PROJECT REPORT
ASCERTAINMENT OF THE
ESTIMATED EXCESS MORTALITY FROM
HURRICANE MARÍA IN PUERTO RICO
IN COLLABORATION WITH THE UNIVERSITY OF
PUERTO RICO GRADUATE SCHOOL OF PUBLIC HEALTH
Ascertainment of the Estimated Excess Mortality from Hurricane María in Puerto Rico
AC
KNOWLEDGMENTS
This project and the creation of this report would not have been possible without the
support of various institutions, agencies and individuals. We would like to
acknowledge the support from the GW Office of the Vice Provost for Research and the
ITS staff who helped us create a secure platform to store our data. We also thank them
for their assistance in establishing the needed institutional agreements. A special
thanks goes to our external panel of experts and internal technical specialists who
reviewed the methods design and provided input on this report (see Annex 2 for a
complete list of panelists).
We thank the Milken Institute School of Public Health for providing administrative
and financial support at the beginning and throughout the study, specially the
Executive Dean for Finance and Administration Gordon Taylor. We want to thank the
then acting Associate Dean for Research Melissa Perry, who took the risk with us, and
the ITS team of the school, Regina Scriven and Joseph Creech. We are also grateful
for the support of Dean Dharma Vázquez of the University of Puerto Rico Graduate
School of Public Health and all of those who provided their help.
This project was supported by the dedication of the personnel of key institutions
in Puerto Rico who provided team members with mortality information, and most
importantly, for helping us to understand their work processes. We acknowledge the
support of the Demographic Registry and particularly Dr. María Juiz Gallego and José
López Rodriguez. At the Bureau of Forensic Sciences, we thank Monica Menendez and
her staff for continued support. The project team is grateful to Dr. Mario Marrazzi at
the Puerto Rico Institute of Statistics who provided us with information and data for
establishing counterfactuals. From the Puerto Rico Planning Board (Junta de
Planificación), Alejandro Díaz Marrero and his colleague Maggie Perez Guzmán
provided information on the travel surveys. We thank Dr. Istoni Da Luz Sant’Ana and
Dr. Israel Almodóvar for their advice on R programming.
We would like to thank Martie Sucec for editing the report, Cynthia Gorostiaga and
Enrique Rivera Torres and the team at the Rivera Group for translation and Kate
Connolly for designing the report.
We would also like to recognize the efforts of the following GW SPH graduate
students whose literature reviews and other work helped support project activities:
Cosette Audi, Lorena Segarra, Courtney Irwin, Paige Craig, Connor Skelton and
Nicolette Bestul.
TABLE OF CONTENTS
LIST OF ACRONYMS
EXECUTIVE SUMMARY
METHODS
SUMMARY OF FINDINGS
INTRODUCTION
MORTALITY
METHODS
FINDINGS
RECOMMENDATIONS
COMMUNICATIONS
METHODS
FINDINGS
RECOMMENDATIONS
References
Annex 1
Annex 2
Annex 3
TABLE OF CONTENTS
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Ascertainment of the Estimated Excess Mortality from Hurricane María in Puerto Rico
ASPR – Ofce of the Assistant Secretary for
Preparedness and Response
BFS – Puerto Rico Bureau of Forensic Sciences
BTS – U.S. Bureau of Transportation Statistics
CDC – Centers for Disease Control and Prevention
CERC – Crisis Emergency Risk Communication
COE – Center for Operations in Emergencies
COOP – Continuation of Operations
DHHS – Department of Health and Human Services
DoH – Puerto Rico Department of Health
DPS – Puerto Rico Department of Public Safety
EMB – Puerto Rico Emergency Management Bureau
FEMA – Federal Emergency Management Agency
GAM – General Additive Model
GLM – Generalized Linear Model
GW SPH – The George Washington University
Milken Institute School of Public Health
IRB – Institutional Review Board
NCHS – National Center for Health Statistics
NGO – Non-Governmental Organization
NIMS – FEMA National Incidence
Management System
NPS – National Planning Scenario
PR – Puerto Rico
PRVSR – Puerto Rico Vital Statistics Registry
PRVSS – Puerto Rico Vital Statistics System
UPR GSPH – University of Puerto Rico
Graduate School of Public Health
WHO – World Health Organization
List of Acronyms
EXECUTIVE SUMMARY
In order to accurately estimate the excess number
of deaths due to Hurricane María, the Governor
of Puerto Rico sought an independent assessment
of mortality and commissioned The George
Washington University Milken Institute School of
Public Health (GW SPH) to complete the assessment.
The project had the following objectives:
1) assess the excess total mortality adjusting for
demographic variables and seasonality, report a
point estimate and condence interval and make
recommendations; 2) evaluate the implementation
of Centers for Disease Control and Prevention (CDC)
guidelines for mortality reporting in disasters and
identify areas of opportunity for improvement;
and 3) assess crisis and mortality communication
plans and actions by the government as well as
understand experiences and perceptions of key
participant groups to make recommendations based
on communications best practices.
METHODS
We implemented the project as three studies, each
with specific yet complementary methodologies.
Our excess mortality study analyzed past mortality
patterns (mortality registration and population
census data from 2010 to 2017) in order to predict
the expected mortality if Hurricane María had not
occurred (predicted mortality) and compare this
figure to the actual deaths that occurred (observed
mortality). The difference between those two
numbers is the estimate of excess mortality
due to the hurricane. We developed a series of
generalized linear models (GLMs) with monthly data
for the pre-hurricane period of July 2010-August
2017, accounting for trends in population size
and distribution over this period in terms of age,
sex, seasonality and residence by municipal level
of socioeconomic development. Our estimates
also considered Puerto Rico’s consistently high
emigration during the prior decade and dramatic
population displacement after the hurricane. We
used the model results to project forward mortality
that would have been expected if the hurricane had
not occurred for two scenarios—if the population
had not changed (census scenario), and explicitly
accounting for massive post-hurricane population
displacement from the island (displacement
scenario). For observed mortality, we used
records for all deaths occurring from September
2017-February 2018, provided by the Puerto Rico
Vital Statistics Records (PRVSR) division of the Puerto
Rico Department of Health (DoH). The estimates
of excess all-cause mortality attributable to the
hurricane are the result of comparing the projections
for the census and displacement scenarios to
observed mortality in the vital registration data.
In order to respond to the Puerto Rican
Government’s query about how well CDC guidelines
for mortality reporting in a disaster were followed,
we conducted a two-part study to assess both the
death certication process and the quality of death
certicate data. We conducted interviews with 26
individuals involved in the death certication and
registration process to understand procedures under
normal conditions and whether and how these were
affected after the hurricane. In addition, we reviewed
legislation and manuals related to death certication
in Puerto Rico, as well as literature on death
certication in general and specically in disasters.
With respect to quality of the death certicates
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Ascertainment of the Estimated Excess Mortality from Hurricane María in Puerto Rico
and coding for causes of death, we consulted the
relevant scientic literature. We conducted a series
of checks on the mortality dataset, assessing it for
completeness, timeliness, internal consistency
and the quality of cause of death reporting by
evaluating garbage codes, or mis-assignments,
in the underlying cause of death.
Our third study assessed crisis and emergency risk
communications by the Government of Puerto Rico
before and after Hurricane María, with an emphasis
on the communications plans in place at the time
of the hurricane, trained staff dedicated to crisis
and emergency risk communication, procedures
for mortality reporting to the public, spokespeople
interaction with the media and key participant
perceptions of the government’s risk communication
and mortality reporting. For the communication
assessment methodology, instruments, and analytical
framework, we applied established guidelines from
CDC and the World Health Organization (WHO) for
communication in emergencies, which are supported
by a robust scientic evidence base. We also applied
principles from the Federal Emergency Management
Agency (FEMA) Whole Community Approach for
community-based emergency preparedness (FEMA
2011). We interviewed 11 Puerto Rico Government
agency leadership and communications personnel
in order to understand: crisis and emergency risk
communication plans, processes and interagency
coordination for the preparation, approval and
dissemination of information to the public; their
experiences related to communications before and
after Hurricane María; and recommendations for
future communications in emergency situations.
We also interviewed 22 key leaders from different
communities in Puerto Rico, representing diverse
stakeholder groups including municipal mayors,
community and faith leaders, emergency responders,
police, non-prot organization personnel, health care
providers and funeral directors. In order to formulate
recommendations for future communications,
these interviews focused on understanding
stakeholder experiences from Hurricane María,
community involvement in disaster communications
planning and perceptions of the government’s risk
communication and mortality reporting.
To assess the post-hurricane information environment,
we reviewed 17 press releases and 20 press
conferences from September 20, 2017-February
28, 2018 to evaluate information content and
spokespeople performance, and to determine the
extent to which trustworthiness, credibility and
accountability were conveyed according to CDC and
WHO guidelines. Finally, we analyzed 172 media
coverage items from major English- and Spanish-
language news outlets during the same time period,
as well as related social media commentary, to
identify factors that may have contributed to public
concerns about mortality reporting, including: reasons
and timing of mortality data reporting; contradictory
information from spokespeople and alternative
sources; information gaps; and perceptions of
the accuracy and transparency of the Puerto Rico
Government’s mortality reports.
SUMMARY OF FINDINGS
Excess mortality estimation
We estimate that in mid-September 2017 there
were 3,327,917 inhabitants and in mid-February
2018 there were 3,048,173 inhabitants of Puerto
Rico, representing a population reduction by
approximately 8%. We factored this into the
migration “displacement scenario” and compared
it with a “census scenario,” which assumed no
displacement from migration in the hurricane’s
aftermath. We found that, historically, mortality
slowly decreased until August 2017, and that rates
increased for the period of September 2017 through
February 2018, with the most dramatic increase
shown in the displacement scenario accounting for
post-hurricane migration.
a)
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The results of our analysis of total excess mortality
by socio-demographic subgroups show that every
social stratum and age group was affected by excess
mortality. However, the impact differed by age and
socioeconomic status. The risk of death was 45%
higher and persistent until the end of the study
period for populations living in low socioeconomic
development municipalities, and older males (65+)
experienced continuous elevated risk of death
through February. Overall, we estimate that 40%
of municipalities experienced signicantly higher
mortality in the study period than in the comparable
period of the previous two years.
We conclude that excess mortality is a good indicator
for impact monitoring during and in the aftermath
of a disaster.
Death certication process
evaluation
Our study shows that physician lack of awareness
of appropriate death certication practices after
a natural disaster and the Government of Puerto
Rico’s lack of communication about death certicate
reporting prior to the 2017 hurricane season limited
the count of deaths that were reported as related to
Hurricane María. Individuals authorized to complete
death certicates include physicians and forensic
physicians; however, most physicians receive no
formal training in death certicate completion, in
particular in a disaster. When asked about the CDC
guidelines the PRVSR circulated after the hurricane
b)
Total excess mortality post-hurricane using the
migration displacement scenario is estimated to
be 2,975 (95% CI: 2,658-3,290) for the total study
period of September 2017 through February 2018.
that recommended physicians ll out a section in the
death certicate with information or other conditions
that contributed to the death, interview respondents
indicated lingering confusion about the guidelines,
while others expressed reluctance to relate deaths to
hurricanes due to concern about the subjectivity of
this determination and about liability.
The PRVSR ofces sustained damage and did not
have power to operate for some time after the
hurricane, and death registration was delayed.
Nevertheless, based on our ndings in the
assessment of death certication quality, the disaster
does not appear to have affected the completeness
of the certicates. For this assessment we compared
Puerto Rico Vital Statistics System (PRVSS) data from
September to December 2017 with the same period
in 2015 and 2016 and found that completeness of
death certicates was high with respect to age and
sex, two indicators widely used to assess this aspect
of mortality registration quality. On timeliness, there
was a statistically signicant delay in the number
of days between date of death and date of death
registration, with an average of 17 days in the period
after the hurricane compared to 12 days in the prior
year. Overall, there was a low percentage of garbage
codes as the underlying cause of death and there
appears to be no impact from the event on the
percentage of codes that were mis-assigned. With
respect to internal consistency, less than 1% of death
certicates had medically inconsistent diagnoses in
the underlying cause of death.
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Ascertainment of the Estimated Excess Mortality from Hurricane María in Puerto Rico
Assessment of Crisis and
Mortality Communications and
the Information Environment
According to interviews with Puerto Rico
Government agency personnel, at the time of the
hurricane, neither the Department of Public Safety
(DPS) nor the Central Communications Ofce in the
Governor’s Ofce had written crisis and emergency
risk communication plans in place. The DoH’s Ofce
of Emergency Preparedness and Response had an
outdated emergency plan, including annexes for
Risk Communication in Emergencies and Mass
Fatality Management. Agency emergency plans
that were in place were not designed for greater
than Category 1 hurricanes, and risk messages
conveyed to the public in preparedness campaigns
were reported by key leaders to inadequately
prepare communities for a catastrophic disaster. Key
leader interview respondents also noted limited
engagement of community stakeholders in strategic
communication preparedness planning. Regardless,
key leader interview participants described
numerous strategic preparedness activities
undertaken at the local level that they believed
to minimize injuries and loss of life, especially for
vulnerable populations.
According to Puerto Rico Government agency
interviews, there were insufcient communication
personnel at the time of the hurricane, and surge
stafng was not adequately mobilized post-
hurricane. Respondents reported a lack of formalized
personnel structure for emergency communication
functions, resulting in inadequate personnel and
spokespeople training in crisis and emergency
risk communication, deciencies in coordination
of communication between central and municipal
governments and between central and federal
government counterparts. Puerto Rico Government
agency leadership interview respondents did not
identify formalized protocols for the coordination
and clearance of mortality reporting between the
DPS and the DoH at the time of the hurricane.
Puerto Rico Government personnel and
key leader interview respondents indicated
that communication contingency plans
were not in place to anticipate multiple
cascading failures of critical infrastructure
and key resource sectors. Consequently, the
central government was not prepared to
use alternative communication channels for
health-related and mortality surveillance,
public health information dissemination and
coordination with communities, including
radio and interpersonal communication.
This contributed to delayed information
availability, gaps in information and the
dissemination of inconsistent information to
the public. Furthermore, there were gaps in the
information provided by the Government of
Puerto Rico, including limited explanation of
the death certication process, distinguishing
between direct and indirect deaths, or
explanations of barriers to timely mortality
reporting. Despite the potential for information
gaps to increase the risk of the propagation of
misinformation and rumors, the Government
of Puerto Rico did not systematically monitor
and address misinformation or rumors in
news outlets and on social media platforms.
Efforts undertaken by outside groups to ll
information gaps and identify hurricane-related
deaths added to conicting mortality reports in
the information environment.
c)
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Key leader interview respondents perceived the
death count to be much higher, and held viewpoints
that government leadership was disconnected from
the realities of Puerto Rican communities, that there
was not transparency in reporting, that information
was intentionally withheld to evade blame and that
adequate systems were not in place to track the
death count.
Our research identied the implementation of
public information campaigns prior to the hurricane
with public health and safety messages, but the
messages did not adequately prepare Puerto Rican
communities for a catastrophic natural disaster.
There was limited community and stakeholder
engagement in disaster communication planning,
and ineffective communication contingency plans in
place, resulting in limited public health and safety
information reaching local communities post-
hurricane and alternative communication channels
that were not systematically utilized for disease
surveillance and information dissemination.
The inadequate preparedness and personnel training
for crisis and emergency risk communication, combined
with numerous barriers to accurate, timely information
and factors that increased rumor generation, ultimately
decreased the perceived transparency and credibility of
the Government of Puerto Rico.
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Ascertainment of the Estimated Excess Mortality from Hurricane María in Puerto Rico
RECOMMENDATIONS
OVERALL POLICY GOAL FOR MORTALITY SURVEILLANCE AND
COMMUNICATIONS
To assure the capacity of mortality surveillance and crisis and emergency
risk communication during natural disasters in Puerto Rico to support
policies and interventions that protect life and health
RECOMMENDATIONS ON MORTALITY
SURVEILLANCE FOR NATURAL DISASTERS
I. Strategic Objectives
To have a reliable and resilient institutional mortality surveillance process that provides
trustworthy and accurate evidence during natural disasters to: Establish the magnitude
of the impact of the disaster, identify areas and groups of highest risk, monitor the
performance of public health protection and prevention, and inform policy-making
and program implementation. These principles are recommended:
Readiness, establish a routine process
Rigorous, based on valid methods
Timeliness, delivering on time
Common good, having as a priority the welfare of all
II. Programmatic Recommendations for Natural Disaster
Mortality Ascertainment
Development of an Organizational Agenda
Develop a federal and Puerto Rico policy architecture for preparedness and response
to major emergencies and natural disasters.
Establish clear leadership of the DoH on mortality surveillance and capacity building
of medical personnel on death certication.
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Assure complete stafng and professional capacity for the PRVSR and the Bureau
of Forensic Sciences (BFS).
Review the legal framework for DoH accountability, for medical facilities and
physician assurance on death certication.
Secure needed nancial resources and reliable infrastructure with federal
government support.
Establish an Excellence Program on Mortality Surveillance for
Performance Monitoring
Institute continuous mortality-based monitoring to assess disaster impact and the
effectiveness of post-disaster interventions using the collaborations with UPR GSPH.
Determine a quality improvement program for death certication with training
for all physicians.
Establish a mechanism for continuous ow of surveillance results and
interpretation to decision makers
Improve efciency and timeliness of ow of information to decision makers and
engage stakeholders from civil society, the media and others.
Ensure provision of feedback to those involved in the death certication process
and in data analyses.
III. Recommendations for Future Advancement of Mortality
Surveillance and Natural Disaster Preparedness
Implement a cause-specic mortality analysis to establish causal pathways and identify
priority areas
Assess and strengthen public health functions.
Evaluate the burden of disease related to mortality following Hurricane María.
Advance the work on the analysis of small area statistics to identify heterogeneity within
municipalities related to mortality from Hurricane María.
Disseminate globally the experience gained by Puerto Rico in this major event.
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Ascertainment of the Estimated Excess Mortality from Hurricane María in Puerto Rico
RECOMMENDATIONS ON CRISIS AND
MORTALITY COMMUNICATION IN
NATURAL DISASTERS
I. Strategic Objectives
To use credible, transparent and effective crisis and risk communication during natural disasters
as a mechanism for informing populations, protecting lives and instilling public trust. These
principles are recommended:
Preparedness, with planning as fundamental for effective crisis and emergency
risk communication
Credibility, as a critical factor for facilitating partnerships and protecting public health
Transparency, as a mechanism for strengthening and informing decision-making
Compassion, with acknowledgment and validation of individual and societal
emotions and concerns
II. Programmatic Recommendations for Natural Disaster
Crisis and Mortality Communications
Create an Integrated Puerto Rico Crisis and Emergency Risk Communication
Plan and Planning Process
Establish clear leadership by the Puerto Rico Emergency Management Bureau (EMB)
and the Central Communications Ofce for the development of a Puerto Rico Crisis and
Emergency Risk Communication Plan. Dene roles, levels of engagement, and specic
tasks for municipalities and all responsible agencies. Identify teams responsible for Plan
updates at municipal, agency, and central government levels.
Engage key stakeholders and local communities in the development of Crisis
and Emergency Risk Communication Plans at municipal, agency, and Puerto Rico
Government levels.
Coordinate and Build Capacity for Crisis and Emergency Risk Communication
Coordinate the Puerto Rico Plan with Agency and Municipal Crisis and Emergency
Risk Communication Plans.
viii
Establish an inter-agency committee to coordinate and oversee mortality surveillance
clearance and reporting to the public in disasters, to include communications and
technical experts.
Formalize a network of municipal communication liaisons to facilitate the timely
exchange of information with the central government pre- and post-disaster.
Ensure expertise in emergency communication planning and management, crisis and
risk communication, and mortality communication of government communication
personnel from agencies responsible for public health and safety functions in disasters.
Identify a cadre of ofcial spokespeople for disasters, including subject matter experts.
III. Recommendations to Build Crisis and Mortality
Communications Preparedness Capacity for
Natural Disasters
Update all Crisis and Emergency Communication Plans annually and following disasters.
Provide crisis and emergency risk communication training for communications
personnel, to include monitoring and addressing rumors and the effective use of social
media in disasters.
Implement media training for disasters with designated spokespeople.
Conduct annual emergency communication exercises, including stakeholders and local
communities.
Develop a dashboard that characterizes current crisis and mortality communication
capacity in disasters and tracks advancement over time for management and
accountability.
Conduct a KAP (knowledge, attitude and perception) population study to identify
communication strategies, messages, key audiences, vulnerable groups, and
communication channels in disasters.
Disseminate broadly promising practices and lessons learned for
community-based disaster.
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Ascertainment of the Estimated Excess Mortality from Hurricane María in Puerto Rico
INTRODUCTION
The Governor of Puerto Rico invited the George Washington University’s Milken Institute
School of Public Health (GW SPH) to submit a proposal (PR Gov 2018) to determine the
excess mortality from Hurricane María.
The proposed study, titled “Ascertaining the Estimated Excess Mortality from Hurricane
María in Puerto Rico,” contained three components: a mortality assessment, an
evaluation of the implementation of the Center for Disease Control and Prevention’s
(CDC) mortality reporting guidelines, and an assessment of crisis, emergency risk, and
mortality communications.
In its overall approach to the commissioned project, the GW SPH agreed to produce a
report with estimates of all-cause excess mortality associated with Hurricane María,
the team proposed to: a) use vital registration data from September 2017 to February
2018 to estimate standardized mortality ratios relative to prior years, adjusting for
age and sex composition of the population, as well as to produce a statistical model
that would account for these factors and produce estimates of excess mortality for
these months, including both point and condence interval estimates of the excess
all-cause mortality and a set of recommendations based on the ndings; (b) evaluate
the implementation of CDC guidelines for death registration during natural disasters
and evaluate the quality of death certicate records before and after the storm to
recommend improvements in these processes; and (c) review crisis and emergency
risk communication plans and procedures in place before and after Hurricane María,
interview participants and Government of Puerto Rico personnel to document how
communication processes were implemented, analyze key issues and events, assess
public perceptions of communications by the Puerto Rican Government, and provide
recommendations best on best practices in disaster communications.
In addition to providing an accurate estimate of excess mortality after the storm, the
GW SPH team also sought to inform the Government of Puerto Rico on the advantages
of using mortality data for monitoring the conditions after a natural disaster. The
study also assesses the government’s challenges in death certication, classication,
recording and reporting processes under normal circumstances and under the
stress of a hurricane disaster. In the future, these results may be followed with an
in-depth analysis of the cause-specic deaths directly and indirectly attributed to the
hurricane. The communication component sought to identify challenges within the
communications system as well as to recommend opportunities for addressing them.
The communications component may also be followed by an in-depth assessment of
communications capacity and processes, as well as the development of strategies to
enhance public health communications during crises.
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Ascertainment of the Estimated Excess Mortality from Hurricane María in Puerto Rico
RESEARCH TEAM
The GW SPH established a research collaboration with the University of Puerto Rico
Graduate School of Public Health (UPR GSPH) for project implementation. Other public
and private institutions and individual experts within and outside of Puerto Rico were
approached to collaborate on the project. Due to the level of con
dentiality required
for the project, as a rst step, a secure environment was established for data storage
and analysis. An interim report described much of the process to build the project,
including institutional arrangements, establishment of the secure warehouse, and the
collaborative environment (GW 2018).
Within the GW SPH, a multi-disciplinary team was assembled, consisting of
epidemiologists, a demographer, a public health nutritionist, environmental health
scientists, two public health research assistants, an anthropologist, a behavioral scientist
and two health communication experts. An external expert review panelist from Johns
Hopkins University joined the research team during the analysis of time-series of the
mortality data set. The UPR GSPH team included three tenured faculty, including a
biostatistician, an epidemiologist, and an epidemiologist with extensive experience
in community research and a biostatistics research assistant (Annex 1 identies the
research members). They contributed methodological expertise, community research
expertise and provided context for the GW SPH researchers on the Puerto Rico situation.
An expert review panel was established (Annex 2), with national and international
experts in different elds, to review the methods at different project stages. Similarly,
we had the support of a group of GW SPH global experts in medical humanitarian crisis
PURPOSE OF THE REPORT
The purpose of this report is to inform the citizens and the Government of Puerto
Rico about the project’s results. We believe the study ndings will enhance the
government’s capacity to develop reliable mortality surveillance systems for hurricane
disaster intervention and management and to implement efcient and robust public
communication systems in the context of a natural disaster. The report also describes
next steps in advancing a much-needed analysis on cause-specic mortality and in
performing an assessment of the capacity for implementing public health functions
that includes emergency surveillance and risk communication.
This report rst presents project methods and ndings and then proceeds to offer two
sets of recommendations.
For more details on the methodology, data and programs used in the excess mortality
calculations, these will be made available online at: http://
prstudy.publichealth.gwu.edu/
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MORTALITY
METHODS
Assessment of Excess Mortality
Excess deaths are deaths that exceed the regular death rate predicted for a given population
(WHO 2018) had there not been a natural disaster or other unexpected or calamitous event,
such as an epidemic or industrial accident (Geronimus et al 2004; Haentjens et al. 2010).
Using vital registration data from seven years prior to the storm, we dened two
counterfactual scenarios for this analysis. The rst, which we have labeled the
‘census’ counterfactual, assumes the rate of change in the resident population
composition and distribution—both in terms of absolute size and factors associated
with differential exposure to the risk of mortality (including age, sex and municipal
socioeconomic development)
1
—remained unchanged after the hurricanes. The
second scenario estimates cumulative excess net migration from Puerto Rico in the
months from September 2017 through February 2018 and subtracts this from the
census population estimates in these months. This is labeled the ‘displacement’
counterfactual. Comparing these counterfactual estimates of mortality over the period
to that actually observed produces estimates of all-cause excess mortality. This excess
can be represented as a count of excess deaths, or a ratio of the number of observed
deaths to expected deaths had the hurricane not occurred.
Any estimation or comparison of mortality over time has to consider the population’s age
and sex distribution and seasonality. Similarly, it is important to take into account changes
in population size. In the case of Puerto Rico we reviewed in- and out migration over the last
decade and the net migration result was negative. The increase in out-migration has affected
the population’s demographics, and the storm accelerated this trend.
1. Age is categorized as between 0 and 39 years, 40 to 65 years, and 65 years and over. Sex is characterized as male and
female. Municipal level socioeconomic development is dened as the tertiles (or equal thirds of the distribution) of
the Municipal Socioeconomic Development Index (SEI), developed by the Puerto Rico Planning Board (Indice 2017).
This measure captures the underlying strength of municipal level structural and institutional capacities.
To estimate excess mortality associated with
Hurricane María, it was necessary to develop
counterfactual mortality estimates, or estimates
of what mortality would have been expected to
be had the disaster not occurred.
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Ascertainment of the Estimated Excess Mortality from Hurricane María in Puerto Rico
The GW Institutional Review Board (IRB) granted the project human subjects exemption
as it represented minimal risk. Data were transferred by the different government
agencies through a secure, private Secure File Transfer Protocol (SFTP) and stored and
managed in a protected environment certied against the HITRUST Common Security
Framework (CSF) for HIPAA compliance and meeting the FIPS 140-2 standard.
We began our analysis with descriptions of age-standardized mortality rates, age-
specic rates and rates by level of municipal socioeconomic development after the
storm relative to previous years. To estimate counterfactual mortality under the census
and displacement scenarios, we developed a series of generalized linear (GLM)
overdispersed log-linear regression models using the historical registration data from
July 2010 to August 2017. These models account for trends in population size and
distribution over this period in terms of age, sex and residence by municipal-level
socioeconomic development. We used the model results to project forward mortality
that would have been expected if the storm had not occurred and the population had
not changed (the census scenario), and explicitly accounting for the massive population
displacement away from the island occurring during this period (the displacement
scenario). Comparing these projections to observed mortality in the vital registration
data, we arrived at our estimates of excess all-cause mortality attributable to the storm.
In addition to the GLM models, we estimated a Generalized Additive Model (GAM) using
the same data as a robustness check on the GLM results. The GLM and GAM models
make different assumptions and treat the data differently, including in the specication
of overdispersion, autocorrelation and long-term and seasonal trends.
To provide context for our results, we have also replicated the analyses of others who
have attempted to estimate excess mortality in the post-María period, comparing their
estimates and their methodologies to those used here.
To perform this analysis, we obtained vital registration mortality data
including deaths by age, sex and municipality of residence from the Puerto
Rico Puerto Rico Vital Statistics Registry (PRVSR) for the period July 1, 2010
to February 28, 2018. We derived baseline estimates of population size in
each month from annual census estimates of population size by age, sex
and municipality of residence. Cumulative monthly population displacement
after the storm in each month was estimated using Bureau of Transportation
Statistics (BTS) data on monthly net domestic migration provided by the
Puerto Rico Institute of Statistics and a survey of airline travelers provided
by the Puerto Rico Planning Board (Planning Board 2018).
4
Death Certication Process
This study evaluated the implementation of the CDC procedures for mortality registration in
the aftermath of the hurricanes in Puerto Rico following the CDC evaluation protocol, Updated
Guidelines for Evaluating Public Health Surveillance Systems (German 2001).
Participants in the death certication process are the persons or organizations that
certify the occurrence of a death, generate, use or otherwise attest to deaths, mortality
registration and/or generate mortality data. For the death registration assessment,
potential interviewees included: physicians, PRVSR staff, funeral home directors,
hospital directors, forensic pathologists, Federal Emergency Management Agency
(FEMA) personnel and members of key associations. We chose interviewees from
different municipalities in Puerto Rico.
The interview guides were tailored to each participant group and informed consent
forms were developed. Spanish and English-language interview guides and informed
consent forms were approved by GW IRB and UPR GSPH. Each interview guide
described: 1) the regular processes, 2) organization or agency policies, and 3) changes
in processes during and after Hurricane María. Our team eld-tested the interview
guides in Puerto Rico; and also reviewed manuals for certication and registration of
deaths produced by the Puerto Rico Demographic Registry, Puerto Rico laws pertaining
to death registration, and several sets of guidelines from CDC and National Center for
Health Statistics (NCHS) on certication of deaths in disasters (Department of Health
(DoH) 2015a; DoH 2015b; CDC ND, CDC 2017).
Upon obtaining IRB authorization, our team traveled to Puerto Rico to conduct interviews —
26 in a two-week period. All interviewees received an informed consent form. To compare
Puerto Rico death certication procedures with those of the US mainland, we used the
same interview guide with a person from a local health department on the mainland that
historically had been affected by a major hurricane. The interviews were audio-recorded using
a secure device. Once transcribed, the recordings and transcriptions were placed in Armor,
the secure platform used by the project to store sensitive data.
The team generated information on (a) processes and procedures of
death certification, classification and registration in Puerto Rico, and
(b) participants involved in each process. Through this initial research,
the team identified all sources with the authority for completing the
death certification and registration process as well as the relevant
institutions and sectors (public and private) responsible for carrying
out each process. Researchers targeted individuals within specific
institutions for interviews and identied areas for conducting site visits.
5
Ascertainment of the Estimated Excess Mortality from Hurricane María in Puerto Rico
Death Certication Data Quality
Studies have established that the quality of death certicate data are affected by the
individual completing the certicate, availability of decedents’ health records and the
vital statistics systems’ architecture where the data are entered, analyzed and reported.
Several studies have highlighted the inherent subjectivity stemming from individuals
who complete the death certicate; these studies document differences in death-
cause attribution of the same patients between physicians and within and between
medical specialties. For individuals who have no readily available or updated health
records, physicians often have to rely on the acute events leading to the death. In the
US, the NCHS reviews all death certicate data and applies algorithms to make the
nal determination of underlying cause of death and sequence of events that led to
the death. Typically, these are automated, with roughly 15% of death certicates being
manually coded.
One purpose of this analysis was to assess the quality of death certicate data after
Hurricane María compared to the two previous years.
We followed standard approaches to assess the quality of the mortality registration
process (Naghavi 2010, World Health Organization (WHO) 2013, Philips 2014). The
indicators we used were: percent of garbage codes as underlying cause of death,
percent of missing age or sex, percent of medically implausible diagnoses and average
number of causes of death reported per person per specied time period.
Data
We obtained vital registration mortality data including deaths by age, sex and
municipality of residence from the PRVSR for the years 2015 through 2017.
Mortality Registration Quality
Cause of death reporting/garbage codes: Mis-assignment of the underlying cause of
death was calculated using a combination of the methods described by Naghavi (2010)
and Philips et al. (2014) and by WHO (2013) and comparing both. Garbage codes refer
to diagnoses that should not be considered as an underlying cause of death or assigning
deaths to causes that are not useful (Naghavi 2010). Garbage codes were classied into:
Type 1, codes without any inherent information about the underlying cause of death
(e.g., heart beat abnormalities, dizziness); Type 2, codes that describe intermediate
causes of death (e.g., heart failure, septicemia, or pulmonary embolism); Type 3, codes
that represent immediate causes of death that are the nal steps in a disease pathway
leading to death (e.g., cardiac arrest, respiratory failure); and Type 4, unspecied causes
The team analyzed death certicate data quality to
formulate recommendations that would improve death
certication procedures during and after a disaster.
6
within a larger cause (e.g., unspecied bacterial infection, metabolic disorder).
Several experts meet on a regular basis to revise the denitions of these groupings.
We used the expanded 1 to 4 garbage coding denitions from Philips et al. (2014)
and personal communication. We also calculated garbage codes as dened by WHO.
Completeness of age and sex: To assess quality of age and sex reporting, we calculated
the number of deaths with unspecied date of birth, age, sex or a combination of these
as a fraction of all deaths reported.
Internal consistency: Following the procedures used by Philips et al. (2014) and by
WHO (2013), we calculated the number of implausible cause of death assignments
for any given age or sex. For example, females diagnosed with testicular or other male
reproductive-organ cancers, males with obstetrical conditions, pregnancy-related
mortality for males or for females under age 10.
Timeliness: This indicator refers to timeliness on many levels. For this analysis,
researchers calculated the number of days between date of death and date of
registration and assessed whether delays were related to the hurricane.
Number of causes of death reported: We calculated the number of causes of death
assigned for each decedent and then calculated the average in each of the specified
time periods to assess whether this was impacted by the event.
We assessed statistical significance using t-tests, chi-square tests, and simple linear
regression models, as appropriate (Suárez, 2017).
7
Ascertainment of the Estimated Excess Mortality from Hurricane María in Puerto Rico
Figure 1. Age-Standardized Monthly Mortality by Year (per 10,000 inhabitants),
Puerto Rico, 2010-2011 to 2017-2018. U.S. Census and Displacement Scenarios
for 2017-2018
FINDINGS
Ascertainment of Excess Mortality
The PRVSR documented 16,608 deaths from September 2017 to February 2018—9,054
males and 7,554 females. Approximately 77% were older adults (65+ years), and 18%
resided in the municipalities with low socioeconomic development. We estimated that
in mid-September 2017 there were 3,327,917 inhabitants and in mid-February 2018
this number was 3,048,173 inhabitants of Puerto Rico, a total population reduction of
approximately 8%. This was factored into the migration “displacement scenario” and
compared with the “census scenario.”
Age-adjusted mortality rates for Puerto Rico tend to be higher in the winter and
early spring, declining in the summer months (Figure 1). Mortality has been slowly
declining from 2010 on, but increased markedly in the period after September 2017,
most dramatically under the displacement scenario accounting for migration after the
hurricane.
8
Results from the preferred statistical model, shown below, estimate that excess mortality
due to Hurricane María using the displacement scenario is estimated at 1,271 excess
deaths in September and October (95% CI: 1,154-1,383), 2,098 excess deaths from
September to December (95% CI: 1,872-2,315), and, 2,975 (95% CI: 2,658-3,290)
excess deaths for the total study period of September 2017 through February 2018.
Table 1 shows observed, predicted and excess mortality by month for the study period
as well as the total study period.
Table 1. Observed, Predicted and Excess (95% CI) Mortality, Puerto Rico,
September 2017 to February 2018, Model 3, Displacement Scenario
SEPT-OCT 2017 SEPT-DEC 2017 SEPT 2017-FEB 2018
OBSERVED
5,921 11,375 16,608
PREDICTED
4,650 9,277 13,633
EXCESS
1,271 2,098 2,975
95% CI
(1154, 1383) (1872, 2315) (2658, 3290)
OBSERVED/PREDICTED
1.27 1.23 1.22
Every social stratum and age group was affected by excess mortality,
however, the impact differed by age and socioeconomic status
(Figures 2 & 3). Risk of death was higher and persistent until the end
of the study period for populations living in low socioeconomic
development municipalities (a ratio of 1.5 at the end of February 2018).
Older males (65+) experienced continuous elevated risk of death through
February, while most other groups approach the baseline mortality risk at
2 and 4 months post-hurricane, and all do so by February.
9
Ascertainment of the Estimated Excess Mortality from Hurricane María in Puerto Rico
Figure 2. Estimated Relative Excess Mortality from Hurricane María in
Puerto Rico, Per Month, by SEI Category
Figure 3. Estimated Relative Excess Mortality from Hurricane María in
Puerto Rico, Per Month, by Sex and Age Group
10
No areas of the island were unaffected, but in its aftermath, some municipalities suffered
greater increases in mortality. Figure 4 displays the estimated percentage increase in the
crude mortality rates by municipality (not accounting for age distribution differences)
for the period inclusive of September-February 2017-18 relative to the average rate in
the same period in 2015-16 and 2016-17 under displacement scenario. Signicant
differences between these two periods are denoted with asterisks. As can be
seen from this gure, the largest mortality differentials are concentrated in the northeast,
and to a lesser extent, southwest portions of the island. Overall, however, approximately
40% of municipalities saw signicant increases in mortality during the study period than
in the comparable period of the previous two years.
Figure 4. Estimated percentage increase in crude mortality rates by
municipality in Puerto Rico from September 2017-February 2018.
The ofcial government estimate of 64 deaths from the hurricane is low primarily
because the conventions used for causal attribution only allowed for classication
of deaths attributable directly to the storm, e.g., those caused by structural collapse,
flying debris, floods and drownings (see below). During our broader study, we
found that many physicians were not oriented in the appropriate certification
protocol. This translated into an inadequate indicator for monitoring mortality in the
hurricane’s aftermath. Verification of attribution takes time, while excess mortality
estimation is a more immediate indicator.
11
Ascertainment of the Estimated Excess Mortality from Hurricane María in Puerto Rico
Death Certication Process
Based on a review of scientic literature, laws and manuals, as well as interviews on
the death certication and registration processes in Puerto Rico, we established that
the persons authorized to complete death certicates include physicians and forensic
physicians. Most physicians have no formal training in completing a death certicate
and thus are not aware of appropriate death certication practices, especially in a
disaster setting. When the special CDC guideline was disseminated after the disaster,
some of those who had access to it found that it conicted with what they had previously
learned. Those interviewed said they did not receive information about how to certify
deaths during, or in conditions created by, a disaster. Several interviewed physicians
were asked about the CDC guidelines the PRVSR circulated after the hurricane that
recommended they ll out a section in the death certicate with information or other
conditions that contributed to the death. Several said— as did a spokesman for the
physician community in hearings—that they understood this section as seeking more
information about health conditions. A few interview respondents indicated some
reasons for reluctance to relate deaths to hurricanes, including concern about the
subjectivity of this determination and about liability.
The analysis shows that physician unawareness of appropriate death
certification practices after a natural disaster and the Government of
Puerto Rico’s lack of communication about death certificate reporting
prior to the 2017 hurricane season substantially limited the count of
deaths related to María.
There was also a communication problem between the PRVSR
and other government agencies and participants in the death
certification and registration process, physicians, funeral home
directors, hospitals and the organizations that represent them
(e.g., the College of Physicians and Surgeons of Puerto Rico and
the Association of Hospitals of Puerto Rico). Many stated that the
Puerto Rico Department of Health (DoH) and the Puerto Rico
Department of Public Safety (DPS) did not notify them about the
CDC special guidelines for correct documentation of cases, on the
importance of correctly documenting deaths related to the
hurricane or on an emergency protocol for handling these cases.
12
The lack of training on death certicate completion is also a problem
on the mainland, and several jurisdictions have sought to remedy this
deciency by creating and requiring training courses on death certication
for physicians and other personnel responsible for completing death
certicates. NCHS has developed an e-course as well. To date, there are
no formal courses on death certication in natural disasters for persons
who ll out death certicates.
Death certication and registration processes in Puerto Rico were affected by Hurricane
María. The PRVSR ofces sustained damages and did not have electric power to operate
immediately after the hurricane. Even for the ofces which had generators, the electronic
system used was not always operational. PRVSR leadership re-deployed staff to ofces
that were still operational and to San Juan so that, at the very minimum, staff could
receive information and begin processing the deaths. Because the agency’s electronic
system was ofine, everything was done on paper, and all certicates were collected
by supervisors and taken to San Juan for quality review and data entry. This resulted in
delays in death registration, ranging anywhere from 7-10 days to 17-27 days. Based
on a concurrent study of quality of the death certicate data, it does not appear to have
affected the completeness of the certicates (see death certication quality).
Once operations resumed, the PRVSR personnel tracked the data coming in. When they
saw that the numbers of death per day were considerably higher than normal, which is
about 75 deaths per day, they began checking death certicates and found that those
relating the deaths to the hurricane were scarce. The PRVSR sought to disseminate the CDC
guidelines to participants in the certication process (physicians, hospitals, funeral home
directors, etc.)
PRVSR personnel indicated they provided the information to the different groups via email,
through the weekly meetings at the government Center for Operations in Emergencies
(COE), as well as through interviews with the press.
According to PRVSR personnel, a very small number of those completing death certicates
did relate the deaths to the hurricane. Most other certicates lacked such information. This
reduced the number of death certicates that indicated a relationship with the hurricane.
As part of this study, the team also interviewed individuals involved in death certication in
mainland states and at the NCHS. According to these respondents, the quality of mortality data is
affected by how much the person lling out the death certicates knows about this task
13
Ascertainment of the Estimated Excess Mortality from Hurricane María in Puerto Rico
Several laws govern the certication of death in Puerto Rico, including the laws that set
up the PRVSR, the Puerto Rico Bureau of Forensic Sciences (BFS), as well as the law for
Funeral Homes (Ley del Registro General Demográco de Puerto Rico, 1931; Ley para
declarar la muerte en caso de eventos catastrócos, 1985; Ley del Departamento de
Seguridad Pública de Puerto Rico, 2017;). In addition, the PRVSR has created
instruction manuals, available online, for lling out death certicates (DoH 2015
a
;
DoH 2015
b
). Nevertheless, none of these laws or manuals address death certication
during disasters. A low impact of federal guidance to support mortality-surveillance
disaster planning both at the BFS and PRVSS was identied.
Death Certication Quality
We compared PRVSS data from September 2017 to December 2017 with the same
period in 2015 and 2016. In addition, we compared the period from September 20 to
September 30 in each of the 3 years.
Table 2. Percent of Garbage Codes as the Underlying Cause of Death by Type and Year
from 2015-2017
YEAR
TYPE 1
GARBAGE CODES (%)
TYPE 2
GARBAGE CODES (%)
TYPE 3
GARBAGE CODES
TYPE 4
GARBAGE CODES
2015
20.1 4.1 3.9 6.5
2016
20.1 3.1 4.3 5.8
2017
23.6 6.3 3.8 6.3
Mortality Registration Quality
Cause of death reporting/Garbage codes: Table 2 shows the trends in Types 1-4 garbage
codes from 2015-2017. Overall, about 20% of the PRVSS records had garbage codes of
at least one type as the underlying cause of death over the study period. However, there
was a statistically signicant increase in Type 1 and Type 2 garbage codes in the period
following Hurricane María compared to the same period in the prior year. There was no
difference in the percentage of Type 3 and Type 4 garbage codes following Hurricane María
Completeness of age and sex: Completeness of death certicate quality was high with
respect to age and sex, which are two indicators widely used to assess mortality registration
quality. Less than 0.1% of records had missing age or sex. There was no statistically signicant
association between the event and completeness of age or sex data.
Internal consistency: With respect to internal consistency, less than 1% of death
certicates had medically inconsistent diagnoses in the underlying cause of death as
dened by Philips et al. (2014), and there was no statistically signicant association
between the event and internal consistency.
14
YEAR
TYPE 1
GARBAGE CODES (%)
TYPE 2
GARBAGE CODES (%)
TYPE 3
GARBAGE CODES
TYPE 4
GARBAGE CODES
2015
20.1 4.1 3.9 6.5
2016
20.1 3.1 4.3 5.8
2017
23.6 6.3 3.8 6.3
Figure 5. Length of Time (In Days) between Date of Death and Date of
Registration of Death (Timeliness) before (September-December 2016)
and after Hurricane María (September-December 2017)
Number of causes of death reported: There was a statistically signicant decrease in
the number of causes of death listed on a death certicate after the hurricane, with
about 47% of death certicates listing two or more causes of death in 2016 compared
to 44% in 2017.
The results presented herein highlight overall improvements that were made to
Puerto Rico’s death registration system over the four years prior to Hurricane María, as
evidenced by low rates of garbage codes, completeness in age and sex recording, high
rates of internal consistency and improvements in timeliness. Following Hurricane
María, there was a slight, although statistically signicant, increase in the percentage of
Type 1 and Type 2 garbage codes. This is in line with our ndings from the assessment
of the death certication process in the previous section that described biased coding
of death certicates in response to inadequate health infrastructure. As stated in the
previous section, the time from date of death to registration also increased signicantly
following the hurricane. This also corroborates the results of our qualitative assessment.
Timeliness: There was a statistically signicant delay in the number
of days between date of death and date of death registration, with an
average of 17 days in the period after the hurricane compared to 12
days in the prior year. Figure 5 shows the percentage of certicates per
day processed for the pre-María period of September-December 2016,
compared to the same period in 2017.
15
Ascertainment of the Estimated Excess Mortality from Hurricane María in Puerto Rico
RECOMMENDATIONS
OVERALL POLICY GOAL FOR MORTALITY
SURVEILLANCE AND COMMUNICATIONS
To assure the capacity of mortality surveillance and the communication of its results to support
policies and interventions for the protection of people´s life and health during crises produced by
natural disasters in Puerto Rico
RECOMMENDATIONS ON MORTALITY
SURVEILLANCE FOR NATURAL DISASTERS
I. Strategic Objectives
To have a reliable and resilient institutional mortality surveillance process that provides
trustworthy and accurate evidence during natural disasters to:
Establish the magnitude of the disaster’s impact
Identify areas and groups of highest risk
Monitor the performance of public health protection and prevention
Inform policy-making and program implementation
We recommend the following guiding principles:
Readiness: establish a routine process
Rigor: based on valid methods
Timeliness: delivering on time
Common good: having as a priority the welfare of all
16
II. Programmatic Recommendations for Natural
Disaster Mortality Ascertainment
A. Development of an Organizational Agenda
Develop a federal and Puerto Rico policy architecture
Establish a planning process for hurricane disasters with overall
responsibility under the Ofce of the Governor.
Update the Public Health and Medical Situation Awareness Strategy
2014 to consider surveillance needs for states and territories and
provide effective guidance for the specicities of natural disasters
(DHHS, 2015).
Create a culture of preparedness and planning at the federal
and Puerto Rico levels, including collaborative data-sharing and
monitoring during the emergencies.
Dene clear leadership
Under all circumstances, the Puerto Rico DoH has responsibility
for all population mortality surveillance. The DoH has the power of
legal attribution, it is the counterpart to the federal governmental
and international agencies that address these issues, and it has to
be able to use the surveillance mechanism for effective and timely
intervention.
Within the DoH, the PRVSR has to be the ofcial site for integration of
such information; this ofce collects statistical data and is responsible
for analysis. The information produced by the PRVSR should be
integrated with the DoH surveillance system. This integration should
be established by administrative order.
The DoH needs to be consulted in policy-making discussions and set
norms and guidance on mortality certication during emergencies.
17
Ascertainment of the Estimated Excess Mortality from Hurricane María in Puerto Rico
Assure strong professional capacity
Train public health professionals in public health preparedness. We recommend that the
Schools of Public Health of Puerto Rico and the continental US establish programs in
this eld to advance Healthy People 2020 goals (CDC 2013).
Assess public health capacity to effectively implement public health functions within
Puerto Rico, including mortality surveillance.
Train personnel to manage mortality surveillance at the local and central levels
of the PRVSR.
Fully staff the PVRSS for key positions with graduate degrees in demography and other
public health disciplines (e.g., biostatistics, epidemiology, data management).
Complete the stafng at the BFS. Surge planning should call for additional personnel
beyond a fully staffed organization.
Review the legal framework
Dene the Puerto Rican DoH’s accountability and review the legal basis supporting
the attribution of responsibilities between the DoH and DPS on the topic of mortality
surveillance and reporting.
Protect medical personnel from consequences of certifying the circumstances of a death
in a natural disaster. A legal framework should also protect medical facilities in fullling
their mandates for certication.
Establish a legal agreement for the continuous information transference and updating
to the DoH for mortality surveillance with the BFS, the Census Bureau and the Puerto
Rico Institute of Statistics.
Assign needed nancial resources and secure reliable infrastructure
Assure the integrity, completeness and resilience of strategic sites, the PRVSS and
the BFS, with, for example, reliable electrical power, safety installations, redundancy
systems, backups, transportation and alternative telecommunication capabilities. Put in
place Continuity of Operations (COOP) plans.
The federal government should support the implementation of this agenda and its
nancing. An executive order should be issued for an expansion of the regular operating
budget to all organizations and especially the DoH, BFS, PRVSR.
18
B. Establish an Excellence Program on Mortality
Surveillance for Performance Monitoring
Use mortality-based monitoring to assess disaster impact and the
effectiveness of interventions in the aftermath
Establish a continuous surveillance system based on the principle of
transparency, staffed by PRVSR and DoH professionals. The system can be
used as a public health tool for systematic analysis and interpretation of
total all-cause deaths.
Develop specic indicators and special monitoring of vulnerable groups
(low SEI and older adults).
Establish collaborations of the UPR GSPH with the government
and, particularly, the DoH for stafng and for students’ professional
development, laying foundations for a Center of Excellence.
Differentiate between terms. Use the term hurricane (or other natural
disaster event) excess death as the indicator to track and identify departures
from predicted/expected mortality. It should use hurricane-attributable
mortality for conrmed cases to both monitor and certify death.
Establish a system of continuous modeling of mortality trends using the
models provided, with constant updates of sociodemographic information.
Allow for recovery monitoring in the system and dene the scope
and duration of remediation interventions by federal and territorial
governmental and social agencies.
Establish a continuous quality improvement program for
death certication
Continuously measure indicators and establish a monitoring system,
particularly when changing to the e-certication system. Include a
continuous measurement of indicators on death certication quality in
the monitoring system. Make this information available to the medical
community at all times.
Train all medical doctors on death certication. Use existing, publicly
available online courses by Pan-American Health Organization (PAHO) or
NCHS. Ensure this training is a requirement of College of Physicians and
Surgeons for medical accreditation.
Implement collaborations of the DoH and the BFS with universities such
as UPR GSPH to train personnel on quality improvement and in-depth
studies of death certication.
19
Ascertainment of the Estimated Excess Mortality from Hurricane María in Puerto Rico
C. Establish a Mechanism for Continuous Flow of Analysis
and Interpretation of Results to Decision Makers
Improve efciency of ow of information to decision makers
Design instruments to convey results in a timely manner to key decision makers during
a natural disaster. Engage stakeholders from civil society, the media and other groups.
Base decisions on evidence from the continuous monitoring system and its indicators.
Ensure provision of feedback to those involved in the death certification process
Convey results in a timely manner to those generating them, such as medical doctors.
Develop instruments to effectively and efciently communicate with these target groups
as part of establishing a surveillance system with a bidirectional ow of information.
III. Recommendations for the future advancement and in
preparation for other potential natural disasters
Analyze cause-specic mortality to establish causal pathways and identify priority areas
(see Annex 3).
Assess and strengthen public health functions at the DoH.
Evaluate the burden of disease related to mortality from Hurricane María.
Advance the work on the analysis of small-area statistics to identify the heterogeneity
within municipalities in the mortality experience from Hurricane María.
Disseminate globally the experience gained by Puerto Rico in this major event.
20
Ascertainment of the Estimated Excess Mortality from Hurricane María in Puerto Rico
COMMUNICATIONS
METHODS
Assessment of Crisis and Mortality Communications
and the Information Environment
The current study includes an assessment of disaster and/or communications planning
and actions taken by the Puerto Rican Government before and after Hurricane María, with
an emphasis on the plans in place at the time of the hurricane, the number of trained staff
dedicated to crisis and emergency risk communication, spokespersons’ interaction with the
media and stakeholder perceptions of the government’s risk communication and reporting
of mortality. The communication assessment methodology, instruments and analytical
framework were informed by established guidelines and principles, which are supported
by robust scientic evidence detailed in: 1) CDC’s Crisis Emergency Risk Communication
(CERC) manual (CDC 2014), 2) WHO’s Communicating Risk in Public Health Emergencies
guidelines (WHO 2017), 3) WHO’s Effective Media Communication During Public Health
Emergencies handbook (WHO 2005) and 4) FEMA’s A Whole Community Approach to
Emergency Management (FEMA, 2011).
Government Personnel and Key Leader Interviews: Two bilingual GW SPH researchers
conducted 33 interviews from April-June, 2018. Eleven interviews were conducted
with Puerto Rico Government agency leaders and communication personnel, and
22 with key leaders representing different stakeholder groups, described more below.
Puerto Rico Government personnel interview participants were identied
based on their role in overseeing government communications personnel,
or in coordinating, developing, approving and/or disseminating public
health, public safety or mortality information to the public. We interviewed
government agency personnel to gain their perspective on planning and
actions related to crisis and public health communications during the pre-
and post-hurricane periods.
22
Government personnel recruited for interviews included agency leaders; press/
communications directors; a demographer with involvement in vital statistics data
management; a health-related program director; and a risk communication analyst.
Interview guides inquired about the following topics: the agency’s role in public
health communication and/or mortality reporting, including communication during an
emergency; communication plans or other processes for the preparation, approval and
dissemination of information to the public; target audiences for communication; inter-
agency collaboration; communications experiences related to Hurricane María; and
recommendations for future communications.
We selected key leader interview participants to represent diverse segments
of society or broadly dened stakeholder groups. These interviews were
meant to understand the range of experiences from Hurricane María,
involvement in disaster planning and communications among leaders in
various communities around the island as well as their perceptions of the
government’s risk communication and mortality reporting.
These interviews were conducted within a sample of Puerto Rico municipalities,
which were selected to obtain a sample with diversity according to the following
criteria: geographical distribution; regional representation; socioeconomic status;
predominant political afliation; demographics; and proximity to hospitals/clinics.
Interview participants included: municipal mayors, community leaders, emergency
management staff, police, a faith leader, health care providers, non-prot organization
staff, and a funeral director. The key leader interview guide focused on the following
areas: experiences related to Hurricane María; perceptions of mortality reporting
and reassessment; risk-communication information received; recommendations for
future communications; and identication of target audiences, optimal channels and
community outreach strategies for information dissemination.
All interviews were audio-recorded using a secure device. The Spanish-language
transcripts were analyzed using qualitative data analysis methodology, which entails
reviewing transcript text, identifying where specic topics are discussed, tagging that
text with codes that represent particular themes, summarizing responses by theme
and then conducting thematic analysis. From this systematic process, researchers
identied areas of consensus and discord among participants, which facilitated the
characterization of experiences and perceptions. The interviews were analyzed in
accordance with guidelines outlined in the documents identied above.
23
Ascertainment of the Estimated Excess Mortality from Hurricane María in Puerto Rico
Press Releases and Press Conferences: Three GW SPH researchers with expertise in public
health communications, risk communication and media systematically reviewed ofcial
press releases the Governor’s Ofce disseminated and press conferences from September
20, 2017-February 28, 2018. These information sources were examined to identify key
messages for hurricane-related mortality reporting to evaluate information content, the
manner in which information was delivered and spokespeople performance.
We reviewed 17 press releases provided by the Governor of Puerto Rico’s Central
Communication Ofce and 20 press conferences, 10 of which were transmitted via the
governor’s Facebook account and 10 of which were provided in audio recording format.
Digital Media Coverage & Social Media Commentary: Three GW SPH researchers with
expertise in public health communications, risk communication and media compiled
and reviewed media coverage from major English- and Spanish-language news outlets
pertaining to hurricane-related mortality reporting, as well as related social media
commentary from September 20, 2017-February 28, 2018 in order to identify factors
that may have contributed to public concerns about mortality reporting. We reviewed
172 digital media news stories and related social media posts. We analyzed these
information sources to identify the following: reasons and timing of the dissemination
of mortality data, contradictory mortality data from Puerto Rico Government spokespeople
and alternative sources, information used to consider a death as hurricane-related,
information gaps lled by non-ofcial information and perception of the accuracy and
transparency of the Puerto Rico Government’s messages about death gures.
GW SPH sought to determine the extent to which trust, credibility,
transparency and accountability were communicated, according to
criteria specified in WHO’s Effective Media Communication During
Public Health and Steps of Communication in Crisis Emergencies
(WHO, 2017) and the CDC CERC manual guidelines (CDC, 2014).
24
FINDINGS
Assessment of Crisis and Mortality
Communications and the Information Environment
Prior to Hurricane María (June 1-September 19, 2017)
Crisis and Emergency Risk Communication Plans and
Inter-agency Coordination
Guidelines from CERC, WHO and FEMA specify the establishment of Emergency
Communication Plans that: emphasize a continuous strategic planning process focused
on both preparedness and response; call for collaboration between agencies and local
stakeholders and communities; detail personnel resources, annual training and surge
capacity; include pre-positioned communication resources/materials; identify mechanisms
for messaging monitoring and adjustment and are responsive to evolving contexts.
• According to interviews with DPS and the DoH personnel, after the establishment
of the DPS, which integrated key emergency and rst responder agencies
(Emergency Management Bureau (EMB), Police, 911, Fireghter Corps, Medical
Emergency Corps, Special Investigations Bureau) and the BFS, emergency
plans for agencies under the DPS umbrella were not updated and coordinated
between agencies, including the communication plans. This led to inoperable and
disconnected emergency plans and a lack of clarity about crisis and emergency risk
communication protocol when Hurricane María struck.
• Interview participants from the DPS, various ofces within the DoH
and EMB indicated there were also no written, updated agency crisis
and emergency risk communication plans in place that specied
coordination after DPS’s establishment in April 2017.
25
Ascertainment of the Estimated Excess Mortality from Hurricane María in Puerto Rico
• Interviews with leadership at the Governor Ofce’s Central Communications Ofce
indicated that no written crisis and emergency communication plans were in place
at the time of the hurricane.
• Leadership from the EMB, the agency responsible for reviewing and approving
agency and municipal emergency plans, indicated that their existing emergency
plans were appropriate for Category 1 hurricanes and did not include scenarios
such as multiple cascading failures in critical infrastructure and key resource (CI/KR)
sectors, as specied in the Department of Homeland Security’s National Planning
Scenario (NPS) #10, for “Category 3 of Higher Hurricane.”
• According to interviews with personnel in the DoH Ofce of Emergency
Preparedness and Response, as well as our review of the annexes from the
emergency plan, the plan had not been updated to reect DPS’s establishment,
but did include annexes for Risk Communication in Emergencies and Mass Fatality
Management. Interview respondents did not mention the existence of an updated,
written plan for mortality surveillance in emergencies, which would specify agency
responsibilities, coordination and clearance protocols for public reporting.
• Key leader interview participants perceived inadequate preparation by the
Government of Puerto Rico and the federal government, evidenced by the
unsuccessful communication between municipalities and the COE, a disabled hospital
system, deciencies in communication among rst responders, handling of deceased
and lack of coordination of health personnel for refuges. Furthermore, key leaders
expressed that Hurricane María revealed Puerto Rico’s social and health inequities.
Communication Personnel Stafng Structure, Training, Processes
and Responsibilities
• Leadership within the Governor’s Central Communications Ofce indicated
that their ofce oversees and coordinates agency Press Directors, but does not
implement, oversee or coordinate activities outside of press-related functions, such
as crisis and risk communication or health/safety promotion. This ofce indicated
responsibility for providing general training for communication personnel, and
identied agency leadership as responsible for providing agency-specic training.
• Based on interviews with government agency personnel, communications staff
allocation was imbalanced, with more personnel dedicated to press relations and
inadequate personnel dedicated to other important areas of communications,
including crisis and emergency risk communication. This is evident in the
stafng structure across agencies—it is common for there to be one or few
communications personnel per agency, with staff having expertise and primary
functions in press relations. According to interviews, there were no personnel
within Puerto Rico Government agencies who were identied as responsible for
training communication personnel across agencies in crisis and emergency risk
communication.
26
• Interview participants from the DPS and various ofces within the DoH described
hurricane-related mass media risk communication campaigns as primarily
implemented annually by contracted public relations/advertising agencies, with
collaboration from government agencies. These contracted personnel were not
mobilized as surge capacity in emergencies.
• Based on responses from government personnel in the Central Communications
Ofce and key leaders in municipalities, it is evidence that the personnel
structure between central and municipal governments to facilitate emergency
communication was inefcient and ineffective for catastrophic disasters. According
to Central Communications Ofce interview respondents, the Municipal Affairs
Ofce in the Governor’s Ofce interacts with municipalities, but not for emergency
communication functions.
Risk Communication Messaging and Local Preparedness
Communication Efforts
• Key leader interview respondents reported that in the months prior to the
hurricane, they were exposed to risk messages disseminated via television, radio
and social media. Most respondents recalled risk messages targeting vulnerable
groups or related to hurricane preparation about food, water, shelter, medication
and evacuation. Respondents recalled less health-related prevention or risk
messages, such as potential consequences of failures in critical infrastructure and
key resource sectors that one might anticipate from a Category 4 or 5 hurricane,
subsequent health implications and how to navigate these challenges.
• Key leader interview participants described preparations undertaken in
their respective communities, including activities such as: 1) designation of
neighborhood leaders to facilitate communication, provide vigilance and attend
to resident needs; 2) local census of bed-ridden individuals, older adults and
other sensitive populations; 3) use of mobile applications, such as WhatsApp, to
facilitate communication among local stakeholders; 4) local inventories of health
professionals and rst responders who could be called upon during response
efforts; 5) implementation of risk messages, such as evacuation and relocation of
vulnerable individuals or households; 6) coordination of local emergency response
teams and 7) training of community leaders to meet the needs of vulnerable
groups, such as those with diabetes.
At the time of the hurricane, numerous agency communication
personnel had not been trained in crisis and emergency risk
communication, nor were they trained regarding their role in a disaster.
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Ascertainment of the Estimated Excess Mortality from Hurricane María in Puerto Rico
• Key leaders reported that, despite the mass media campaign and local
preparedness efforts, communities were not adequately prepared for
the direct and indirect impacts of a Category 4 hurricane: segments of
the public did not take the warnings as seriously as they should have;
segments of the public had prepared, but not with adequate supplies
or arrangements for vulnerable populations for an extended time period;
and some respondents thought that there was no way to plan for some
of the unforeseen circumstances from Hurricane María. The lack of recent
history with a major event may have also inuenced how the public
understood the risk.
• Vulnerable populations identied by key leader interview respondents included:
low-income individuals who could not prepare adequately due to limited
nancial resources; older adults; individuals with chronic medical conditions;
patients requiring ongoing and specialized treatment; and patients with required
prescription medications, including controlled substances.
28
Following Hurricane María (September 21, 2017–February 28, 2018)
According CERC and WHO framework guidelines, government administrations build
public condence in disaster preparedness and response capabilities by having in place:
appropriate communication personnel and leadership; coordinated procedures for
transparent public information sharing, stakeholder engagement, and rumor control;
appropriate channels for information dissemination; and trained, agile spokespeople
who strategically involve experts when necessary, utilize tested communication
strategies, provide consistent, veried information free of suppositions and deliver
information in a way that instills trust and transparency.
Communication Personnel, Training and Inter-agency Coordination
• According to Puerto Rico Government communications personnel interviews,
there was a high level of interaction among inter-agency communication
personnel located in the COE, but an overall lack of coordination of messaging,
public information clearance and sharing of information for situational
awareness between the COE and municipalities, primarily due to the loss of
telecommunications and inadequate contingency plans. This resulted in the
dissemination of information via media channels that was inconsistent with
information from the COE.
• Government agency communications personnel also cited challenges in
responding to an elevated number of media inquiries due to insufcient stafng.
• Government agency communications personnel interviews indicated that
surge capacity was not adequately mobilized at the time of the hurricane. COE
communication personnel worked 12-hour shifts (or longer) every day for weeks
to months post-hurricane.
• Communication personnel interview participants described deciencies
in coordination between Government of Puerto Rico communication
personnel and CDC, Department of Health and Human Services (DHHS)
and FEMA counterparts located at the COE.
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Ascertainment of the Estimated Excess Mortality from Hurricane María in Puerto Rico
Risk Communication, Channels, and Local Communication Strategies
• According to interviews with government agency personnel, the collapse of
telecommunications and power infrastructure challenged situational awareness,
impaired informed decision-making and delayed information dissemination to the
media and the public.
• Government communication personnel indicated that they relied on mass media
for information dissemination; however, according to key leader interviews, many
Puerto Ricans experienced extended power and telecommunications outages.
Social media was not highlighted by communication personnel as a major
channel of information exchange with the people of Puerto Rico or stakeholder
engagement, except for dissemination of press conferences and information via
Facebook. Responses from interviews with government communication personnel
indicated they did not engage in strategic rumor monitoring and control activities
via social media or other channels post-hurricane.
• Key leader interview participants identied three mechanisms of post-hurricane
information exchange: text messaging, police radios and direct interpersonal
communication, with the latter being the most widely used. However, interviews
indicated interpersonal communication was not strategically utilized by
government personnel for mortality and disease surveillance or for coordinated
post-hurricane health and safety risk and prevention messaging. Key leaders cited
numerous “missed opportunities” by DoH personnel to efciently and resourcefully
use interpersonal communications post-hurricane. Key leader interview
respondents described specic situations when they attempted to relay mortality
or disease surveillance information via interpersonal communication, but they
perceived inadequate follow-up from DoH leadership.
• Key leaders cited radio as a relatively reliable and credible channel of post-
hurricane communication; however, this channel was reported as utilized only
to a very limited extent for disseminating health-related prevention messages
and information. Respondents highlighted perceived inadequacies of health-risk
communication messaging, even after telecommunications services were restored.
• Key leaders identied trusted information sources, including local
representatives, community leaders and individuals who align with
the same political party; however, there was limited engagement by
government personnel of local representatives or leaders for
coordinated risk communication efforts in local communities.
30
Mortality Reporting
• Generating an accurate death count in an emergency and communicating this
information to the public is complex and needs to be well established. Damaged
infrastructure and power and telecommunication outages presented major
challenges to mortality surveillance, creating difcult circumstances for reporting
this information to the public in a timely manner.
Agency leadership interview respondents from both agencies agreed on reporting
deaths as hurricane-related if classied as such on the death certicates. According
to interviews with communication personnel, appropriate technical experts were
not involved in the timing, clearance or delegation of responsibilities for public
reporting of mortality. Personnel from the DoH Ofce of Public Health Preparedness
and Response indicated that no unied, interagency command was designated to
coordinate, provide clearance and report mortality in emergencies, a practice that
existed previously. As of April 2018, leadership of the DPS and the DoH continued
to disagree about which agency would be responsible for mortality reporting in
future emergencies.
• Government agency interview participants did not know of a formal,
written protocol in place for the coordination of mortality reporting
between the DPS and the DoH.
• A review of information from press releases, press conferences, media
coverage and social media commentary indicates that the Government
of Puerto Rico apparently did not provide the public with an overview
of the complex death certication process, which would have laid the
foundation for interpreting subsequent mortality reporting and helped
to explain factors contributing to delays. This, combined with delays
in mortality reporting due to the storm’s aftermath, resulted in major
information gaps, which facilitated the emergence of rumors in an
attempt to have the public’s questions answered.
31
Ascertainment of the Estimated Excess Mortality from Hurricane María in Puerto Rico
Numerous attempts were undertaken by outside groups to ll these information
gaps and employ alternative mechanisms to identify hurricane-related
deaths, resulting in numerous conicting mortality reports. The perceived lack
of consistency in mortality reporting was reected by key leader interview
respondents, who indicated that the multiple reports added to confusion and
perceived non-transparency.
• Post-hurricane media coverage included interviews with physicians and funeral
home directors who called into question clarity and consistency of the death
certication process. According to key leader respondents, the public did not
sufciently understand the importance of designating deaths as hurricane-related,
but once they learned of potential documentation discrepancies and implications,
ofcial mortality report credibility suffered. Several key leader respondents
perceived the ofcial death toll to be an undercount given their direct experiences
with mortality in their individual municipalities. The perception that the death count
was higher led some key leaders to view government leadership as disconnected
from the realities of Puerto Rican communities, that there was not transparency
in reporting, that information was intentionally withheld to evade blame and that
there were not adequate systems in place to track death count.
• According to a review of media, ofcial sources were cited as reporting the
authorization of hundreds of cremations from September 20 to October 18 for
cadavers with certications of a natural death; media reported this as being an
elevated number of cremations from the year prior to the hurricane. However,
explanations of cremation trends by a government subject-matter expert were not
available in media coverage, leaving lingering suspicions of non-transparency in
reporting deaths as hurricane-related and increasing risk of rumor generation.
• A review of media coverage and social media commentary noted that the abrupt
increase in reported deaths from 16 to 34 on October 4th was perceived by the
public as an effort to manipulate the death count for political interests, contributing
to the controversy. A review of media coverage, press releases and press conferences
revealed that no explanation was given to ll this void of information, such as a
description of the “Burkle Effect,” a phenomenon seen in post-disaster contexts,
where a virtual collapse of mortality surveillance immediately after the event is
followed by a spike in mortality reporting as recovery progresses.
• Media coverage and social media commentary showed that additional controversy
resulted from the publicized potential deciencies in accounting for indirect deaths
in media coverage. After a series of questions from the media, the Secretary of
Public Safety said in a press appearance on November 8th that the government
would announce only the deaths that doctors certied. Potentially adding to the
controversy, media coverage continued to report anecdotes of indirect deaths due to
persistent power outages and injustices in receiving federal benets due to the lack
of documentation of indirect deaths. The extended post-hurricane recovery period led
some key leader interview respondents to perceive that indirect deaths occurring up
to months post-hurricane were not being captured in the ofcial death count.
32
• Key leader interview participants believe it is important to know more about the
death count and cause of death for future disaster preparedness planning and
response efforts. Overall, they supported the reassessment of the death count
from Hurricane María the Governor ordered, especially if the ndings could be
informative for future disaster preparedness planning.
Spokespersons Roles Following Hurricane María
given spokesperson performance during press conferences or media interviews and
negative perceptions and characterization of how they conveyed messages or of
their capabilities, as reported in media coverage and social media commentary.
• Contradictory information and the release of unconrmed information to the
media, including death reports, demonstrated a lack of clearance protocol (or
adherence to the protocol), personnel training and coordination of messages by
government ofcials. These contradictions and apparent lack of coordination may
have contributed to decreased credibility of the government.
• The Governor of Puerto Rico served as the main spokesperson both pre- and
post-hurricane. A review of press conferences indicated he seemed prepared with
relevant information and talking points, which aligned with press releases from his
ofce. An examination of the Governor’s interactions with the press, using criteria
from the WHO and CDC guidelines showed he listened to questions and responded
with facts without using technical language; he managed uncertainty by saying
what was known and what had been done, while also identifying what was still in
the process of being reviewed or updated; and he acknowledged uncertainty in
the death count early and indicated a willingness to provide information when it
became available. However, the Governor deferred to the Secretary of Public Safety
on numerous occasions instead of calling upon an expert to provide information
about mortality surveillance.
• The lack of coordinated crisis communication and media training across
Puerto Rico Government agencies and their spokespersons were evident,
33
Ascertainment of the Estimated Excess Mortality from Hurricane María in Puerto Rico
• The Secretary of Public Safety was a frequent spokesperson post-hurricane. In
accordance with WHO and CDC spokesperson criteria, during his interactions with
the media, the Secretary delivered clear, concise information; conveyed authority;
acknowledged uncertainty in the mortality count; and also indicated a willingness
to provide more information when it was available. However, he did not provide
details about the death certication process, identify specic barriers to this
process, or explain reasons for delays or lack of information. The Secretary did not
identify a subject-matter expert early in the post-hurricane period to provide these
details, which may have decreased credibility and increased the perceived lack of
transparency evident in media reports and social media commentary. It was not
until a November 8th press conference when subject-matter experts were available
to respond to questions about mortality; inclusion of such experts in media
presentations earlier in the recovery period would have been ideal. Furthermore,
a review of media coverage and press conferences in the post-hurricane period
indicated that the Secretary provided contradictory information when he stated
that the government would not be inuenced by assumptions, but then offered
estimations about average increases in daily deaths without detailing the source
or calculation of these statistics or the rationale for using them. This likely added to
doubts about the government’s transparency.
• Despite the active, extensive dialogue on social media about the
mortality issue, no government agency communication personnel
we interviewed described any efforts to engage with social media
audiences as part of an overarching social media strategy, potentially
a missed opportunity and a aw in the overall communication strategy.
34
RECOMMENDATIONS
RECOMMENDATIONS ON CRISIS AND HEALTH
COMMUNICATION IN NATURAL DISASTERS
I. Strategic Objective
To use credible, transparent and effective crisis and risk communication during natural
disasters as a mechanism for informing populations, protecting lives and instilling public
trust. The following guiding principles are recommended:
Preparedness, with planning as fundamental for effective crisis and emergency
risk communication
Credibility, as a critical factor for facilitating partnerships and protecting public health
Transparency, as a mechanism for strengthening and informing decision-making
Compassion, with acknowledgment and validation of individual and societal
emotions and concerns
II. Programmatic Recommendations for Natural Disaster
Crisis and Mortality Communications
A. Develop a Crisis and Public Health Communication Policy
and Organizational Development Agenda
Create an Integrated Puerto Rico Crisis and Emergency Risk Communication
Plan and Planning Process
Establish a continuous planning process under the leadership of EMB and Central
Communications Ofce that integrates all responsible agencies and municipalities for
the development of a Puerto Rico Crisis and Emergency Risk Communication Plan.
Dene roles, levels of engagement and specic tasks for municipalities and agencies.
Establish Crisis and Emergency Risk Communication Plans and planning processes for
government agencies and municipalities.
35
Ascertainment of the Estimated Excess Mortality from Hurricane María in Puerto Rico
Engage key stakeholders and local communities in the development
of Crisis and Emergency Communication Plans at the municipal,
agency, and Puerto Rico Government levels.
Specify the following in the plans:
The roles and responsibilities for communication personnel
Appropriate procedures, protocols and actions necessary in
different crisis phases according to CERC guidelines (pre-crisis,
initial, maintenance, resolution and evaluation)
Coordination with Puerto Rico and federal government agencies,
institutions and key stakeholders
Key target audiences (including vulnerable populations),
messages and dissemination channels before and after
emergencies with specied contingencies
Messages about mortality and other health impacts to be
conveyed to various target audiences, as well as the modes and
channels for dissemination of this information
Creation of tools and materials that are appropriate for
communication about disaster-related mortality
A team responsible for updating Puerto Rico, agency and
municipal plans at least annually and following disasters
Dene clear leadership and alignment for effective, transparent
and credible public health communications in disasters.
Identify a cadre of ofcial spokespersons for disasters, including
subject matter experts.
Create a clear protocol for public release of messages and
information-sharing between agencies.
Coordinate and Build Capacity for Crisis and Emergency Risk
Communication
Create an interagency and multilevel coordinating architecture to
support key public health communication functions
a. Coordinate Puerto Rico Crisis and Risk Communication Plan
with Agency and Municipal Plans.
36
b. Establish an inter-agency committee to coordinate crisis and emergency risk
communication preparedness and response across agencies, including the
coordination and oversight of mortality surveillance clearance and reporting
to the public in disasters, to include communications and technical experts.
c. Establish a formalized network of municipal communication liaisons to facilitate the
timely exchange of information with the central government pre- and post-disaster.
Ensure personnel capacity for effective crisis and emergency risk communication
Stafng structures in government agencies must be reassessed. Stafng structure in
disasters needs to be established in crisis communication plans. Consider how stafng
level needs evolve as a disaster unfolds, across agencies, and across public health
communications functions.
Personnel must be hired within government agencies responsible for public health and
safety with expertise in emergency communication planning and management, crisis
and risk communication, and mortality communications. Consider adding personnel
with these areas of expertise for the Central Communications Ofce, the DPS and EMB,
in particular, given its role in overseeing municipal and agency emergency plans.
Given the growing importance of social media, especially in disasters, dedicate stafng
for disseminating information to social media as well as closely monitoring responses
on social media; this is essential to an integrated emergency risk communication effort
and information exchange during all phases of a disaster.
Consider nding a scal balance between contracting of public relations/advertising
agencies for public information campaigns and bolstering a cadre of permanent
communication personnel within government agencies, the latter of which can play a
direct role in the emergency response and recovery process.
Broad community engagement in disaster communication preparedness and
response activities
Ensure broad community involvement as a critical approach to developing crisis and
emergency risk communication plans and messages.
Strengthen community engagement during the crisis and emergency risk
communication preparedness planning process by using participatory approaches
and establishing strategies that will capitalize on this engagement for improved
communication during the response and recovery period, such as utilizing interpersonal
networks to disseminate information as a complement to mass media channels.
37
Ascertainment of the Estimated Excess Mortality from Hurricane María in Puerto Rico
III. Recommendations to Build Crisis and Mortality
Communications Preparedness Capacity for
Natural Disasters
Update Puerto Rico, agency, and municipal Crisis and Emergency Risk
Communication Plans annually and following disasters.
Provide annual crisis and emergency risk communication training for
communications personnel, to include monitoring and addressing rumors
and the effective use of social media in disasters.
Implement media training for disasters with designated spokespersons.
Conduct annual disaster preparedness exercises and simulations for
communications, including key stakeholders and local communities.
Develop a dashboard that characterizes current crisis and mortality
communication capacity in disasters and tracks advancement over time for
management and accountability.
Conduct a KAP (knowledge, attitude and perception) population study to
identify communication strategies, messages, key audiences, vulnerable
groups, and communication channels in disasters.
Conduct research for the development of best practice guidelines for
mortality communication to the public in disasters, building on lessons
learned from Hurricane María.
Disseminate broadly promising practices and lessons learned for
community-based disaster preparedness and response.
Develop an ongoing process for crisis and emergency risk communication
capacity building through the engagement of external experts, advisors,
academics and practitioners with expertise in this area.
38
Ascertainment of the Estimated Excess Mortality from Hurricane María in Puerto Rico
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María in Puerto Rico. Advances on Phase 1. Preliminary report. Retrieved from: https://www.scribd.com/
document/384759295/GW-Preliminary-Report-on-Death-Count-in-Puerto-Rico
World Health Organization. (2005). Effective Media Communication During Public Health Emergencies
Handbook. Retrieved from: http://www.who.int/csr/resources/publications/WHO_CDS_2005_31/en/
World Health Organization. (2013). Data quality assessment (DQA) tool version 1.0. Retrieved from:
http://www.who.int/entity/healthinfo/DQA_Tool.zip
World Health Organization. (2017). Communicating Risk in Public Health Emergencies. A WHO guideline for
emergency risk communication (ERC) policy and practice. Retrieved from: http://apps.who.int/iris/bitstream/
handle/10665/259807/9789241550208-eng.pdf?sequence=2
World Health Organization. (2018). Denitions: emergencies. Retrieved from: http://www.who.int/hac/about/
denitions/en/
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Ascertainment of the Estimated Excess Mortality from Hurricane María in Puerto Rico
ANNEX 1
GW Team
Dr. Elizabeth Andrade, Dr.P.H., M.P.H.
Behavioral Scientist, Project Researcher
Elizabeth Andrade is Assistant Professor in the Department of Prevention and
Community Health and the Administrative Core Director of the Avance Center for the
Advancement of Immigrant/Refugee Health at GW’s Milken Institute School of Public
Health. Dr. Andrade is a behavioral scientist with expertise in planning, implementing,
and evaluating public health interventions, health communications, and health
disparities research using community-based participatory methods. She has worked
extensively with immigrant Latino populations in the Washington DC Metropolitan Area
and with communities in Latin America.
Nicole Barrett, M.P.H.
Senior Research Associate, Project Research Assistant
Nicole Barrett is a Senior Research Associate at GW’s Milken Institute School of
Public Health, Department of Prevention and Community Health. She has expertise
in qualitative research, community-based participatory research, and social marketing
and health communication. She supports various research projects with instrument
development; IRB submissions and approvals; manuscript, report and conference
presentation development; data collection and analysis; and grant proposal
submissions.
Dr. Uriyoan Colon-Ramos, Sc.D., M.P.A.
Nutritionist, Project Researcher
Uriyoan Colón-Ramos is a Professor in GW’s Department of Global Health and
the Department of Exercise and Nutrition Science. She is a public health nutrition
investigator. She has published about mortality and diet-related chronic disease
morbidity in Puerto Rico. Her work has contributed to the knowledge of existing
dietary disparities among Hispanic subgroups, the process of translation of science
into nutrition policy in Latin America and the social and environmental determinants
of dietary behaviors among vulnerable populations in the US, Latin America and the
Caribbean.
1
Dr. Mark Edberg, Ph.D., M.A.
Anthropologist, Project Researcher
Mark Edberg is an Associate Professor in the GW’s Department of Prevention and
Community Health, with appointments in the Department of Anthropology and Elliott
School of International Affairs. Dr. Edberg is currently principal investigator and director
of the Avance Center for the Advancement of Immigrant/Refugee Health, an exploratory
research center with funding from the National Institute on Minority Health and Health
Disparities and the CDC. He is also founder and director of the Center on Social Well-
Being and Development.
Alejandra Garcia-Meza, M.P.H.
Consultant, Project Researcher
Alejandra Garcia-Meza is a Research Associate at GW’s Milken Institute School of Public
Health, Global Health Department. She has experience in policy analysis, stakeholder
mapping, program impact evaluation, qualitative and quantitative analysis, clinical
research and grant management. She is currently collaborating with the Yale School of
Public Health and the Pan American Health Organization on developing a course for
health ministries in Latin-America to evaluate and develop continuous quality control
systems for nutrition programs and interventions.
Dr. Ann Goldman, Ph.D., M.P.H, M.A.
Epidemiologist, Economist, Project Coordinator
Ann Goldman, originally from Puerto Rico, has worked on researching the costs of
prevention programs and other economic topics within different institutional settings for
the last 15 years. She has been involved in designing and implementing protocols for
cost analysis and cost effectiveness studies on population health intervention initiatives.
The projects she has worked on have sought to enhance the abilities of members of
vulnerable groups, in the developing world as well as in the US, to achieve improved
health and enjoy a better quality of life.
Dr. Lynn Goldman, M.D., M.S., M.P.H.
Dean of the Milken Institute School of Public Health,
Environmental Health Specialist, Project Researcher
Lynn Goldman’s responsibilities are informed by her broad and deep public policy and
academic experience. Dr. Goldman was Assistant Administrator for Toxic Substances in
the Environmental Protection Agency under President Bill Clinton. Under her watch,
the EPA overhauled the nation’s pesticide laws, expanded right-to-know requirements
for toxin release, among other achievements. She participated in several discussions
on Hurricane Katrina’s environmental public health impact. She is a member of the
National Academy of Medicine and serves on the National Academy of Medicine
Council, the Governing Board of the National Academy of Sciences and as a member
of the Advisory Committee to the CDC Director and a member of the Food and Drug
Administration Science Board.
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Ascertainment of the Estimated Excess Mortality from Hurricane María in Puerto Rico
Dr. Amira Roess, Ph.D., M.P.H.
Epidemiologist, Project Researcher
Amira Roess is an assistant professor at GW’s Milken Institute School of Public Health,
Department of Global Health. She is an epidemiologist with expertise in infectious
diseases and interventions to reduce the transmission and impact of infectious
diseases, especially emerging and zoonotic diseases globally. Dr. Roess has expertise
in mortality analysis and addressing US health disparities.
Dr. John Sandberg, Ph.D., M.A.
Demographer, Project Researcher
John Sandberg is an Associate Professor in GW’s Department of Global Health,
trained as a social demographer. He has published several works on US children’s
time use, including analyses of how they spend time and changes occurring in time
use in the last 20 years, as well as determinants and patterns of children’s time use
with fathers in two-parent families. His current research explores the relationship of
children’s time use to parental child-socialization values and gender-role attitudes.
Dr. Carlos Santos-Burgoa, M.D., Ph.D., M.P.H.
Epidemiologist, Principal Investigator
Carlos Santos-Burgoa is a Professor in GW’s Department of Global Health, where he
also serves as the Program Director for the Global Health Policy MPH program. Dr.
Santos-Burgoa is raising awareness of the importance for equity and development of
the public health functions within the health systems and seeking to advance their
performance. He was Dean of the School of Public Health of Mexico at the National
Institute of Public Health, Director General of the Health Environment and Work
Institute—a private consulting and research rm, Director General at Mexico´s Ministry
of Health and Senior Advisor and Acting Department Director at the Pan American
Health Organization. As Director General for the Ministry of Health in Mexico, Dr.
Santos-Burgoa was in charge of disaster management in the 2007 Tabasco oods
and the non-pharmacological response to the 2009 Pandemic Inuenza A(H1N1) in
Mexico. He was also responsible for chemicals emergency management in Mexico
and updated the Radiologic Emergency Program for nuclear facilities.
Dr. Scott Zeger, Ph.D., M.S.
(Johns Hopkins University, Bloomberg School of Public Health)
Biostatistician, Project Researcher and Expert Panel Member
Scott Zeger is a Professor of Biostatistics at the Johns Hopkins Bloomberg School of
Public Health. He conducts statistical research on regression analysis for correlated
responses in surveys, time series and longitudinal or genetics studies. Professor
Zeger has been elected Member of the National Academy of Sciences’ Institute of
Medicine, Fellow of the American Association for the Advancement of Science and of
the American Statistical Association. He was originally invited as an external panel
expert. He is incorporated in this list as he got heavily involved in the project’s analysis
of excess mortality component.
3
UPR GSPH Team
Noel Estrada Merly, M.S.
Graduate Research Assistant, Project Research Assistant
Noel Estrada is in Graduate School of Public Health, Department of Epidemiology and
Biostatistics. He received a bachelor’s degree in Cellular & Molecular Biology from the
University of Puerto Rico, Rio Piedras Campus. He is currently studying the differences
in survival for hepatocellular carcinoma and underlying diseases. His research interests
are cancer, chronic diseases and emergency management. He also served as research
assistant in the Eastern Caribbean Health Outcomes Research Network (ECHORN)
collaborative project.
Dr. Cruz María Nazario, Ph.D.
Epidemiologist, Project Researcher
Cruz María Nazario is a professor in the Biostatistics and Epidemiology Department,
Graduate School of Public Health, University of Puerto Rico. She has mentored over 130
master’s and doctoral students. Her career combines long experience in eldwork and
epidemiologic study design and analysis, with her academic work and the defense of the
right to health for poor communities in Puerto Rico. Dr. Nazario is a member of the Robert
Wood Johnson Foundation National Advisory Committee, Clinical Scholars Program.
Dr. Cynthia Pérez, Ph.D.
Epidemiologist, Project Researcher
Cynthia Pérez is a Professor of Epidemiology in the Graduate School of Public Health at
the University of Puerto Rico. She has directed mentoring and training of public health
students, medical students, residents, fellows and faculty in the elds of epidemiology
and biostatistics for the past 20 years. Her research has spanned public health issues in
Puerto Rico, where she has designed, implemented and administered population-based
studies targeting various geographic areas in the island. She has also devoted some of
her time to coauthor various books including Biostatistics in Public Health Using Stata
and Applications of Regression Models in Public Health.
Dr. Erick Suarez Pérez, Ph.D., M.A.
Biostatistician, Project Researcher
Erick. Suarez is a biostatistician in the Graduate School of Public Health, University of
Puerto Rico . He has been involved in various research projects, where he developed
the experience to apply statistical analysis and rigorous methodologies to public health
problems in population-based studies and secondary data analysis. He has coauthored
two books related to public health: Biostatistics and Public Health (CRC/Press, 2016)
and Applications of Regression Models in Epidemiology. In addition, he has worked with
microarrays data analysis to assess the gene expression and DNA repair capacity among
breast cancer patients.
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Ascertainment of the Estimated Excess Mortality from Hurricane María in Puerto Rico
Additional GW Team Members
Ljubica Latinovic, M.D., M.H.A.
Communications Expert, Consultant
Ljubica Latinovic is a specialist in risk communication. She currently serves as a
risk communications advisor for the Pan American Health Organization, providing
support to countries when necessary. She has long-term experience at the Health
Promotion Department of the Ministry of Health of Mexico where she worked in
risk communication and managed social marketing. She has also worked in crisis
risk communication for the Ministry of Health in Mexico during the 2009 Inuenza
Pandemic. She has coordinated and designed strategies for risk communication
in emergencies and disasters with Collaborating Centers for International Health
Regulations.
Ivonne Rivera, M.P.H.
Expert in Qualitative Analysis, Consultant
Ivonne Rivera is an expert with over 15 years of experience in qualitative research.
She leads a consulting practice that provides services to organizations in designing
and conducting qualitative research studies, as well as supporting research activities
with transcription and translation. Her clients have included government agencies,
research companies and advertising agencies. She has expertise working with
various communities nationwide, allowing her to take a culturally and linguistically
appropriate approach with research participants. She also has 13 years of experience
working in clinical research.
5
ANNEX 2
External Panel of Experts
Samuel Clark, Ph.D., M.A.
Demographer
Samuel Clark is a demographer who works on African demography and epidemiology
and developing new methods for population sciences. His work includes improving
the ‘verbal autopsy’ method used to quantify the burden of disease for populations
without full-coverage vital statistics systems. He also works in developing new
population indicator measurement strategies, and in a variety of projects investigating
levels and trends in fertility and mortality, mostly in Africa, and sometimes building
models of age schedules of fertility and mortality that can be used widely as inputs to
other analyses. His work involves collaborations with the CDC, WHO, UNICEF, among
others. He was invited to join the Puerto Rico expert panel due to his expertise in
verbal autopsies and his wealth of experience as a demographer, which helped inform
the methods for estimating excess mortality from Hurricane María.
Debarati Guha Sapir, Ph.D.
Epidemiologist
Debarati Sapir is the Director of the Center for Research on the Epidemiology of Disasters
and a Professor at University of Louvain School of Public Health, in Brussels, Belgium.
She holds an Adjunct Professorship at Tulane University Medical Centre (New Orleans)
for Health and Humanitarian Aid. The GW SPH team invited Dr. Sapir to join the expert
panel due to her expertise in research methods for disaster epidemiology. Since 1984,
she has been involved in eld research and training in emergency and humanitarian aid
issues, working closely with WHO, UNHCR, UNDP and European Commission in various
regions of the world. Her experiences provided seasoned input in the study design and
methods and critical and constructive feedback on the project results.
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Ascertainment of the Estimated Excess Mortality from Hurricane María in Puerto Rico
Bernardo Hernández Prado, DSc., M.S.
Epidemiologist, Mortality Estimation Expert
Bernardo Hernández Prado is an Associate Professor at the Institute for Health
Metrics and Evaluation (IHME) at the University of Washington. He works with IHME’s
Integrated Surveillance Systems research team in evaluating the Salud Mesoamérica
2015 project. Dr. Hernández has collaborated with IHME on the Population Health
Metrics Research Consortium project for validating verbal autopsy and chronic disease
diagnosis questionnaires. Dr. Hernández’s work on verbal autopsies, a key component
of Phase II of this project helped inform the methods. His research has focused on
maternal health and mortality, social and health program evaluation and the effect of
physical activity and improved nutrition on the health of children and mothers. His
overall work experience with research and data analysis also proved to be incredibly
useful for the mortality estimation component.
Matthew Seeger, Ph.D.
Communications Expert
Matthew Seeger is currently Dean of the College of Fine, Performing and
Communication Arts at Wayne State University. His research concerns crisis and risk
communication, health promotion and communication, crisis response and agency
coordination, the role of media (including new media), crisis and communication
ethics, failure of complex systems and post-crisis renewal. He has worked with the
CDC and the National Center for Food Protection and Defense. He is also a member of
the WHO Guidelines Development Group for Emergency Risk Communication. He is
currently involved in a multi-year, interdisciplinary project focusing on contamination
of the Flint, Michigan water system. His expertise provided invaluable guidance on
the methods and ndings for the project’s communications component.
Dr. Scott Zeger, Ph.D., M.S.
(Johns Hopkins University, Bloomberg School of Public Health)
Biostatistician
Scott Zeger is a Professor of Biostatistics at the Johns Hopkins Bloomberg School of
Public Health. He conducts statistical research on regression analysis for correlated
responses in surveys, time series, longitudinal or genetics studies. Dr. Zeger has been
elected a Member of the National Academy of Sciences’ Institute of Medicine, Fellow
of the American Association for the Advancement of Science and of the American
Statistical Association. He was originally invited as an external panel expert and is
listed here as he got heavily involved in the analysis of excess mortality component
of the project.
7
Internal Technical Experts
Daniel Hoffman, Ph.D., M.P.H.,
Epidemiologist
Daniel Hoffman’s career has blended research, public service and a commitment to
training a new generation of public health professionals. Dr. Hoffman has pursued
interests in environmental hazards, cancer epidemiology and leadership capacity-
building. He was appointed the School’s rst Associate Dean for Public Health. He
currently directs the School’s Eastern and Central European Health Leadership Program,
funded by USAID. Dr. Hoffman was asked to join the internal expert panel due to his
experience in building capacities for National Disaster Medical System Hospitals staff
and work in disaster epidemiology.
Pietro Marghella, DHSc, MSc, MA, CEM, FACCP
Complex humanitarian emergencies expert
Piertro Marghella is an expert on medical and public health preparedness and response for
large-scale disasters and complex emergencies. He served for 20 years as a Medical Plans,
Operations, and Intelligence Ofcer in the United States Navy, retiring as the Director of
Medical Contingency Operations for the Ofce of the Secretary of Defense. He is a Fellow in
the American College of Contingency Planners (ACCP), which he co-founded and served as
rst President. Dr. Marghella was appointed as a Special Advisor to the Secretary of Health of
Puerto Rico after Hurricane María. His knowledge of the disaster and experience in complex
humanitarian emergencies made him an invaluable expert to advise on this project.
Sam Simmens, Ph.D., M.A
Biostatistician
Sam Simmens emphasizes the social and behavioral components of public health-
related statistical methods. As a researcher, he collaborates with colleagues in all
of the health-related elds, applying his skills to research focused on HIV, cancer,
obesity, mental health, maternal and infant development, chemical and stress-related
environmental exposures and numerous other health issues. He is the Director of GW’s
Biostatistics and Epidemiology Consulting Service (BECS)for all faculty.
Ronald Waldman, M.D., M.P.H.
Complex humanitarian emergencies expert
Ronald Waldman began his career in WHO’s Smallpox Eradication Program. He joined
CDC’s Epidemic Intelligence Service in 1979 and was assigned to the Refugee Health
Unit in Somalia, where he worked intermittently through 1985. He then became
Director of the Technical Support Division of CDC’s International Health Program Ofce.
He has worked in numerous emergency settings in policy and coordination roles,
including the Iraq War of 1991, the aftermath of the Rwanda genocide, and the Balkan
Wars. He was the USG Coordinator of the health sector relief effort following the Haiti
Earthquake and, later that year, a senior advisor to the UN Ofce for the Coordination
of Humanitarian Affairs in Pakistan. He is currently Professor of Global Health at MISPH
and the President of Doctors of the World – USA.
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Ascertainment of the Estimated Excess Mortality from Hurricane María in Puerto Rico
ANNEX 3
AIM: Attribution of direct and indirect deaths:
An in-depth analysis of cause-specic mortality
from Hurricane María
The rst phase of this study aimed to identify the total excess mortality in the six
months following Hurricane María, which made landfall in Puerto Rico on September
20, 2017. The second phase of this project seeks to identify which deaths were directly
and indirectly attributed to the hurricane.
A. Study Justication and Aim
• Identify vulnerable populations most at risk for mortality following the
hurricane, either based on underlying health conditions, residential
location and/or socioeconomic status. This information is essential to
inform preparedness and response protocols to target the most vulnerable
populations and those facing unprecedented morbidity from chronic
conditions amid a failing health system. The results of this proposed analysis
are critical for reducing the human toll of future disasters.
• Use a standardized, rigorous, scientic process to investigate the
circumstances in which deaths occurred immediately after, and in the
six months following, the hurricane. Those circumstances must be taken
into consideration when systematically assigning mortality attribution to
the hurricane. In addition to informing preparedness and response plan,
the methodology proposed will advance the science of public health in
ascertaining cause-specic deaths in future natural disasters.
B. Methods
• The protocol developed was informed by a series of systematic literature
reviews. We propose to build upon new CDC guidelines by developing
methods to collect and integrate contextual information (e.g., location,
underlying health condition, socioeconomic status, events leading up to
the death) with a systematic algorithm to identify conditions that could
have contributed directly or indirectly to the deaths observed in the event’s
aftermath. These conditions will be obtained from multiple sources of data.
9
B.1. Systematic literature reviews
• Develop and test a methodology to ascertain direct, indirect and possibly
attributable deaths to natural disasters, building upon the work of other
researchers in response to Hurricanes Ike and Sandy in the US and the
Fukushima triple disaster in Japan.
• Address these critical gaps found in literature reviews:
Lack of consensus on a denition and time frame for attributing
indirect mortality following a disaster
Lack of consensus on guidelines for a process that integrates verbal and
social autopsies with ofcial mortality data to ascertain indirect causes
• Work with the external advisory panel to develop and implement methods
B.2. Identication and acquisition of multiple sources of data to
describe the circumstances of the deaths
• Use datasets from the Bureau of Forensic Sciences, 911 emergency calls
obtained from the Bureau of Police and FEMA data.
• A future step will explore the feasibility of including deaths of Puerto Ricans
who were living there until after the hurricane but died outside of Puerto Rico
in key states (i.e., Florida, New York) to develop a comprehensive dataset.
B.3. Development of procedure to attribute causes of death
• Develop an algorithm to identify the likely conditions leading to direct and
indirect mortality cases from the hurricane. The algorithm is designed to describe:
Direct Causes. This would also include a nite timeframe for such forces
that would act directly on the individual (to be discussed and dened).
Other Causes (Indirect, Probable): We would divide these into the
four major causes of death commonly used in forensics pathology:
accidental/injuries, suicide, homicide and natural deaths (we identied
the top nine causes of death in Puerto Rico and will complement this
information with the prevalence report of ICD-10 codes during the
timeframe considered for this study).
Information about circumstances, context, time-frame and death codes
in the algorithm will be transformed into an algorithm that can identify
the deaths that are (a) attributable to hurricanes; (b) possibly attributable
to hurricanes but lack key conrmatory data; and (c) not attributable to
hurricanes. We will pilot test the performance of the algorithm with all of
the deaths currently directly attributed to the hurricane.
We will randomly identify a sample among ‘other’ deaths to characterize
their mortality circumstances, based on criteria of interest and vulnerability.
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Ascertainment of the Estimated Excess Mortality from Hurricane María in Puerto Rico
B.4. Development of methods to investigate deaths that are ‘possibly
attributable to hurricanes’.
• Work with our global expert panel and local/technical expert panel to decide
on a sampling criterion for further investigation of possibly attributable to
hurricanes but lack key conrmatory data’ cases.
• Split the ‘possibly attributable to hurricanes but lack key conrmatory data’
sample into one of two categories.
Cases who received care in their nal days at a medical facility
Cases where deaths occurred outside of a hospital or within a
medical facility with limited diagnostic capability.
• Two next steps will be taken:
Conduct medical record abstraction to identify the context-specic
conditions in the rst group, and/or
Perform a verbal and social autopsy for those in either group
following a predened protocol.
C. Ethical considerations, protection of human subjects
and condentiality
The GW SPH and UPR GSPH IRBs will review all data collection, analysis and
storage procedures and protocols to ensure they comply with the guidelines
and regulations required for protection of human subjects. All procedures will
follow ethical principles to show respect for persons, benecence and justice,
via informed consent for primary data collection, condentiality for all data
and minimization of risks for all procedures.
D. Expected Final Product
The ndings from this study will inform the development of a set of
recommendations to be considered by the Bureau of Forensic Sciences
for reclassication of causes of deaths in relation to their attribution to the
hurricane. We will also provide a procedure to analyze and dene the context
and conditions that lead to a death being attributed to a hurricane which
can be used as an input to improve current guidance and practice. We will
develop a communication brief to explain the procedure to policy-makers
and the public.
11
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