CLINICAL ARTICLE

Infectious Disease in Ecuador

Jose R. Guxman, Hugo M.Jurado, and Michael A. Kron

The republic of Ecuador, which has a population of for diagnosis, treatment, and prevention of infectious
10 million, is one of the smallest of the Andean coun- diseases in international travelers.
tries in South America. Although it covers only an area
of 110,000 square miles, it yields an extraordinary diver- Bacterial Disease
sity of infectious diseases. Public health problems reflect
socioeconomic realities and uniquely diverse climates, cul- Cholera
tures, and geography.Equador extends h m the Galapagos The pandemic of cholera caused by the ElTor strain
Islands 600 miles to the west, to inhabited Andean high- of Vibrio colerae, which reached Central and South Amer-
lands with altitudes over 15,000 feet, and to both the ica during 1991-1992,produced an estimated 63,000 cases
coastal and Amazonian rain forests. Health statistics in of severe symptomatic disease in Ecuador. Sporadic cases
Ecuador are widely variable by western standards. Life of endemic cholera now exist throughout the country.'**
expectancy is 64-68 years, and infant mortality rates are The combination of inadequate sanitation, lack of know-
up to 60 per 1000.The physical and geographic barri- ledge of the disease characteristics in large segments of
ers to health care facilities are highly variable in differ- the lower socioeconomic classes, added to cultural risk
ent provinces.This was evidenced dramatically by recent factors, such as preparation of seafood with little o r no
death rates from cholera in 1991-92, which ranged fiom cooking (e.g., ceviche), were all responsible for the rapid
0% in Guayaquil to over 50% in isolated highland villa-
ges or in the Oriente (eastern provinces). Major cities,
provincial borders, and selected topographic features are
illustrated in the accompanying map of Ecuador (Fig. 1.)
This review reports data on some of the major in-
fectious diseases existent in Ecuador. Emphasis is on the
viral, bacterial, protozoal, or helminthic diseases, which
are uncommon elsewhere in the world, but which are
prevalent, or especially important to public health offi-
cials in Ecuador. Table 1 lists reportable disease categories
in Ecuador, 1986-1993. Recognition of the diversity of
infectious agents endemic to Ecuador may prove useful

Jose R. Guzman, MD: National Center for Tropical Medicine,

University of Guayaquil, Guayaquil, Ecuador, National
Institutes of Health of Equador, lnstituto Leopoldo lzquieta
Perez, Guayaquil, Ecuador; Hugo H. Jurado, MD: National
Center for Tropical Medicine, University of Guayaquil,
Guayaquil, Ecuador; and Michael A. Kron, MD: Department
of Medicine, Michigan State University, East Lansing,
Michigan, U.S.A.
Reprint requests: Michael Kron, MD: Department of
Medicine, 8338 Clinical Center, Michigan State University,
East Lansing, Michigan 48824 Figure 1 Map of Ecuador noting provincial boundaries, major
( J Travel Med 2:89-95, 1995) cities, and important geographic features

89
90 J o u r n a l of Travel M e d i c i n e , V o l u m e 2, N u m b e r 2

Table 1 Reportable Human Infectious Diseases in Ecuador*

Bacteria Virus Protozoa Helminths
Cholera Influenza Leishmaniasis Paragonimiasis
Typhoid/paratyphoid Polio Chagas Ec hinococcosis
Tuberculosis Yellow fever Malaria Onchocercosis
Plague Encephalitis (VEE) Cysticercosis
Brucellosis Rabies
Leptospirosis Herpes
Typhus Influenza
Leprosy Measles
Diphtheria Mumps
Meningococcal disease Rubella
Tetanus Dengue
Parotiditis SIDA
Syphilis/gonorrhea
Diarrhea (all causes)
*Adapted from Ministry of Health statistics, 1992’

dissemination and morbidity of cholera in Ecuador. In mimicking the chronic dermatologic manifestations of
Guayaquil, 3750 cases of cholera were documented in a onchocercosis has been reported as an atypical manifes-
3-month period, from January to March of 1991. Over- tation of yaws in Ecuador. Unusually high rates of
all, clinical characteristics of the disease in Ecuador were
similar to those reported in other countries, with up to
50% of persons experiencing severe nausea and vomit-
ing, which initially precluded the use of oral rehydration
solutions.

Battonellosis
Acute febrile illnesses and chronic verrucous disease
caused by strains of Bartonella bacillijormis are endemic in
two Ecuadorian provinces, Loja and Manabi (Fig. 2). For
many years, speculation has existed as to the presence of
different strains of B. bacillijormis in Ecuador. This is
because the severity of illness documented in Manabi
appears distinct from the acute hemolytic disease, Orroyo
fever, which is common in southern Ecuador and in Peru?
Organisms can be seen in silver-stained histologic sections
of verrucous skin lesions, which are morphologically
similar to the agents of bacillary angiomatosis or cat
scratch disease.Analysis of serologic responses (IFA) and
ribosomal DNA analysis of one Ecuadorian strain of B.
bacill$rmis, at the Centers for Disease Control, Atlanta,
Georgia, has confirmed the existence of bartonellosis in
the lowland province of Manabi (M. Kron et al., unpub-
lished observations.)

Yaws
Yaws (pian) is endemic in the northern coastal
province of Esmeraldas.Typicalclinical disease produced
by strains of Eeponemapertincre is contracted by direct con-
tact with infectious lesions. Disease is characterized by
multiple, large ulcerating papules (Fig. 3). Irregularly
depigmented cutaneous lesions, o r “leopard skin”,
Figure 2 Bartonellosis in a 14-year-old Ecuadorian resident
of Manabi. Friable, chronic verrucous lesionstypically appear
on the hands and lower extremities. Biopsy of the lesions
reveals chronic inflammation, and endothelial cell swelling.
Organisms are visible on silver-stained sections.
Guzrnan e t a l , I n f e c t i o n s i n E c u a d o r
seropositivity have been reported in residents along the
Santiago and Cayapa riven4
Viral Disease
Dengue
Acute febrile illness from dengue serotypes 1,2,and
4 are endemic in urban and rural areas throughout
Ecuador.' The principal mosquito vector, Aedes aegypti,
is widely distributed in the urban areas of the province
of Guayas. Entomologic indices, which measure num-
bers of mosquito larvae per household, are often greater
than 50 in Guayas.Values greater than 16 reflect condi-
tions highly conducive for vector borne disease epi-
demics. Concern has arisen in recent years subsequent
to the isolation of new dengue serotypes from the neigh-
boring countries of Brazil,Venezuela,and Colombia.This
is because some of the new serotypes are associated with
severe hemorrhagic dengue complications following
prior exposure to less virulent strains. In a country where
yellow fever is endemic, concern has also arisen over the
possibility that minimal cross reactivity between selected
antigens in the available yellow fever vaccines and new
Figure3 Yaws: extensive ulcerating macules and papulestyp-
ical of yaws in northwestern Ecuador
91
dengue serotypes, might predispose vaccinated persons
who first contract new strains of dengue to develop the
more severe hemorrhagic disease. In vitro, cross react-
ivity between antigens of dengue virus and yellow fever
has not been confirmed. Nonetheless, noncompliance
with yellow vaccine vaccination may be encountered in
areas of Ecuador.
Yellow Fever
Sylvatic yellow fever has remained endemic among
primates in the Oriente at least since the 1940s.A recent
human outbreak in the province of Nap0 in unvacci-
nated persons reported 49 possible cases, with 18 con-
firmed before aggressive public health measures and
vaccine distribution could be instituted.6The only doc-
umented deaths from yellow fever have been in unvac-
cinated persons.
Rabies
Human and canine rabies has been reported pri-
marily in the western provinces of Guayas, in and around
Guayaquil. Recently, however, sporadic cases of human
rabies have been reported in Cuenca and other Andean
cities. Between November 1992 and February 1993, the
Hospital for Infectious Disease, the Ministry of Health,
in Guayaquil,recorded 28 histologically- and serologicdy-
confirmed human deaths from rabies contracted from
unvaccinated dogs (H.Jurado, Ministry of Health, Hos-
pital Director, personal communication). In the province
of Napo, bats have been reported to transmit rabies to
domestic livestock.
AIDS
As of 1993, only 374 HIV seropositive persons had
been reported to the Health Ministry of Ecuador. O f the
137 cases ofAIDS (SIDA) reported, 8% were women.
Two imported cases of AIDS were recognized in the
Galapagos Islands. Initially, risk factors associated with
HIV seropositivity in Ecuador included unprotected
homosexual contact and, interestingly, a history of sex-
ual contact with non-Ecuadorians. Presently, unprotected
heterosexual intercourse is the primary method of trans-
mission. Opportunistic infections reportedly associated
with SIDA in Ecuador may be different from the HIV-
associated opportunistic infections accepted in more
industrialized countries. Therefore, more detailed epi-
demiologic studies are required. HIV-associated infections
in Ecuador include candidiasis, pneumonia, leishmania-
sis, histoplasmosis, cryptococcosis, and disseminated
strongyloidiasis.The seroprevalence of HIV is likely to
grow now that more accurate serologic testing is avail-
able through a network of clinical laboratories operated
by the National Institutes of Health of Ecuador, Insti-
tuto Leopoldo Izquieta Perez.'
92 J o u r n a l of Travel M e d i c i n e , V o l u m e 2, N u m b e r 2

Protozoan Disease

Malaria
In spite of aggressive malaria control programs,
which include case finding and vector control, malaria
(paludismo) caused by both Plasmodiumfalctpamm and Plas-
modium vivax remains endemic in 19 of the 21 provinces.
The two provinces with highest prevalence in 1991,
included Esmeraldas (19,183 cases) and Guayas (11,284),
followed by Manabi (10,531),Los Rios (8734), Pichin-
cha (5014), and Nap0 (3759). Clinical chloroquine resis-
tance and cerebral malaria has been noted increasingly
in Guayas and Esmeraldas. Malaria has not been reported
from the Galapagos Islands.’

Leishmaniasis Figure4 Leishmaniasis: cutaneous leishmaniasis of the ante-

Detailed analysis of vector populations (Lutzomyia rior lower leg presenting with a history of several weeks of a
sandflies) and Leishmania strains,which cause cutaneous and progressive ulcerating lesionwith prominent indurated margins.
mucocutaneous disease have been conducted extensively
for the past decade in collaborative efforts between Japan-
ese investigators and investigators from the University of
Guayaquil.The incidence of leishmaniasis has risen dra-
matically between 1983 (3.3 per 100,000) and 1990 (35 manifestations are usudy restricted to mucosal injury and
per 100,000),possibly as an artifact ofimproved diagnos- penetration, and motile trophozoites are generally appar-
tic methods and surveillance.Although reportedly more ent upon examination of wet preparations of uncon-
common in Zamora, Esmeraldas,and Manabi, cutaneous centrated stool samples from symptomatic persons. Inva-
leishmaniasis has been documented throughout the coun- sion of rnesenteric vessels has led to hepatic involvement
try.Mucocutaneous disease is rare. Karyotype analysis of in the form of macro- or microabcesses (Fig. 6).
Ecuadorian Laishmania strains (L. mexicana,L. panamensis,
and L. braziliensis) from different geographic areas reflect Helminthic Disease
species diversity typical of New World isolates (Fig. 4).8,9
Paragonimiasis
Chagas Disease Chronic pulmonary paragonimiasis produced by
Acute and chronic manifestations of infection with the trematode Paragonimus mexicanus, may be one of the
Zypanosoma cmzi is common in Guayas, Los Rios, Man-
abi, El Oro, and Loja. Most recently, culture-proven
acute disease has been identified in the province of Nap0
(Fig. 5).’”The overall prevalence of disease in Ecuador
is not known and likely greatly under appreciated.Anec-
dotally, it has been observed that as many as 0.5% of the
nonmalarial acute febrile illnesses investigated by malaria
control workers is due to Chagas disease (unpublished
observations, provincial malaria control project, Napo).
The diagnosis of acute Chagas disease may be compli-
cated by the absence of a “classic” innoculation site-a
chagoma, Romana’s sign, etc.

Balantidiasis
Chronic and fdminant dysentery due to Balantid-
ium coli has been reported in rural areas of Esmeraldas
province and in Guayas. As in other parts of the world
where Balantidiasis has been reported, the majority of all Figure 5 Giemsa-stained thick blood smear demonstrating
infected persons report contact with domesticated pigs, typical morphoogy of Tipanusoma cruzi with prominent sub-
which are the main reservoir of the disease. Pathologic terminal kinetoplast.
Guzman e t al, I n f e c t i o n s i n E c u a d o r
Figure 6 lnvasive Balantidiasis: histologic section of patient‘s
colon obtained at autopsy shows two trophozoites of Balan-
tidium coli invading a mesenteric vessel.
most prevalent and least recognized public health prob-
lems in Ecuador.The disease affects an estimated 600,000
persons throughout the country.”,” Fresh water crabs
(cangrejo del rio or pangora), and possibly fresh water
species of shrimp (sengue),which harbor encysted meta-
cercaria, are the intermediate host from which humans
contract this zoonosis. Exhaustive surveys identi@ing
infective crustaceans during the past 20 years have doc-
umented active transmission in the provinces of Guayas,
El Oro, Zamara, Loja, Los Rios, Bolivar, Manabi, Pinci-
cha, Esmeraldas, Cotopaxi (lowlands only), Nap0 (high
prevalence), Paztaza, and Succumbios. Complex public
health measures to control this disease in rural areas have
met with limited success to date, due to the need to com-
bine aggressive patient education programs in areas where
culinary habits are culturally ingrained. Efforts are being
made to eradicate both domestic and sylvatic animal
reservoirs. Unusual clinical variants of paragonimiasis,
including cutaneous disease, have been documented in
Ecuador (Fig. 7).
Taeniasis and Cysticercosis
While Taenia saginatu will cause strictly intestinal dis-
ease due to adult parasites, Taeniu solium can produce dis-
ease by either of two routes. Human intestinal taeniasis
with Tsolium occurs because ingested eggs can develop
into adult worms. Tissue disease, or cysticercosis, is
acquired through ingestion of larval parasites (cysticerci)
present in contaminated, or “measily” pork. Central ner-
vous system, neuro-ophthalmologic, and soft tissue dis-
ease due to larval T. solium is well known throughout
Ecuador. Intestinal taeniasis is particularly high in the
provinces of Pastaza (incidence 77 per 100,000) and
93
Figure 7 Cutaneous paragonimiasis: An intact adult fluke
(on the skin to the right of the skin incision) was removed
from a freely movable subcutaneous nodule in a patient with
concurrent typical pulmonary paragonimiasis.
Loja (45 per 100,000 humans). In the same provinces,
up to 12% of humans o r domestic swine have been
shown to have cysti~ercosis.’~~’~Risk factors for intesti-
nal taeniasis in humans and animals include ingestion of
embryonated parasite eggs in soil or fecally-contaminated
foodstuffs.
Onchocerciasis
Since 1980, the human filarial parasite, Onchocerca
volvulus, has been documented as a cause of cutaneous
(Figs. 8 and 9) and ophthalmologic disease along several
river systems in northwestern Ecuador, especially i n the
province of Esmeraldas.” Isolated foci of onchocercia-
sis have already been identified along the Rio Cojimes,
which border the province of Manabi. A rapid increase
in the disease prevalence in residents living along the
Santiago and Cayapas rivers has been associated with a
prevalent and efficient blackfly vector, Sirnulium exiguum.
Concern has been raised regarding the potential spread
of onchocerciasis from western to eastern provinces,
due to migration of untreated populations eastward in
search of employment associated with the petroleum
industry and the presence of competent blackfly vectors.
Alarming statements about the spread of onchocerciasis
to eastern Ecuador are false in that active transmission
has not been documented in the Oriente.16The few real
cases of human onchocerciasis diagnosed in the Oriente
to date are in persons recently migrated from the coast.
Fascioliasis
The epidemiology of human fascioliasis has not
been well studied in Ecuador. However, this disease is not
uncommon in the highlands of western Ecuador,
94 Journal of Travel Medicine, V o l u m e 2, N u m b e r 2

Figure 9 Onchodermatitis: A severe pruritic inflammatory

Figure8 Onchocerciasis: a subcutaneous nodule (rightfore-
head) or "onchocercomata" w a s surgically removed, and
found to harbor adult male and female parasites encased in
an inflammatory nodule.
dermatitis can arise in patients with onchocerciasis due t o the
death Of microfilaria (laWal) parasites which migrate freely
through the skin.

particularly in the provinces of Chimborazo, Cotopaxi,
and Azuay. Domestic livestock remain a primary host and
reservoir for this zoonosis, which may remain asympto-
matic in humans or produce subtle nonspecific illness and
disease referable to the biliary tract. Presently, ongoing
studies of disease prevalence in humans and domestic live-
stock will make use of sensitive immunoassay, which
identifies parasite excretorysecretory antigens in stool
o r urine."
Gnathostomiasis
The complex life cycle o f Gnathostoma spinigerum
requires maturation of third stage o r infective larvae in
frogs, snakes, birds, o r fish. Humans acquire disease when
larval G. spinigerum infective larvae are ingested in poorly
cooked o r raw foods (intermediate host). Migratory
panniculitis caused by movement of the larval nematode
is a recognized disease in coastal provinces of Ecuador.
Associated with some of the culinary risk factors for
cholera (e.g., undercooked ceviche pescado (fish soup),
the diagnosis of gnathostomiasis is usually made clinically
in patients with known risk factors. Delayed hypersen-
sitivity reactions to partially purified Gnathortoma anti-
gens are sometimes useful to support the clinical diag-
nosis in the face of historic risk factors.'* Morbidity o r
mortality associated with gnathostomiasis varies depend-
ing o n the location of larval migration, and response to
chemotherapy is often poor.

Table 2 Summary of Modes of Disease Transmission, Diagnosis, and Treatment

Disease Transmission Diagnosis Treatment
Cholera Food/water Clinical, culture Hydration, doxycycline
Bartonellosis Sandfly Clinical, biopsy Penicillin, tetracycline
Yaws Contact Clinical, serology Benzithine penicillin
Dengue Mosquito Clinical, serology Supportive
Yellow fever Mosquito Clinical, serology Supportive
Rabies Canine, bat Clinical, histopathology Supportive
HIV Blood/body fluids Serology Supportive
Malaria Mosquito Blood film Antimalarials
Leishmaniasis Sandfly Biopsy, culture Antimonials
Chagas disease Reduviid Bu@ coat/serology Nifurtimox, beznidazole
Balantidiasis Food, water Stool exam Tetracycline
Paragonomiasis Fresh water crustaceans Sputum cytology Praziquantel
Taeniasis/cysticerccx i s Food, drink Stool exam/serology Praziquantel
Onchocerciasis Blackfly Skin biopsy Ivermectin
Fasioliasis Food Stool exam, serology Praziquantel
Gnathostomiasis Seafood Clinical, skin testing Surgery, supportive
Guzman et al, Infections i n Ecuador
Conclusion
The spectrum of infectious dlseases in Ecuador is a
result of diverse geography,p l e n a vector habitat,and logis-
tically-complex public health problems.With the excep-
tion of schistosomiaisis and Afiican trypanosomiasis,nearly
all major groups of human parasitic disease can be found
among the population. Awareness of known routes of
infection will minimize the risk of disease in international
travelers (Table 2.) Development of new public health
strategies, such as coordination of vector-borne disease
control in Pan-Andean countries, will direct efforts for era-
diction and control of many infectious diseases in Ecuador.
Acknowledgments
This work was supported in part by NIH grant
A101019 and by the National Center forTropica1 Med-
icine, University of Guayaquil, Guayaquil, Ecuador.
We wish to acknowledge the support of the admin-
istration, faculty, and staff of the University of Guayaquil;
the National Center for Tropical Medicine, Guayaquil,
Ecuador; the National Institutes of Health of Ecuador;
Instituto Leopoldo Izquieta Perez, Quito; and the Min-
istry of Public Health of Ecuador, Quito. Drs. Clovis Lom-
bardi and Mario Barcasal, of the Panamerican Health
Organization in Quito, provided assistance in the col-
lection of data published in Ecuador. Dr Linda Scaffidi
provided a helpful critical review of the manuscript.
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