Ecuador is an “exotic” country in the minds of many. To the uninitiated, we may imagine dangerous creatures and debilitating diseases lurking around every corner. However, the vast majority of travelers, even to remote, exposed or “high-risk” regions of Ecuador, rarely encounter any health issues excepting the inevitable minor stomach ailments associated with eating new foods.
We offer programs in all four of the country’s regions – La Costa (the coast), La Sierra, (the mountains), Amazonia (the Amazon basin), and the Galapagos. In this blog post, I’ll cover some of the common issues to consider prior to traveling with us on a Sustainable Summer program in Ecuador.
Malaria, Dengue, Zika and Other Vector Diseases
Vectors are living organisms that can transmit infectious diseases between humans or from animals to humans. The most common vectors for infectious disease are ticks and mosquitoes. For such a small country, Ecuador has wildly varied topography and climates and, consequently, the epidemiology of vector disease across the country is also quite varied.
Most travelers to Ecuador arrive in and out of Quito in the highlands. High elevations (8000 – 9000 feet in and around Quito) and cold evenings (average low of 50 °F), which means very few mosquitoes. The aedes species of mosquito, which can carry Dengue, Zika, and Chikungunya, is not thought to be able to survive at these elevations. Additionally, there is no malaria there.
In general, wetter and warmer regions are where mosquitoes can survive and breed, although not all species of mosquito are vectors for viral disease and different species can transmit different diseases. For instance, malaria is transmitted by a different mosquito than the one the species that transmits Dengue, Chikungunya, and Zika. Additionally, the former are nocturnal and the latter are day-biters.
Although Zika itself is not currently thought to pose a serious health risk to adults (more on that below, including a a possible although unconfirmed connection to Guillain-Barré syndrome), it is believed to cause microcephaly – a serious brain disorder – in the children of women who contract Zika while pregnant. Zika has only very recently been confirmed in Ecuador (and many other tropical and subtropical regions in the Western Hemisphere), although it has been endemic to Africa and Asia for over half a century. Zika is transmitted by the aedes mosquito, which is the same species that carries Dengue and Chikungunya. It can also be transmitted from an infected person to an uninfected person through sex.
Zika in Ecuador and South America
According to this article published on the Ecuadorian Ministry of Public Health’s website (in Spanish, retrieved Feb 1st, 2016), as of Jan 28th, 2016, there were 22 confirmed cases of Zika in Ecuador. Of those, 9 of those are believed to have been contracted outside of the country while the remaining 13 were contracted within Ecuador.
It seems plausible that this number will go up and that the Zika virus will remain endemic in Ecuador for some time. Public health officials around the world are working to better understand the Zika virus and to develop eradication and prevention measures. The WHO (World Health Organization) has declared Zika an International Health Emergency due to the apparent connection between Zika in pregnant women and microcephaly. The Ecuadorian authorities have promised an aggressive response to the outbreak and advised women to postpone pregnancy.
CDC Recommendations About Zika
The CDC (Center for Disease Control) has advised women who are pregnant or who may become pregnant to avoid travel to regions with Zika. The CDC is advising all other travelers to “practice enhanced precautions” when visiting Ecuador (and other regions where Zika is present. Essentially this means being extra vigilant about avoiding mosquito bites.
According to CDC, “about 1 in 5 people infected with Zika will get sick. For people who get sick, the illness is usually mild. For this reason, many people might not realize they have been infected. The most common symptoms of Zika virus disease are fever, rash, joint pain, or conjunctivitis (red eyes). Symptoms typically begin 2 to 7 days after being bitten by an infected mosquito.”
We think it’s important to to note that Zika is not a permanent condition. The risk with Zika – as it is currently understood – is to the unborn child of a pregnant woman who contracts the disease. According to CDC, “Zika virus usually remains in the blood of an infected person for only a few days to a week. The virus will not cause infections in an infant that is conceived after the virus is cleared from the blood. There is currently no evidence that Zika virus infection poses a risk of birth defects in future pregnancies.”
There is a possible, although unconfirmed, connection between Zika and Guillain-Barré syndrome (GBS), an immune disorder. CDC says, “While most people fully recover from GBS, some people have permanent damage and in rare cases, people have died. We do not know if Zika virus infection causes GBS. It is difficult to determine if any particular pathogen ’caused’ GBS.”
A Personal Perspective on Travel and Zika
There is no question that Zika is a serious concern for public health. However, should non-essential travel be avoided due to Zika? The CDC doesn’t think so and neither do I. The risk of contracting Zika is quite small if basic precautions are taken. As currently understood, the consequences of contracting Zika are also not serious, with the notable exception for women who are or might become pregnant. My wife, my 6-month old daughter, and I will be traveling to a region with Zika in March. We are not concerned about Zika.
Additional Information on Zika
The CDC website has a ton of information. This interactive piece in the New York Times is also very helpful, concise, and clear: http://nyti.ms/23vSvSc
There is no malaria in Quito or the Sierra region or in the Galapagos.
For participants traveling to Ecuador’s coast on our (our Seeds of Change program), we will be visiting the coast region during the dry reason and mosquitoes carrying malaria are not able to survive. It may not be advisable to take anti-malaria pills for this reason, although you should seek medical advice from your primary care physician or a travel medicine specialist prior to the program.
For participants in either of our Amazon programs, the lower elevations of the Amazon basin are technically a malaria risk zone according to the Center for Disease Control. However, many travelers and all locals prefer preventative measures to prescription prophylactics, although you should seek medical advice from your primary care physician or a travel medicine specialist prior to the program. It is worth noting that there are certain regions of the Ecuadorian Amazon that have much higher incidences of malaria than others, although this may not be reflected in the reporting by health authorities like the CDC. Anecdotally, the regions of Napo Province we visit on our Amazon programs have very low reports of malaria incidence.
Most jungle lodges that I am aware of in the Ecuadorian Amazon recommend insect repellant over anti-malarial prophylaxis. However, the subject of anti-malarials and other medications is complex and highly personal. We can only provide you with information about what our field staff do and emphatically recommend that you speak with your physician about the circumstances.
My personal preference and the preference of most experienced travelers to Ecuador is to forgo anti-malarials, but that may not be the right choice for you. In short, the risk of contracting malaria on our program is quite low, but it’s technically there. Malaria medication may bring you peace of mind, but know that there are downsides to using the medication, so be sure you and your physician or travel medicine specialist have a frank conversation about the circumstances.
Dengue Fever and Chikungunya
In lower-elevation regions of Ecuador there is also a risk of contracting Dengue Fever or Chikungunya from the aedes mosquito. Chikungunya was only first detected in the Americas in 2013. Dengue has been around much longer. Both diseases cause a serious fever, but are rarely fatal if treated. Dengue outbreaks tend to occur in seasonal ebbs following prolonged rainy periods. In coastal Ecuador, this means that the prevalence of Dengue is going to be higher during the winter rainy season and much lower during the summer dry season when our groups are visiting. Using data reported by the Ecuadorian Ministry of Public Health from 2013, we can see that Dengue cases during a wet season week in February, 36 cases of Dengue were reported in Manabi province, compared to 13 reported during a dry season week in July.
The vast majority of Dengue cases in Ecuador are in the coastal provinces. In the Amazon region, Dengue exists but is comparatively rare. Napo province, the Amazon province we operate programs in, averages only 1 reported Dengue case per week.
In general, Dengue is more common in urban areas. This partially explains the much lower incidence of Dengue in the sparsely populated Amazon region compared to the heavily populated Coast region. Dengue can be effectively managed locally with proper mitigation practices. Since aedes species mosquitoes thrive in artificial containers that hold water, simple practices like elimination of such containers (old tires, plastic buckets, etc) and designing good drainage systems near human settlements will significantly lower the prevalance of Dengue locally.
Prevention of Vector Disease on Sustainable Summer Programs
Please see the Malaria section information above on anti-malarial prophylaxis. Unlike malaria, there are no preventative drugs that can be taken to protect against Dengue, Chikungunya, or Zika.
Non-Medical Prevention Measures
We can break our non-medical prevention measures down into a few basic categories.
Awareness: Such as being aware of outbreaks locally and avoiding them – we monitor CDC and other advisories from health authorities. We also know peak exposure times (aedes species mosquitoes are most active during the day whereas Malaria transmitting mosquitoes are most active during dusk, dawn, and evening hours) and places (grasses harbor ticks; standing water breeds mosquitoes).
Individual Prevention Measures: Such as wearing long-sleeved shirts, pants, and shoes and tucking pants into socks; wearing an insect repellant (the CDC recommends DEET, Picaridin, and Lemon Eucalyptus Oil), being aware of repellent efficacy and reapplying accordingly; using a bed net; and checking for ticks. Not all of these prevention measures are going to be relevant at all times and for all locations. We discuss specific protocols with students during orientation and ongoing during a program.
Institutional Prevention Measures: We hardly ever see mosquitoes on our programs. A big reason for that is that we choose both itineraries where vector disease transmission is very rare and also choosing accommodations that practice effective mitigation measures. As mentioned in the section above, aedes species mosquitoes thrive in artificial containers that hold water. Eliminating the potential for standing water to collect reduces the prevalence of vectors and thus the risk of transmission.
Symptoms, Treatment, and Recovery
In the extremely unlikely event that you contract Malaria while traveling, you will most likely not display symptoms until you return home due to the incubation period of the disease (7-9 days and possibly as much as a year). The incubation period for diseases carried by aedes species mosquitoes (Dengue, Zika, Chikungunya) is typically shorter (a few days to a week or so).
Symptoms for Malaria, Dengue, and Chikungunya present in such a way that it will be unlikely to be mistaken. Recall the worst fever you’ve ever had and crank it up a notch. It will be unpleasant, but patients in otherwise good health that receive treatment rarely have issues greater than a severe and prolonged fever. The symptoms for Zika are considerably more benign with only about 1 in 5 showing symptoms of a mild fever.
Any participant that displays symptoms while in Ecuador will be immediately transported to a medical facility for examination. We are rarely more than an hour from appropriate facilities and excellent health care is available in Quito’s private hospitals, which are never more than a half a day’s drive or flight from any of our locations during a program.
Final Thoughts on Vector Disease
This is not a comprehensive list of vector diseases endemic to Ecuador. In addition to Malaria and Dengue and now Zika, which we often hear about in the media or popular culture, there is tick-borne encephalitis, Chagas, and others. These are all serious diseases, and we treat them seriously by practicing appropriate preventative measure while traveling, but as a resident of the northeastern US, I personally find Lyme disease far more scary than all of them simply because it’s so common (over 25,000 cases in the US in 2014), but much harder to prevent and detect and yet has really serious chronic effects if not treated.
Animal Bites and Scratches
One of the most exciting parts about traveling to Ecuador is the exotic wildlife. In past trips I’ve seen monkeys, bats, tortoises, sloths, lemurs, and more birds than I could count in a lifetime, all in the wild. There are probably dozens of other animals I’ve seen but been unable to identify: A rustle of the jungle foliage, a glimpse of something out of the corner of the eye, but alas, no sign of anything except the gentle sway of some branches. This is a routine event in Ecuador.
I’ve never seen a snake in Ecuador. Although I’m sure they’re there, they keep to themselves. Same goes for spiders. I’ve seen some big ones here and there, but they leave you alone. Many people fear snake and spider bites, but the chances of seeing one, let along getting bit by one, are simply very, very low. Simple measures like wearing shoes when outside, hiking in a group, and avoiding leaning against trees in the jungle are good preventative tactics, all of which are reviewed with our groups during orientation.
The bigger risk is a dog bite. There are stray dogs in just about every town or village. You encounter them on a regular basis. Unless provoked, they don’t pose much of a threat, so our hard and fast rule is to let sleeping dogs lie! Never approach a dog, even one that looks clean or friendly, under any circumstances. Monkeys are also known to bite on occasion. They look cute and playful, and usually are friendly, but it’s not worth getting bit so we don’t let our students play with monkeys. Sorry. It’s still fun to observe them playing. Just keep your hands on cameras, hats, and other “toys” since monkeys are known to sneak up and “steal” them from unsuspecting watchers.
Food and Water
If you don’t get some mild stomach ailments while visiting Ecuador, consider yourself lucky. We will be eating new and different foods that are delicious, but sometimes necessitate a day or two of adjustment for our unaccustomed digestive tracts. Many travelers I know swear that ingesting an uncooked clove of garlic along with a glass of water before breakfast during the first couple days of travel is a surefire way to get your tummy in line. Once adjusted, avoiding street food and not drinking tap water will keep your digestive system functioning in top performance for the duration of the trip. Purified water is available in abundance every places we stay. We’ll also provide a rundown of the “what to eat/what not to eat” situation in every locale that we visit. Generally speaking, we don’t necessarily adhere to the common traveler maxim of not eating raw, unpeeled vegetables and fruits since we primarily stay in places where we know exactly how the food is prepared, however there are certain times and places where this is decidedly good advice. We recommend that all students bring a mild, over-the-counter anti-diarrheal such as Imodium to help counter an upset stomach. Your healthcare professional may also write a Cipro prescription for particularly aggressive stomach ailments, although we carry some in our first aid supplies for such contingencies as well. Cipro should be reserved for truly severe symptoms.
The capitol of Ecuador, Quito, is over 9000 feet in elevation, the second highest of any capital city in the world (after La Paz, Bolivia). The airport and Tumbaco Valley, where we stay during orientation is lower, about 8000 feet, the same as you would find in Vail and some other ski towns in Colorado. Although medical complications due to altitude are rare at this elevation, it’s enough to cause some mild breathlessness and fatigue. We’ll only be in Quito for a short time and will then descend to lower elevations where altitude sickness is not possible.
For participants on our Seeds of Change program, we will be spending a few days in Ecuador’s highlands region at over 12,000 feet of elevation. We will be hiking and altitude sickness is a possibility. Fortunately, we will spend time acclimatizing and it’s unlikely that we will have any issues. The only cure for altitude sickness is rest and descent to a lower elevation.
The steady rays of the equatorial sun are a constant during our trip. High SPF sunscreen, a wide-brimmed hat, and lots of water intake are necessary preventative measures. We’ll include a detailed list of recommendations to protect against the elements in our packing list.
What You Should Do
Seek medical advice from your primary care physician or a travel medicine specialist at least 8 weeks prior to the program. Make sure you are explicit about the exact trip itinerary. A good travel medicine specialist will discuss an appropriate plan of action customized to your medical history and risk factors, which may include a vaccination schedule and both medical and non-medical prophylactic measures. If you live in the New York metropolitan region, we can recommend a travel medical specialist. You can also reference the CDC (Center for Disease Control) website for a list of travel medical clinics.
Most people traveling to Ecuador will already have received many of the recommended vaccinations. The likely additions to a traveler’s vaccination record, assuming no recent travel to other “tropical” destinations, are Typhoid and Hepatitis A and B. Yellow Fever will probably also be recommended for participants Sustaining the Amazon traveling to the Amazon region with us. Technically, the government of Ecuador requires visitors to carry proof of a Yellow Fever vaccination when entering the country, although I’ve never heard of this requirement being enforced except as stated in the previous sentence.
We will provide a complete list of recommended over-the-counter prescriptions and equipment to ensure a safe and healthy trip to Ecuador with Sustainable Summer in our suggested packing list. Please feel free to contact us with any questions. We’ve been traveling to Ecuador years and are happy to help!