NCST Technical Investigation of 

Hurricane Maria (Puerto Rico)

Characterization of Morbidity and Mortality

Project Leader: Judith Mitrani-Reiser

NCST Advisory Committee Meeting, June 30, 2020

Objective: To complete a quantitative morbidity and mortality assessment

of Puerto Rico, to better understand how damaged buildings and supporting

infrastructure played a role in the injuries and deaths associated with

Hurricane Maria. The study results will provide guidance to improve codes,

standards and inform future approaches to accurately attribute and predict

life loss due to building failure(s) caused by windstorms.
Background (1/2)

NCST Advisory Committee Meeting, June 30, 2020

Analysis of Daily Excess Deaths*

• New York Times (NYT) analysis compares the number of deaths for each day in 2017 with the

average of the number of deaths for the same days in 2015 and 2016.

• NYT and other news organizations estimate that the actual death toll could be over 1,000,

based on analysis of daily mortality data from Puerto Rico’s Vital Statistics Record Office.

• Deadliest day was September 25, 2017.

• Possible reasons for additional deaths may be related to delayed medical treatment or poor

conditions in homes and hospitals, and oxygen tanks that ran out.

Analysis of Monthly Excess Deaths**

• Researchers compare 2017 monthly death counts in Puerto Rico after Hurricane Maria to

mean monthly death counts estimated from vital records from 2010 through 2016.

• Researchers estimate 1,139 (95% CI 1006-1272) excess deaths through December 2017, using

death counts from Puerto Rico’s Vital Statistics Record Office.

• Greatest monthly excess death occurred in October 2017.

• Estimate is likely ‘conservative’ because of mean death counts used the upper 95% CI and did

not adjust for the population that left the island.

* Robles, F., Davis, K., Fink, S, Almukhtar, S., 2017. “Official Toll in Puerto Rico: 64. Actual Deaths May Be 1,052.” The New York Times. December 9, 2017.

** Santos-Lozada AR, Howard JT. Use of Death Counts from Vital Statistics to Calculate Excess Deaths in Puerto Rico Following Hurricane Maria. JAMA; Aug. 

2, 2018: doi:10.1001/jama.2018.10929.
Background (2/2)

NCST Advisory Committee Meeting, June 30, 2020

Population-Based Survey of Deaths***

• Harvard Chan School of Public Health led a community-based study that includes a representative

stratified population-based sample of 3,299 households (of an estimated 1,135,507 total households),

using a remoteness index based on travel time to nearest city.

• Researchers estimate a median excess of 4,645 deaths (95% CI range – 793 to 8,498), and a 62%

increase in mortality rate between September 20 and December 31 in 2017.

• One third of the deaths surveyed are related to delayed or interrupted health care.

• On average, persons in the survey were older and households were larger than ACS 2016 baseline.

Statistical Analysis of Death Certificates 

• George Washington University analyzed past mortality patterns using mortality registration and

population census data from 2010 to 2017, predicting mortality if Hurricane Maria had not occurred,

and a comparing actual deaths to predicted deaths.

• Researchers estimate a total excess mortality post-hurricane to be 2,975 (95% CI: 2,658-3,290).

• Study accounts for trends in population size and distribution over this period in terms of age, sex,

seasonality, residence by municipal level of socioeconomic development, and emigration during the

prior decade and dramatic population displacement after the hurricane.

** * Kishore N, Marques D, et al. Mortality in Puerto Rico after Hurricane Maria. NEJM 2018; 379:162-170

**** George Washington University , in collaboration with the University of Puerto Rico Graduate School of Puerto Rico, 2018. “Ascertainment of the Estimated 

Excess Mortality from Hurricane Maria in Puerto Rico,” a Project Report for the Governor of Puerto Rico, August 28, 2018. 
Project Plans (1/4)

NCST Advisory Committee Meeting, June 30, 2020

Develop Integrated Database of Deaths in Puerto Rico

• Collect and merge geocoded data on the deaths occurring up to six months after Hurricane

Maria made landfall in Puerto Rico.

• Data sources include the Puerto Rico Vital Registration System with available datasets from the

Bureau of Forensic Sciences, including DMORT E-Cases records, pathology registry records,

case identification, case review, and cremation and institutional death databases.

• Additional data to consider are 911 emergency calls obtained from the Bureau of Police, and

funeral and burial assistance data from FEMA and the American Red Cross.

Integrated Database

Puerto Rico Vital 

Registration System 

e.g., death 

certificates

Bureau of Forensic 

Sciences

e.g., DMORT records, 

pathology records, 

cremation databases 

Bureau of Police

e.g., 911 

emergency call 

records

FEMA and/or

American Red 

Cross

e.g., funeral and 

burial assistance
Project Plans (2/4)

NCST Advisory Committee Meeting, June 30, 2020

Spatial and Temporal Clustering of Deaths

• Analyze the integrated database to calculate cause-specific mortality rates adjusted for age and

gender and compare these to the prior years.

• Examine each broad cause of death (i.e. ICD-10 codes) and specific causes of death typically

attributed to hurricanes (e.g., drowning, death from a fallen object, etc.) and compare them to

previous years.

• Identify significant increases in death rates from particular causes between the period after the

storm and years prior; flag all deaths from those causes in the first two weeks after the storm.

• Identify spatial and temporal clusters of deaths occurring up to six months after the storm.

Source:	Santos-Burgoa et	al.,	2018	(with	permission)
Project Plans (3/4)

NCST Advisory Committee Meeting, June 30, 2020

Verbal Autopsies with Next of Kin and

Key Informants

• Develop an inclusion and exclusion criteria for

identifying deaths that occurred within 14

days of the storm’s landfall, for in-depth study.

• Identify deaths from the integrated database

that may have been caused by a building

and/or building system failure(s).

• Complete verbal autopsies for this census of

deaths with next of kin of decedents or key

informants capable of identifying direct and

indirect deaths associated with the disaster,

and specifically those potentially related to

building failures.

• Suggested mode is face-to-face, but currently

considering other options.

VERBAL AUTOPSY

Q1

Q2

Q3

Q4

Q5

Q6

Q3

Q4

Q5

Q6

Q7

Q8

Q9

Q10

Q11

Baseline information on 

respondent and interview

Information on the 

deceased, place of death, 

death registration 

information, etc.

Account of events leading to 

death, including direct result of 

a building and/or building 

system failure(s) and forces of 

the hurricane (e.g., wind, 

flooding, and landslides)

Treatment and health services 

sought for final illness, risk 

factors, previous 

injuries/accidents, etc.
Project Plans (4/4)

NCST Advisory Committee Meeting, June 30, 2020

Clinical Panel (option that may be exercised during the award period)

• Retrieve additional data (e.g., medical records) of indeterminate cases and/or interview next

of kin or key informants with specific questions generated by the panel. This data shall be

reviewed by the panel again for final determination.

• Convene a panel of experts to review cases of deaths identified as potentially due to building

failures. The expert panel shall include medical personnel from Puerto Rico, and other types of

experts as identified by the Contractor in collaboration with NIST.

Gather all data 

associated with a 

death, including 

additional medical 

records

Convene panel of 

experts to review data 

for each case and 

make final 

determination or 

develop questions for 

next-of-kin.

Interview 

respondents using 

additional 

questions 

developed by panel 

of experts.

Panel of 

experts makes 

final 

determination 

for all cases.
Recent Progress

NCST Advisory Committee Meeting, June 30, 2020

Recent Progress • NCDMPH’s Disasters and Health 

Workshop held in April 2020.

• Testified at the National Academies of 

Medicine’s Study on Morbidity 

Attribution after a Major Disaster.

• Met with HHS to collected GIS Map 

Book with info on schools and 

hospitals.

• Completed full and open competition 

procurement package in May 2019; 

solicitation posted Nov and closed in 

Dec; evaluation panel assessments in 

Jan; consensus completed in Feb; 

meeting with offerors in March.; 

negotiations in April/May

• NCDMPH’s Disasters and Health 

Workshop held in April 2019.

• Testified at the National Academies of 

Medicine’s Study on Morbidity 

Attribution after a Major Disaster.

• Met with HHS to collect GIS Map Book 

with information on schools and 

hospitals.

• Completed full and open competition 

procurement package in May 2019; 

solicitation posted Nov 2019 and 

closed in Dec 2019; evaluation panel 

assessments in Jan 2020; consensus 

completed in Feb 2020; meeting with 

offerors in March/April/May 2020; 

NIST near decision on award.

Photo: Mitrani-Reiser (2019)
Key Next Steps

NCST Advisory Committee Meeting, June 30, 2020

Award Contract:

• Host kick-off meeting with contractors and NIST staff

• Develop project work plan and align contractor’s products with overall HM NCST project 

management plan

Integrated Database:

• Identify available data readily accessible to contractors and NIST staff

• Identify data gaps and develop MOUs to retrieve secondary data, as needed

• Work with other project leads to inform spatial and temporal analyses to complete

Verbal Autopsy:

• Finalize mode for surveying next of kin (face-to-face over phone interviews)

• Provide literature review completed by NCDMPH in 2019 (under IAA) to inform verbal 

autopsy (VA) instrument development

• Work with other project leads to inform final VA instrument

• Obtain required approvals for VA instrument and deploy with next of kin or key informants 
NCST Technical Investigation of 

Hurricane Maria (Puerto Rico)

Characterization of Morbidity and Mortality

Project Leader: Judith Mitrani-Reiser, PhD, NIST

Project Team: Thomas D. Kirsch, MD, MPH

Director and Professor, National Center for Disaster Medicine and 

Public Health, Uniformed Services University

NCST Advisory Committee Meeting 

– June 30, 2020

Questions?

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