This test, the microagglutination test (MAT), is a serologic test that tests the level of antibodies created by the immune system in response to the leptospira bacteria. Although this test has high specificity, it has low sensitivity, again indicating that it can miss many truly infected individuals. It is typical that doctors will submit paired serum samples form early in the course of illness and then later in order to attempt to demonstrate a 4 fold rise in titer an indication of a positive results. Additionally, individuals living in a leptospira endemic region may have relatively high initial MAT test that only indicate previous infection, but not necessarily disease. Commonly, clinicians will submit blood and urine for PCR testing, however this is often time sensitive in that samples should be collected before antibiotic treatment, and there is typically a delay of 1 to 5 days depending on the lab used.,  An outbreak of leptospirosis may have affected survivors in the weeks following the hurricane. The bacterial infection is contracted through water contaminated with animal urine, with an incubation period of 2 to 30 days. Since large areas of Puerto Rico were without tap water, residents were forced to use other sources of water that may be contaminated, such as local streams. By October 23, four people were suspected of having died from the disease while 74 others were suspected of being infected. There were 18 confirmed cases, 4 confirmed deaths and 99 suspected cases by 7 November. Puerto Rico averages 5 cases of leptospirosis per month under normal conditions. Despite the possibility of an outbreak, officials did not deem the situation being as dire. In July 2018, CNN in collaboration with the Center for Investigative Journalism (CPI), published an online article in which they had seven disease experts review an official Puerto Rico government mortality database. The seven experts all agreed that since the records listed such a large number of confirmed cases of the bacterial disease leptospirosis, Puerto Rico officials should have declared an "epidemic" or an "outbreak" after Hurricane Maria, instead of choosing to not declare that a leptospirosis outbreak had occurred. The data reviewed included 57 laboratory-confirmed cases of leptospirosis illnesses in 2017. Of those, 54 of them were reported after Hurricane Maria made landfall on 20 September 2017. The number of laboratory-confirmed cases amounted to at least a three-fold increase in cases compared to 2016 and 2015. Many of Puerto Rico's essential public health, health care, and other government services were rendered inoperative in the immediate aftermath of Hurricane Maria.