Letter to the Editor| Volume 360, ISSUE 2, P197-198, August 2020

COVID-19 in Puerto Rico: Perspective From an Internal Medicine Resident Physician

      Dear Editor
      The current pandemic caused by SARS-COV-2 virus has impacted Puerto Rico as it has much of the world. This island of over 3.1 million inhabitants rests in the Caribbean Sea and is a territory of the United States. Since the pandemic began, healthcare providers have been working on the front lines, screening and treating patients with suspected or confirmed COVID-19 infection. I am an Internal Medicine Resident at the Mayaguez Medical Center located in the Southwest part of the island and I would like to offer my impressions of how the pandemic has affected our approach to patient care and education.
      The first cases of COVID-19 were reported in the island on March 13, 2020 and as of April 23, Puerto Rico confirmed 1416 cases from 10,740 tested persons. At that time, the system had a total of 1940 tests pending. In addition, the Puerto Rico Health Department reported 69 deaths from COVID-19, which represents a case fatality rate of 4.9%.

      Dashboard Puerto Rico COVID-19. (2020, April 18). Available at: Accessed June 11, 2020.

      On February 29, the Puerto Rico Government created the Puerto Rico Medical Task Force COVID-19, a group of educators, epidemiologists, pharmacists and physicians charged with collecting, analyzing and communicating medical and demographic data regarding COVID-19 to facilitate decision making; this team was also held responsible for updating citizens about medical screening, potential treatments and preventive techniques. In collaboration with the Governor, the Medical Task Force ordered a 10 hours curfew (implemented on March 15), restricted meetings and daily activities, imposed a car plate regulation standard for transit, and recommended 14 days of quarantine for people with symptoms or exposed to a confirmed COVID-19 patient.

      Departamento de Salud de Puerto Rico. (2020, April 18). Available at: Accessed June 11, 2020.

      A direct phone line was created to assist persons with questions or with potential COVID-19 related symptoms. The National Guard was activated to help monitor travelers entering the island on March 12. By March 31, 239 cases had been confirmed and 8 deaths had been recorded.
      Following the CDC recommendations reviewed on April 13, 2020, the Puerto Rican population was further encouraged to stay home, avoid crowded places, use masks in public, engage in strict hand hygiene routine and clean and disinfect exposed surfaces.

      People Who Need to Take Extra Precautions. (2020, March 20). Available at: Accessed June 11, 2020.

      Importantly, persons found disregarding such guidelines exposed themselves to fines or incarceration (implemented on March 16). Education about COVID-19 continues to be provided through television programs, the press, social networks and via interactions with healthcare providers.
      As the Government reported to the press on April 15, the expected date for the peak of the infection in Puerto Rico was delayed to early May until which time people are expected to maintain social distancing at grocery stores and pharmacies and not leave their home without covering their face. Hand sanitizers are provided at the front door of every open establishment, and restaurants remain offering food via delivery and carry-out only. Schools and universities are providing courses online. By April 23, several businesses had lost their business license and over 600 people have been arrested for breaking the curfew. However, in general, the public response has been positive and there have been no protests related to the lockdown.
      As an internal medicine resident physician, we work in the front lines, examining, admitting and discharging patients with a broad spectrum of diseases including COVID-19. Before the coronavirus pandemic, droplet precautions during history taking and physical examination were limited to specific diagnoses (e.g., suspected tuberculosis or Influenza infection). Now, trainees follow droplet precautions with all patients as the ability to distinguish asymptomatic carriers remains suboptimal. Personal protection equipment like N95 masks and face shields are part of our daily outfit. Learning the correct use and cleaning of the equipment is essential to avoid cross contamination. As could be expected, we have adapted our own disinfecting processes before entering our homes to protect our families. Hospital visit hours have been eliminated to reduce social contact and external contamination. Because communication between physicians and care givers has been affected, obtaining family phone numbers and full names has become routine. Telemedicine is practiced on resident's outpatient clinics when available. Patients needing assistance call to clinic in advance to describe their signs and symptoms and medical recommendations are provided regarding the process for the visit. If patients need to be evaluated face-to-face, the visit is scheduled in advance to avoid lines on the waiting area and possible spread of the virus. Many follow-up visits are performed by phone and prescriptions are directly sent to the pharmacy, which was not a common occurrence.
      Residency training has changed significantly as hospitals have decreased capacity. Published articles in academic journals with data from other locations and clinical guidelines regarding diagnosis and treatment strategies have been invaluable

      ATS Journals. (n.d.). Available at: Accessed June 11, 2020.

      ; equally valuable have been guidelines developed by hospital staff and administration. At our place, like in others, training program leadership continues to work on developing and updating screening and treatment protocols following the latest evidence-based guidelines. Consistent with social distancing recommendations, technology has become crucial for holding meetings and core presentations via videoconferencing and tests follow a digital platform.
      Overall, we have learned about a new disease, about how to address our patient's needs in the era of social distancing, and about how to behave accordingly at home and at work in a very short period of time.

      Ross, J. E. (2020, April 1). Resident response during pandemic: this is our time. Available at: Accessed June 11, 2020.

      I am particularly proud of how Puerto Ricans have managed (and accepted) this new way of life pending new information. Meanwhile, we prepare for the challenges common to the island in coming months including the arboviral diseases. Aedes aegypti is the mosquito vector of arboviral disease, and it is present during the whole year in Puerto Rico. With the raining season getting closer, an outbreak of arboviral diseases, like Dengue virus, would not be unexpected. In addition, the hurricane season will start in June and citizens will soon be preparing their homes and families for possible environmental disasters as witnessed in 2017 with Hurricanes Irma and Maria, which devastated the island. COVID-19 is one more challenge to overcome, but being on the frontlines of this pandemic, I have no doubt I will be prepared for what is to come.


      The author thanks Jesse Roman for his review and recommendations for the manuscript; and Dr Rosa Roman Carlo for her mentorship.


      1. Dashboard Puerto Rico COVID-19. (2020, April 18). Available at: Accessed June 11, 2020.

      2. Departamento de Salud de Puerto Rico. (2020, April 18). Available at: Accessed June 11, 2020.

      3. People Who Need to Take Extra Precautions. (2020, March 20). Available at: Accessed June 11, 2020.

      4. ATS Journals. (n.d.). Available at: Accessed June 11, 2020.

      5. Ross, J. E. (2020, April 1). Resident response during pandemic: this is our time. Available at: Accessed June 11, 2020.