In Reply The arguments presented by Drs Cruz-Cano and Mead are mistaken in some important conceptual, empirical, and methodological aspects. We stated in our Research Letter that the estimates were conservative and that they did not consider population denominators.1
Cruz-Cano and Mead state that the methodology “did not account for long-term trends and seasonal patterns, which can have significant effects on mortality rates.” However, our method1 accounted for seasonal patterns because it modeled each individual month’s expected deaths as the mean over the previous 7 years, and the variability in this series accounted for the uncertainty around it. When we analyzed a longer series of data going back to the year 2000, the results are similar.2
Santos-Lozada AR, Howard JT. Excess Deaths After Hurricane Maria in Puerto Rico—Reply. JAMA. 2019;321(10):1005–1006. doi:10.1001/jama.2018.20878
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