Saturday, March 19, 2016

Puerto Rico Braces for Its Own Zika Epidemic - NYT

Puerto Rico Braces for Its Own Zika Epidemic

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The governor’s office recently announced detailed plans to attack mosquito hot spots: cemeteries, abandoned houses, auto junkyards, unsealed septic tanks and piles of old tires.
Each of the island’s 78 municipalities has until April 1 “to clean up their acts,” Dr. Rullán said.
As of Friday, 900,000 of an estimated one million discarded tires had been picked up and moved to depots far from residential areas.
Much of the work was done by convicted drug abusers living in a network of halfway houses who can earn early release through public service, he said.
Many of the island’s hundreds of schools have no screens or air-conditioning. Since high school girls account for about 20 percent of all pregnancies here, officials plan to screen the windows to keep out mosquitoes.
That alone is a big job. “That means measuring each window,” Dr. Rullán said. “And what are you going to do about doors if you have 50 kids running in and out?”
As a first step, the public school dress code has been changed so girls can wear pants, and teachers are supposed to give mosquito repellent to all girls.
Here is a look at the most prominent rumors and theories about Zika virus, along with responses from scientists.
In the island’s 109 cemeteries and its many auto junkyards and public dumps, mosquito-control teams have begun spraying pesticides that kill the insect’s larvae. But the work is never-ending because rain washes it away.
Moreover, the island is dotted with hundreds of abandoned homes with water-collecting birdbaths and pools. Puerto Rico has 500,000 septic tanks, each of which can produce up to 1,500 mosquitoes a day if left unsealed.
Teams cannot enter an abandoned property or screen a septic tank when the owner is absent, “so we’re asking for a new law letting us enter,” Dr. Rullán said.
The ideal, he said, would be to spray every property within 150 yards — the distance a mosquito normally travels — of every pregnant woman’s home.
The island’s birthrate is about 10 per 1,000 women, and nearly 100 women a day become pregnant here. Just finding them all would be a gargantuan task.
A Hunt for Solutions
Other mosquito-control efforts are even less effective.
Highly visible fogging by trucks is what most people associate with government mosquito-fighting. Butpermethrin, the insecticidal fogger used for years, may actually be useless.
Tests at several sites have found that its ability to kill mosquitoes has significantly faded, so the island will have to choose a new pesticide and retrain workers to use it.
Even with the right chemical, the impact of fogging is dubious. Aedes mosquitoes typically hatch in gardens and slip into houses to hide in closets and under beds. When the spray trucks go by, many people close their windows, locking themselves in with the enemy.
Aedes mosquitoes are “sip feeders” and bite several times for each blood meal. The number required to make it likely that just one member of the household is infected is as few as three mosquitoes, experts have found.
Moreover, by a “very inconvenient coincidence,” the Environmental Protection Agency has effectively banned the chemical used here to kill juvenile mosquitoes, Audrey Lenhart, a C.D.C. entomologist, noted. The chemical, temephos, has been in use since 1965 and definitely works, she said. But it is not very profitable, so when the agency demanded safety data costing about $3 million to gather, the manufacturers decided instead to quit making it.
Puerto Rico still has a nine-month supply, Dr. Lenhart said, and the E.P.A. may issue an emergency use permit for more.
Mosquitoes are not the only mode of Zika transmission, however. Health authorities here have also been forced to grapple with an unexpected twist: the discovery that sex spreads the virus.
The government has frozen the price of condoms, threatening stores with fines of up to $10,000 if they raise them. (It did the same for repellent and window screens.)
At nutrition clinics, teachers like Ms. Morales have struggled to explain, as they hand out condoms, why the partners even of pregnant women should wear them.
In a radio interview in January, Puerto Rico’s health secretary, Dr. Ana Ríus, advised women to delay pregnancy altogether, if possible, until the epidemic is over.
But local radio commentators accused her of alarmism, and Roberto González, archbishop of the Catholic Church, publicly criticized the government’s condom distribution plans. Instead, he counseled people to “practice self-discipline, which we believe is the only rational attitude and faith.”
It will be many months before officials know whether their efforts have slowed the lightning advance of the Zika virus.
“Come October, when the babies start being born,” Dr. Rullán said, “I’ll know if we acted in time or not.”
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Obama visit an 'opening act' for Rolling Stones concert in Cuba

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Life | Sat Mar 19, 2016 1:50pm EDT
A visitor from California has her picture taken by a travel companian next to images of Cuba's President Raul Castro and U.S. President Barack Obama in Havana, Cuba March 19, 2016. The headline on the poster reads: ''Welcome to Cuba.'' REUTERS/Enrique De La Osa
A visitor from California has her picture taken by a travel companian next to images of Cuba's President Raul Castro and U.S. President Barack Obama in Havana, Cuba March 19, 2016. The headline on the poster reads: ''Welcome to Cuba.''
Reuters/Enrique De La Osa
HAVANA The Rolling Stones were meant to play a rock 'n' roll show in Havana on Sunday but were delayed five days because of the inconvenient arrival of another foreign visitor: U.S. President Barack Obama.
Obama lands on Sunday for a 48-hour visit 15 months after he reversed more than half a century of U.S. policy on Cuba and started normalizing relations with the former Cold War adversary.
The Stones' Latin American tour happened to roughly coincide and the band was at first set to play Havana on Sunday, but organizers then learned of the Obama trip and postponed the show until Friday, the band's production manager said.
"At one point we thought he (Obama) was coming to the show," Dale "Opie" Skjerseth told reporters on Saturday from the outdoor sports complex where the Stones will play.
"He's our opening act," Skjerseth joked.
The Stones added the free show to the end of a Latin American tour, becoming the first major international rock stars to play Cuba.
"They like to be the first of everything," Skjerseth said.
He said the band members were also aware their music and that of the Beatles and Elvis Presely were once banned by the Communist government as "ideological deviation."
"They figured they'd like to come here and give it (rock) to them," Skjerseth said.
Havana is preparing for Obama with an extraordinary street-paving campaign and restricting areas he will visit for security reasons. At the same time, the groundwork for the Stones production has also been impressive if not unprecedented for Cuba.
The band brought in 61 shipping containers with an estimated 500 tonnes of equipment such as the stage, speakers, lights and video screens, Skjerseth said. A Boeing 747 arrived on Friday from Mexico carrying the last of the equipment, he said.
A crew of 140 Stones employees and at least 80 Cubans have set up on grounds including a football field and adjoining baseball fields with room for hundreds of thousands of spectators, who are invited to arrive for free on a first-come, first-served basis.
(Reporting by Daniel Trotta, Editing by Franklin Paul)
Then-U.S. Army First Lieutenant Kirsten Griest (C) and fellow soldiers participate in combatives training during the Ranger Course on Fort Benning, Georgia, April 20, 2015. REUTERS/Spc. Nikayla Shodeen/U.S. Army/Handout via Reuters
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Obama’s Efforts to Ease US Restrictions on Cuba

Thursday, March 3, 2016

Puerto Rico braced for more Zika cases - BBC News | Zika is expected to infect 1 in 5 Puerto Ricans, raising threat to rest of U.S.

How Free Electricity Helped Dig $9 Billion Hole in Puerto Rico - The New York Times
A Warning on Bankruptcy in Puerto Rico’s Debt Crisis - The New York Times
Puerto Rico wants to erase half its debt - Feb. 1, 2016
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Puerto Rico Governor Tries to Distance Himself from His Brother | National Legal and Policy Center
Puerto Rico Debt Crisis: More Trouble On the Way | Wall Street Daily
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Puerto Rico Adopts Rules for Medical Marijuana Program
Puerto Rico Offers Some Proposals to Tackle Its Debt - NBC News
No Wonder Puerto Rico Is Bust: The Venezuelan Mistake - Forbes
Puerto Rico Leaders Urge Congress to Act on Growing Health, Economic Crises : US News : Latin Post
House Republicans Lean Toward Federal Oversight for Puerto Rico - Bloomberg Politics
Officials Detain 13 Cuban Migrants Found Near Puerto Rico
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Puerto Rico offers plan to restructure its debt - The Washington Post
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U.S. Senate Democrats united on debt restructuring for Puerto Rico -letter | Reuters
Puerto Rico to Present Broad Debt-Restructuring Plan Friday - Bloomberg Business
The fairness of bankruptcy for Puerto Rico | TheHill
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BRUCE FEIN: Bankruptcy bill for Puerto Rico is unconstitutional - Washington Times
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US Treasury Secretary Demands Action on Puerto Rico's Crisis - ABC News
US Treasury Secretary demands action on Puerto Rico’s crisis - The Washington Post
Treasury Secretary Jack Lew to Visit Puerto Rico - NBC News
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Bond insurers sue Puerto Rico over debt default, clawbacks | Reuters
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Puerto Rico Declares Zika Emergency
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State of emergency declared in Puerto-Rico as Zika cases climb to 22 — RT USA
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Zika is expected to infect 1 in 5 Puerto Ricans, raising threat to rest of U.S.

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SAN JUAN, Puerto Rico — Zika has landed forcefully in America, in one of its poorest and most vulnerable corners, a debt-ridden territory lacking a functioning health-care system, window screens and even a spray that works against the mosquitoes spreading the virus in homes, workplaces, schools and parks.
There are 117 confirmed cases of the virus in Puerto Rico, four times the number at the end of January. The island territory, which has a population of 3.5 million people, is “by far the most affected area” in the United States, Tom Frieden, director of the Centers for Disease Control and Prevention (CDC), said Friday. The number will almost certainly rise sharply in coming weeks, making it ever more likely that the virus will spread to the continental United States.
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Dozens of flights move daily between San Juan and Orlando, Washington, New York and other major cities on the mainland. Cruise ships stop here as part of their Caribbean tours. College students will soon head here on spring break.
The growing outbreak has laid bare how deeply Puerto Rico’s debt crisis has cut public programs, including basic health and environmental control services needed to fight the virus. Most homes and public schools — and even some medical facilities — don’t have window screens. A specialist in birth defects at Puerto Rico’s top hospital has trouble obtaining basic supplies, such as toner for his office printer. There are hundreds of abandoned houses — not only in low- and middle-income neighborhoods but also in gated communities — because owners have fled to the mainland as a result of the economic crisis.

At dusk, health department workers spray permethrin in the middle-class neighborhood of Riveras de Cupey in San Juan, Puerto Rico. The government is beefing up anti-mosquito measures as the Zika virus spreads through the island. (Allison Shelley for The Washington Post)
Experts say urgent action is needed before mosquitoes reach their peak with the start of the rainy season in April. Experts from the CDC estimate that 700,000 people — about 20 percent of the population — could be infected across the island by the end of the year, based on previous outbreaks of dengue and chikungunya, related viral diseases.
In response, the CDC has sent 30 experts from its Atlanta headquarters and elsewhere to Puerto Rico, adding to the 70 CDC staff members based here who usually work on dengue fever but now are focusing on Zika. Frieden is expected to visit soon. President Obama’s $1.9 billion emergency Zika request to Congress includes $250 million for Puerto Rico.
“I don’t think we’re going to be able to stop the Zika outbreak,” said Steve Waterman, chief of the CDC’s dengue branch, located on the city’s west side. “There will be a substantial Zika outbreak that will peak in the summer and fall. It’s likely that thousands of pregnant women will be exposed and infected, so that’s why our efforts are focused on protecting as many pregnant women as possible.”
Five of the 117 confirmed cases involve pregnant women. And unlike in the continental United States, where cases are the result of infected travelers to Latin America and elsewhere bringing the virus back home, almost all the cases in Puerto Rico involve people bitten here by infected Aedes aegypti mosquitoes, which also spreads dengue fever and chikungunya.
What you need to know about the Zika virus and how it spreads
Because of the suspected link between Zika and potentially devastating birth defects, authorities are focusing on protecting as many pregnant women as possible. That includes 4,000 expectant mothers living in parts of the island where mosquitoes are spreading the virus. That’s more than one-third of Puerto Rico — primarily San Juan, the northeast and the southern coast.
Only the CDC and Puerto Rico’s health department labs can perform the special Zika testing. The labs expect to run 100,000 tests over the year for pregnant women, five times as many as they handle now, Waterman said. Determining whether someone is infected is complicated because most people don’t show symptoms. It’s also hard for tests to easily differentiate between dengue and Zika infections.
On Monday, authorities in Puerto Rico began distributing free Zika prevention kits to pregnant women that were created by the CDC and the CDC Foundation. The kits include information and tools to help them reduce risk of infection and include repellent, products that kill mosquito larvae, and condoms.
Mosquitoes have ample breeding grounds here. In the Villa Palmeras cemetery in barrio Obrero, a low-income neighborhood in northeastern San Juan, virtually all of the thousands of graves have built-in flower stands where water, and mosquito larvae, collect. There are 109 cemeteries across Puerto Rico and thousands of flower holders.
Mosquito larvae also flourish underground, in water meters and vent pipes of septic tanks, which contain more water than elsewhere in the United States, said Roberto Barrera, a CDC entomologist.
And then there are the mountains of used tires, which mosquitoes flock to, said Johnny Rullan, a former health secretary who is helping the government eliminate breeding sites. Puerto Rico has accumulated more used tires than anywhere else in the United States, experts said. In the past three weeks, temporary collection centers have received more than 561,000 tires.

Elwin Moran, 26, helps pile used tires at a former shoe factory in Humacao, Puerto Rico. The Humacao environmental board is collecting abandoned tires from neighborhoods. (Allison Shelley for The Washington Post)
‘Part of living on the island’
Perhaps the most difficult challenge is changing people’s attitudes and behavior about an ever-present pest that is as much a part of life here as steamy weather and graceful old banyan trees.
“What can I say, it’s part of living on the island,” said José Fernandez, a supervisor at a tire collection center in Humacao, in the southeast.
Emeris Canales Morales, 27, a single mother who is 23 weeks pregnant, lives in a home that overlooks a small cemetery on one side and a fetid canal on the other. Plastic bottles and other trash collect along the banks of the canal. Her windows have no screens. In December, the mosquitoes were biting so hard that she woke up with red welts covering her arms.
At a prenatal clinic for high-risk pregnancies at San Juan’s University Hospital at the Puerto Rico Medical Center, she was among the first to sign up for free Zika screening for women in their first and second trimesters.

Tourists visit two of Puerto Rico’s most famous landmarks — Fort San Felipe del Morro fortress and Santa Maria Magdalena de Pazzis cemetery. Mosquitoes thrive in wet conditions, such as cemeteries. (Allison Shelley for The Washington Post)
She won’t know the results for at least another week. Her first two pregnancies ended in miscarriages because of complications from diabetes. She is hoping for the best this time.
“I haven’t had the fever or the red eyes or the rash,” said Canales, who lives in Loiza, a northeast community that is one of the island’s poorest areas.
But even for pregnant women, it’s hard to stay vigilant against the mosquito.
“When there was chikungunya, we joked about it until everyone had it,” she said. “Until people have the sickness, nobody in Loiza will take it seriously.”
Said Brenda Rivera, chief epidemiologist for Puerto Rico’s health department: “Controlling Zika is going to be a daunting task.” The department is coordinating the island’s response to the public health emergency.

Entomologist Roberto Barrea examines materials at a lab where his team breeds thousands of mosquitoes for research at the CDC’s dengue branch in San Juan. (Allison Shelley for The Washington Post)
Poor and unprepared
Women in Puerto Rico give birth to about 33,000 babies a year. The island has one of the highest teenage birth rates in the United States, and many public high schools have no window screens. The government is estimating how much it would cost to add screens, said Grace Santana, chief of staff to Gov. Alejandro Javier García Padilla.
Nearly half of Puerto Rico lives below the poverty line. The thousands of pastel-hued public housing projects that dot the island don’t have air conditioning. Residents don’t have window screens, in part because they can’t afford them, but also because they don’t want to block the breeze. Adding screens to those homes would cost about $70 million, said Santana.
At dusk on a recent day, a maroon pickup truck drove through the streets in the middle-class neighborhood of Riveras de Cupey, in San Juan’s south, spraying permethrin, a commonly used insecticide, from a machine mounted on the back.
But Aedes aegypti mosquitoes already have developed resistance to permethrin in some parts of Puerto Rico, said Audrey Lenhart, a CDC research entomologist. She is testing which insecticides are most effective, something that was never done before.
How a bloodsucker transmits the Zika virus
“The Puerto Rican government doesn’t really have a well-developed vector control and surveillance program,” she said, referring to basic programs to eliminate insects, birds and other vectors that transmit disease.
CDC teams are helping authorities rebuild mosquito control programs, expand testing, and monitor and track thousands of pregnant women and their babies. They also are working with U.S. companies to provide window screens for women’s homes, and to bring to market a CDC-invented trap that could be a potent and cheap way to snare and kill adult mosquitoes.
For doctors such as Alberto De La Vega, an expert in high-risk pregnancies at the University Hospital in San Juan, Zika is one of many serious concerns. He worries that additional Zika testing will create huge demands on an already burdened health system.
“We’re having problems getting supplies, but we have to uphold U.S. standards,” he said. He has modern ultrasound equipment, but he pays out of his own pocket for the paper sheets that cover exam room beds.
He tells his patients they need to remove standing water and wear repellent.
“What we can do as physicians is very little,” he said. “By the time we identify problems with the fetus, it’s usually well into the second trimester, and by then it’s too late.”
Everything you ever wanted to know about the Zika virus and its spread across North and South America. (Daron Taylor,Claritza Jimenez/The Washington Post)
‘I’m going to have the baby’
The new mystery disease has infected Zulmarys Molina Paredes, 29. She’s one of the five pregnant women with a confirmed Zika diagnosis. But at 16 weeks in her pregnancy, an ultrasound shows her baby developing normally.
Molina and her 2-year-old son, Marco, live in Humacao in a peach-colored public housing project with her mother, aunt and brother. She is the sole breadwinner. She thinks she became infected at the private university where she works as an admissions officer, during tours of the campus. The campus has an artificial lake surrounded by trees full of mosquitoes.
Her headaches began Feb. 5. The following Monday, she looked in the mirror and was stunned.
“I was starting to put on my makeup and realized I was covered in a rash,” she said. “I got really scared.”
The emergency room doctor sent Molina’s blood to be tested. Nine days later, she was told her test was positive for Zika. But the doctor also said scientists didn’t know how often women with Zika infections have babies with birth defects such as microcephaly, where they are born with abnormally small heads.
Given the uncertainty, she is choosing to believe — and to pray — that everything will be fine. An amniocentesis is scheduled for next week. More ultrasounds will follow.
“I don’t care what happens. I’m going to have the baby,” Molina said. “I have faith that she’s going to be fine.” Her due date is Aug. 6. She will name her daughter Michaela.