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How Puerto Rico Became a Vaccine Leader

By Elaine K. Howley
Dec. 3, 2021
A masked patient pulls up his sleeve as a medical worker holds a syringe.
A masked patient rolls up his sleeve as a medical worker holds a syringe.

When COVID-19 hit the Caribbean island of Puerto Rico, an unincorporated U.S. territory of 3.2 million people about 1,000 miles southeast of Miami, residents feared its impact.

These fears were heightened by ongoing infrastructure challenges stemming from 2017’s Hurricane Maria; the electrical grid hasn’t fully recovered and many roadways still lie in disrepair, making it difficult to reach hospitals and medical facilities. What’s worse, an exodus of some 130,000 people — 4% of the population — has left many hospitals critically understaffed.

But Puerto Rico quietly defied expectations. That’s in part due to widespread vaccine acceptance and the efforts of public health officials, hospitals, and medical schools in disseminating early, targeted messaging warning of the dangers of COVID-19.

“Education has been very strong since the beginning,” says Humberto Guiot, MD, an infectious disease specialist and interim dean at the University of Puerto Rico School of Medicine.

Providing the population with what he calls “validated scientific information,” delivered by medical task force experts rather than politicians has “made a difference,” he says.  

Today, 90% of the island’s population has received at least one dose of a COVID-19 vaccine, and about 82% of the total population has been fully vaccinated, according to Nov. 15 data released by the Puerto Rico Department of Health.

Trusting Science

Stemming the contagion began in March 2020 when the pandemic was first declared. Then, political leaders took it seriously and instituted one of the most comprehensive lockdowns in the United States, including strict curfews, business closures, and activation of the National Guard to help contain the virus.

Gov. Pedro Pierluisi assembled a “coalition of scientists who were not government affiliated” to advise him on how to evaluate data surrounding the pandemic and adjust policy responses accordingly, says Kenira Thompson, PhD, vice president for research at Ponce Health Sciences University and president of Ponce Research Institute. “They were letting science drive public policy.”

When it came time to administer vaccines, public health officials were encouraged to set the tone that addressing the crisis would best be done in a “science-based” way and that “the vaccine is the best tool we have to help,” says Thompson.

Local hospitals, medical schools, and the Puerto Rico National Guard, which has been heavily involved in delivering vaccines, especially to rural and remote locations, also worked to deliver science-based health messaging to residents across the territory.

Early on, the Governor’s task force and other public health officials worked on a framework for how to roll out a vaccine when it became available in mid-December.

Removing barriers to access has been a key component of the drive to vaccinate as many as possible across the island. To do that, the Department of Health created more than 450 vaccination sites — in everything from retail pharmacies to rural health clinics, says Carmen Zorrilla, MD, interim dean of research at the University of Puerto Rico (UPR) Medical Sciences Campus and professor of obstetrics and gynecology at the UPR School of Medicine.

Ponce Health Sciences University also pitched in by clearing out space in its very large freezers to store the Pfizer vaccine before it could be transported to clinics. Additionally, the university served as a hub for administering and distributing vaccines.

“I think at one time we had more than 90% of the vaccine on the island in storage in our facilities,” says Olga Rodríguez de Arzola, MD, dean of the School of Medicine at Ponce Health Sciences University.

Innovation in Education

Medical students were also a key part of the vaccination effort.

Months after students at the Universidad Central del Caribe School of Medicine began remote learning, they were called back to work at school-sponsored vaccination clinics, says Dean José Capriles Quirós, MD, MPH.

“We needed to find a way besides online teaching to develop skills for our students,” he says, “so the concept of an immunization clinic model run by students came into place.”

Some 400 students were involved. The leaders among them determined how to establish and run the on-campus clinic. All students learned how to manage and administer shots while being overseen by faculty. They also established a drive-thru vaccination clinic to better serve people with mobility issues.

“It was a great opportunity for our students to develop leadership to apply public health practice, core knowledge, and develop skills” in a clinical setting, with immediate real-world benefits for patients, says Capriles Quirós.

A Cultural Divide

Throughout much of the United States, social media has sowed political division, which has made achieving the kind of high vaccination rates seen in Puerto Rico much more difficult.

But on the island, social media has aided the vaccination push.

“The university did a very nice social media campaign to educate the community about the benefits of the vaccination process and advocate for that,” says Rodríguez de Arzola. She notes that it’s also been a good way for many of these clinics to advertise hours and availability.

The island’s high vaccination rates may also derive from overall acceptance of science.

Puerto Rico has had “very good rates of vaccination for children, historically,” Zorrilla says. “The culture here is that people accept vaccines mostly. There are also regulations requiring vaccines for school.”

Tapping into local leaders’ knowledge of their communities has also helped bring vaccines to people who otherwise might not have been able to get them, Rodríguez de Arzola says. Municipal health departments identified people who lacked transportation and the National Guard brought vaccines to them.

This has been especially important for older adult populations living in care “homes where they’re on their own and don’t have transportation,” she says. That communication with community leaders really helped us do the outreach to people who wanted the vaccine but for whom it was hard to get to a vaccination center.”

A Tailored Approach

Now the push to vaccinate Puerto Rico’s younger residents is in full swing.

To better meet the needs of these patients, Zorrilla says the island’s clinics are working to help kids feel less stressed when they get their shots. This includes bringing in therapy dogs to help soothe anxious children and using kid-friendly decor.

Ultimately, much of Puerto Rico’s success can be summed up as collaboration, says Guiot.

He notes that there are six health professions schools at UPR: medicine, nursing, dental medicine, pharmacy, public health, and health professionals. In a grand example of interprofessional collaboration, UPR leadership leveraged each school’s particular expertise — such as tapping students and faculty at the school of pharmacy to prepare doses and students from the school of nursing to administer the shots — to make clinics run smoothly while helping students engage in their chosen field of study.

“Everybody had a role,” he says. “Everybody was engaged from day one. Everybody collaborated.”