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BackgroundIn Puerto Rico, relative to the United States, a disparity exists in detecting oral precancers and early cancers. To identify factors leading to the deficit in early detection, we obtained the perspectives of San Juan healthcare practitioners whose practice could be involved in the detection of such oral lesions.MethodsKey informant (KI) interviews were conducted with ten clinicians practicing in or around San Juan, Puerto Rico. We then triangulated our KI interview findings with other data sources, including recent literature on oral cancer detection from various geographic areas, current curricula at the University of Puerto Rico Schools of Medicine and Dental Medicine, as well as local health insurance regulations.ResultsKey informant-identified factors that likely contribute to the detection deficit include: many practitioners are deficient in knowledge regarding oral cancer and precancer; oral cancer screening examinations are limited regarding which patients receive them and the elements included. In Puerto Rico, specialists generally perform oral biopsies, and patient referral can be delayed by various factors, including government-subsidized health insurance, often referred to as Reforma. Reforma-based issues include often inadequate clinician knowledge regarding Reforma requirements/provisions, diagnostic delays related to Reforma bureaucracy, and among primary physicians, a perceived financial disincentive in referring Reforma patients.ConclusionsAddressing these issues may be useful in reducing the deficit in detecting oral precancers and early oral cancer in Puerto Rico.

Background Until recently, Zika virus (ZIKV) infections were considered mild and self-limiting. Since 2015, they have been associated with an increase in microcephaly and other birth defects in newborns. While this association has been observed in case reports and epidemiological studies, the nature and extent of the relationship between ZIKV and adverse pregnancy and pediatric health outcomes is not well understood. With the unique opportunity to prospectively explore the full spectrum of issues related to ZIKV exposure during pregnancy, we undertook a multi-country, prospective cohort study to evaluate the association between ZIKV and pregnancy, neonatal, and infant outcomes. Methods At research sites in ZIKV endemic regions of Brazil (4 sites), Colombia, Guatemala, Nicaragua, Puerto Rico (2 sites), and Peru, up to 10,000 pregnant women will be recruited and consented in the first and early second trimesters of pregnancy and then followed through delivery up to 6 weeks post-partum; their infants will be followed until at least 1 year of age. Pregnant women with symptomatic ZIKV infection confirmed by presence of ZIKV RNA and/or IgM for ZIKV will also be enrolled, regardless of gestational age. Participants will be tested monthly for ZIKV infection; additional demographic, physical, laboratory and environmental data will be collected to assess the potential interaction of these variables with ZIKV infection. Delivery outcomes and detailed infant assessments, including physical and neurological outcomes, will be obtained. Discussion With the emergence of ZIKV in the Americas and its association with adverse pregnancy outcomes in this region, a much better understanding of the spectrum of clinical outcomes associated with exposure to ZIKV during pregnancy is needed. This cohort study will provide information about maternal, fetal, and infant outcomes related to ZIKV infection, including congenital ZIKV syndrome, and manifestations that are not detectable at birth but may appear during the first year of life. In addition, the flexibility of the study design has provided an opportunity to modify study parameters in real time to provide rigorous research data to answer the most critical questions about the impact of congenital ZIKV exposure. Trial registration NCT02856984 . Registered August 5, 2016. Retrospectively registered.

This article presents an overview of our research team’s disaster response to the massive destruction of Hurricanes, Irma and Maria, in September 2017, in light of the 120-year colonial legacy and long-term, widespread environmental contamination in Puerto Rico. Both local and federal governmental responses have been extremely inadequate, especially in light of the long-standing issues of environmental contamination throughout the island. Community organizations in Puerto Rico have been fighting for environmental justice for decades, often succeeding, and always confronting government unwillingness to address environmental protection. Hurricanes Irma and Maria afforded attention to Puerto Rico through international news coverage and awareness of its colonial status, rundown infrastructures (especially the electric grid), indebtedness, and environmental hazards. Since the hurricanes, the research teams of the Puerto Rico Test Site to Explore Contamination Threats (PROTECT), the Center for Research on Early Childhood Exposure and Development (CRECE), and Zika in Infants and Pregnancy (ZIP) have worked tirelessly to address the needs of our research participants, partnering clinics, as well as the local team to ensure safety and wellness. We have been able to continue our environmental public health work with pregnant women and children. In response to the historical problems and current crisis, we offer a “visionary rebuilding” approach for remediation of the hurricanes’ effects, and for a deeper solution to the environmental and other social injustices Puerto Rico has long faced.

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