Tracking the spread and outcome of the coronavirus in Ecuador: UPDATED FOR TUESDAY, DECEMBER 1, 2020
The big question this week is where we stand with the spread of COVID-19 in Ecuador’s larger cities, and what does the government say about the numbers.
Because the two pieces of information are not in synch.
Last week Dr. Francisco Pérez, director of policies and planning of the Ministry of Health of the Municipality of Quito, was interviewed about the situation in that city.
First, he let it be known that he “did not have the data” on how full the hospitals were in his city. He said that information is managed by the national Ministry of Public Health—seemingly implying that the national Ministry of Health is not telling the Quito Ministry of Health how many people are in its city hospitals.
He did, however, say that over the last few weeks they (the Quito Ministry of Health) have seen an increase in the number of hospitalizations for the virus and that “the situation of intensive care beds continues to be what it was previously….it has high occupancy and there is a waiting list… that is not as long as in the first months of the pandemic.
Dr. Pérez also said that the cases of COVID-19 in Quito remain constant. He added that in the last three weeks, there has been more or less a sustained contagion, of “around 2,000 cases a week.”
He then implied that since this is happening during a period of increased mobility, it is not an “abrupt explosion” of cases, and that the city is achieving its goal of keeping the cases under control.
That’s an interesting take on the situation. But it is not as bad as the one offered by National Minister of Health, Juan Carlos Zevallos, who also claimed last week that “in the three weeks following November 3rd holiday, there has been a decline in the number of cases nationwide, although that may vary between provinces and between cities.”
He also said that the number and demand for hospital beds has not changed.
Regarding Quito, he said that the number of cases is contained and in Guayaquil there has even been a decrease in infections in the last week.
Regarding the contagion rate of the coronavirus, he said that according to the latest report, it is below 1.0—which is the ideal number to contain the pandemic—nationwide, with the exception of Napo, which has 1.10.
“Basically, at the national level, they have controlled (…) this situation that we are going through in Ecuador, in particular, is very different from what is happening in neighboring countries and is very different from what is also happening in Europe, that rebound that we have seen, that second wave that is talked about in Europe, we have not seen it here until now …,” he said.
Now, with that as background, we will say that none of this matches with the numbers provided by the Ministry of Health to the public. In our analysis of the data, the number of hospitalizations rose slightly from three weeks ago, and the number of patients being placed in an ICU bed, and the number of deaths, also have both risen consistently over the last three weeks (see the attached graphs).
As for the number of new cases, Zevallos said they have been falling over the last three weeks, which may have been true on November 25th. However, on November 29th, the government itself reported 6,474 new cases this week. Last week it reported 5,348 news cases.
As opposed to a decline, this is a 21% increase in the number of new cases reported over the last week.
Finally, with respect to the contagion rate “below 1.0”, we have no idea where Zevallos is getting that number from.
According to the website http://metrics.covid19-analysis.org/, the actual Rt number (i.e., the effective reproduction number or, as Zevallos calls it, the rate of contagion) on the day Zevallos made his announcement, was 1.18 (with a range in the country of (1.15-1.21).
Now, while this may seem like splitting hairs, it is not. The difference between being below 1.0 and above 1.0 tells public health researchers whether the virus is spreading, is in check, or is backing down.
To be clearer, the effective reproduction number (Rt) characterizes the COVID-19 spread rate, defined as the average number of secondary infectious cases produced by a primary infectious case. It’s used to define the potential for spread at a specific time.
If Rt > 1, the virus will spread out and the disease will become an epidemic; if Rt = 1, the virus will spread locally and the disease is endemic; if Rt < 1, the virus will stop spreading and the disease will disappear eventually.
With this information in hand, we believe that the numbers, and what the government is reporting, are not in synch. And, that the country still has some danger of the virus spreading faster and further as we are seeing in Europe and the US.
Clearly there is a significance difference between what Zevallos is saying and what is the reality of the situation here in Ecuador.
It is not a time for the Minister of Health to be offering the idea that Ecuador has somehow “taken control” of the virus. It is a time to be more vigilant and to ensure that the provincial controls are strong and are being monitored.
Using the other numbers from the Ministry of Health
As we wrote last week, most of the numbers that are coming out from the government each week are only somewhat of a “barometer,” something to tell us what direction the spread of the coronavirus is going in.
It is not an actual weekly count of cases, as the government continues to run a backlog of samples (almost46,000 of them this week), that are tested in a somewhat disorganized way.
Since multiple labs are testing the samples, and they have multiple sample collections sets, there appears to be no rhyme or reason as to why a certain week’s tests of samples are being completed and reported. Nor is it clear that the test results are from multiple other weeks, not necessarily the week they are reported.
To make this clearer, a few weeks ago we began providing a new graphic that tracks how many cases were added or subtracted to the national number, by the epidemiologic week. So, you can see how for example, that6,474 of the cases added to this week’s national numbers were actually spread over 39weeks. Of the 6,474 new cases reported this week, only 1,672 were from samples collected last week.
What this also means, is that we can never get a true number of how many cases happen in one week, since this backlog reporting is a continuous problem. In other words, if we try to only look at the 1,672 cases that the government posted for new cases for this past week, we would not be taking into account any numbers they add to this epidemiologic week in the future. That number will most certainly rise.
So, we will never have a “fixed” number that pinpoints exactly how many cases occurred in what week. The only solution for that problem would be if the government suddenly catches up on its sample backlog and can ensure that the weekly reports are done in real time.
Again, because of this, we are now taking the stance that the best real indicator of improvement (or worsening) of the COVID-19 situation will be the daily number of hospitalizations, and recorded COVID-19 deaths. For this reason, a few weeks ago we added a new data set of hospitalizations, and a new graphic illustrating those numbers.
Case numbers are no more than historical snapshots
There are a lot of ways to slice the datasets into individual provinces, sample collection dates, test completion dates, and even percent of backlogged tests versus completed tests. But the point to be taken from all of this is that the current method of sample collection to test completion is unreliable and the results of those tests offer little in terms of epidemiologic study.
What we see in general across all the provinces, is a time-delayed snapshot of what was going on in the country. Obviously the farther out we get from a specific fixed date, the more accurate this historical reference becomes. But it does not allow a response to virus: epidemiologists can’t identify “hot spots” or causation for most of the new cases.
Four weeks ago, Minister of Health Zevallos, acknowledged that there are thousands of backlogged tests but said that, as of November 1st, a new change was made in the system so that, in “the next phase” there will be timely data.
Last week, we finally began to see the beginning of that. Ecuador reduced its backlog of test samples by more than 8% last week and continued to reduce it this week by 5.24% (or 2,406 tests).
Now, there is a caveat here: there are still over 43,500 tests in the backlog. This week the government completed 2,406 more tests than the number of samples it collected. Which means that it could take as many as 4-5 months to clear the backlog in its entirety.
So, until we see the number of tests in backlog no more than two or three weeks behind, and see more samples being tested than collected, we will not be using the number of new cases reported each week as a measurement of improvement in the crisis.
How to make use of the data
What the government’s failure in the testing program tells us is this:
- The positivity rate is of little value due to spot testing.
- Weekly assumptions about increases in infections are false.
- At most, the reported numbers can only help us to identify trends in the spread of the virus.
- The graphical charts provided for the nation, Pichincha, Guayas, Manabi and Azuay, do offer both historical and real-time figures of infection and can be considered to be useful tools. However, even in these charts, there will be trailing test results that cause a skew in the data.
- Deaths and hospital admissions and transfer to ICU beds (which are reported daily by the hospitals), may be the best way to track the pandemic in Ecuador.
With these things in mind, while we will continue to track and report the analysis of some of the numbers as we have been, we will put additional emphasis on the reported number for hospitalized patients and reported deaths(see attached datasets and graphs). We have added a new section to the “COVID-19 Test Results” spreadsheet that gives a picture of the hospitalizations rates.
In four provinces—Pichincha, Guayas, Azuay and Manabi—and on a national level, the graphical charts provided by the Ministry of Health (page 3 of the graphical charts) do offer some real-time analysis of the rate of infection, if they are compared to the preceding week.
However, there will still be a trailing of results that will mean that each of these graphs will completely change each week, and there may be peak weeks that will not show up in the graphs until weeks later.
So, while they are the best set of data available from the poorly run testing program, the interpretation of the data should always be suspect.
Test collection and processing pales in comparison to other countries
Ecuador continues to behind six other South American countries (Brazil, Peru, Colombia, Chile, Venezuela and Argentina) in both the total number of tests given and the rate of tests per million people.
Based on the Ecuadorian Institute of Statistics and Censuses (INEC) population projections, Ecuador has only tested about 3.66% of its population. With 649,551tests completed, Ecuador has tested 36,590/1 million people, sitting at 147th (down from 146th) out of 215 countries tracked worldwide. This is dismal when compared to Ecuador’s direct neighbors.
Its neighbors Colombia, Peru and Chile (who’s population is size is closest to Ecuador at 19.18 million people) have tested 12.43%, 15.20% and 27.61% of their populations, respectively.
Colombia has tested 124,300/1 million people and ranks 94th on the list. Peru has tested 151,992/1 million people and ranks 87th on the list. Chile has tested 276,067/1 million people and ranks 49th on the list.
[Chile only has 8.1% more people than Ecuador but has tested 8.15 times more people!]
Venezuela, who’s economy is considered to be in the worse shape in South America has tested 8.09% of its 28.4 million people. Even Argentina, who also has serious economic issues, has tested 8.50% of its citizens.
Hospitalizations and deaths are now the focus
The number of new test results (not new cases)rose significantly slightly from 5,348 last week to 6,474 this week. The rate of new positive test results also rose again from 2.97% to 3.49%.
Again, these figures may be across several weeks, or months.
Nationally, the number of hospitalizations rose albeit slightly this week from 852 to 857, and the number of patients in the ICU rose from (slightly) 369 to 371. Added to that, the number of new deaths rose from 193 to 222; this is the fourth week in a row of a rise in that number.
So, what we can seem to count on to establish the spread and impact of the coronavirus is the reporting of the number of new deaths and hospitalizations.
The fact that the number of ICU patients and the number of new deaths are still rising, seems to be in conflict with the reported fall in the rate of new cases.
More detail on both hospitalizations and new deaths can be found in the attached graphs.
Backlog shrinks significantly
As we said above, the number of tests in backlog fell again this week by 5.24% this week, a significant improvement. The number of samples awaiting testing fell from 45,942 to 43,536.
If this trend continues, and the country reduces the number of tests it reports from prior weeks (some as old as 39 weeks), then we will return to discussing the number of new cases in our report.
Provincial death numbers rise
This week, 11 provinces had lower rates of new deaths than last week while the overall rate of new deaths rose from 1.48 to 1.68%. This accounts for 222 new deaths versus 193 reported last week. This figure has risen for four weeks in a row.
Sample collection and testing both rise
For the second time in a row, the number of samples collected, and the number of tests completed, rose together. This also happened with a dramatic fall in the number of tests in backlog (as discussed above).
This week, they collected 28,581 new (its largest increase in sample collection since October 18th), and they completed 30,987 more tests than last week; that is the largest increase in test completion since we began analyzing the data on May 10, 2020.
This is a significantly positive move; if the government can continue to do this week after week, then epidemiologic tracking becomes much more useful.
Here is a quick review of the graphical highlights below (as of Sunday, November29, 2020 at 8:00AM):
- 13,423deaths have been attributed to COVID-19.
- 620,970 test samples have been taken collected.
- 192,117tests have returned positive (+).
- 413,898tests have returned negative (-).
- 43,536test samples remain “dammed” or backlogged in the testing process.
- 7% of the deaths have been among the ages 20 to 49 years old.
- 3% of the deaths have been among the ages 50 to 64 years old.
- Only 13.2% of the deaths have been among the ages 65 years and older.
- 9% of cases have been on males, 47.1% in females.
- Guayas province accounts for 12.6% (down from 12.7% last week) of confirmed cases (24,277) and 25.63% (down from 25.83% last week) of the confirmed deaths (3,441).
- Pichincha province accounts for 36.2% (up from 36.0%% last week) of confirmed cases (69,513) and 16.39% (up from 16.16% last week) of the confirmed deaths (2,201).
- Azuay province accounts for at6.2% of confirmed cases (11,843) and 1.67%of the confirmed deaths (225).
- No province has escaped deaths due to COVID-19.
HOW ACCURATE ARE THE NUMBERS?
The numbers from the government are only “accurate” as historical references, since they cannot guarantee that tests completed this week are from samples collected over the last seven days.
However, the graphic accompanying this article (it is provided by the government, but has been modified for easier readability), does offer some recent graphical dated information on four provinces, and at a national level.
The numbers and statistics below are based on all case data collected by the government as of 8:00 a.m. on Sunday, November 29, 2020. More detail of all of the numbers are available in the graphics that follow.
The numbers in the graphic reflect the number of people who tested positive or negative for the virus, with both the polymerise chain reaction or (PCR) test which looks for antigens and identifies the presence of the virus in the body, and the “Rapid” test which looks for antibodies to the virus and identifies a person’s immune response to the virus. The PCR test gives an earlier identification of those who have been infected by the coronavirus and whether they have an active infection. Ecuador is now only reporting new PCR test results (however, prior Rapid tests are included in its report).
These numbers do not reflect the actual total number of people infected across the country or the number of deaths that can be attributed to COVID-19. The dates on the graphic are also adjusted back to when symptoms began, not when the positive test occurred.
For those who want a deeper level of information for a particular town or city, see: https://www.gestionderiesgos.gob.ec/coe-nacional/