intensive care with COVID,” he said.
In addition to these effects, COVID-19 patients develop physical central nervous system, brain and cognitive problems that can cause seizures, strokes, Guillain-Barré Syndrome and can increase the risk of developing Parkinson’s and Alzheimer’s diseases, according to the Mayo Clinic. It is important that the patient is aware of this and visits a neurologist for diagnosis and treatment, rather than assuming that they have a mental illness.
The direct health complications from COVID-19 and indirect ones, due to the stress, anxiety and fear caused by the pandemic, are also being reflected in other conditions such as deaths from heart conditions.
The CPI’s analysis of mortality trends found excess deaths from hypertension and heart attacks. According to Cardiologist Luis Molinary, this spike responds to patient reluctance to go to their medical appointments, the severe inflammatory effect that the virus has on the circulatory system, and the impact that increased emotional stressors have on the heart, which has been cynically described as Broken Heart Syndrome. This occurs when a wall of the heart stops working properly.
“Now, that same stress and anxiety caused by the coronavirus, even if it’s just about people thinking there’s a virus that can cause death, that causes stress and tension. People are obviously afraid of leaving the house, that a family member will get sick, that they may have complications from the coronavirus and obviously, on top of that, specifically in Puerto Rico, we have other problems such as earthquakes,” Molinary said, adding that the hurricane season compounds to the concerns that affect Puerto Ricans.
“Psychiatric conditions, depression, and anxiety are direct indicators of problems that can cause a heart attack or weaken the atheromatous plaque, because it increases the state of inflammation,” he said.
He assured that with the pandemic physicians from different disciplines, such as cardiologists, endocrinologists and primary care physicians, began to see depressed patients who sat crying in their offices. Deaths from heart attacks were nearly 15% higher in March compared to the average for the same month in the previous five years.
The inflammatory effect of the virus directly affects the heart muscle in several ways. It increases the coagulation state, forms thrombosis, and causes myocarditis, which can cause congestive heart failure. When a patient has myocarditis, they can also suffer arrhythmias that can cost them their lives. These conditions also affect asymptomatic COVID-19 patients who may not be aware that they are infected with the virus.
COVID-19 patients, even if they are asymptomatic, can also experience other serious long-term effects on their health such as scarring of the lungs and loss of lung capacity.
As for the excess in deaths from hypertension that showed a 34% increase in April compared to the previous five years, the cardiologist attributed the increase to the lack of medical attention.
“Those patients who stopped coming to the doctor’s office, those patients who didn’t have their medicine, those patients who were unknowingly out of control because they didn’t have their [blood pressure] machine and whose [medications] obviously had to be adjusted, those patients were definitely going to fall into the mortality statistic,” he indicated.
He pointed out that hypertension patients do not normally die from that cause as the main one, but from other complications of the disease, so the increase in this cause of death is atypical.
Finally, diseases of the endocrine, nutritional and metabolic systems, which include some of the patients with the highest risk of death from COVID-19 such as diabetes and obesity, also registered significant excesses of death from February to May, but the increase was markedly for all endocrine causes in April, when as a whole they reflected an increase of 19% compared to the average from 2015 to 2019.
Dr. Michelle Mangual, Director of the San Juan Municipal Hospital’s Endocrinology Department, said these deaths must respond to a combination of undiagnosed cases and ill patients who stopped going to their follow-up appointments.
She pointed out that “having diabetes is a risk factor for complications from COVID,” while they are also patients who can easily lose control if they neglect their diet and medical care.
“Speaking with other colleagues and [from] their experiences in different hospitals, we were seeing that many patients [whose situation became] complicated and required intubation were obese patients with a body mass index in the obesity range,” he said.
There are different explanations for this increased risk of death from COVID-19 in obese patients, he said. They have a respiratory problem due to mechanical restriction caused by excess adiposity, that is, accumulation of fat. Furthermore, the state of obesity itself is a state of chronic inflammation, and patients with the virus that get complicated are those with a very significant increase in all inflammatory cytokines.
On the other hand, the doctor said that the effect of a lack of medical attention can take time to manifest itself and added that this is why endocrinologists have been seeing more complicated patients in the last two months.
Deaths in residences and nursing homes skyrocket
Other significant and worrisome increases in mortality trends were detected in the place of death of people during the pandemic. Despite the low number of official deaths from COVID-19 in nursing homes and elderly care centers during the first few months, overall deaths in these places increased significantly, according to the CPI analysis. Between February and May, 1,164 deaths were registered in nursing homes, which is 333 deaths more than the average for the same months, mainly due to causes associated with the nervous, circulatory, respiratory and mental health systems.
Epidemiologist Cruz María Nazario, professor at the University of Puerto Rico’s School of Public Health at the Medical Sciences Campus, argued that these deaths of older adults could have been wrongly classified at the onset of the pandemic due to the lack of tests and because some of the symptoms that are now known to be related to COVID-19 as well, such as poor appetite, loss of taste, apathy, tiredness, and neurological problems, are similar to those of dementia and Alzheimer’s disease. Alzheimer’s is one of the specific causes of death that spiked in those months with 29% increase in March, 24% in April, and 20% in May, according to the CPI findings.
“Many of the deaths that occurred in those places where there are elderly people can represent a very large [COVID] underreport that should be investigated because there is a possibility that they haven’t been counted as COVID-19 and it’s a death associated with it,” said the epidemiologist.
Also, the deaths of people at their homes reflected an increase of 13%. Simultaneously, deaths in hospitals decreased during the initial months of the pandemic. Between March and May, 327 more residential deaths were recorded in comparison to the average of the previous five years for the period. These deaths were mainly attributed to endocrine, circulatory and respiratory causes.
The trend is compatible with testimonies from paramedics who said they had gone to nursing homes to evaluate patients and told them they had to be taken to the hospital, but they refused for fear of contagion. Soon the paramedics were called back, because the patients’ condition deteriorated and when they arrived they had already passed away at their home, Dr. Molinary said.
“That’s why I was very insistent at the beginning of this pandemic [saying] ‘stay at home, but if you have any medical condition, you have to go to the hospital,’ because, in my opinion, patients who stayed at home, deteriorated,” Molinary said.
Dr. Nazario argued that the excess deaths that the CPI identified should be linked to COVID-19 because they are direct deaths from the virus, which were not detected due to the lack of testing and were attributed to other comorbidities, and indirect deaths due to circumstances prompted by the pandemic.
“What happens is that at the statistics level and given the problems we have in collecting mortality data, we’re going to see some [causes of death] that obviously stand out. It seems to me that we have a very large underreport of deaths indirectly associated with COVID-19, and that problem has also been highlighted by the CDC,” she said.
The federal agency has recognized the large underreporting of deaths from COVID-19 in Puerto Rico and other jurisdictions and warned that caution should be exercised when interpreting mortality data because most are over 10 days late, she added.
“We have to be very careful with these deaths [reported by the government] because they’re delayed, they’re incomplete and in fact, in some instances, by up to 60%,” he said.
The July and August upturn
Most deaths in Puerto Rico take two to six weeks to be included in the Demographic Registry database due to bureaucracy with funeral homes and the agency’s data review process. So, the numbers for the months of July and August — when the Department of Health (DS, in Spanish) reported the highest increase in infections and deaths from COVID-19 in Puerto Rico — are not yet available as comprehensively as they need to be to determine whether the trends registered in March and April have been maintained, increased or decreased.
However, and with data still substantially incomplete for the month of August, the CDC is already reporting significant excess deaths for Puerto Rico, greater than those for the spring, and the same is happening in other jurisdictions in the United States.
Along the way, the doctors interviewed have also seen severe COVID-19-related hospitalizations triple, and although diagnostic tools have improved with greater availability of tests, progress has not been the same in the scope of treatment.
“In terms of drugs, there’s really nothing that works. Unfortunately. The only thing that might work to some extent would be dexamethasone, [with which] we’ve seen an improvement in patients with moderate disease, but there are patients who have severe illness, that is, the patient who requires a more aggressive type of oxygenation or who’s on a mechanical ventilator Neither Remdesivir, nor Tocilizumab, nor plasma really make a big difference. It has been the experience of all the subspecialists,” said Infectologist Colón Pérez.
Dr. Lemuel Martínez, president of the Puerto Rico Infectious Diseases Society, agreed that there are studies that point to a reduction in mortality in patients only in cases related to the usage of the dexamethasone steroid. He added that, in the case of plasma, there is data that suggest effectiveness, but this depends on complex and unpredictable factors such as the level of antibodies and donor compatibility. Recent studies on Remdesivir have shown discouraging results, he added. In spite of this, his colleague, Gabriel Martínez, from San Cristóbal Hospital in Ponce, said he is having a favorable experience with his patients using a combination of early steroid use, Remdesivir, and plasma.
Colón Pérez predicts that, if the public keeps up current levels of face masks use and social distancing measures, Puerto Rico will remain at current levels of infection, with between 200 and 400 new daily cases, until the vaccines arrive. He said the progress in trials being conducted by competing pharmaceutical companies leads him to believe that there will be a vaccine available during the first quarter of 2021 and, although it will not be available for everyone, he believes that the epidemic can be controlled if health workers and at-risk populations are immunized.
In the meantime, not only will high mortality continue, but complications of morbidity and long-term effects in infected patients who survive will also linger. Cardiologist Molinary is concerned about the virus’s direct effects on the heart and lungs. He predicted that these complications, both in diagnosed patients and asymptomatic patients who do not know they are infected, will begin to be seen in the statistics related to complications of cardiac and respiratory cases.
Likewise, Pulmonologist Nieves Garrastegui drew attention to the severe damage that the surviving patients who had respiratory diseases are being left with. He mentioned the case of a young woman in Chicago, who had to undergo a double-lung transplant after having the condition, among others.
“Patients who had the most aggressive COVID-19 can develop what we know as pulmonary fibrosis and can also develop chronic respiratory problems such as bronchiectasis. We’ve seen a limitation in the respiratory capacity in these patients after they fully recovered, and it has nothing to do with the fact that the virus is active, but rather with the fact that it was the sequel to what the virus did in the lung,” he explained.
He mentioned that other major consequences are neurological problems, headaches, and photophobia, which is sensitivity to bright or excessive light.
“There are after-effects in all organs,” he added.
The future of the pandemic in Puerto Rico
“I think we’re facing a great challenge. We aren’t going to have a real decrease in cases,” Epidemiologist Nazario predicted.
“What we’re going to have is an under-reporting of cases because testing isn’t being done. I’ve heard the Department of Health say they’re doing their best. I don’t think they’re doing the most possible. We’ll have fewer cases [diagnosed], and those cases will end up in an emergency room, if they’re severe, or in a hospital, and they will represent a death,” she added.
She also expressed concern about the pressure that the volume of cases is already having on the island’s health system. She noted there have been days in August and September when beds in the intensive care units have been at 70% occupancy, which is considered a critical level.
“That is at crisis level because no hospital is built to be empty [and only serve COVID-19 patients]. It’s 70% that’s being split between patients with the virus and other conditions that require intensive care. So, if we waste the opportunity to identify the cases, to isolate the cases, to quarantine the person who has to be in quarantine, what we’re going to do is provoke a reappearance, clusters of cases, which I believe is something that we should be worried about. I don’t think the crisis is over,” she warned.
She also expressed concern at the large fluctuations in detected contagions and the number of tests that the Department of Health reports daily, which is a reflection of the difficulties that the agency has in taking samples and processing them, not of the actual status of the epidemic . Delays of up to 14 days in getting test results back also prevent an effective response, she added.
“Tests are done to control the contagion, and we’re not going to control the pandemic until we do enough tests,” she said.
Infectologist Colón Pérez also put his hopes on citizens changing their habits and getting used to wearing a face mask and keeping a distance of between six and nine feet from each other so that the rate of infection and deaths do not continue to increase because a lockdown cannot be a permanent containment measure.
“If we change the way we handle ourselves, I’m sure that the spike and the tsunami won’t happen, but if we don’t make those changes, the spike and the tsunami will come, and we will have higher mortality, “he concluded.
Dr. Nazario and Dr. Mark Grabowsky, an epidemiologist who has worked with the CDC, the National Institutes of Health (NIH), and the World Health Organization (WHO), agreed in separate interviews that Puerto Rico must change its strategy to control contagion .
“It seems to me that Puerto Rico needs to follow a different strategy. A better approach is to test high risk contacts, ”Grabowsky said.
He mentioned the problem with the Department of Health’s current public policy of reaching the elderly population by testing in nursing homes, when in Puerto Rico, more than 95% of them live at home or with relatives. He said it’s vital to facilitate access to molecular tests, without the need for a prescription or the current high cost, because to control the virus, testing must be done on people with symptoms and asymptomatics, which are the ones spreading the virus.
Meanwhile, Nazario emphasized the need to carry out more tests and get real-time results, as well as to do efficient contact tracing to identify cases, put them in quarantine, to be able to contain the outbreaks. Grabowsky agreed, adding that getting test results back in an agile way would improve data quality and making informed and timely decisions. The epidemiologist said that, although ideal, those technologies that provide real-time results are not widely available.
The expert said the government of Puerto Rico has not been supporting its decisions to reopen sectors with quantifiable data. This lack of transparency, he added, causes distrust in the population because it can make them believe that decisions are being driven by interest groups or corruption.
After the strict closure in March and April, the hasty reopening in May without meeting the CDC criteria of having two consecutive weeks of a reduction in reported cases, and the strong uptick in July and August, on September 8, Gov. Vázquez Garced abruptly reopened virtually all sectors without providing data to support her decision. The measure, which generated strong criticism from the medical and scientific community, was implemented after she lost the primaries in Puerto Rico, in the midst of an increase in hospitalizations and deaths, with a positivity rate of between 11% and 14% and with a shortage of molecular tests in the island.
“The Government has opted to ignore its responsibility and continue instead with the discourse of holding citizens accountable for the situation,” Nazario said.
When asked if he believes mortality trends detected by CPI will continue, he said the future development of the pandemic in Puerto Rico will be dependent on individual responsibility.
“We believe that if citizens don’t comply with social distancing measures, the use of masks, and continuously washing their hands, this increase is likely to continue.”
Looking ahead, Grabowsky noted that the pandemic must be managed by making decisions that are as effective and fair as possible. This requires a comparative quantification of costs and effects of the determinations being evaluated.
“In Puerto Rico, the thinking should not be that the virus will magically go away. Rather, until there is an effective vaccine, it will be a series of choices of lockdown versus increased transmission. The society needs to have an informed discussion of what will happen with each choice and what we are willing to tolerate as a society, ”Dr. Grabowsky said.
This discussion, which must be inclusive and open, must revolve around what Puerto Ricans value most as a society, and what the projected risks are of each public policy decision. For example, it is more important to open schools for children, beaches and recreational areas or churches, and what the risks are in each case.
He concluded by saying that, given the reality of the disease and Puerto Rico’s inability to close its air traffic, the island, like a large portion of the planet, will have to get used to the fact that there will be infections and deaths, and focus on strategies to minimize the impact until the vaccine arrives.
Mortality analysis methodology
The Center for Investigative Journalism and its team of experts analyzed mortality in Puerto Rico during the COVID-19 pandemic using the Mortality Data Base of the Demographic Registry. The database was obtained through an access to public information lawsuit against the agency and the Puerto Rico Department of Health.
Through this preliminary mortality analysis from COVID-19 and all other causes of death, CPI determined excess deaths caused by the new disease and by other causes in the 20 grouped causes established in the Instruction Manual of Vital Statistics of United States Centers for Disease Control and Prevention.
Excess deaths were calculated using the difference between monthly registered deaths in 2020 and the average of the monthly registered deaths for 2015-2019. They were also calculated using a 95% upper limit level of confidence, and setting at this point the excess deaths. Using this methodology and limit, excess deaths for March and April would be 254 and from March to August 678.
The data used for the analysis was updated by the Demographic Registry September 9th. It is substantially incomplete for the months of July and August because the death registration process in Puerto Rico can take from 30 to 60 days.
Journalists: Omaya Sosa Pascual, Jeniffer Wiscovitch
Expert analysts: Dra. Ángeles Rodríguez, Dr. Juan Carlos Orengo, Dr. Vivian Green
General management: Carla Minet
Project manager: Dra. Ramaris Albert Trinidad
Editing: Carla Minet, Laura Candelas
Data journalists and visualizations : Youyou Zhou, Marc Lajoie
Data check: Dra. Ramaris Albert Trinidad
Illustration: Gabriela Vázquez Martínez
Animation: Marc Lajoie
Programming: Luis Roca
Videos: Dennis Manuel Rivera Pichardo
Photos: Dennis A. Jones, Eric Rojas, Luis R. Vidal, Dennis Manuel Rivera Pichardo
Translation: Michelle Kantrow Vázquez
This investigative project is possible in part with the support of the Facebook Journalism Project.