By Jaime Moreno
In Ecuador, it is important to comply with the stay-at-home order until the government announces changes, which will be based on a review of data by the country’s health authorities. This quarantine will be at least until April 20, 2020. On that date, the Ecuadorian data will have to be reviewed to make decisions.
What we are facing
Covid-19 is the community pandemic that as of March 30 affects 172 countries with 821,753 diagnosed and mortality of 40,550 people. In Ecuador there are 2,240 confirmed cases and 75 deaths. To top it off these numbers are underreported.
It is necessary for Ecuadorians to stay at home, but this mandate is difficult for the poorest Ecuadorians to fulfill, for example, on the coast where families with adults, children and the elderly may live in a room of 15 square meters at a temperature that reach 30 ° C. Public and private solidarity deserves everyone’s applause, but unfortunately it will fall short.
The fundamental strategy is to temporarily separate those with possible Covid-19 symptoms from those over 60 years who have serious pre-existing conditions that put them at greater risk. It is particularly important to protect the elderly from contracting the virus from children who may have mild or no symptoms but who may unwittingly infect the elderly.
Ecuador is already executing strict restrictions to prevent infection and to diminish the numbers of coronavirus victims, imposing national curfews and prohibiting commuting among provinces. At this point, the following terms merit definitions:
Quarantine refers to the separation of people (or communities) who have been exposed to an infectious disease.
Isolation is separation of people known to be infected. In some countries these two terms refer to both types of interventions. (Parmet WW, NEJM 18 Mar 2020).
Mitigation is not stopping the amplification of the disease, it is accepting that many people will get sick. Mitigation measures include hygiene recommendations such as hand washing, social distancing, staying home, and if there is an infected case, exams and isolation of contacts. Mitigation is designed to diminish the speed of the infection over a long period of time, more than acting on the acute peak of the epidemiologic curve, with the hope of vaccine developments.
Suppression is to stop the pandemic at its outset. In a short time. It implies stringent restrictions to all movement including public and private transportation, austere curfews, canceling all social activities, closing restaurants, movies, and schools, and more rigorous testing. (Brown A., Mar 2020; Huzar T., Mar 20, 2020).
Currently in Ecuador, Covid-19 suppression is the only viable strategy!
Possible Covid-19 propagation scenarios in Ecuador
Without the controls ordered by the government on March 16, the Covid-19 could reach a peak of 10 million Ecuadorians infected over two months. With a case fatality rate of one percent, there would be 100,000 deaths. If it were possible to detect and isolate 75 percent of those infected without imposing restriction on mobility, the peak of infection would be delayed for more than a year, giving more time to prepare. Even so, during the peak there would be more than two million infected.
Fortunately, the government’s emergencia sanitaria declaration is designed to prevent this scenario.
Restriction of intra-provincial mobility to 25 percent combined with the detection and isolation of 75 percent of those infected could reduce the infection peak to 700,000 and delay it for two years. The model is implemented on a provincial scale. It is recommended to change the scale to cantonal or parochial, which requires disaggregated data at that level. This would help to focus mobility restriction measures geographically and increase the effectiveness of controlling the epidemic.
Taking into account the incubation period of Covid-19, the effects of any measure would take two weeks to be observed. It will be necessary to carefully adjust the measures over time in order to balance the economic and social activity of the country with the control of the epidemic to avoid the collapse of the health system.
The model presented here is preliminary and has not yet been peer-reviewed. (Hernán Aguirre, LIA-MODO, Shinshu University, Japan, Mar 21, 2020)
The search for effective treatments
At this time, there are no effective and safe antiviral medicines to treat Covid-19. As expected, research is active worldwide, with over 100 well designed and funded studies. One of the pharmaceutical companies that manufacture and distribute hydroxychloroquine (Plaquinol in Ecuador, Plaquenil USA) says that a 30-patient in-vitro study is too preliminary for clinical use. As an example, Columbia University, New York, is starting one of the randomized clinical trials with 1600 participants: “Hydroxychloroquine Post Exposure Prophylaxis for Coronavirus Disease” to answer the question if Plaquenil is effective and safe to treat Covid-19. We should wait for results as soon as possible.
The coronavirus Covid-19 is an RNA virus, which already has numerous mutations, so the development of vaccines will also take time. Let us remember that after 39 years there is no etiological treatment or vaccines for HIV. (Baden LR, NEJM Mar 18, 2020; UpToDate Mar 25, 2020; ClinicalTrials.gov Mar 25, 2020).
More studies are needed!
Doctors and more health workers
This vulnerable group should have sufficient incentives and PPE (Personal Protective Equipment): suitable gowns, caps, masks, eye protection, gloves.
We must support all of the Ecuadorian doctors and more health professionals, who with knowledge and faith work tirelessly throughout the country.
We should offer them rational schedules that will allow them enough resting periods to overcome stress and physical tiredness. There is a dire need for a paradigm shift, a culture of work change that increases the resilience of health professionals including physicians and nurses, and also administrative and cleaning personnel and janitors. We must change the understanding of what is needed to fight this pandemic — this is, indeed, a war strategy.
In Cuenca there are less than 60 ventilators and more than 1,000 victims that will probably need them.
In the United States there are 62,000 high-capacity ventilators and 98,000 medium capacity ventilators. The CDC estimates that 2,400,000 Covid-19 victims may need them. Under these circumstances, the health professionals’ decision will be to choose ventilators for younger patients over older ones — a truly horrifying prospect. (Truog RD., NEJM Mar 23, 2020)
Dr. Jaime Moreno Aguilar Hematología-Laboratorio Consultorios Santa Inés, Torre 1, Oficinas 003 y 102 Daniel Córdova y Federico Proaño Teléfono: 072843136
Celular 1: 0997281884