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Pet ownership and therapy dogs as companion animals and emotional support have potential health benefits. We report the experiences at a COVID-19 vaccination center after authorizing children's vaccines. When the Pfizer-BioNTech vaccine for children aged 5 to 11 years was authorized for emergency use, we adapted the center's space to receive children, adding cartoon posters and balloons and using children's adhesive bandages, among others. Located at a Campus with six health professional schools, medical students dressed as storybook or movie characters. Children were asked to make drawings during the post vaccination observation period. We incorporated therapy dogs as part of our strategy for a child-friendly center during vaccination activities. Parents expressed that the COVID-19 immunization seemed to be better accepted by children as the dogs in the center entertained them. Many children were in close contact with the dogs while receiving the shots, caressing them, or having the small dogs on their laps. Children's drawings reflected colors, flowers, families, images of happiness, dogs with their names, their own pets, and superhero characters. There were no negative images of syringes, injections, or germs. To our knowledge, this was the only vaccine center in Puerto Rico that implemented therapy dogs as a strategy to create a friendly environment for COVID 19 immunization efforts targeted for children. Based on this experience, we encourage the use of therapy dogs in other immunization activities and will further gather prospective data in the future.

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OBJECTIVE: There have been significant successes in the fight against HIV/AIDS due to the access to rapid HIV testing, interventions to reduce the mother-to-child transmission (MTCT) risk, potent and effective antiviral medications, and other biomedical prevention strategies. The purpose of this work is to demonstrate that Puerto Rico eliminated Mother-to-Child Transmission of HIV (MTCT) following the 2017 World Health Organization (WHO) criteria for validating the elimination of MTCT and Syphilis. METHODS: Existing epidemiological data from Puerto Rico was used to document the elimination of MTCT and Syphilis. Data to calculate the indicators was obtained from the various divisions of the Puerto Rico Department of Health, including vital statistics, surveillance data, and programmatic outcomes. RESULTS: Puerto Rico eliminated MTCT and syphilis, according to the WHO indicators, earlier than other countries. We can trace the outcomes to 1994 using the incidence rate of perinatally-acquired HIV of <50/100,000; to 2007 using HIV perinatal transmission rates for non-breastfeeding countries (<2%), to 2008 using 90% of women receiving ART at delivery, and to 2005 using the incidence rate of congenital syphilis of <50/100,000. CONCLUSION: Not only have we eliminated the MTCT of HIV and syphilis, but the efforts have been sustained since 2000. The elimination of transmission of infectious diseases requires the intersection of scientific feasibility, coordinated interventions, and political will, successfully attained in Puerto Rico.

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Importance: Existing research has established a causal link between Zika virus (ZIKV) infection and severe birth defects or consequent health impairments; however, more subtle cognitive impairments have not been explored. Objective: To determine whether infants of mothers with at least 1 positive ZIKV test show differences in cognitive scores at ages 3 to 6 months and ages 9 to 12 months. Design, Setting, and Participants: This cross-sectional study recruited infants enrolled in existing ZIKV study cohorts associated with the Maternal-Infant Studies Center and the Puerto Rico Clinical and Translational Research Consortium at the University of Puerto Rico and from the broader San Juan metropolitan area. The study took place at the Puerto Rico Clinical and Translational Research Consortium at the University of Puerto Rico. Participants were recruited through convenience sampling if their mothers underwent ZIKV testing prenatally and were at the target ages during the study period. Infants who were born preterm (<36 weeks' gestational age), with low birth weight (<2500 g), or with a known genetic disorder were excluded. Infants were tested from ages 3 to 6 months or ages 9 to 12 months from May 2018 to April 2019. Data analysis was performed from March to April 2019. Exposures: Zika virus status was measured prenatally and in the early postnatal period using real-time polymerase chain reaction or a ZIKV IgM antibody capture enzyme-linked immunosorbent assay. Main Outcomes and Measures: The infants' development was assessed using the Mullen Scales of Early Learning (translated to Spanish and adapted for Puerto Rico), and assessors were blinded to each infant's ZIKV status. Results: A total of 65 study participants were included. The mean (SD) age of the infants at the time of cognitive testing was 8.98 (3.19) months. Most of the infants were white (55 [84.6%]) and Puerto Rican (64 [98.5%]); 38 of the infants were male (58.5%). General cognitive and domain-specific scores did not differ significantly between prenatally ZIKV-positive and ZIKV-negative infants except for receptive language score (mean difference = 5.52; t = 2.10; P = .04). Exposure to ZIKV (B = -5.69; ß = -0.26 [95% CI -11.01 to -0.36]; P = .04) and a measure of Hurricane Maria exposure (time without water, B = -0.05; ß = -0.27 [95% CI, -0.10 to -0.01]; P = .03) were both independently and significantly associated with receptive language scores after adjusting for key confounders. Conclusions and Relevance: Although infants exposed to ZIKV prenatally showed unaffected motor and visually mediated cognitive development, they did show deficits in receptive language scores. Receptive language skills were also associated with the degree of exposure to Hurricane Maria, with those who spent more time without water after the hurricane having lower receptive language scores.

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On February 1, 2016, the World Health Organization (WHO) declared the ZIKV virus outbreak a Public Health Emergency of International Concern (PHEIC). Pregnant women and their infants, are vulnerable to the impact of this vector-borne illness (mosquito) and sexually transmitted viral infection. The uncertainty surrounding the possibility of congenital anomalies due to ZIKV infection during pregnancy bring a renewed debate about the rights of women to control their reproductive decisions. Current strategies, resources and services aimed at prevention priorities fall short of responding to a clear framework regarding sexual reproductive health, rights and justice. A comprehensive approach to reproduction, in times of Zika, needs to empower women of reproductive age and their families to make decisions and to act on those decisions. This paper highlights the contributions of the Maternal-Infant Studies Center (CEMI-Spanish Acronym) in close collaboration with the Department of Obstetrics and Gynecology of the University of the Puerto Rico School of Medicine and the University Hospital in providing comprehensive health care to pregnant women with ZIKV or at risk of ZIKV, at the very onset of the epidemic. CEMI approaches the care of pregnant women from a reproductive justice perspective, integrating clinical services, education, research, and advocacy. Transformación Prenatal (Centering Group Prenatal Care, GPC) currently implemented at the Puerto Rico University Hospital High Risk Clinics has been pivotal to achieve this aim. Based on the health professionals' experiences and women's testimonies, we articulate a set of principles and key actions that would benefit women, their family and children.

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OBJECTIVE: Zika virus (ZIKV) infection was identified in Puerto Rico on December 2015, and the outbreak encouraged us to characterize clinical manifestations and laboratory findings of intrauterine exposed infants. METHODS: Retrospective medical record review of infants born to mothers with confirmed ZIKV infection during pregnancy was performed from January 2016-June 2017. We included patients admitted to UPH Neonatal Intensive Care Unit or referred for follow-up at UPH High Risk Clinics. The database was approved by the University of Puerto Rico, Medical Sciences Campus, IRB. RESULTS: 191 infants born to ZIKV positive mothers during pregnancy were identified. Normal head sonogram was found in 93% of the normo cephalic infants. Ocular findings were reported in 50% of the patients with microcephaly and 31% of the normo-cephalics. Fifteen newborns (7.8%) presented with microcephaly, of which 73% showed calcifications in head sonogram, and had severe anomalies on brain MRI. Auditory brainstem response test was performed on all newborns, 80% were within normal limits. CONCLUSION: Among the group of infants born to mothers with Zika positive test 4% had microcephaly. Of concern to us is the fact that 31% of normo cephalic infants had ocular manifestations and 7% of them had findings on head sonogram. While microcephaly is the severest form of Congenital Zika Syndrome, ocular manifestations might characterize the spectrum of disease. These findings reiterate the importance of detailed neonatal evaluations of exposed infants.

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The world has encountered a new and serious epidemic which has disproportionately affected fetuses and infants. What makes the Zika virus (ZIKV) epidemic such a threat in our times, is that a whole generation can be affected by birth defects caused by a seemingly innocuous maternal infection, which in most cases go unnoticed and undiagnosed. Spreading to over 80 countries and affecting millions, it is associated with severe birth defects known as congenital Zika syndrome (CZS), which include fetal brain development abnormalities (microcephaly and brain calcifications), retinal abnormalities, and contractures and hypertonia of the extremities. Testing strategies are challenging because of the lack of symptoms and cross reactivity with other viral infections. Obstetrical complications include fetal loss and the need for an emergency cesarean delivery. The rate of CZS has been described as ranging from 5 to 6% among cohorts in the US, reaching 11% for 1st trimester exposure. Prolonged viremia during pregnancy has been documented in a few cases, reaching 89 days after the onset of symptoms in one case and 109 days after such onset in another. If the ZIKV can infect, multiply in, and persist in diverse placental cells, then movement across the placenta, the fetal brain, and the maternal peripheral blood is possible. There is a sense of urgency, and we need safe and effective vaccines and treatments, particularly for pregnant women. If we do not expand testing and develop methods for early diagnosis and treatment, thousands of infants will be exposed to a neurotropic virus that causes severe birth defects and that could also affect the lives of those who form the next generation.

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The reduction in the mother-to-infant transmission of HIV has been among the early successes of care and treatment of women living with HIV. Prenatal HIV counseling and testing, the availability of diverse antiretroviral therapies, elective cesarean section, and the use of formula milk have significantly reduced the mother-to-infant transmission in the USA and Europe. We are presenting two cases of seroconversion during pregnancy, identified during labor and delivery, of women who received risk reduction counseling and serial HIV testing during pregnancy. Because there are no guidelines for (or easy access to) the use of pre-exposure prophylaxis (PrEP) in pregnancy, they were offered other strategies for prevention including risk reduction counseling, condoms, and serial HIV testing. These cases support the use of PrEP during pregnancy. Both infants were negative and the women are currently receiving long-term highly active antiretroviral therapy. One of them recently delivered another infant. After these two women seroconverted, we decided to offer PrEP to all pregnant women presenting for care who report having an HIV positive partner. During the period 2012-2014, we treated ten HIV negative pregnant women who were partners of HIV positive men. Since 2015, we have seen 20 pregnant women in HIV discordant relationships. Of those, seven received PrEP. No seroconversions have been observed among the pregnant women on PrEP. Although small numbers, seroconversion during pregnancy was observed in two of 13 (15%) of the pregnant women in HIV-discordant relationships seen in our clinic, excluding those treated with PrEP. Given the safety data and experience with tenofovir and emtricitabine among pregnant women living with HIV, we believe PrEP should be offered in pregnancy and that guidelines should reflect this option as an additional strategy to reduce risks during pregnancy and to further reduce infant HIV transmission risk.

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OBJECTIVES: To evaluate the impact of group prenatal care (Centering Pregnancy) on the rate of Preterm Birth (PTB) and low birth weight. Women were enrolled into Centering Pregnancy (Transformación Prenatal) if they fell in the category of poverty, and had at least one risk for PTB according to known risk factors for low birth weight or PTB. METHODS: Mother's age, parity, risk factors, prenatal/delivery complications, infants' Gestational Age (GA), birth weight, Apgar scores, delivery route, indications for delivery, and use of Neonatal Intensive Care Unit (NICU) were abstracted from charts of mothers who received group or traditional care at the University Hospital in San Juan, PR. RESULTS: More infants were born at term if the mothers received Centering Pregnancy. The mean birth weight and gestational age of the infants were higher (6.59 vs. 6.33 lbs. and 37.8 vs. 36.8 weeks) than for those in traditional care. Centering Pregnancy also had lower rates of preterm birth (27.7% vs. 34.1%) and births earlier than 31 weeks (2.8% vs. 9.9%). All were statistically significant (P<0.05). CONCLUSIONS: We successfully implemented group prenatal care (Centering Pregnancy) for the first time in PR in a complex environment: tertiary care hospital with a high-risk prenatal clinic. Despite having known risk factors for preterm birth, the mothers in Centering Pregnancy had better outcomes. In an environment of adverse determinants of health, the program was effective in reducing the odds for adverse infant outcomes early in life and demonstrating that innovative models of health care can improve such outcomes.

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OBJECTIVE: To examine the impact of the HIV normalization discourse on the life of a group of perinatally HIV-infected (pHIV-I) youth in Puerto Rico. METHODS: A qualitative research study was conducted to explore the life experiences of pHIV-I youth in Puerto Rico. Twenty in-depth interviews were carried out among 12 women and eight men aged 18 to 30 years. Questions focused primarily on their life experiences and the meaning they ascribe to HIV. Interviews were analyzed and interrelationships, connections and patterns were assessed. FINDINGS: Normalization messages were present in most of the participants' narratives. The majority considered their HIV diagnosis like "any other health condition" and most of them had a positive attitude towards life. When study participants positioned themselves from a social perspective, contradictions of normalization messages emerged. Some participants reported that because HIV is highly stigmatized, their rejections, discrimination and stigma experiences are different from those of patients with other chronic conditions. Those with HIV also face unique and difficult situations such as losing family members, dealing with a potentially fatal illness, and maintaining secrecy about their health conditions. CONCLUSION: While the normalization discourse is very common in the medical field, it does not necessarily translate into the personal and social spheres of HIV-positive youth. Interventions to assist patients in dealing with the social implications of the HIV condition are still needed.