Since the beginning of the year, the epidemiological curve of the Ministry of Health graphs has registered an increase in cases, which has caused hospital centers to become saturated, mainly in Quito and Guayaquil, but also in other locations in the country as well.

Given this, the cantonal and national COE issued restrictions for the Easter holiday with which they sought to stop the spread of contagion. Among the measures are the vehicle restriction and the announcement of a state of exception in eight provinces of the country, which would allow the declaration of a curfew.

Ecuador is not the only country that has been registering an increase in cases, other countries in the region and on other continents are experiencing the same situation. However, there they have been called a new wave of infections; since the beginning of the pandemic many of them have already had at least three, especially in Europe.

In the country, the authorities have not yet named it this way and in a national broadcast on March 30, President Lenín Moreno pointed out that there was a “setback” in the fight against COVID-19.

Rebound in cases or new wave of infections?

Last Sunday, during the session of the Guayaquil COE, Dr. Carlos Farhat, an epidemiologist and a member of the health table attached to the instance, pointed out that in Guayaquil there could be talk of a significant upturn in cases and that the definition of second wave is merely one of interpretation.

“If the number continues to increase, increase and exceed, overflowing the attention span, then we would definitely be facing a second wave,” he said.

Epidemiologist Daniel Simancas, Director of the Center for Research in Public Health and Clinical Epidemiology at UTE University, explained that there is talk of a wave when the number of cases has been reduced to zero and it is reactivated, which is why Ecuador has not yet experienced it. But that could be because of the small number of tests that are carried out, which makes us see a part of reality that is not even that close.

“Talking about a second wave, talking about a sustained increase in cases is the most technical thing, a peak they call it, a rebound in cases and also an increase in deaths, the excess of deaths compared to previous years and also the increase of consultations, hospitalizations and people who require intensive care, when the waiting list increases, that is, a patient does not find where to hospitalize and does not find where to enter intensive care is striking ,because it makes us think that the partial prevention strategies are taken and yet it is emerging, the effect of mobility restrictions has failed and there has been a very important increase, ” he said.

Another epidemiologist and former external adviser of the Pan American Health Organization (PAHO), Catalina Yépez, believes that in Guayaquil at least, there is a second wave of infections. She clarifies that although other countries, especially in Europe, already speak of a fourth wave, in South America there is talk of a second wave, although in Ecuador the discourse has only discussed a first wave with different peaks

“In my opinion, according to epidemiological behavior, we are in a second wave, at least in Guayaquil, and in neighboring provinces such as Manabí, Los Ríos, it has not yet arrived, but in Guayaquil it has. Fundamentally, what is influencing this is the introduction of new variants, and that the entire population is not immunized since the first wave. As long as we continue to have susceptible people, we are going to continue giving the virus the opportunity to continue infecting, and we give it the opportunity for it to continue replicating itself until we find the best possible way to evade any encirclement of us to infect ourselves,” she said.

There are indicators that show the seriousness of the situation, according to the experts, such as the increase in hospitalizations and deaths. The disease does not generate a serious condition in all, meaning not all are referred to a hospital, and they manage to go undiagnosed, leaving an underreporting of other cases that may not show such severe symptoms.

Election could be a super-spreader event

During this time, several events have marked the mobility of people: on February 7th, in the first electoral round and February 15th and 16th, with the Carnival holiday, where acts of social disobedience were recorded. This last event definitely caused an increase in COVID-19 cases, although specialists mention that there is an underreporting of people who cannot undergo diagnostic tests due to their high cost.

Simancas and Yépez differ on the impact that the first electoral process could have on the situation the country is going through now, because not all citizens were exposed to the same situations. During that day it was reported that in several precincts there were long lines and crowds of people, while in others the voters did not take long to complete the process.

“This is a source of exposure and a very high-risk situation; military personnel must be trained,” said Yépez.

Simancas says that this event does not have a greater importance than what it is intended to be, because the majority of the population used biosecurity measures such as the mask. He points out that what happens after the process, such as a family or social gathering that takes place, is what would spread the virus.

According to specialists, in an ideal scenario, where measures are complied with, and adequate risk communication is carried out, the congestion of the hospital system and the number of serious cases could be decline in two and three months. However, if strict physical distancing, proper use of a mask and disinfection are not carried out on April 11th, it could take until June, July or August to see a decline

“With an event like April 11th, if the bull is not taken by the horns and it is not decided that there must be a strict physical distancing and we do not send clear messages to the population that they have to take care of themselves, they have to be with the mask, then what is going to be is that we are going to be about to finish the second wave, but then we are going to see the impact of April 11 and we would not get out of this until June,” said Yépez.

Simancas says, “We have a saturation that will last two or three months as we are seeing, if the same happens in Easter, if the same happens in the elections, we have about two or three months [of increase in serious cases], we will see a decrease in cases only by the end of July or the first weeks of August.”

Citizen behavior becomes risky

There are several factors that have influenced Ecuador’s rise in cases in recent weeks and the increase in waiting lists to get a hospital bed. One of them is citizen behavior, both disobedience and non-observance of the recommendations given in the last thirteen months.

This is not a phenomenon occurring only in Ecuador: it is happening worldwide, where people are resuming social habits that they had without caring about the risk to which they are exposed, although they know it, or come to think that they will not be able to be infected because they have already overcome the virus.

“ People are with pandemic fatigue, they cannot bear being locked up, the restrictions, they are claiming their freedom and are aware that the risk is to die, unfortunately it is not an individual risk, it is a collective risk and when the rights affect another then there is vulnerability of rights when one disrespects the regulations, that is not understood, the majority of the population has collaborated, but it is time that we have another strategy to control the virus,” said Simancas.

He adds that due to the dynamics of the disease, a person who was infected during a holiday can spread the virus between ten and fourteen days to other people, and these in turn in the same period to others, creating a ball of contagion in people who relaxed, which will lead to saturation.

These decisions are also motivated by a perception of inaction on the part of the authorities, since several ideas are repeated that despite the time of restrictions, they have not been able to control the pandemic or do not accentuate the idea that the virus is still in transmission community.

“There comes a time when people, especially the youngest, want to return to that normalcy that they had in November, December 2019, January 2020, have a gesture of rebellion that is being seen all over the world, disguised in bravery, and that’s why they meet in meetings, they stay in crowds, they get together, they believe that nothing is going to happen, they believe that everyone has already been infected,” said Yépez.

Government communication and planning failure

Another factor that the epidemiologists identified is a failure in communication by the Government about the risk that the population still has with COVID-19, in part because of the arrival of some vaccine doses and with them, the perception that the pandemic was close to completion.

Simancas said that citizens’ thinking changed compared to the beginning of the pandemic due to an ambiguous message from the authority “that this pandemic is over, that there is how to mobilize, that we must lose our fear of the virus to try to win. Or to reactivate, in quotation marks, the economy when it is known that without health it is very difficult for the economy to be saved.”

In the citizen, there remains a perception that the actions that have been used for more than thirteen months have not been as effective or are improvised, and that is in part due to the government’s failure to communicate, or to plan.

Yépez points out that the virus’s own behavior already anticipated that there would be a new increase in infections, however, there was no planning for its impact to be less, through the increase of hospitalization beds or ICUs, or the acquisition of medicines and more.

“The codes of conduct with which we human beings also go through a lot, because of what we see, a lot goes through the examples we observe, so if we see that leaders crowd together, they come together, they make decisions that they know are dangerous, yes they do it, why am I not going to do it myself … If you see that the message is not going to end in the population, do the other thing, get ready,” she added.

Regarding the vaccination process, the experts said that it should be intensified, while leaving a clear message in the population that this is only a tool that will help reduce hospitalizations. And, that despite being vaccinated, biosecurity measures must still be followed as the pandemic has not yet gone away.

Incidence of variants in the increase in cases

Yépez and Simancas point out that variants are also one of the factors that increase the cases in several areas, however, they are not yet playing a fundamental role in generating the saturation of the health system as it is being experienced.

“The virus has not changed its way of spreading, of aggravating, it is more contagious, the new variants are more lethal, but the way of containing the virus has not changed, they are the same prevention measures, strategies must be increased,” Simancas stressed.

At the national level, the Universidad San Francisco de Quito (USFQ), Universidad de Especialidades Espíritu Santo (UEES) and the National Institute for Public Health Research (Inspi) are in charge of genomic surveillance of the virus through the identification of variants, although the work has mainly been concentrated in the first two institutions. At the country level, around 300 sequences of the virus have been made.

At the national level, there are two variants that raise concern: the English variant B.1.1.7 (in community transmission in Quito and Guayaquil) and the New York variant B.1.526 (detected in Guayaquil).

Both Fernando Espinoza, director of the UEES research unit, and Paúl Cárdenas, a researcher at the USFQ Institute of Microbiology, point out that these variants do not yet play a relevant role in explaining the situation in the country, and they agree with epidemiologists that there are other factors that predominate, also motivated by the economic situation of the families, but they are still concerned.

“With this virus, to say what happens next week, this moment, I would not dare. Generally, I have been very optimistic throughout this year, but curiously I am seeing what is happening in Chile, the scandal that is happening in Brazil, what is happening in Italy … it has me worried that the variants may bother us more than I had thought,” said Espinoza.

The two variants have the characteristic of greater transmissibility; the English one has also been proven to increase mortality.

“We have seen that the variants that are in the south of Colombia are passing to Ecuador and are even reaching Guayaquil. Mobility, despite the fact that the borders are closed, is very high.

We do not realize that we already have national flights, international flights, all land transport is working, but definitely what we have is this human mobility that then leads to that the variants reach the different cities,” added Espinoza.

In the last 45 days, in the sample runs that Espinoza has carried out in Quito, 20% of the new cases had the English variant, 10% corresponded to the New York variant and the rest to others already identified over the last year.

Cárdenas said that in the case samples he has run, 12-20% have been the UK variant. He believes that these variants may be part of the cause of reinfections, but that the possibility also exists that people may have already lost their immune response after being infected between March and April.

“In the genomic surveillance analysis of the last months that we have carried out in Quito, and in other provinces of the country, we continue to find between 12% and 20% of cases have this new UK variant. Obviously, in a few weeks this may change, and we may see this 12% to 20% increase to 30-50%, as has happened in other countries, which means that these variants could have a relevant importance in the increase of cases.”

“So far, I think the variant factor plays an important role, but we cannot say that it is a determining factor yet. Most of the cases that we are finding are still variants that have already been previously reported in the country,” said Cárdenas.

Actions to take and reduce cases

Before learning about the new measures dictated by the national COE and President Lenín Moreno, the specialists agreed that the mobilization of people should be avoided as this increases the probability of contagion by generating greater interaction among citizens.

Yépez says that the surveillance of variants must continue and called on this year’s Presidential candidates to send messages of non-crowding and care, so that their supporters respect them.

“April 11th has to be a sum of efforts from the State, the population so that it is precisely a civic act, but also that it does not end up generating a crisis greater than the one we have,” she said.

Simancas said that contact tracing should also be used to identify cases, and that it has been suggested to have a zone of isolation of patients with mild or moderate symptoms to reduce the rate of secondary attack, that is, isolate them until the picture passes.

“With tests, with tracing, with vaccination, this is how the economy is reactivated, so you can set people free without compromising your mental state and without compromising your risk of death, you cannot take people out and tell them to lose your fear of the virus when you have no bed to hospitalize and intensive care, when there is no access to free or low-cost tests, then the best and most cost-effective way to reactivate the economy is by generating various public health strategies to contain this pandemic,” he said.