Leilani Dominicci has all the typical worries of pregnant women plus a new one spreading across Puerto Rico: the fear she will become infected with the Zika virus and put her baby at risk.
Her unease has escalated so much that the 38-year-old attorney barely leaves her home in the capital of San Juan because of warnings the island faces an onslaught of the mosquito-borne illness.
As the virus sweeps through the hemisphere, Puerto Rico has become America's own front line in the battle against it — home to 3.5 million U.S. citizens and with a tropical landscape that is an ideal breeding ground for the mosquito that spreads Zika, as well as the dengue and chikungunya already common here.
Officials have barred local blood donations, ramped up efforts to eradicate the Aedes aegypti mosquito and are trying to monitor every pregnant woman on the island due to fears Zika might cause birth defects. The voluntary registry by the U.S. Centers for Disease Control and Prevention extends to all Zika-infected women and their babies throughout the United States.
The Puerto Rican governor, meanwhile, has declared a public health emergency, and the CDC, which earlier urged pregnant women to reconsider visits to Puerto Rico, has asked Congress for $250 million in emergency aid to battle Zika here. The CDC has also sent nearly 40 health workers to help, and is using the island as a test bed for Zika studies.
"For the U.S., it really is the territory that is going to have the most infections," said Steve Waterman, head of the CDC's dengue branch in Puerto Rico. "It has the best medical and public health infrastructure to try and answer some of these questions at the same time that we're trying to control the disease."
Among the CDC's main goals is to test every pregnant woman in Puerto Rico for Zika and prevent people like Dominicci from contracting the virus. The CDC is urging people to take preventive measures, a call that Dominicci and her husband heeded after the first Zika case was reported in December.
"We have locked ourselves up at home," said Dominicci, who is nearly 37 weeks pregnant. "It's a constant concern, especially for women like us who are so far along because our options are limited. Ending a pregnancy at this stage is not even legal."
Zika causes headaches, fever and a rash, though most people with the virus never show symptoms. CDC researchers in Brazil and Puerto Rico are trying to determine whether the virus can cause microcephaly, a condition in which babies are born with abnormally small heads, and a rare paralyzing condition, Guillain-Barre, which can be fatal.
At least 117 people have tested positive for Zika in Puerto Rico, including five pregnant women. At least five people have been hospitalized, including a man recovering from Guillain-Barre.
Waterman said more than 20 percent of the island population could contract Zika in an outbreak that could peak by summer.
"Our objective is to protect as many pregnant women as possible and that is what we are trying to do," he said.
More than 80 percent of adults in Puerto Rico already have had dengue and an estimated 30 percent had chikungunya, viruses spread by the same insect. But Zika poses a greater concern, said Dr. Brenda Rivera, the island's epidemiologist.
"None of those diseases have the implication for future generations that this one does, at least that we think it does," she said.
It's a preoccupation shared by Yelitza Irizarry, a 39-year-old attorney who lost a baby in December and is undergoing fertility treatment. She wears pants and long-sleeved shirts, has shuttered the windows in her home and drenches herself in repellent every few hours. Still, she can't stop thinking about Zika and potential birth defects.
"It raises a thousand concerns," she said.
CDC officials have set up a temporary lab to breed mosquitoes and determine if they are resistant to insecticides that Puerto Rico is using.
The center has also trained lab workers in using a test created in Puerto Rico this year that can detect dengue, chikungunya and Zika all at once to cut costs and speed up the process. It's launching a study to analyze how long Zika remains in semen, saliva and urine, and tracking birth defects and Guillain-Barre cases.
The Puerto Rican government halted all blood donations this month and began buying blood from the Red Cross to prevent potential contamination, following recommendations from the U.S. Food and Drug Administration.
The territory also issued an administrative order freezing the price of condoms, fearing sellers might take advantage of fears to raise prices given that there's some evidence Zika can be spread through sex.
Concerns about Zika have traveled throughout the Caribbean, where officials express concern it could hurt tourism industry even though there has been no significant effect yet.
Martinique and French Guiana have declared an epidemic with more than 6,000 suspected cases, including at least 38 pregnant women and five people with Guillain-Barre. Haiti has reported more than 500 cases, but the actual number is believed to be much higher because of weak monitoring systems. Many Haitians live in shacks with little protection from insects that breed in trash-clogged canals and gullies.
Health officials stress that eliminating breeding sites is key to preventing a Zika epidemic in the Caribbean.
In Puerto Rico, crews have rounded up used tires that can collect water, installed window screens at public schools and have fumigated thousands of neighborhoods, including Dominicci's. She said the number of mosquitoes has decreased greatly, but she still worries some will slip into her home. Her niece is developmentally disabled, and she said it's been a struggle for her family.
"Bringing a child into the world in those conditions has to be devastating," she said of the potential tie between microcephaly and Zika. "I no longer have any options. I have to welcome my daughter no matter what at this point in my pregnancy."
