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Excess Mortality Due to Hurricane Maria to Be Measured Using a Simple Method

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BACKGROUND: This descriptive finding examines excess deaths following Hurricane María, in Puerto Rico for September and October 2017. OBJECTIVE: We seek to determine the degree of excess deaths in Puerto Rico based on historical patterns of variability in deaths by month for the 2010-2016 period and using estimation techniques.
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  Estimates of excess deaths in Puerto Rico following Hurricane María Alexis R. Santos-Lozada, Pennsylvania State University Jeffrey T. Howard, Independent Researcher Abstract BACKGROUND This descriptive finding examines excess deaths following Hurricane María, in Puerto Rico for September and October 2017. OBJECTIVE We seek to determine the degree of excess deaths in Puerto Rico based on historical patterns of variability in deaths by month for the 2010-2016 period and using estimation techniques. METHODS Data for this study come from death records from the Puerto Rico Vital Statistics system. We aggregated data by month and year (2010-2016) and produced means (expected deaths) and 95% confidence intervals (C.I., or patterns of variability) for each month. Using public statements from the Puerto Rico Department of Public Safety, we estimate the number of deaths for September and October 2017 and compare it to the level of expected deaths considering the pattern of variability. RESULTS Expected deaths for September and October were 2,383 (95% C.I. 2,296-2,469) and 2,428 (95% C.I. 2,380 - 2,476), respectively. Estimates for total deaths, for September and October 2017 were 2,987 (95% CI 2,900-3,074) and 3,043 (95% C.I. 2995-3,091), respectively. The difference between our estimates and the upper 95% CI for the average deaths is 518 deaths for September and 567 deaths for October.  CONCLUSIONS The mortality burden may higher than official counts, and may exceed the current official death toll by a factor of 10. CONTRIBUTION Presentation of deaths by year and month for Puerto Rico in the 2010-2016 period, derivation of excess deaths using estimation techniques, and comparison of estimates to historical patterns of deaths to assess the impact of Hurricane María.  1.   Introduction Hurricane Maria is the most devastating environmental disaster to have hit Puerto Rico in recent history, with winds of 155 mph it is the strongest since 1928 when the island was hit by Hurricane San Felipe with winds of 160 mph (Zorrilla, 2017). Recent discussions surrounding Hurricane Maria have centered on healthcare system resiliency (Alcorn, 2017), assessment of structural damages (Clery, 2017), but mostly on the number of deaths attributable to this environmental disaster (Sosa Pascual, 2017). This paper examines historical patterns of deaths by month for Puerto Rico, in the post-2010 period, and provides estimates of deaths for September and October 2017. 2.   Historical Patterns of deaths by year and month 2010-2016 There is a wide body of literature that assesses mortality increases during and after natural disasters, but few are found within the demographic literature. These studies approach excess deaths by comparing historical point estimates, with estimates for the period of interest. The main examples come from public health and environmental sciences literature with the most studied being the 1995 Heat Wave in Chicago (Klinenberg, 2002; Semenza et al., 1996; Whitman et al., 1997), earthquakes in California (Kloner, Leor, Poole, & Perritt, 1997; Peek-Asa, Ramirez, Shoaf, Seligson, & Kraus, 2000) and most recently Hurricane Katrina (Brunkard, Namulanda, & Ratard, 2008; Jonkman, Maaskant, Boyd, & Levitan, 2009; Stephens et al., 2007). In this paper, we use data from the Puerto Rico Vital Statistics System (PRVSS) to present a new and timely approach to examine excess deaths in Puerto Rico for September and October 2017 – or following Hurricane Maria. To address the question of how many deaths could be classified as excess in reference to historical patterns; we use death records from the PRVSS to establish averages and historical ranges by month using data for the post-2010 period (2010-2016). Figure 1 shows the historical trend for total deaths by year for Puerto Rico for the post 2010 period. During this period, total deaths in Puerto Rico ranged between 28,403 and 30,002 deaths per year.   Figure 1: Total deaths by year in Puerto Rico, 2010-2016 Figure 2: Number of deaths by month and year, in Puerto Rico, 2010-2016    Figure 2, is a visual representation of total deaths by year and month for the 2010-2016 period. Table 1, includes the same information as Figure 1, but incorporates averages by month and corresponding 95% confidence intervals (95% C.I.). Total deaths by month within the period have been stable and clear patterns can be observed such as increased deaths in January and December. The data point for October 2014, was 2,891 deaths, a clear outlier to the pattern of variability. This data point exceeded the historical range by more than two standard deviations. We imputed the average number of deaths for this month in place of this outlier (2,486 deaths, still the highest number of the series), which provides a data point more consistent with the patterns observed for the 2010-2016 period. In addition, we include average and 95% C.I. for the total deaths by year, based on historical patterns the average number of deaths is 29,506 with corresponding ranges of variation of 29,097 and 29,914 deaths. This information was used to compute average deaths and corresponding 95% C.I. that are presented in Table 1 and Figure 3. The average number of deaths then represent the expected number of deaths and the 95% C.I. represents the ranges of deaths that would be considered within the historical range of variability. 2010 2011 2012 2013 2014 2015 2016 Average 95% C.I.January 2,3922,7282,6192,5782,4842,7442,7412,6122,485 - 2,739 February 2,2272,3632,4482,3762,2162,4032,5922,3752,255 - 2,495 March 2,4952,7702,5752,7052,4892,4272,4602,5602,439 - 2,681 April 2,2982,4482,4782,3142,3962,2592,2402,3482,261 - 2,434 May 2,4492,4772,3792,3992,4792,3392,3102,4052,343 - 2,466 June 2,4052,4582,5552,3372,3872,1462,3542,3772,261 - 2,494 July 2,4782,4682,4462,4852,4202,3802,4532,4472,413 - 2,481 August 2,5752,4432,4702,4972,5362,2722,4272,4602,369 - 2,550 September 2,2812,3592,4542,4692,4952,2582,3632,3832,296 - 2,469 October 2,4682,4832,4202,3982,4862,3912,3522,4282,380 - 2,476 November 2,5122,3602,4552,2682,6492,2682,4772,4272,299 - 2,555 December 2,7762,6452,5742,5402,8892,5162,8442,6832,543 - 2,824 Total 29,35630,00229,87329,36629,92628,40329,61329,50629,097 - 29,914 Table 1: Deaths by year and month for Puerto Rico, 2010-2016 with monthly averages and 95% confidence intervals Note:  October 2014, was an outlier for historical ranges - the smoothing process for this data point is explained in the text. Source: Puerto Rico Vital Statistics System, 2010-2016
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