key: cord-0707614-u7ywd2nq authors: Alava, Juan José; Guevara, Angel title: A critical narrative of Ecuador's preparedness and response to the COVID-19 pandemic date: 2021-04-23 journal: Public Health Pract (Oxf) DOI: 10.1016/j.puhip.2021.100127 sha: f144afa5dda6ac34d096a92451cc1a3caf2666bc doc_id: 707614 cord_uid: u7ywd2nq Ecuador’s National Health System has been severely overwhelmed by the COVID-19 pandemic despite substantial public health efforts. This was primarily due to limited health emergency planning responses. Ecuador’s COVID-19 mortality rate was 8.5% in early June 2020. The capital city (Quito), Guayaquil city and Manabí province were the most severely impacted by the COVID-19 pandemic, resulting in thousands of positive cases. Using the World Health Organization (WHO) Operational Planning Guidelines to Support Country Strategic Preparedness and Response Plan for COVID-19 as a reference point, we highlight the urgent need to implement a proactive preparedness and response plan to address the COVID-19 pandemic, with the aim of improving Ecuador’s public health system. The mitigation of COVID-19 transmission and hazard reduction is crucial in protecting the most vulnerable at-risk populations in this nation. at this time 3 . Indeed, the unprecedented public health crisis created by the global spread of COVID-19 presented unparalleled challenges all over Latin America. In Ecuador, COVID-19 has severely affected not only the nation's public health system and emergency response, but has also had socio-economic, equity and ethical dimensions. Despite the health emergency, there was a limited response from Ecuador's public health system, in addition to a slow operational capacity and strategic preparedness plan to mitigate the spread of the infection and cope with the escalating number of cases and deaths. With an overwhelmed health system, due to the high number of infected patients and delayed proactive response, COVID-19 put the health of Ecuadorians at high risk. In this commentary, we provide a brief overview of the COVID-19 emergency response to support public health and primary healthcare in Ecuador by addressing the following questions: What were the impacts of COVID-19 in Ecuador? How effective was the COVID-19 emergency response? What were the weaknesses and issues encountered with the measures adopted? What opportunities has the COVID-19 pandemic presented? Based on the lessons learned, to date, we also provide recommendations of specific health emergency response actions to improve Ecuador's health policy in terms of preparedness capacity during the COVID-19 pandemic, which can benefit other Latin American countries, and also provide relevant insights for public health policymakers and practitioners. Following the first confirmed case of COVID-19 in Ecuador on 29 February 2020 4 and the subsequent community transmission and increasing mortality during March 2020, the national borders were closed. However, at the same time, an alarming situation occurred in Ecuador's western city of Guayaquil (Guayas province) [home to ~3 million people]; a high number of J o u r n a l P r e -p r o o f deceased bodies (due to COVID-19 and other diseases) were left unattended for several days at 32°C on the streets and sidewalks, and in homes and healthcare facilities, as the hospitals were becoming rapidly overwhelmed. 5, 6 In an effort to address this health and sanitary emergency, Ecuador's government deployed a military taskforce towards the end of March. 6 Within 1 week, around 300 to 500 or 800 bodies were collected; however, many bodies remained on the streets and in homes awaiting collection. 6 The potential transmission of COVID-19 from these deceased bodies was of great concern, as COVID-19 infections and deaths of forensic medical personnel who were in contact with COVID-19 contaminated corpses was concurrently reported in Thailand. 7 Ecuador's capital, Quito (Pichincha province), was also among the most severely impacted cities by COVID-19. In early June 2020, Ecuador had ~40,000 confirmed cases and more than 3390 COVID-19 deaths, 2,3 with a high mortality rate of 8.5%. By mid-March 2021, >302,000 cases and ~16,240 COVID-19 deaths had been recorded (i.e. a mortality rate of 5.3%). 2, 3, 4 The fatality rate, however, was probably much higher as many people died of the virus without being diagnosed. In fact, during April and by early May 2020, Ecuador was becoming one of the COVID-19 epicenters in South America. 5 Ecuador's government and local governments implemented additional public health actions in an effort to communicate and educate the population about preventative measures, such as hand washing, use of facemasks and proper social distancing, while trying to maintain a functioning healthcare system. Despite the health emergency response efforts, medical personnel and frontline health workers were in great need of personal protection equipment (PPE) to protect themselves against COVID-19. Ecuador urgently requested international support to acquire technical resources, medicine and PPE. Ecuador was assisted by the Pan-American Health Organization (PAHO), who donated PPE resources for health workers during April 2020. 9 At the same time, several other Latin America countries, and European and Asian nations, including Spain, Italy, India, Iran, Iraq and Pakistan, were also severely impacted by COVID-19 and requesting international assistance. 10, 11, 12, 13 An active screening system for early detection, confirmation of cases and isolation of infected individuals, in addition to contact-tracing capabilities to track people who were in contact with infected individuals was also absent during the early stages of the pandemic in Ecuador. This In light of the COVID-19 health crisis in Ecuador, a specific preparedness and response plan for this country was required. The WHO emphasised the necessity to conduct a detailed gap and needs analysis to develop a COVID-19 Country Preparedness and Response Plan (CPRP), using the operational planning guidance for United Nations country teams (UNCTs). 14 The CPRP relies on eight fundamental pillars 14 (see Table 1 ). These pillars can proactively be tested and adapted to Ecuador's existing NHS to combat COVID-19, and also serve as a preparednessresponse framework to be applied for other infectious viral diseases. Within these pillars (Table 1) , an intense rapid testing system, with confirmation and isolation of infected individuals, followed by contact-tracing to identify those who were in contact with COVID-19 positive cases and subsequently quarantine these individuals, as well as stay at home orders and social i. Implementing the immediate closure of international borders to the most exposed countries, which are serving as sources of viral spread. ii. Deploying an efficient rapid testing programme for virus detection and effective contact-tracing capacity for isolation of symptomatic and asymptomatic individuals (e.g. super spreaders) in airports, maritime and terrestrial international borders. iii. Ensuring the availability of both abundant PPE stocks for frontline healthcare workers and appropriate medication for effective medical treatment. Neither Ecuador nor any other country in the world were prepared for such a pandemic, despite the early warnings of emerging and remerging infections by severe acute respiratory syndrome (SARS)-coronaviruses that have gone on for many years. 17, 18, 19 The proactive formulation of a response action plan to prevent the transmission of viral diseases along with adequate strategic preparedness 19 to improve the medical care capacity in Ecuador's health J o u r n a l P r e -p r o o f policy agenda is vital to protect the public health of Ecuadorians from highly contagious and lethal viral diseases in the long term. Given the lessons learned from the COVID-19 pandemic, Ecuador's health policy should be revisited to ensure that human health is proactively prioritised. Author statements  Assessing the capacity of the local market to meet increased demand for medical and other essential supplies, and coordinate international requests of supplies through regional and global procurement mechanisms (e.g. PAHO, WHO)  Identifying potential major impacts on the transportation systems of health supplies, education and food transportation networks ICU, intensive care unit; PAHO, Pan-American Health Organization; PPE, personal protective equipment. 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Gobierno de la Republica de Ecuador A Citizen science facemask experiment and educational modules to improve coronavirus safety in communities and schools Severe acute respiratory syndrome coronavirus as an agent of emerging and reemerging infection Animal Infections and the Next Human Pandemic Deadliest Enemy: Our War Against Killer Germs This work is dedicated to the Ecuadorian health personnel and frontline healthcare workers who lost their lives during the COVID-19 pandemic while assisting COVID-19 infected patients and other people affected by the virus; and in memory of Dr. Juan José Alava Párraga and Guido Alava Párraga, who were pioneers of the public health and tropical medicine in Manabí Province, Ecuador. We thank the valuable insights and comments from the reviewers to improve the article. Not required. The first author thanks the Nippon Foundation for providing research funding. None declared.