Rebuilding for Resiliency: How Puerto Rico's Environmental Health Department Managed Several Public Health Emergencies and Emerged Stronger
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A D V A N C E M E N T O F T H E PRACTICE
D I R E C T F R O M C D C E N V I R O N M E N T A L H E A LT H S E R V I C E S
Rebuilding for Resiliency: How
Puerto Rico’s Environmental Health
Department Managed Several
Raymond J. Aura Ortiz
Public Health Emergencies and
Lopez
Centers for
Sánchez, MHSA
Puerto Rico Emerged Stronger
Disease Control Department of
and Prevention Health
mental health services, workforce, and IT
E d i t o r ’s N o t e : The National Environmental Health Association infrastructure:
(NEHA) strives to provide up-to-date and relevant information on 1. Build the environmental health workforce
and improve environmental health pro-
environmental health and to build partnerships in the profession. In tocols and processes (e.g., update equip-
pursuit of these goals, NEHA features this column on environmental ment; hire staff; provide training for food/
health services from the Centers for Disease Control and Prevention milk, water, and radiology divisions; and
update regulations).
(CDC) in every issue of the Journal.
2. Develop environmental health IT infra-
In these columns, authors from CDC’s Water, Food, and Environmental structure, collect and use data, standardize
Health Services Branch, as well as guest authors, will share insights and assessment procedures with electronic appli-
information about environmental health programs, trends, issues, and cations, and use REDCap (www.project-red
cap.org) as an electronic assessment tool.
resources. The conclusions in these columns are those of the author(s) and
3. Design a long-term workforce development
do not necessarily represent the official position of CDC. program for the department (e.g., develop
Raymond Lopez is an environmental health scientist for the Division of and deliver classroom and field-based train-
Environmental Health Science and Practice within CDC’s National Center ing on scientific, technical, and procedural
aspects of environmental health).
for Environmental Health. Aura Ortiz Sánchez is the program manager of Project activities involving facility inspec-
environmental health within the Puerto Rico Department of Health and the tions, equipment procurement, and IT
Public Health Crisis Response—Cooperative Agreement Program. infrastructure made rapid progress in 2018
but slowed in the subsequent years when
Puerto Rico experienced seismic activity and
COVID-19. In late December 2019, a series
T
he island of Puerto Rico endured sev- mph, leaving devastating damage to roads, of daily earthquakes struck the island and
eral emergencies/disasters between homes, powerlines, food service establish- the Puerto Rico Seismic Network registered
2017 and 2021 that threatened both ments, drinking water and wastewater sys- 43 significant aftershock quakes. Again, the
its physical infrastructure and human re- tems, and healthcare facilities. As a result, island’s population was left with unstable
source capital. From a devastating hurricane most of the island’s population lost access to and unsafe working and living conditions,
to a worldwide pandemic, the Puerto Rico basic resources and services such as electrical power outages, water contamination, emo-
Department of Health (PRDOH) Environ- power, clean water, wastewater systems, and tional distress, and property loss (Photo 1).
mental Health Program faced each challenge healthcare. Many people were fearful of returning to
with the mission-minded resolve that is key The Centers for Disease Control and their homes; temporary shelters were over-
for rising above seemingly insurmountable Prevention (CDC) supported three proj- run with thousands of people seeking refuge
setbacks. When Hurricane Maria made land- ects from 2018–2021 to assist PRDOH’s (Photo 2). The large influx of people into
fall in September 2017, the catastrophic Cat- hurricane recovery efforts, specifically to shelters resulted in major logistical chal-
egory 5 storm brought a large storm surge, help strengthen its ability to respond to lenges, including caring for older adults,
heavy rains, and wind gusts well above 100 these hazards and to revitalize environ- immunocompromised individuals, children,
28 Volume 83 • Number 10
Photo 1. The series of daily earthquakes that
struck Puerto Rico in late 2019 left buildings
unstable and residents fearful for their safety.
Photo 2. After the earthquake, thousands of refugees sought shelter, which increased the risk for
Photo courtesy of the Puerto Rico Department
foodborne illness and hygiene-related illness. Photos courtesy of the Puerto Rico Department of Health.
of Health.
and other at-risk populations. Immediately, managing their stress and emotions as first
project staff and resources shifted from hur- responders during the crises they had just Project Highlights: Making
ricane recovery to emergency response, spe- endured. In response, PRDOH coordinated Inspection Data Useful
cifically inspecting shelters, mobile medical with Americares and the Federal Emergency
units, food service facilities, and water sup- Management Agency (FEMA) to deliver two
Going Digital
ply trucks. The department also addressed resilience-building sessions—a one half-day
issues involving stray animals, pests, food workshop and a one half-day conference—to Puerto Rico Department of
safety, water sanitation, and sewage. In total, all environmental health personnel, includ- Health began converting paper
the department developed 38 different edu- ing inspectors, regional directors, admin- inspection forms to digital,
starting with the Radiological
cational resources for digital and print distri- istrative personnel, division directors, and
Division.
bution to provide guidance and help improve project contractors. During these activities,
food safety and water sanitation for the local staff expressed their work-related stress and Performing 11,374 Inspections
population (Figure 1). discussed strategies for self-care and how to
356 radiologic facilities like
When COVID-19 cases increased in March prepare themselves to take care of others.
dentists, clinics, X-ray centers,
2020, the project-related work drastically Puerto Rico’s multiple public health emer- and hospitals
slowed again as the pandemic required full gencies posed challenges to the development
4,410 public/municipal and
staff attention. Furthermore, since staff were and delivery of topic-specific trainings. The
private drinking water facilities
directed to work from home, conducting in- National Environmental Health Associa-
person inspections of facilities was nearly tion (NEHA) intended to deliver in-person 6,608 food establishments
impossible. Once again, PRDOH redirected trainings on food safety, including topics on
resources to develop COVID-19 procedures professional food managers, food safety dur-
and protocols for inspectors and guidance ing natural disasters, and temporary food
for the community on hand-washing tech- establishments. The increase in COVID-19 and delays. Nevertheless, NEHA worked dil-
niques, sanitary preparedness, and require- cases, however, forced PRDOH and project igently with its partners to overcome these
ments for obtaining a sanitary license for partners to find alternate delivery methods. challenges and the trainings are now avail-
food establishments. The group decided that self-guided online able on NEHA’s website for PRDOH staff to
After 3 years of tremendous personal and trainings would be the best solution but this take at their own pace.
professional stress on PRDOH staff, depart- required NEHA to redesign the trainings, Despite multiple challenges, progress in
ment leaders realized staff needed help which introduced another set of challenges Puerto Rico moved forward, with nearly all
June 2021 • Journal of Environmental Health 29
A D V A N C E M E N T O F T H E PRACTICE
project activities completed on time. Prog-
ress of the project activities could only be
possible through the teamwork of CDC, FIGURE 1
PRDOH, project staff, NEHA, the Associa- Examples of Educational Resources to Improve Food Safety and
tion of State and Territorial Health Officials, Water Sanitation Developed by the Puerto Rico Department of Health
FEMA, Americares, and the Food and Drug
Administration. “We can only achieve suc- RECOMENDACIONES A Limpie y Mantenga su Cisterna de Agua
cess by respecting and valuing everyone’s CONSUMIDORES AL
role on the team,” says PRDOH Program SELECCIONAR UN FOOD TRUCK LIMPIE
1. Elimine los desechos y agua de la cisterna
2. Restriegue el interior con un cepillo LimpiO y detergente de lavar pLATOS
Manager Aura Ortiz Sánchez. She demon- DOCUMENTOS Y PERMISOS 3. Enjuague con agua limpia y vacίela
strated true resiliency by doing whatever El establecimiento cuenta con los
permisos requeridos, incluyendo la Certificación
DESINFECTE CON CLORO
Sanitaria del Departamento de Salud de Puerto
was needed to keep public health a priority Rico y los Certificados de Salud individuales y
vigentes de todo el personal.
1. Llene la cisterna de agua
2. Cierre las llaves de paso a la cisterna
in Puerto Rico and helping department staff Mínimo una persona del equipo que maneja los alimentos posee
la Certificación Profesional de Seguridad Alimentaria.
3. Añada cloro, de uso casero : 3 tazas de cloro
por cada 100 galones de agua
Desinfecte con cloro
tazas de cloro por
to manage the stress of their personal and ÚLTIMO REPORTE DE INSPECCIÓN
4. Si la cisterna está conectada a las tuberías de la
casa, abra las llaves y deje correr el agua hasta
galones de agua
1,000 galones---------------30 tazas de cloro
que huela a cloro
professional responsibilities. As a result, the
900 galones-----------------27 tazas de cloro
El establecimiento posee un aviso o rótulo visible 800 galones-----------------24 tazas de cloro
5. Cierre las llaves y deje reposar el agua al menos
a la clientela indicando disponibilidad del último 700 galones-----------------21 tazas de cloro
12 horas 600 galones-----------------18 tazas de cloro
reporte de inspección sanitaria.
project activities have improved the island’s El último reporte de inspección sanitaria realizada
está disponible a petición de la clientela.
6. NO BEBER / NO USAR ESTA AGUA
7. Vacίe toda el agua despues de las 12 horas
500 galones-----------------15 tazas de cloro
400 galones-----------------12 tazas de cloro
300 galones-----------------9 tazas de cloro
200 galones-----------------6 tazas de cloro
capacity to respond to future emergencies. 8. Vuelva a llenarla con agua fresca
9. Abra cada llave y deje correr el agua hasta que
100 galones-----------------3 tazas de cloro
USO DE GUANTES NO huela a cloro
PRDOH has not only improved and updated Se realiza lavado de manos correcto antes de utilizar guantes.
Se cambian los guantes al ensuciarse, * Período de mantenimiento cada 6 meses.
infrastructure and equipment to help them cuando se rompen y con cada cambio de tarea.
No se reutilizan los guantes; son una protección
Evite microbios y Utilice * Debe tener un filtro de sedimento
en la entrada y salida de la cisterna.
do their jobs but also has staff with resil- entre las manos y los alimentos. Añada 1 cucharada de cloro lίquido sin
aroma, por cada 100 galones de agua en su
cisterna para evitar que crezcan microbios.
iency skills and the resources they need to HIGIENE DEL PERSONAL
Se protege correctamente el cabello, usando redecilla o gorra, Secretaría Auxiliar Salud Ambiental
serve their community. y la barba, usando protector.
No está enfermo, tiene uñas cortas y limpias, no
utiliza prendas si cocina y el uniforme está limpio;
For more information on CDC’s disaster tomar estas precauciones ayuda a prevenir
el riesgo de contaminación de los alimentos.
response and recovery activities for environ- Procedimiento para el Lavado de Utensilios
MANEJO DE ALIMENTOS
mental health, visit www.cdc.gov/nceh/ehs/ Mantenimiento de temperatura de los alimentos
Organizar y Raspar
Eliminar todo el
es apropiada, en frío o caliente. exceso de alimento
rra/index.html. Al servir, no se tocan alimentos alimentos listos
para consumo con las manos directamente.
en un zafacón.
Alimentos están protegidos.
Los productos cuentan en su etiqueta con Secar al aire
información del distribuidor y licencia sanitaria. en un escurridor inclinado
Corresponding Author: Raymond J. Lopez, para el drenaje del agua.
Nunca secar con papel toalla o paño.
ALREDEDORES
Environmental Health Scientist, Division of Limpios y libres de roedores, plagas y animales.
Environmental Health Science and Practice, Existe un rótulo indicando que está prohibido fumar en
el establecimiento y sus alrededores según
la Ley #40; incluyendo cigarrillo electrónico.
National Center for Environmental Health, Lavar Enjuagar Desinfectar
BUSCANOS EN
con un detergente en con agua limpia sumergir por 30 segundos en
Centers for Disease Control and Preven- D EP ARTAMENTO D E SALU D D E P U ERTO RIC O
SEC RETARÍA AU XILIAR D E SALU D AMBIENTAL
D IV ISIÓ N D E HIGIENE D E ALIMENTO S
Secretaría Auxiliar
Salud Ambiental
agua a 110°F o más para remover
el detergente
agua a 110°F o más con
solución desinfectante aprobada.
tion, 4770 Buford Highway NE, Atlanta, GA
WWW.SALU D .GO V .P R
30341. Email: oyo2@cdc.gov.
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