Perspective from Ecuador, the Second Country with More Confirmed Cases of Coronavirus Disease 2019 in South America: A Review
Identifieur interne : 000893 ( Pmc/Corpus ); précédent : 000892; suivant : 000894Perspective from Ecuador, the Second Country with More Confirmed Cases of Coronavirus Disease 2019 in South America: A Review
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Abstract
To face the pandemic outbreak of a novel coronavirus many countries developed a series of containment methods; however, developing countries in South America had reacted apathetically to this worldwide concern. Ecuador's response to the novel virus Coronavirus Disease 2019 (COVID-19) started on February 26, 2020, one month after the outbreak began in China. As of today, the countries with more confirmed cases in South America are Brazil and Ecuador. Although Brazil has two times the number of cases than Ecuador (Brazil: 700 cases per 100000 people vs. Ecuador: 400 cases per 100000), the huge population difference between the two countries raises concerns about the public health policies implemented by the Ecuadorian government. Even though there is no cure for COVID-19, chloroquine and hydroxychloroquine are promising alternatives. The COVID-19 pandemic outbreak has shown that there is room for improvement in the healthcare systems worldwide and the disastrous results on the fragile often unprepared are those systems in developing countries.
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DOI: 10.7759/cureus.7452
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PubMed Central: 7187996
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Perspective from Ecuador, the Second Country with More Confirmed Cases of Coronavirus Disease 2019 in South America: A Review</title></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmc">7187996</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7187996</idno><idno type="RBID">PMC:7187996</idno><idno type="doi">10.7759/cureus.7452</idno><idno type="pmid">NONE</idno><date when="????">????</date><idno type="wicri:Area/Pmc/Corpus">000893</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000893</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Perspective from Ecuador, the Second Country with More Confirmed Cases of Coronavirus Disease 2019 in South America: A Review</title></analytic><series><title level="j">Cureus</title><idno type="eISSN">2168-8184</idno><imprint><date when="????">????</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>To face the pandemic outbreak of a novel coronavirus many countries developed a series of containment methods; however, developing countries in South America had reacted apathetically to this worldwide concern. Ecuador's response to the novel virus Coronavirus Disease 2019 (COVID-19) started on February 26, 2020, one month after the outbreak began in China. As of today, the countries with more confirmed cases in South America are Brazil and Ecuador. Although Brazil has two times the number of cases than Ecuador (Brazil: 700 cases per 100000 people vs. Ecuador: 400 cases per 100000), the huge population difference between the two countries raises concerns about the public health policies implemented by the Ecuadorian government. Even though there is no cure for COVID-19, chloroquine and hydroxychloroquine are promising alternatives. The COVID-19 pandemic outbreak has shown that there is room for improvement in the healthcare systems worldwide and the disastrous results on the fragile often unprepared are those systems in developing countries.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Cnn, Cnn" uniqKey="Cnn C">CNN CNN</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Bialek, S" uniqKey="Bialek S">S Bialek</name></author><author><name sortKey="Boundy, E" uniqKey="Boundy E">E Boundy</name></author><author><name sortKey="Bowen, V" uniqKey="Bowen V">V Bowen</name></author><author><name sortKey="Chow, N" uniqKey="Chow N">N Chow</name></author><author><name sortKey="Cohn, A" uniqKey="Cohn A">A Cohn</name></author><author><name sortKey="Dowling, N" uniqKey="Dowling N">N Dowling</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="El, Comercio" uniqKey="El C">Comercio El</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="El, Comercio" uniqKey="El C">Comercio El</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="El, Comercio" uniqKey="El C">Comercio El</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="De Disponible En, Https Www Elcomercio Com Actualidad Restricciones Movilidad Excepcion Quito Html" uniqKey="De Disponible En H">https://www.elcomercio.com/actualidad/restricciones-movilidad-excepcion-quito.html de 2020]. 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<front><journal-meta><journal-id journal-id-type="nlm-ta">Cureus</journal-id><journal-id journal-id-type="iso-abbrev">Cureus</journal-id><journal-id journal-id-type="issn">2168-8184</journal-id><journal-title-group><journal-title>Cureus</journal-title></journal-title-group><issn pub-type="epub">2168-8184</issn><publisher><publisher-name>Cureus</publisher-name><publisher-loc>Palo Alto (CA)</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmc">7187996</article-id><article-id pub-id-type="doi">10.7759/cureus.7452</article-id><article-categories><subj-group subj-group-type="heading"><subject>Internal Medicine</subject></subj-group><subj-group><subject>Infectious Disease</subject></subj-group><subj-group><subject>Epidemiology/Public Health</subject></subj-group></article-categories><title-group><article-title>Perspective from Ecuador, the Second Country with More Confirmed Cases of Coronavirus Disease 2019 in South America: A Review</article-title></title-group><contrib-group><contrib contrib-type="editor"><name><surname>Muacevic</surname><given-names>Alexander</given-names></name></contrib><contrib contrib-type="editor"><name><surname>Adler</surname><given-names>John R</given-names></name></contrib></contrib-group><contrib-group><contrib contrib-type="author"><name><surname>Hallo</surname><given-names>Alejandro</given-names></name><xref ref-type="aff" rid="aff-1">1</xref></contrib><contrib contrib-type="author"><name><surname>Rojas</surname><given-names>Alejandra</given-names></name><xref ref-type="aff" rid="aff-2">2</xref></contrib><contrib contrib-type="author" corresp="yes"><name><surname>Hallo</surname><given-names>Carlos</given-names></name><xref ref-type="aff" rid="aff-3">3</xref></contrib></contrib-group><aff id="aff-1"><label>1</label> Internal Medicine, Hospital de Especialidad Eugenio Espejo, Quito, ECU</aff><aff id="aff-2"><label>2</label> Investigacion, Universidad Central del Ecuador, Quito, ECU</aff><aff id="aff-3"><label>3</label> Internal Medicine, New York University (NYU) Langone Health, Manhattan, USA</aff><author-notes><corresp id="cor1">Carlos Hallo <email>carloshalloc@gmail.com</email></corresp></author-notes><pub-date date-type="pub" publication-format="electronic"><day>28</day><month>3</month><year>2020</year></pub-date><pub-date date-type="collection" publication-format="electronic"><month>3</month><year>2020</year></pub-date><volume>12</volume><issue>3</issue><elocation-id>e7452</elocation-id><history><date date-type="received"><day>24</day><month>3</month><year>2020</year></date><date date-type="accepted"><day>28</day><month>3</month><year>2020</year></date></history><permissions><copyright-statement>Copyright © 2020, Hallo et al.</copyright-statement><copyright-year>2020</copyright-year><copyright-holder>Hallo et al.</copyright-holder><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by/3.0/"><license-p>This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.</license-p></license></permissions><self-uri xlink:href="https://www.cureus.com/articles/29796-perspective-from-ecuador-the-second-country-with-more-confirmed-cases-of-coronavirus-disease-2019-in-south-america-a-review">This article is available from https://www.cureus.com/articles/29796-perspective-from-ecuador-the-second-country-with-more-confirmed-cases-of-coronavirus-disease-2019-in-south-america-a-review</self-uri><abstract><p>To face the pandemic outbreak of a novel coronavirus many countries developed a series of containment methods; however, developing countries in South America had reacted apathetically to this worldwide concern. Ecuador's response to the novel virus Coronavirus Disease 2019 (COVID-19) started on February 26, 2020, one month after the outbreak began in China. As of today, the countries with more confirmed cases in South America are Brazil and Ecuador. Although Brazil has two times the number of cases than Ecuador (Brazil: 700 cases per 100000 people vs. Ecuador: 400 cases per 100000), the huge population difference between the two countries raises concerns about the public health policies implemented by the Ecuadorian government. Even though there is no cure for COVID-19, chloroquine and hydroxychloroquine are promising alternatives. The COVID-19 pandemic outbreak has shown that there is room for improvement in the healthcare systems worldwide and the disastrous results on the fragile often unprepared are those systems in developing countries.</p></abstract><kwd-group kwd-group-type="author"><kwd>sars-cov-2</kwd><kwd>covid-19</kwd><kwd>ecuador</kwd></kwd-group></article-meta><notes><p content-type="disclaimer">The content published in Cureus is the result of clinical experience and/or research by independent individuals or organizations. Cureus is not responsible for the scientific accuracy or reliability of data or conclusions published herein. All content published within Cureus is intended only for educational, research and reference purposes. Additionally, articles published within Cureus should not be deemed a suitable substitute for the advice of a qualified health care professional. Do not disregard or avoid professional medical advice due to content published within Cureus.</p></notes></front><body><sec sec-type="intro"><title>Introduction and background</title><p>Alarm bells over the world started to ring after the news regarding a case of pneumonia caused by a novel virus in Wuhan, China. The virus supposedly originated in one of the largest markets in Wuhan. On January 7, 2020, the Centers for Disease Control and Prevention (CDC) isolated the virus and called it severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The disease caused by this virus was named Coronavirus Disease 2019 (COVID-19) by the World Health Organization (WHO).</p><p>Even though the majority of cases present with flu-like symptoms, 3.4% of patients develop severe pneumonia, septic shock, respiratory failure, and multiorgan failure leading to a fatal outcome [<xref rid="REF1" ref-type="bibr">1</xref>-<xref rid="REF2" ref-type="bibr">2</xref>].</p><p>On January 30, 2020, the WHO declared the COVID-19 outbreak a global health emergency. Countries applied many measures, hoping to contain the spread of the disease; for example, restricting mobility and quarantines. Additionally, incoming flights from countries with a high prevalence of the disease were suspended, first from China and then followed by Italy and Spain.</p><p>In South America, Brazil is the country with the highest number of COVID-19-confirmed cases followed by Ecuador. Although Brazil has two times the number of cases than Ecuador, it is important to analyze the prevalence of the disease in the context of the countries’ population. While Brazil, with a population of 212,559,417, has a total of 1,549 confirmed cases (0.007%); Ecuador, with a population of 17,567,751, has 789 confirmed cases (0.004%) [<xref rid="REF3" ref-type="bibr">3</xref>-<xref rid="REF4" ref-type="bibr">4</xref>]. The greater ratio of cases per population in Ecuador raises the concern about the efficacy of the containment measures and public health policies taken by the country.</p><p>The limitations of the healthcare systems in developing countries increase their chances of being affected more during a pandemic outbreak.</p></sec><sec sec-type="review"><title>Review</title><p>Confirmed cases and Ecuadorian response</p><p>After the announcement that COVID-19 was spreading rapidly across Asian countries, European countries went into an alarm state and started to design containment measures while South American countries reacted apathetically, delaying decisions on preventive measures, underestimating the severity of the events.</p><p>Ecuador's response to the novel virus COVID-19 started on February 26, 2020. The set of measures included monitoring the temperature and other COVID-19-related symptoms in travelers from high-risk countries [<xref rid="REF5" ref-type="bibr">5</xref>]. On February 29, 2020, Ecuador confirmed the first case of COVID-19. The patient had arrived from Spain two weeks before the diagnosis was made [<xref rid="REF6" ref-type="bibr">6</xref>].</p><p>After the WHO declared COVID-19 as a pandemic outbreak on March 11, 2020, Ecuador declared a national health emergency [<xref rid="REF7" ref-type="bibr">7</xref>-<xref rid="REF8" ref-type="bibr">8</xref>]. All non-essential activities were suspended indefinitely and the use of virtual platforms was encouraged for academic activities, jobs, and medical care. As did other countries did, Ecuador also closed its land, air, and sea borders to citizens and non-citizens for 21 days [<xref rid="REF7" ref-type="bibr">7</xref>,<xref rid="REF9" ref-type="bibr">9</xref>]. Restrictions to vehicular or pedestrian traffic and a national curfew from 7 pm to 5 am also took place [<xref rid="REF9" ref-type="bibr">9</xref>-<xref rid="REF10" ref-type="bibr">10</xref>].</p><p>Despite these measures, the virus continued spreading across the Ecuadorian provinces. On March 23, 2020, 789 confirmed patients with COVID-19 and 18 deaths related to the virus were reported by the Ministry of Health of Ecuador [<xref rid="REF11" ref-type="bibr">11</xref>]. The mortality rate was similar to other countries [<xref rid="REF10" ref-type="bibr">10</xref>,<xref rid="REF12" ref-type="bibr">12</xref>]. The number of confirmed patients increased, so did the number of people in epidemiological monitoring and quarantine.</p><p>The infection risk in physicians also increases in countries with a high prevalence of SARS-CoV-2. In Italy, more than 3,000 health providers were infected becoming an increasing concern among health providers worldwide. In Ecuador, 24 doctors have been tested positive for the virus one month after the first patient's admission with COVID-19. The rising number of physicians testing positive for COVID-19 raises concern amid a growing outcry over the shortage of protective equipment and medical supplies [<xref rid="REF13" ref-type="bibr">13</xref>].</p><p>Guayas, with 607 confirmed cases, is by far the most affected province by COVID-19 in Ecuador. Measures applied in the rest of the country with relative success failed in this province. The out-of-control increase in confirmed cases poses the risk of collapsing the health care system there. This situation led the government to declare the province as a national security zone, leaving operational planning to the army [<xref rid="REF8" ref-type="bibr">8</xref>,<xref rid="REF14" ref-type="bibr">14</xref>].</p><p>Transmission</p><p>The transmission was described as animal-to-person in affected patients at the Huanan Seafood Wholesale Market of Wuhan [<xref rid="REF15" ref-type="bibr">15</xref>]. At the moment, person-to-person transmission and fomite transmission have been linked with the spread of the illness [<xref rid="REF16" ref-type="bibr">16</xref>]. Li compiled information on the dynamics of the novel virus, estimating a transmission rate of R0 2.2 for COVID-19 [<xref rid="REF7" ref-type="bibr">7</xref>]. In addition, Cascella mentions that close contact with an infected person is needed to transmit the virus. Therefore, relatives and health professionals are at greater risk [<xref rid="REF15" ref-type="bibr">15</xref>].</p><p>There are some discrepancies about the transmission. While some studies support the animal-to-human transmission, including a case of a pet that tested positive for COVID-19, the CDC states that there is no evidence that pets can transmit the virus or present the symptomology of infection [<xref rid="REF17" ref-type="bibr">17</xref>-<xref rid="REF19" ref-type="bibr">19</xref>].</p><p>Prevention</p><p>The main goal in the control of a pandemic outbreak is to achieve R0 less than 1 (one positive patient can infect less than one extra person). To reach this goal, prevention is paramount [<xref rid="REF15" ref-type="bibr">15</xref>].</p><p>The WHO and CDC recommend avoiding contact with symptomatic people and agglomerations [<xref rid="REF20" ref-type="bibr">20</xref>-<xref rid="REF22" ref-type="bibr">22</xref>]. Basic hygiene practices, such as constant hand washing and the use of face masks in symptomatic patients, are also recommended to prevent the spread of the virus [<xref rid="REF20" ref-type="bibr">20</xref>].</p><p>Many countries utilized quarantine and mobilization restrictions to control the spread; however, these measures may not be sufficient in developing countries such as Ecuador [<xref rid="REF23" ref-type="bibr">23</xref>].</p><p>Pathophysiology</p><p>The cause of COVID-19 is a ribonucleic acid (RNA) virus of the Coronaviridae family called SARS-CoV-2. Although the exact pathophysiology of SARS-CoV-2 is unknown, its structural similarity with other viruses of the Coronaviridae family allows an understanding of its dynamics and the evolution of the disease [<xref rid="REF16" ref-type="bibr">16</xref>]. The clinical presentation may vary from flu-like symptoms to severe pneumonia similar to SARS-CoV and Middle East respiratory syndrome-related coronavirus (MERS-CoV) [<xref rid="REF24" ref-type="bibr">24</xref>].</p><p>Channappanavar and Granlinski mention that the most aggressive strains of the Coronavirinae family, like SARS-CoV, have protein E in their envelope that stimulates NF-kB, a protein complex involved in cellular responses, including stress, cytokine signaling, response to viral infections, and apoptosis. Protein E, along with other proteins, interferes with the host immune response (tumor necrosis factor (TNF) alpha and interleukin 6 (IL-6)) [<xref rid="REF24" ref-type="bibr">24</xref>]. These processes produce uncontrolled inflammation, resulting in lung edema and fibrosis [<xref rid="REF24" ref-type="bibr">24</xref>-<xref rid="REF25" ref-type="bibr">25</xref>]. </p><p>Treatment</p><p>Efforts to control COVID-19 had been made by many countries, starting with investigations to develop a vaccine from the attenuated or inactive virus [<xref rid="REF26" ref-type="bibr">26</xref>]. The National Institute of Allergy and Infectious Diseases announced the beginning of the first trial on 45 volunteers between 18 and 55 years old. This first phase is estimated to last for six weeks [<xref rid="REF27" ref-type="bibr">27</xref>]. The Kaiser Research Institute is evaluating the feasibility of the mRNA-1723 vaccine [<xref rid="REF28" ref-type="bibr">28</xref>].</p><p>The management of patients with acute respiratory syndrome consists of assisted oxygen ventilation to achieve a saturation percentage of oxygen (SpO2) of 90% and antipyretics [<xref rid="REF16" ref-type="bibr">16</xref>].</p><p>Multiple drugs are being studied to treat COVID-19, with promising results. In the United States and China, a randomized clinical trial has been initiated to test the efficacy of remdesivir [<xref rid="REF29" ref-type="bibr">29</xref>]. At the moment, oseltamivir, a neuraminidase inhibitor, has been used more extensively [<xref rid="REF16" ref-type="bibr">16</xref>].</p><p>Chloroquine, a drug used worldwide, has a promising effect in the treatment of severe pneumonia by COVID-19 at a dose of 500 mg<sup>2 </sup>times a day [<xref rid="REF30" ref-type="bibr">30</xref>-<xref rid="REF31" ref-type="bibr">31</xref>]; however, Zhou questions its use due to its side effects. Instead of using chloroquine, Zhou suggests hydroxychloroquine as an alternative treatment [<xref rid="REF32" ref-type="bibr">32</xref>]. Hydroxychloroquine seems to attenuate the progression to more severe scenarios of COVD-19 infection, although its dosage still needs further study [<xref rid="REF31" ref-type="bibr">31</xref>].</p></sec><sec sec-type="conclusions"><title>Conclusions</title><p>The low mortality of COVID-19 may be the reason for developing countries underestimating the magnitude of this pandemic outbreak. The health care systems risk collapsing due to the increasing number of confirmed patients who need intensive care and the spread of the disease in health providers. The high demand for financial and human resources by this disease leads to a collateral increase in mortality from other causes. The COVID-19 pandemic outbreak has shown that there is still room for improvement in healthcare systems worldwide to prevent its catastrophic impact, especially on the fragile and often unprepared systems in developing countries.</p></sec></body><back><fn-group content-type="competing-interests"><fn fn-type="COI-statement"><p>The authors have declared that no competing interests exist.</p></fn></fn-group><ref-list><title>References</title><ref id="REF1"><label>1</label><element-citation publication-type="website"><article-title>CNN. ¿Cuál es la tasa de mortalidad del coronavirus? 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