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Introduction: The importance of nurturing care for child development is well-established, and parents play a central role in providing this care. However, cultural values and traditions can influence child-rearing practices, and there are gaps in child welfare in Ecuador. Two research questions delve into caregivers' definitions of nurturing care for children aged 0-5 and its alignment with World Health Organization's concept., Methods: A qualitative methodology was applied to comprehensively explore caregivers' perspectives and application of nurturing care across diverse cultural contexts in rural areas of Cotopaxi and Loja in Ecuador. Using snowball sampling primary caregivers, healthcare professionals, childcare workers, and community leaders were interviewed and participated in focus groups, examining its congruence with WHO's Nurturing Care Framework for Early Childhood Development., Results: While there is alignment with the WHO framework, the study reveals challenges such as a lack of awareness of the term "nurturing care" among participants. Findings also indicate issues in health communication, reliance on traditional medicine, and myths around nutritional practices. The role of technology in early learning is explored, noting both its advantages and disadvantages. Notably, preventive health activities were not mentioned, emphasizing a universal need for knowledge., Conclusion: This study urges tailored interventions for nurturing care, emphasizing success tied to robust healthcare and child protection. Urgency lies in cultural sensitivity, local adaptation, and targeted training for implementation. These insights contribute significantly to the global discourse, stressing the importance of context-specific approaches. Implications are crucial for policymakers, practitioners, and researchers dedicated to elevating care quality for vulnerable populations worldwide., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Tello, Mendoza-Gordillo, Moreano, Bates, Quinn, Rogel and Grijalva.)

Introduction: Chagas disease is a neglected tropical disease caused by the parasite Trypanosoma cruzi that is transmitted mainly by the feces of infected Triatomines. In Ecuador the main vector is Rhodnius ecuadoriensis which is distributed in several provinces of the country. More than 40% of these insects in the wild have T. cruzi as part of their intestinal microbiota. For this reason, the objective of this research was to characterize the intestinal bacterial microbiota of R. ecuadoriensis ., Methods: The methodology used was based on the DNA extraction of the intestinal contents from the wild collected insects (adults and nymphs V), as well as the insects maintained at the insectary of the CISeAL. Finally, the samples were analyzed by metagenomics extensions based on the different selected criteria., Results: The intestinal microbiota of R. ecuadoriensis presented a marked divergence between laboratory-raised and wild collected insects. This difference was observed in all stages and was similar between insects from Loja and Manabí. A large loss of microbial symbionts was observed in laboratory-raised insects., Discussion: This study is a crucial first step in investigating microbiota interactions and advancing new methodologies., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Villacís, López-Rosero, Bustillos, Cadena, Yumiseva, Grijalva and Villacís.)

Chagas disease, discovered over a century ago, continues to pose a global health challenge, affecting millions mainly in Latin America. This historical review with commentary outlines the disease's discovery, its evolution into a global concern due to migration, and highlights significant advances in diagnostics and treatment strategies. Despite these advancements, the paper discusses ongoing challenges in eradication, including vector control, congenital transmission, the disease's asymptomatic nature, and socioeconomic barriers to effective management. It calls for a multidisciplinary approach, enhanced diagnostics, improved treatment accessibility, and sustained vector control efforts. The review emphasizes the importance of global collaboration and increased funding to reduce Chagas disease's impact.

Objective: Health literacy is associated with many patient outcomes. This study sought to determine the association between a person's level of health literacy and their knowledge about Chagas disease., Methods: A cross-sectional survey was conducted with people living in two counties in rural Loja Province, Ecuador who attended a mobile health clinic. The communities in which the study was conducted are at high risk of Chagas disease and have limited access to both health care and educational resources. The Spanish version of Short Assessment for Health Literacy measured health literacy. The Chagas Disease Knowledge questionnaire measured knowledge of Chagas disease. T-tests and correlational analysis were used to assess associations., Results: Overall 85 people participated in this study. A majority of the respondents were female (64.1%), and a plurality were married (40.7%) and had education less than secondary (40.7%). The average age of the sample was 44.31 ± 18.85. Health literacy levels and Chagas disease knowledge in the communities were low. About half of people had inadequate health literacy. No association between health literacy and Chagas knowledge was found., Conclusion: Health literacy levels and Chagas disease knowledge were not found to be correlated. Explanations for the lack of association may include common causes of inadequate investment in Chagas disease education as well as neglect of health systems in rural Ecuador. Efforts to improve both health literacy and Chagas disease knowledge in poorer, rural areas of Ecuador are needed., Innovation: This is the first study to assess relationships between health literacy and knowledge of Chagas disease in an uninfected population. For novel conditions, relationships between health literacy and disease knowledge should be investigated before communication campaigns are adapted., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Talia Caridi reports financial support was provided by the Research and Scholarly Advancement Fellowship and the Medical Student Research Seed Funding Grants from the Heritage College of Osteopathic Medicine Benjamin R Bates reports financial support was provided by The Urban Communication Foundation. Cora G. Farra reports financial support was provided by Ohio University, Provost's Undergraduate Research Fund. Cora G. Farra reports financial support was provided by Ohio University, Barbara Geralds Schoonover Professorship Fund. Athar Memon reports financial support was provided by Ohio University, Barbara Geralds Schoonover Professorship Fund. Mario J. Grijalva reports financial support was provided by Pontifical Catholic University of Ecuador. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Chagas disease (CD) is one of the most devasting parasitic diseases in the Americas, affecting 7-8 million people worldwide. In vitro and in vivo experiments have demonstrated that growth hormone (GH) serum levels decrease as CD progresses. Interestingly, inactivating mutations in the GH receptor in humans result in Laron syndrome (LS), a clinical entity characterized by increased serum levels of GH and decreased insulin growth factor-1 (IGF-1). The largest cohort of LS subjects lives in the southern provinces of Ecuador. Remarkably, no clinical CD cases have been reported in these individuals despite living in highly endemic areas. In the current ex vivo study, we employed serum from GHR -/- mice, also known as LS mice (a model of GH resistance with high GH and low IGF-1 levels), and serum from bovine GH (bGH) transgenic mice (high GH and IGF-1), to test the effect on Trypanosoma cruzi infection. We infected mouse fibroblast L-cells with T. cruzi (etiological CD infectious agent) and treated them with serum from each mouse type. Treatment with GHR -/- serum (LS mice) significantly decreased L-cell infection by 28% compared with 48% from control wild-type mouse serum (WT). Treatment with bGH mouse serum significantly decreased infection of cells by 41% compared with 54% from WT controls. Our results suggest that high GH and low IGF-1 in blood circulation, as typically seen in LS individuals, confer partial protection against T. cruzi infection. This study is the first to report decreased T. cruzi infection using serum collected from two modified mouse lines with altered GH action (GHR -/- and bGH)., (© 2023 The Authors. FEBS Open Bio published by John Wiley & Sons Ltd on behalf of Federation of European Biochemical Societies.)

Background: Chagas disease (CD) is a tropical parasitic disease spread by triatomine bugs, which are bugs that tend to infest precarious housing in rural and impoverished areas. Reducing exposure to the bugs, and thus the parasite they can carry, is essential to preventing CD in these areas. One promising long-term sustainable solution is to reconstruct precarious houses. Implementing home reconstruction requires an understanding of how householders construct barriers and facilitators they might encounter when considering whether to rebuild their homes., Methods: To understand barriers and facilitators to home reconstruction, we performed in-depth qualitative interviews with 33 residents of Canton Calvas, Loja, Ecuador, a high-risk endemic region. Thematic analysis was used to identify these barriers and facilitators., Results: The thematic analysis identified three facilitators (project facilitators, social facilitators, and economic facilitators) and two major barriers (low personal economy and extensive deterioration of existing homes)., Conclusions: The study findings provide important loci for assisting community members and for agents of change in home reconstruction projects to prevent CD. Specifically, the project and social facilitators suggest that collective community efforts ( minga ) are more likely to support home reconstruction intentions than individualist efforts, while the barriers suggest that addressing structural issues of economy and affordability are necessary.

Introduction: Chagas disease (CD) is a neglected tropical disease that affects 6 to 7 million people worldwide. In South America, CD is a major health problem in several regions, causing more than 12 000 deaths per year. CD is caused by a parasite called Trypanosoma cruzi, mostly transmitted through the contaminated feces of certain species of triatomine bug, commonly known as the 'kissing bug'. CD is endemic in Loja province in the southern region of Ecuador, where triatomines have been found in 68% of communities. Previous promotion of healthy practices in Loja province have included educational programs directed toward youth to affirm cultural and social norms that support health and prevent CD transmission. The present study was designed to evaluate current knowledge related to CD among youth in the three communities of Loja province following previous intervention programs., Methods: A descriptive, qualitative approach was applied using individual semi-structured interviews with 14 young people (eight females, six males) from three rural communities in Loja province. Interviews assessed knowledge about CD transmission, knowledge about the parasite-vector-disease pathway, and the role of youth in preventing Chagas disease in their communities., Results: Following a thematic analysis of the data, the study results showed there is cursory knowledge of the triatomine insect that can carry the causative parasite for CD. Participants were able to generally talk about the vector, habitat and prevention practices for triatomine infestation. Nevertheless, limited understanding of transmission dynamics in the parasite-vector-disease pathway itself was found. One major finding was that prevention practices were not correctly applied or followed, increasing the risk of exposure in the community. Youth also articulated that CD is stigmatized in their communities, which may be a barrier for prevention efforts., Conclusion: Gaps in knowledge about the parasite-vector-disease pathway were identified among youth. Overall, youth responses indicated positive regard for prevention practices and a desire to be involved in prevention programs. Developing educational programs focusing on CD transmission may be needed to improve control and prevention of this parasitic disease. The implications of these findings are discussed for developing effective control programs in the region.

Background: Controlling monkeypox effectively requires clinicians have knowledge of monkeypox, attitudes supporting of controlling it, and intentions to adopt practices to address it. Little is known, however, about levels of knowledge, attitudes, and practices (KAPs) in clinician populations in Ohio, United States., Methods: A cross-sectional, internet-based questionnaire assessed knowledge related to monkeypox, attitudes toward ability to control monkeypox and the threat of monkeypox, and prior relevant practices of having received a smallpox vaccine or having knowledge of monkeypox before 2022, intentions to adopt preventive practices, and demographics. Frequency reporting was used to assess overall knowledge and attitudes. Binary logistic regression was used to predict which KAPs were associated with behavioral intentions., Results: A total of 197 clinicians participated. No demographic factor was associated with KAPs. Clinicians had relatively poor levels of knowledge. Participants expressed mixed attitudes about eventual control of monkeypox and about threat posed by monkeypox. About one in four participants reported previous knowledge of monkeypox, and about 40 % had received a smallpox vaccine Clinicians reported insufficient levels of intention to adopt preventive practices. Binary regression analysis suggests only perceptions of the threat of monkeypox to public health were associated with intentions to vaccinate self or others., Conclusions: Educational interventions with clinicians should address inadequate knowledge to support correct diagnosis and treatment. Efforts to enhance the perception of threat of monkeypox to public health may support adherence to preventive recommendations., Competing Interests: Competing interests The authors declare that they have no conflict of interests., (Copyright © 2022 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Although vaccines have been developed to prevent COVID-19, vaccine hesitancy is a significant barrier for vaccination programs. Most research on COVID-19 vaccine hesitancy has blamed misinformation and misstated concerns about effectiveness, safety, and side effects of these vaccines. The preponderance of these studies has been performed in the Global North. Although Latin American has been substantially and negatively impacted by COVID-19, few studies have examined COVID-19 vaccine hesitancy there. We explored reasons volunteered for COVID-19 vaccine hesitancy from a sample of 1,173 Colombians, Ecuadorians, and Venezuelans. Overall, COVID-19 vaccine hesitancy in these three countries is higher than desirable, but most people who are COVID-19 vaccine hesitant offered one reason or fewer. The reasons offered are diverse, including myths and exaggerations, but also individual-level contraindications for vaccination and structural barriers. Because of the diversity of reasons, single-issue mass campaigns are unlikely to bring about large shifts in COVID-19 vaccine hesitancy in Colombia, Ecuador, and Venezuela. Our data suggest that interpersonal communication, particularly in Ecuador, and addressing structural concerns, particularly in Venezuela, are likely to have the greatest impact on vaccine uptake.

Introduction: Social support has been found in many contexts, and in urban Ecuador, to be protective of health, particularly in the context of disaster. Fewer studies have explored the presence and impact of social support in rural Ecuador. This study engages a rural community in Ecuador to examine the general levels of social support, differences in social support based on different demographic groupings and relationships among social support and health outcomes and protective health behaviors., Methods: A cross-sectional design was used to survey 416 people in a rural Ecuadorian community that had recently experienced an earthquake. Spanish-language versions of the Multidimensional Scale of Perceived Social Support and the Interpersonal Support Evaluation List-12 were applied, as well as questions about demographics and risk reduction behaviors. Body mass index, blood pressure, and cholesterol and blood sugar levels were assessed. Analysis of variance assessed differences in social support among demographic groupings, risk reduction behaviors, and health outcomes., Results: Levels of social support were moderate. Few statistically significant (ie p<0.05) differences in amount of social support received or in sources of social support were found. Men, people 80 years or older, divorced or widowed people, and people living in peripheral areas received less social support than women, people of all other ages, married/cohabitating people, and people living within the village, respectively. Effect sizes of these differences were small. No relationship between social support and health outcomes were found, and few were found for risk reduction factors., Conclusion: These findings indicate that social support may function differently in rural Ecuador than in urban contexts. Those promoting social support in rural communities may wish to focus on community-level, not individual-level, interventions. Limitations of applying an assessment of social support from urban Ecuadorian contexts to rural Ecuadorian contexts are discussed.

Background: Although the practice of communication is often called upon when intervening and involving communities affected by NTDs, the disciplinary framework of health communication research has been largely absent from NTD strategies. To illustrate how practices conceptualized and developed within the communication field have been applied in the context of NTD elimination, we conducted a scoping review focusing on two diseases currently targeted for elimination by the WHO: lymphatic filariasis and Chagas disease., Methods: We examined studies published between 2012 and 2020 in five electronic databases. Selected articles were required to (i) have explicit references to communication in either the abstract, title, or key words; (ii) further elaborate on the search terms (communication, message, media, participation and health education) in the body of the article; and (iii) sufficiently describe communication actions associated to those terms. Using the C-Change Socio-Ecological Model for Social and Behavior Change Communication as a reference, the articles were analysed to identify communication activities, theoretical frameworks, and/or rationales involved in their design, as well as their intended level of influence (individual, interpersonal, community, or enabling environment)., Results and Implications: A total of 43 articles were analysed. Most interventions conceptualized communication as a set of support tools or supplemental activities delivering information and amplifying pre-defined messages aimed at increasing knowledge, encouraging community involvement, promoting individual behavior change, or securing some degree of acceptability of proposed strategies. Although important attempts at further exploring communication capabilities were identified, particularly in participation-based strategies, for most studies, communication consisted of an underdeveloped and under-theorized approach. We contend that a more complex understanding of the capacities offered by the health communication field could help attain the biomedical and social justice goals proposed in NTD elimination strategies. Three ways in which the field of health communication could further enhance NTD efforts are presented: informing interventions with theory-based frameworks, exploring the political complexity of community participation in specific contexts, and identifying conceptualizations of culture implied in interventions' design., Conclusion: This article is a call to action to consider the resources offered by the health communication field when researching, designing, or implementing NTD interventions., Competing Interests: The authors have declared that no competing interests exist.

The objective of this study was to evaluate the effectiveness of selective and community-wide house insecticide spraying in controlling triatomines in the subtropical areas of Loja Province, Ecuador. We designed a quasi-experimental pre-post-test without a control group to compare entomological levels before and after spraying. The baseline study was conducted in 2008. Second, third, and fourth visits were conducted in 2010, 2011, and 2012 in three rural communities. Out of the 130 domestic units (DU) visited, 41 domestic units were examined in each of the four visits. Selective and community-wide insecticide interventions included spraying with 5% deltamethrin at 25 mg/m 2 active ingredient. At each visit, a questionnaire was administered to identify the characteristics of households, and DUs were searched for triatomine bugs. In addition, parasitological analysis was carried out in life triatomines. One and two rounds of selective insecticide spraying decreased the probability of infestation by 62% (pairwise odds ratios [POR] 0.38, 95% confidence interval [CI] 0.17-0.89, p  = 0.024) and 51% (POR 0.49, 95% CI 0.23-1.01, p  = 0.054), respectively. A similar effect was observed after one round of community-wide insecticide application in Chaquizhca and Guara (POR 0.55, CI 0.24-1.25, p  = 0.155) and Bellamaria (POR 0.62, CI 0.22-1.79, p  = 0.379); however, it was not statistically significant. Trypanosoma cruzi infection in triatomines ( n  = 483) increased overtime, from 2008 (42.9% and 8.5% for Rhodnius ecuadoriensis and Panstrongylus chinai , respectively) to 2012 (79.5% and 100%). Neither of the two spraying methodologies was effective for triatomine control in this area and our results point to a high likelihood of reinfestation after insecticide application. This underscores the importance of the implementation of physical barriers that prevent invasion and colonization of triatomines in households, such as home improvement initiatives, accompanied by a concerted effort to address the underlying socioeconomic issues that keep this population at risk of developing Chagas disease.

Chagas disease is endemic in ~70% of Ecuador. Rhodnius ecuadoriensis and Triatoma carrioni (Hemiptera: Reduviidae) are the primary vectors of Chagas disease in Southern Ecuador. This study tested the effectiveness of selective deltamethrin application of Domiciliary Units (DUs) infested with triatomines, coupled with community education activities and a community-based surveillance system. Ten communities were selected in Loja Province, 466 DUs were examined, of these, 5.6% were infested with R. ecuadoriensis (Density [D] = 4 triatomines/DUs searched, Crowding [CR] = 71 triatomines/infested house, Colonization Index [CI] = 77% infested DUs with nymphs) and 8% with T. carrioni (D = 0.6, CR = 7, CI = 64%). Infested DUs were sprayed with deltamethrin. Subsequent visits were conducted at 6 and 12 mo after spraying. At each time point, new entomological searches were carried out in all DUs. All entomological indexes dropped significantly for the primary vector species one year after the initial intervention (R. ecuadoriensis: I = 2%, D = 0.1, CR = 7, CI = 100%; T. carrioni: I = 1.6%, D = 0.1, CR = 5.5, CI = 50%). Fifteen min educational talks were conducted in every DUs and workshops for schoolchildren were organized. Community-based surveillance system was established. However, there is a high risk of DUs reinfestation, possibly from sylvatic habitats (especially of R. ecuadoriensis) and reinforcing educational and surveillance activities are necessary., (© The Author(s) 2022. Published by Oxford University Press on behalf of Entomological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: Chagas disease (CD) is caused by the protozoan parasite, Trypanosoma cruzi. It affects 7 to 8 million people worldwide and leads to approximately 50,000 deaths per year. In vitro and in vivo studies had demonstrated that Trypanosoma cruziinfection causes an imbalance in the hypothalamic-pituitary-adrenal (HPA) axis that is accompanied by a progressive decrease in growth hormone (GH) and prolactin (PRL) production. In humans, inactivating mutations in the GH receptor gene cause Laron Syndrome (LS), an autosomal recessive disorder. Affected subjects are short, have increased adiposity, decreased insulin-like growth factor-I (IGFI), increased serum GH levels, are highly resistant to diabetes and cancer, and display slow cognitive decline. In addition, CD incidence in these individuals is diminished despite living in highly endemic areas. Consequently, we decided to investigate the in vitro effect of GH/IGF-I on T. cruzi infection., Design: We first treated the parasite and/or host cells with different peptide hormones including GH, IGFI, and PRL. Then, we treated cells using different combinations of GH/IGF-I attempting to mimic the GH/IGF-I serum levels observed in LS subjects., Results: We found that exogenous GH confers protection against T. cruzi infection. Moreover, this effect is mediated by GH and not IGFI. The combination of relatively high GH (50 ng/ml) and low IGF-I (20 ng/ml), mimicking the hormonal pattern seen in LS individuals, consistently decreased T. cruzi infection in vitro., Conclusions: The combination of relatively high GH and low IGF-I serum levels in LS individuals may be an underlying condition providing partial protection against T. cruzi infection., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: Access to professional health care providers in Loja Province, Ecuador can be difficult for many citizens. The Health Care Access Barrier Model (HCAB) was established to provide a framework for classification, analysis, and reporting of modifiable health care access barriers. This study uses the HCAB Model to identify barriers and themes impacting access to health care access in southern rural Ecuador., Methods: The research team interviewed 22 participants and completed 15 participant observation studies in the study area. Interviews and a single focus group session of artisans were recorded and transcribed from Spanish to English, and thematic analysis was performed., Results: The thematic analysis found financial, structural, and cognitive health care access barriers. Cost of medications, transportation, missed responsibilities at work and home, difficulty scheduling appointments, and misconceptions in health literacy were the predominant themes contributing to health care access. These pressure points provide insight on where actions may be taken to alleviate access barriers., Conclusion: Modifiable health care access barriers outlined in the HCAB are evident in the study area. Further research and implementation of programs to resolve these barriers, such as the creation of health care subcenters and/or mobile clinic, insurance coverage of specialized care, increasing availability and accessibility to affordable transportation, improving roadways, introduction of a 24/7 call center to schedule medical visits, monetary incentive for primary care physicians to practice in rural and underserved areas, provision of affordable work equipment, and emphasizing the improvement of health care literacy through education, may diminish current barriers, identify additional barriers, and improve overall health in the rural area of Loja, Ecuador and similar rural regions around the world., (© 2022. The Author(s).)

Accurate prediction of vectors dispersal, as well as identification of adaptations that allow blood-feeding vectors to thrive in built environments, are a basis for effective disease control. Here we adopted a landscape genomics approach to assay gene flow, possible local adaptation, and drivers of population structure in Rhodnius ecuadoriensis, an important vector of Chagas disease. We used a reduced-representation sequencing technique (2b-RADseq) to obtain 2,552 SNP markers across 272 R. ecuadoriensis samples from 25 collection sites in southern Ecuador. Evidence of high and directional gene flow between seven wild and domestic population pairs across our study site indicates insecticide-based control will be hindered by repeated re-infestation of houses from the forest. Preliminary genome scans across multiple population pairs revealed shared outlier loci potentially consistent with local adaptation to the domestic setting, which we mapped to genes involved with embryogenesis and saliva production. Landscape genomic models showed elevation is a key barrier to R. ecuadoriensis dispersal. Together our results shed early light on the genomic adaptation in triatomine vectors and facilitate vector control by predicting that spatially-targeted, proactive interventions would be more efficacious than current, reactive approaches., Competing Interests: The authors have declared that no competing interests exist.

Background: Recent studies in the United States have shown that between 56 to 74% are willing to receive the COVID-19 vaccine. A significant portion of the population should be vaccinated to avoid severe illness and prevent unnecessary deaths. We examined correlates of COVID-19 vaccine acceptance among a representative sample of adults residing in Ohio., Methods: We conducted a cross-sectional study using an online platform (n = 2358). Descriptive statistics, chi-square test and multivariable regression analysis were performed., Results: Overall, 59.1% of the participants indicated COVID-19 vaccine acceptance to be vaccinated. In the multivariable model, the likelihood of COVID-19 vaccine acceptance was lower for younger individuals compared to those 55 years and older. The odds of COVID-19 vaccine acceptance were lower for: females compared to males (OR 0.58, 95% CI: 0.47-0.71; P = 0.001), non-Hispanic blacks compared to non-Hispanic whites (OR: 0.49 95% CI: 0.35-0.70; P = 0.001), previously married (OR 0.64 95% CI: 0.49-0.84; P = 0.002) and never been married (OR 0.75 95% CI: 0.59-0.96; P = 0.023) compared to married people, individuals with less than high school (OR 0.21 95% CI: 0.08-0.60; P = 0.003) and high school education (OR: 0.45 95% CI: 0.36-0.55; P < 0.001) compared to those with education beyond high school, and for individuals who had no confidence in the abilities of the state government (OR 0.69 95% CI: 0.53-0.89; P = 0.005) and other world governments to combat COVID-19 (OR 0.67 95% CI: 0.50-0.91; P = 0.009). A one unit increase in knowledge about COVID-19 (OR 1.19, 95% CI: 1.13-1.26; P < 0.001), behavioral adherence (OR 1.25, 95% CI: 1.15-1.37; P < 0.001), perceived susceptibility (OR 1.10, 95% CI: 1.03-1.17; P = 0.004), perceived severity (OR 1.09, 95% CI: 1.03-1.16; P = 0.003), and trust in COVID-19 messages from the government scores (OR 1.08, 95% CI: 1.06-1.10; P < 0.001) were associated with an increase in the likelihood of COVID-19 vaccine acceptance., Conclusions: COVID-19 vaccine acceptance differed by sociodemographic and other modifiable factors. Findings can inform local public health authorities in the development of effective, context-specific communication strategies to improve vaccination uptake., (© 2022. The Author(s).)

Transmission risk of Chagas disease has been associated with human-vector contacts and triatomines colonizing dwellings, but alternative scenarios, independent of domestic colonization, are poorly documented. In the present work, we estimated the frequency of human blood meals in triatomines from domicile, peridomicile, and sylvatic environments in two endemic regions in Ecuador. Blood meal origins were identified by sequencing a cytb gene fragment. Human blood meals were detected in 42% of the triatomines among 416 analyzed, including 48% of sylvatic triatomines (both adults and nymphs). In triatomines from domicile and peridomicile, Trypanosoma cruzi infection rate was > 20%, and reached 48% in sylvatic triatomines. Human is a common source of blood for triatomines whether they live in or near dwellings in both regions, and the high rate of T. cruzi infection represents an important risk of transmission of Chagas disease. Consequently, control strategies should also take into account possible nondomestic transmission.

Context: Diabetes has become a global noninfectious pandemic with rates rapidly rising around the globe. The major drivers of this increase in type 2 diabetes are obesity, an increase in processed foods, and a decrease in physical activity. In the United States, the National Diabetes Prevention Program (NDPP) has proven to be an effective lifestyle intervention to delay or prevent new-onset type 2 diabetes. However, there is limited evidence that such a lifestyle program will work in a South American community., Objectives: This pilot program aims to determine if a modified version of the Centers for Disease Control and Prevention (CDC) Diabetes Prevention Program (DPP) would be feasible in an Ecuadorian population. The goals of this pilot program were a 7% weight loss, >150 min of physical activity per week, and a reduction of fat calories to yield a reduced risk of type 2 diabetes. This program was led by family medicine physicians and was offered to people with prediabetes in Quito, Ecuador., Methods: The program was modified to include only the first half of the DPP curriculum, which included a schedule of 16 classes in the first 6 months. Further, the program was provided in Spanish and modified to be more culturally specific to this population. Participants were recruited from the faculty and staff of Pontifical Catholic University of Ecuador (Pontificia Universidad Católica del Ecuador [PUCE]) in Quito. Outcomes measured included A1c reduction, weight loss, increase in physical activity minutes, and progression to type 2 diabetes mellitus (T2DM)., Results: The sample included 33 people with prediabetes. The mean age of the participants was 52 years (range, 41-66 years), the mean body mass index (BMI) was 27.6 kg/m 2 (range, 21.0-40.3 kg/m 2 ), and the mean HbA1C was 6.2% (range, 5.7-6.4%). The attendance was 97.8% at 6 months. The mean weight loss was 3.4 kg per participant (range, 1.5 kg weight gain to 8.3 kg weight loss); in percentage points, this was a mean weight loss of 3.6% (range, 2.3% gain to 11.8% weight loss). Three-fourths of the participants lost weight (78.3%). The majority of participants (75.8%) met the target physical activity level of 150 min per week, and all participants increased their physical activity levels from baseline. No participants progressed to type 2 diabetes during this study., Conclusions: The DPP 6 month pilot was effective in this population with prediabetes in Ecuador. The largest changes were made in physical activity time. Holding the program at worksites and providing lunch were key factors in the very high retention rate in this study., (© 2021 Susana Alvear Durán et al., published by De Gruyter, Berlin/Boston.)

Background: COVID-19 threatens health systems worldwide, but Venezuela's system is particularly vulnerable. To prevent the spread of COVID-19, individuals must adopt preventive behaviors. However, to encourage behavior change, we must first understand current knowledge, attitudes, and practices (KAPs) that inform response to this health threat., Methods: We explored KAPs among Venezuelans using a cross-sectional, internet-based questionnaire. The questionnaire explored individuals' knowledge about COVID-19; their attitudes toward the world's and the Venezuelan authorities' abilities to control it; and their self-reported practices. We also collected demographic data. Binomial logistic regression analyses were used to predict the adoption of preventive behaviors based on demographic variables, individual knowledge level, and individual attitudes., Results: 3122 individuals completed the questionnaire. Participants had a high level of knowledge about COVID-19. They expressed high levels of optimism that the world would eventually control COVID-19, but they were very pessimistic about the public authorities in Venezuela. Most participants adopted preventive practices. Binomial regression suggests younger people, less educated people, and manual laborers hold lower levels of knowledge, and these groups, as well as men, were less likely to adopt preventive practices. Knowledge, by itself, had no association with optimism and little association with self-reported practices., Conclusions: As other KAP studies in Latin America found, knowledge is not sufficient to prompt behavior change. Venezuelans' pessimism about their own country's ability should be explored in greater depth. Health promotion in Venezuela may wish to target the most at risk groups: men, younger people, less educated people, and manual laborers., Competing Interests: The authors have declared that no competing interests exist.

Trypanosoma cruzi , a zoonotic kinetoplastid protozoan parasite, is the causative agent of American trypanosomiasis (Chagas disease). Having a very plastic, repetitive and complex genome, the parasite displays a highly diverse repertoire of surface molecules, with pivotal roles in cell invasion, immune evasion and pathogenesis. Before 2016, the complexity of the genomic regions containing these genes impaired the assembly of a genome at chromosomal level, making it impossible to study the structure and function of the several thousand repetitive genes encoding the surface molecules of the parasite. We here describe the genome assembly of the Sylvio X10/1 genome sequence, which since 2016 has been used as a reference genome sequence for T. cruzi clade I (TcI), produced using high coverage PacBio single-molecule sequencing. It was used to analyze deep Illumina sequence data from 34 T. cruzi TcI isolates and clones from different geographic locations, sample sources and clinical outcomes. Resolution of the surface molecule gene distribution showed the unusual duality in the organization of the parasite genome, a synteny of the core genomic region with related protozoa flanked by unique and highly plastic multigene family clusters encoding surface antigens. The presence of abundant interspersed retrotransposons in these multigene family clusters suggests that these elements are involved in a recombination mechanism for the generation of antigenic variation and evasion of the host immune response on these TcI strains. The comparative genomic analysis of the cohort of TcI strains revealed multiple cases of such recombination events involving surface molecule genes and has provided new insights into T. cruzi population structure., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Talavera-López, Messenger, Lewis, Yeo, Reis-Cunha, Matos, Bartholomeu, Calzada, Saldaña, Ramírez, Guhl, Ocaña-Mayorga, Costales, Gorchakov, Jones, Nolan, Teixeira, Carrasco, Bottazzi, Hotez, Murray, Grijalva, Burleigh, Grisard, Miles and Andersson.)

Background: Vaccination is the most effective way to prevent infection and severe outcomes caused by influenza viruses in pregnant women and their children. In Ecuador, the coverage of seasonal influenza vaccination in pregnant women is low. The aim of this study was to assess the knowledge, attitudes, and practices (KAP) of pregnant women toward influenza vaccination in Quito-Ecuador., Methods: A cross-sectional study enrolled 842 women who delivered at three main public gynecological-obstetric units of the Metropolitan District of Quito. A questionnaire regarding demographics, antenatal care, risk conditions and knowledge, attitudes and practices related to influenza vaccination was administered. We examined factors associated with vaccination using log-binomial regression models., Results: A low vaccination rate (36.6%) against influenza was observed among pregnant women. The factors associated with vaccination included the recommendations from health providers (adjusted PR: 15.84; CI 95% 9.62-26.10), belief in the safety of the influenza vaccine (adjusted PR: 1.53; CI 95% 1.03-2.37) and antenatal care (adjusted PR: 1.21; CI 95% 1.01-1.47). The most common reasons for not vaccinating included the lack of recommendation from health care providers (73.9%) and lack of access to vaccine (9.0%)., Conclusions: Health educational programs aimed at pregnant women and antenatal care providers have the most potential to increase influenza vaccination rates. Further studies are needed to understand the barriers of health care providers regarding influenza vaccination in Ecuador.

Understanding the blood meal patterns of insects that are vectors of diseases is fundamental in unveiling transmission dynamics and developing strategies to impede or decrease human-vector contact. Chagas disease has a complex transmission cycle that implies interactions between vectors, parasites and vertebrate hosts. In Ecuador, limited data on human infection are available; however, the presence of active transmission in endemic areas has been demonstrated. The aim of this study was to determine the diversity of hosts that serve as sources of blood for triatomines in domestic, peridomestic and sylvatic transmission cycles, in two endemic areas of Ecuador (central coastal and southern highland regions). Using conserved primers and DNA extracted from 507 intestinal content samples from five species of triatomines (60 Panstrongylus chinai , 17 Panstrongylus howardi , 1 Panstrongylus rufotuberculatus , 427 Rhodnius ecuadoriensis and 2 Triatoma carrioni ) collected from 2006 to 2013, we amplified fragments of the cytb mitochondrial gene. After sequencing, blood meal sources were identified in 416 individuals (146 from central coastal and 270 from southern highland regions), achieving ≥ 95% identity with GenBank sequences (NCBI-BLAST tool). The results showed that humans are the main source of food for triatomines, indicating that human-vector contact is more frequent than previously thought. Although other groups of mammals, such as rodents, are also an available source of blood, birds (particularly chickens) might have a predominant role in the maintenance of triatomines in these areas. However, the diversity of sources of blood found might indicate a preference driven by triatomine species. Moreover, the presence of more than one source of blood in triatomines collected in the same place indicated that dispersal of vectors occurs regardless the availability of food. Dispersal capacity of triatomines needs to be evaluated to propose an effective strategy that limits human-vector contact and, in consequence, to decrease the risk of T. cruzi transmission.

In rural Ecuador pregnant women face complex challenges navigating the terrain between traditional and biomedical maternal health care services. Semi-structured interviews were conducted in three rural communities in Southern Ecuador that have presented active Chagas disease transmission with women who were pregnant or have given birth within the last five years. This study was conducted to identify and understand the experiences of mothers in these communities and the decisions they make to maintain the wellness of themselves and their children. The researchers recorded women's maternal health stories, analyzed their access to maternal health care, and explored factors influencing their birth location preferences and health seeking behaviors. The researchers found that women in this region are utilizing medical pluralism to sustain maternal health and the well-being of their children.

Analysis of genetic polymorphism is a powerful tool for epidemiological surveillance and research. Powerful inference from pathogen genetic variation, however, is often restrained by limited access to representative target DNA, especially in the study of obligate parasitic species for which ex vivo culture is resource-intensive or bias-prone. Modern sequence capture methods enable pathogen genetic variation to be analyzed directly from host/vector material but are often too complex and expensive for resource-poor settings where infectious diseases prevail. This study proposes a simple, cost-effective 'genome-wide locus sequence typing' (GLST) tool based on massive parallel amplification of information hotspots throughout the target pathogen genome. The multiplexed polymerase chain reaction amplifies hundreds of different, user-defined genetic targets in a single reaction tube, and subsequent agarose gel-based clean-up and barcoding completes library preparation at under 4 USD per sample. Our study generates a flexible GLST primer panel design workflow for Trypanosoma cruzi, the parasitic agent of Chagas disease. We successfully apply our 203-target GLST panel to direct, culture-free metagenomic extracts from triatomine vectors containing a minimum of 3.69 pg/μl T. cruzi DNA and further elaborate on method performance by sequencing GLST libraries from T. cruzi reference clones representing discrete typing units (DTUs) TcI, TcIII, TcIV, TcV and TcVI. The 780 SNP sites we identify in the sample set repeatably distinguish parasites infecting sympatric vectors and detect correlations between genetic and geographic distances at regional (< 150 km) as well as continental scales. The markers also clearly separate TcI, TcIII, TcIV and TcV + TcVI and appear to distinguish multiclonal infections within TcI. We discuss the advantages, limitations and prospects of our method across a spectrum of epidemiological research., Competing Interests: The authors have declared that no competing interests exist.

Preventing the transmission of SARS-CoV-2 (causative agent for COVID-19) requires implementing contact and respiratory precautions. Modifying human behavior is challenging and requires understanding knowledge, attitudes, and practices (KAPs) regarding health threats. This study explored KAPs among people in Ecuador. A cross-sectional, internet-based questionnaire was used to assess knowledge about COVID-19, attitudes toward ability to control COVID-19, self-reported practices related to COVID-19, and demographics. A total of 2399 individuals participated. Participants had moderate to high levels of knowledge. Participants expressed mixed attitudes about the eventual control of COVID-19 in Ecuador. Participants reported high levels of adoption of preventive practices. Binomial regression analysis suggests unemployed individuals, househusbands/housewives, or manual laborers, as well as those with an elementary school education, have lower levels of knowledge. Women, people over 50 years of age, and those with higher levels of schooling were the most optimistic. Men, individuals 18-29, single, and unemployed people took the riskiest behaviors. Generally, knowledge was not associated with optimism or with practices. Our findings indicate knowledge about COVID-19 is insufficient to prompt behavioral change among Ecuadorians. Since current COVID-19 control campaigns seek to educate the public, these efforts' impacts are likely to be limited. Given attitudes determine people's actions, further investigation into the factors underlying the lack of confidence in the ability of the world, and of Ecuador, to overcome COVID-19, is warranted. Edu-communicational campaigns should be accompanied by efforts to provide economically disadvantaged populations resources to facilitate adherence to recommendations to prevent the spread of the virus.

The genus Triatoma contains numerous species, principal or secondary vectors of Chagas disease, which have been included in the three main lineages of Triatomini tribe based on morphological and biogeographical characteristics: North American, South American, and T. dispar complex. The three members of the T. dispar complex are distributed in Ecuador. This complex has been scarcely studied through molecular approaches, and the taxonomic position of this complex is not confirmed. In this study, we explored the phylogenetic relationships within the genus Triatoma, including five species from North and Central America, six from South America, and the three species belonging to the T. dispar complex. Partial sequences of four mitochondrial genes (Cyt b, COII, 16S-rRNA, 12S-rRNA) and two nuclear genes (18S-rRNA, ITS2) were obtained from 74 specimens. Phylogenetic trees were built with concatenated and single sequences through maximum likelihood (ML), maximum parsimony (MP), and Bayesian methods. The trees built using concatenated sequences showed three main branches (clusters) highly supported by significant bootstrap values; the T. dispar complex appeared as a monophyletic group separate from species of North and Central American origin and South American origin. On the contrary, for each gene tree, the three main clusters were not always significantly supported, mostly because genetic information is dramatically reduced when a single gene is considered. Consequently, concatenation of genes gives relevant results and is highly recommended for further in-depth examination of the relationships of several species and complexes of triatomines that remain unresolved. Moreover, our current molecular data fully revealed the division of genus Triatoma into at least three main genetic groups., (Copyright © 2020. Published by Elsevier B.V.)

Rhodnius ecuadoriensis is one of the most important vector species of Chagas disease in Ecuador. This species is distributed in the Central coast region and in the south Andean region, and an incipient speciation process between these geographical populations was previously proposed. The current population genetics study only focused on the Central coast region and analyzed 96 sylvatic specimens of R. ecuadoriensis associated with Phytelephas aequatorialis palm trees. We used Cytb and 16S-rRNA sequences and a Cytb-16S-rRNA concatenated set to explore (i) the genetic variability, spatial structuring, and demographic history of R. ecuadoriensis, and to determine (ii) the relationship between the genetic and climatic variabilities. A particularly high genetic variability was observed without detectable general genetic structure; only some terminal genetic clusters were observed. We did not observe isolation by geographical distance (IBD), and it is likely that ancient expansion occurred, according to Fs index and mismatch distribution for Cytb-16S-rRNA concatenated sequences. Hierarchical clustering showed that the current locality origins of the bugs were grouped into four bioclimatic clusters. Genetic and bioclimatic distances were not correlated, but some genetic clusters were associated with bioclimatic ones. The results showed an ancient evolution of the species in the region with a possible old expansion. The absence of spatial genetic structure could be due to climatic conditions (possible selection of singular genotypes) and to passive transportation of palms tree materials where R. ecuadoriensis are living., Competing Interests: Declaration of Competing Interest The authors declare having no competing interests of any kind related to this article., (Copyright © 2020. Published by Elsevier B.V.)

Population adoption of social distancing measures during the COVID-19 pandemic is at times deficient, increasing the risk of SARS-CoV-2 transmission. Healthcare workers and those living in areas of intense transmission may benefit from implementing biosafety measures in their daily lives. A mixed-methods approach, combining components of single negotiation text and the Delphi method, was used to create a COVID-19 biosafety-at-home protocol. A consensus building coordinator liaised with 12 experts to develop the protocol over 11 iterations. Experts had more than 200 years of combined experience in epidemiology, virology, infectious disease prevention, and public health. A flyer, created from the final protocol, was professionally designed and initially distributed via social media and institutional websites/emails in Ecuador beginning on May 2, 2020. Since then, it has been distributed in other countries, reaching ∼7,000 people. Translating research laboratory biosafety measures for the home/street environment might be challenging. The biosafety-at-home flyer addresses this challenge in a user-friendly format.

Background: Trypanosoma cruzi, the causative agent of Chagas disease, and T. rangeli are kinetoplastid parasites endemic to Latin America. Although closely related to T. cruzi and capable of infecting humans, T. rangeli is non-pathogenic. Both parasite species are transmitted by triatomine bugs, and the presence of T. rangeli constitutes a confounding factor in the study of Chagas disease prevalence and transmission dynamics. Trypanosoma cruzi possesses high molecular heterogeneity: seven discrete typing units (DTUs) are currently recognized. In Ecuador, T. cruzi TcI and T. rangeli KP1(-) predominate, while other genetic lineages are seldom reported., Methods: Infection by T. cruzi and/or T. rangeli in different developmental stages of triatomine bugs from two communities of southern Ecuador was evaluated via polymerase chain reaction product size polymorphism of kinetoplast minicircle sequences and the non-transcribed spacer region of the mini-exon gene (n = 48). Forty-three mini-exon amplicons were also deep sequenced to analyze single-nucleotide polymorphisms within single and mixed infections. Mini-exon products from ten monoclonal reference strains were included as controls., Results: Trypanosoma cruzi genetic richness and diversity was not significantly greater in adult vectors than in nymphal stages III and V. In contrast, instar V individuals showed significantly higher T. rangeli richness when compared with other developmental stages. Among infected triatomines, deep sequencing revealed one T. rangeli infection (3%), 8 T. cruzi infections (23.5%) and 25 T. cruzi + T. rangeli co-infections (73.5%), suggesting that T. rangeli prevalence has been largely underestimated in the region. Furthermore, deep sequencing detected TcIV sequences in nine samples; this DTU had not previously been reported in Loja Province., Conclusions: Our data indicate that deep sequencing allows for better parasite identification/typing than amplicon size analysis alone for mixed infections containing both T. cruzi and T. rangeli, or when multiple T. cruzi DTUs are present. Additionally, our analysis showed extensive overlap among the parasite populations present in the two studied localities (c.28 km apart), suggesting active parasite dispersal over the study area. Our results highlight the value of amplicon sequencing methodologies to clarify the population dynamics of kinetoplastid parasites in endemic regions and inform control campaigns in southern Ecuador.

Background: Chagas disease is a parasitic infection transmitted by "kissing bugs" (Hemiptera: Reduviidae: Triatominae) that has a huge economic impact in Latin American countries. The vector species with the upmost epidemiological importance in Ecuador are Rhodnius ecuadoriensis (Lent & Leon, 1958) and Triatoma dimidiata (Latreille, 1811). However, other species such as Panstrongylus howardi (Neiva, 1911) and Panstrongylus chinai (Del Ponte, 1929) act as secondary vectors due to their growing adaptation to domestic structures and their ability to transmit the parasite to humans. The latter two taxa are distributed in two different regions, they are allopatric and differ mainly by their general color. Their relative morphological similarity led some authors to suspect that P. chinai is a melanic form of P. howardi., Methods: The present study explored this question using different approaches: antennal phenotype; geometric morphometrics of heads, wings and eggs; cytogenetics; molecular genetics; experimental crosses; and ecological niche modeling., Results: The antennal morphology, geometric morphometrics of head and wing shape and cytogenetic analysis were unable to show distinct differences between the two taxa. However, geometric morphometrics of the eggs, molecular genetics, ecological niche modeling and experimental crosses including chromosomal analyses of the F1 hybrids, in addition to their coloration and current distribution support the hypothesis that P. chinai and P. howardi are separate species., Conclusions: Based on the evidence provided here, P. howardi and P. chinai should not be synonymized. They represent two valid, closely related species.

Competing Interests: The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript. IA, MCL, MCT, AMR, and MZ are involved in the development of serological assays based on parasite-derived biomarkers for the early assessment of treatment response in Chagas disease. No patents applications or other forms of intellectual properties will be considered in this development work.

Objectives: Chronic malnutrition and anemia are prevalent in developing countries. This research aimed to determine the prevalence of chronic malnutrition and anemia and their associated factors in children under five using a multi-causal model in a rural community in the coast of Ecuador., Methods: The study included 314 children under 5 years old who were residents of San Isidro, Ecuador. Indicators of chronic malnutrition and anemia were identified. Mothers/caregivers were surveyed on socio-economic and environmental conditions, feeding and care practices, access to health services and biological characteristics. Bivariate and multivariable Poisson regression were performed., Results: The prevalence was 12.42% (n = 39) for chronic malnutrition and 16.98% (n = 54) for anemia. There was a significant and independent association between chronic malnutrition and family income less than $80 USD per month (Prevalence Ratio [PR] = 2.74, 95% CI 1.04, 7.20), maternal height less than 150 cm (PR 3.00, 95% CI 1.69, 5.32) and residence in a household with more than 4 children (PR 3.05, 95% CI 1.48, 6.29). Anemia was 2.57 times higher (95% CI 1.17, 5.65) in children with more than two episodes of diarrhea in the last 6 months. Prenatal care (5 to 8 visits) provided a protective effect for anemia (PR 0.48, 95% CI 0.27, 0.89)., Conclusions for Practice: Findings support the need for comprehensive interventions targeted toward chronic malnutrition and anemia in children from rural coastal communities. Improvement of socioeconomic conditions, family planning, prenatal care and reduction of diarrheal diseases should be prioritized.

Limited genetic data are currently available for three vectors of Chagas disease in Ecuador, Panstrongylus howardi, P. chinai, and P. rufotuberculatus. Previously regarded as mainly sylvatic, these species have been poorly studied. Recently, they have been more frequently reported in domiciles and peridomiciles and are now considered true secondary vectors of Chagas disease in a country where an estimated 200,000 people are infected by Trypanosoma cruzi, a causative agent of this disease. In order to fill this gap, we obtained DNA for sequencing from 53 insects belonging to these three species and mainly sampled from the two Ecuadorian provinces of Loja and Manabí. We used six mitochondrial loci (COI, COII, ND4, CytB, 16S, and 12S) and two nuclear ones (ITS2 and 18S). We interpreted the phylogenetic trees built with single and concatenated data through maximum likelihood, Bayesian Markov chain Monte Carlo, and maximum parsimony methods. We provide evidence that P. chinai and P. howardi are indeed two supported species closely related and derived from a common ancestor. Additionally, the phylogenetic position of P. rufotuberculatus was confirmed as being distant from P. chinai and P. howardi and clustered with Triatoma dimidiata, a species belonging to the Northern American Triatoma clade., (Copyright © 2019. Published by Elsevier B.V.)

Introduction: Control of triatomine infestation is a key strategy for the prevention of Chagas disease (CD). To promote this strategy, it is important to know which antecedents to behavioral change are the best to emphasize when promoting prevention., Objective: The aim of this study was to determine predictors for intention to prevent home infestation based on the Health Belief Model (HBM), a commonly used health intervention planning theory., Materials & Methods: A cross-sectional study was conducted with 112 heads of household in six communities with endemic and high rates of triatomine infestation in Loja province, Ecuador. The data was collected by a questionnaire including perceived severity, susceptibility, benefits to action, barriers to action, and self-efficacy. These data were also used to predict actual infestation of homes., Results: Community members reported strong intentions to prevent home infestation. HBM constructs predicted about 14% of the observed variance in intentions. Perceived susceptibility and severity did not predict behavioral intention well; perceived barriers to small-scale action that reduce likelihood of infestation and self-efficacy in participating in surveillance systems did. Self-efficacy and perception of barriers were equally powerful predictors. The HBM constructs, however, did not predict well actual infestation., Conclusion: The findings supported the HBM as a way to predict intentions to prevent infestation of the home by triatomine bugs. The findings highlight that messages emphasizing self-efficacy in participating in surveillance systems and overcoming barriers to small-scale action that reduce likelihood of infestation, rather than a focus on risk, should be central messages when designing and implementing educational interventions for CD. The gap between behavioral intention and actual infestation reveals the need to assess home practices and their actual efficacy to fully enact and apply the HBM., Competing Interests: The authors have declared that no competing interests exist.

Insecticide spraying of housing units is an important control measure for vector-borne infections such as Chagas disease. However, some vectors may survive treatment, due to imperfect spraying by the operator or because they hide deep in the cracks or other places, and re-emerge in the same unit when the effect of the insecticide wears off. While several mathematical models of this phenomenon have been previously described and studied in the literature, the model presented here is more basic than existing ones. Thus it is more amenable to mathematical analysis, which is carried out here. In particular, we demonstrate that an initially very high spraying rate may push the system into a region of the state space with low endemic levels of infestation that can be maintained in the long run at relatively moderate cost, while in the absence of an aggressive initial intervention the same average cost would only allow a much less significant reduction in long-term infestation levels.

Genetic exchange enables parasites to rapidly transform disease phenotypes and exploit new host populations. Trypanosoma cruzi, the parasitic agent of Chagas disease and a public health concern throughout Latin America, has for decades been presumed to exchange genetic material rarely and without classic meiotic sex. We present compelling evidence from 45 genomes sequenced from southern Ecuador that T. cruzi in fact maintains truly sexual, panmictic groups that can occur alongside others that remain highly clonal after past hybridization events. These groups with divergent reproductive strategies appear genetically isolated despite possible co-occurrence in vectors and hosts. We propose biological explanations for the fine-scale disconnectivity we observe and discuss the epidemiological consequences of flexible reproductive modes. Our study reinvigorates the hunt for the site of genetic exchange in the T. cruzi life cycle, provides tools to define the genetic determinants of parasite virulence, and reforms longstanding theory on clonality in trypanosomatid parasites.

Background: The mortality rate in children under 5 years old (U5MR) has decreased considerably in Ecuador in the last decade; however, thousands of children continue to die from causes related to poverty. A social program known as Bono de Desarrollo Humano (BDH) was created to guarantee a minimum level of consumption for families and to reduce chronic malnutrition and preventable childhood diseases. We sought to evaluate the effect of the BDH program on mortality of children younger than 5 years, particularly from malnutrition, diarrheal diseases, and lower respiratory tract infections., Methods: Mortality rates and BDH coverage from 2009 to 2014 were evaluated from the 144 (of 222) Ecuadorian counties with intermediate and high quality of vital information. A multivariable regression analyses for panel data was conducted by using a negative binomial regression model with fixed effects, adjusted for all relevant demographic and socioeconomic covariates., Results: Our research shows that for each 1% increase in BDH county coverage there would be a decrease in U5MR from malnutrition of 3% (RR 0.971, 95% CI 0.953-0.989). An effect of BDH county coverage on mortality resulting from respiratory infections was also observed (RR 0.992, 95% CI 0.984-0.999). The BDH also reduced hospitalization rates in children younger than 5 years, overall and for diarrhea., Conclusions: A conditional cash transfer program such as BDH could contribute to the reduction of mortality due to causes related to poverty, such as malnutrition and respiratory infections. The coverage should be maintained -or increased in a period of economic crisis- and its implementation strengthened.

Background: Human transmission of Chagas disease (CD) most commonly occurs in domiciliary spaces where triatomines remain hidden to feed on blood sources during inhabitants' sleep. Similar to other neglected tropical diseases (NTDs), sustainable control of CD requires attention to the structural conditions of life of populations at risk, in this case, the conditions of their living environments. Considering socio-cultural and political dynamics involved in dwellings' construction, this study aimed to explore social factors that contribute or limit sustainability of CD's prevention models focused on home improvement., Methods and Main Findings: Using Healthy Homes for Healthy Living (HHHL)-a health promotion strategy focused on improvement of living environments and system-based health promotion-as a reference, a qualitative study was conducted. Research participants were selected from three rural communities of a CD endemic region in southern Ecuador involved in HHHL's refurbishment and reconstruction interventions between 2013 and 2016. Folowing an ethnographic approach, data were collected through interviews, participant observation, informal conversations and document analysis. Our results indicate that the HHHL model addressed risk factors for CD at the household level, while simultaneously promoting wellbeing at emotional, economic and social levels in local communities. We argue that sustainability of the CD prevention model proposed by HHHL is enhanced by the confluence of three factors: systemic improvement of families' quality of life, perceived usefulness of control measures, and flexibility to adapt to emerging dynamics of the context., Conclusion: HHHL's proposed home improvement, facilitated through system-based rather than disease specific health promotion processes, enhances agency in populations at risk and facilitates community partnerships forged around CD prevention. Although an independent analysis of cost-effectiveness is recommended, structural poverty experienced by local families is still the most important factor to consider when evaluating the sustainability and scalability of this model., Competing Interests: The authors have declared that no competing interests exist.

In the past 5-10 years, Venezuela has faced a severe economic crisis, precipitated by political instability and declining oil revenue. Public health provision has been affected particularly. In this Review, we assess the impact of Venezuela's health-care crisis on vector-borne diseases, and the spillover into neighbouring countries. Between 2000 and 2015, Venezuela witnessed a 359% increase in malaria cases, followed by a 71% increase in 2017 (411 586 cases) compared with 2016 (240 613). Neighbouring countries, such as Brazil, have reported an escalating trend of imported malaria cases from Venezuela, from 1538 in 2014 to 3129 in 2017. In Venezuela, active Chagas disease transmission has been reported, with seroprevalence in children (<10 years), estimated to be as high as 12·5% in one community tested (n=64). Dengue incidence increased by more than four times between 1990 and 2016. The estimated incidence of chikungunya during its epidemic peak is 6975 cases per 100 000 people and that of Zika virus is 2057 cases per 100 000 people. The re-emergence of many vector-borne diseases represents a public health crisis in Venezuela and has the possibility of severely undermining regional disease elimination efforts. National, regional, and global authorities must take action to address these worsening epidemics and prevent their expansion beyond Venezuelan borders., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Chagas disease is caused by Trypanosoma cruzi (Kinetoplastida: Trypanosomatidae). It is transmitted to humans primarily through contaminated feces of blood-sucking vectors of the subfamily Triatominae, known in Ecuador as 'chinchorros'. Some Triatominae species can adapt to domiciliary and peridomiciliary environments where T. cruzi can be transmitted to humans. Triatoma carrioni (Larrousse 1926) colonizes domestic and peridomestic habitats up to 2,242 m above sea level (masl) in southern Ecuador (Loja Province) and northern Peru. This study describes the life cycle, feeding, and defecation patterns of T. carrioni under controlled laboratory conditions using mice as hosts. Specimens were collected in Loja Province, Ecuador, and maintained in the laboratory. The life cycle was approximately 385.7 ± 110.6 d. There was a high mortality rate, 40.9% for first instars and 38.9% for fifth instars (NV). Feeding and defecation patterns for each life stage were examined by recording: insertion time of the proboscis into the host, total feeding time, time to first defecation, and weight of the bloodmeal. Total feeding time varied between 20.6 ± 11.4 min for first instars (NI) and 48.9 ± 19.0 min for adult females. The time to first defecation was variable but ranged from 9.8 ± 10.6 min for NI to 39.4 ± 24.7 min for NV during feeding. This suggests that T. carrioni has an annual life cycle and is a potential vector of T. cruzi in Loja Province. Improved knowledge of populations of T. carrioni in domestic and peridomestic environments of Ecuador can have a significant impact on the prevention and control of Chagas disease., (© The Author(s) 2019. Published by Oxford University Press on behalf of Entomological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: The white-naped squirrel, Simosciurus nebouxii (previously known as Sciurus stramineus), has recently been identified as an important natural host for Trypanosoma cruzi in Ecuador. The nests of this species have been reported as having high infestation rates with the triatomine vector Rhodnius ecuadoriensis. The present study aims to determine the levels of nest infestation with R. ecuadoriensis, the ecological variables that are influencing the nest site selection, and the relationship between R. ecuadoriensis infestation and trypanosome infection., Results: The study was carried out in transects in forest patches near two rural communities in southern Ecuador. We recorded ecological information of the trees that harbored squirrel nests and the trees within a 10 m radius. Manual examinations of each nest determined infestation with triatomines. We recorded 498 trees (n = 52 with nests and n = 446 without nests). Rhodnius ecuadoriensis was present in 59.5% of the nests and 60% presented infestation with nymphs (colonization). Moreover, we detected T. cruzi in 46% of the triatomines analyzed., Conclusions: We observed that tree height influences nest site selection, which is consistent with previous observations of squirrel species. Factors such as the diameter at breast height and the interaction between tree height and tree species were not sufficient to explain squirrel nest presence or absence. However, the nest occupancy and tree richness around the nest were significant predictors of the abundance of triatomines. Nevertheless, the variables of colonization and infection were not significant, and the data observed could be expected because of chance alone (under the null hypothesis). This study ratifies the hypothesis that the ecological features of the forest patches around rural communities in southern Ecuador favor the presence of nesting areas for S. nebouxii and an increase of the chances of having triatomines that maintain T. cruzi populations circulating in areas near human dwellings. Additionally, these results highlight the importance of including ecological studies to understand the dynamics of T. cruzi transmission due to the existence of similar ecological and land use features along the distribution of the dry forest of southern Ecuador and northern Peru, which implies similar challenges for Chagas disease control.

Background: Eggs have epidemiological and taxonomic importance in the subfamily Triatominae, which contains Chagas disease vectors. The metric properties (size and shape) of eggs are useful for distinguishing between close species, or different geographical populations of the same species., Methods: We examined the effects of egg viability on its metric properties, and the possible consequences on species recognition. Four species were considered: Panstrongylus chinai, P. howardi and Triatoma carrioni (tribe Triatomini), and Rhodnius ecuadoriensis (tribe Rhodniini). Digitization was performed on pictures taken when the viability of the egg could not clearly be predicted by visual inspection. We then followed development to separate viable from non-viable eggs, and the metric changes associated with viability status of the eggs were tested for species discrimination (interspecific difference)., Results: The shape of the complete contour of the egg provided satisfactory species classification (95% of correct assignments, on average), with improved scores (98%) when discarding non-viable eggs from the comparisons. Using only non-viable eggs, the scores dropped to 90%. The morphometric differences between viable and non-viable eggs were also explored (intraspecific comparison). A constant metric change observed was a larger variance of size and shape in non-viable eggs. For all species, larger eggs, or eggs with larger operculum, were more frequently non-viable. However, these differences did not allow for an accurate prediction regarding egg viability., Conclusions: The strong taxonomic signal present in egg morphology was affected by the level of viability of the eggs. The metric properties as modified in non-viable eggs presented some general trends which could suggest the existence of an optimum phenotype for size and for shape. Globally, viable eggs tended to have intermediate or small sizes, and presented a less globular shape in the Triatomini, or a relatively wider neck in Rhodnius ecuadoriensis.

Background: Chagas disease (CD) is a life-threatening illness caused by the protozoan parasite Trypanosoma cruzi, which is transmitted by triatomine bugs. Triatomine bugs inhabit poorly constructed homes that create multiple hiding spots for the bugs. Modifying the actual structure of a home, along with the homeowners' practices, can reduce triatomine infestation. This research was designed to collect culturally-relevant information to develop a health campaign to decrease risk of CD transmission by promoting home maintenance and better hygiene in rural communities of southern Ecuador., Methods and Main Findings: The Health Belief Model (HBM) guided focus group discussions and the interpretation of the results. Four focus groups ranging from 4 to 10 participants were conducted between May and June 2014 in three communities of Loja province in Southern Ecuador. A thematic analysis was used to identify within the data related to perceptions of susceptibility, severity, benefits, barriers and self-efficacy related to CD and its prevention. The results provide clear guidance for the development of Chagas-prevention messages., Conclusion: Data obtained emphasize the importance of standardizing messages presented to the communities for CD prevention. Messages should provide more information on the protective nature of the behaviors promoted for CD prevention; overcoming barriers such as cost and convenience, and build on facilitating factors, including community members' interest on quality of life, protection of their families, and relationship with the land., Competing Interests: The authors have declared that no competing interests exist.

This qualitative study engaged a group of young people in participatory research and evaluation activities in order to study to what extent engaging youth in health interventions can inform research and evaluation processes. We applied a youth participatory research and evaluation approach (PRE) to inform research and evaluation on the impact of a Chagas disease control program in southern Ecuador. Our main interest was to examine the methodological contributions of PRE to knowledge sharing for health intervention planning in the context of global health and neglected tropical diseases. The results of this study suggest that by demystifying research and evaluation practices and rendering them accessible and relevant, marginalized youth can develop critical and reflexive thinking skills that could be useful for decision-making on health promotion. Our findings also reveal the potential of youth as active participants in project development in ways that enhance, validate, and improve health interventions. Young people are interested in learning about and sharing local knowledge that can benefit research and evaluation processes. Despite the numerous strengths demonstrated by PRE, the inherent complexities of international development, such as cultural differences, asymmetrical power relations, and the ongoing challenges of sustainability, remain., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

The seroprevalence and epidemiology of Bartonella bacilliformis infection in the Andean highlands of Ecuador is largely unknown. We conducted a sero-epidemiologic survey of 319 healthy children aged 1-15 years living in six rural, mountain communities in Loja Province, Ecuador. Blood was collected by finger stick onto filter paper and dried, and the eluted sera analyzed for antibodies to B. bacilliformis by rPap31 ELISA. Demographic, entomologic, and household variables were assessed to investigate associated risk factors for antibody seropositivity to B. bacilliformis. Seroprevalence of 28% was found among children in the study communities. Increased risk of seropositivity was associated with the presence of lumber piles near houses. Decreased risk of seropositivity was observed with the presence of animal waste and incremental 100 meter increases in elevation. Although investigation of clinical cases of Carrion's disease was not within the scope of this study, our serology data suggest that infection of children with B. bacilliformis is prevalent in this region of Ecuador and is largely unrecognized and undiagnosed. This study highlights the need to further investigate the prevalence, pathogenesis, epidemiology, and disease impact of this pathogen in Ecuador.

Insecticide spraying of housing units is an important control measure for vector-borne infections such as Chagas disease. As vectors may invade both from other infested houses and sylvatic areas and as the effectiveness of insecticide wears off over time, the dynamics of (re)infestations can be approximated by [Formula: see text]-type models with a reservoir, where housing units are treated as hosts, and insecticide spraying corresponds to removal of hosts. Here, we investigate three ODE-based models of this type. We describe a dual-rate effect where an initially very high spraying rate can push the system into a region of the state space with low endemic levels of infestation that can be maintained in the long run at relatively moderate cost, while in the absence of an aggressive initial intervention the same average cost would only allow a much less significant reduction in long-term infestation levels. We determine some sufficient and some necessary conditions under which this effect occurs and show that it is robust in models that incorporate some heterogeneity in the relevant properties of housing units.

Since its discovery in 1947 in Uganda, ZIKV has spread to 61 countries with a total of 229,238 confirmed human cases worldwide. Specifically, Ecuador has recorded 3,058 confirmed cases and 7 confirmed cases of congenital syndrome associated with ZIKV. Using the Health Belief Model (HBM), this pilot study was conducted to assess Zika virus-related knowledge and attitudes among adults in Ecuador. The survey data were collected in public places in rural and urban areas of Ecuador in May 2016. Seven items measured ZIKV knowledge and 23 items measured attitudes toward ZIKV. A total of 181 Ecuadorians participated in this study. The average age of the sample was 33.4. With respect to ZIKV knowledge, the majority of the participants had heard of ZIKV (n = 162, 89.5%). More males reported first hearing of ZIKV on the internet ( p = 0.02), more rural individuals reported knowing someone diagnosed with ZIKV ( p = 0.02), more primary school educated individuals reported hearing about ZIKV first from their doctor/nurse ( p = 0.03), and more high school graduates correctly identified that ZIKV could be transmitted from mother to child ( p = 0.03). As for the HBM constructs, there was a statistically significant difference between gender and cues to action ( p = 0.04), with males having a statistically significant lower mean on the cues to action items compared to females. There were also statistically significant differences between those categorized as having "adequate" knowledge compared to "low" knowledge on the benefits construct ( p = 0.04) and the perceived severity construct ( p = 0.03). There is a clear need for education about the transmission and prevention of ZIKV. High levels of self-efficacy for prevention behaviors for ZIKV combined with low perceived barriers in this community set the stage for effective educational interventions or health promotion campaigns that can ameliorate the knowledge deficits surrounding transmission and prevention., Competing Interests: Conflicts of interest: The authors do not have any conflicts of interest to disclose.

Background: Although the central coast of the Ecuador is considered endemic for Chagas disease, few studies have focused on determining the risk of transmission in this region. In this study we describe the triatomine household infestation in Manabí province (Central Coast region), determine the rate of Trypanosoma cruzi infection and study the risk factors associated with infestation by Rhodnius ecuadoriensis., Methodology/principal Findings: An entomological survey found three triatomine species (Rhodnius ecuadoriensis, Panstrongylus rufotuberculatus and P. howardi) infesting domiciles in 47.4% of the 78 communities visited (total infestation rate of 4.5%). Four percent of domiciles were infested, and nymphs were observed in 77% of those domiciles. The three species were found in altitudes below 500 masl and in all ecological zones except cloud forest. Within the domicile, we found the three species mostly in bedrooms. Rhodnius ecuadoriensis and P. rufotuberculatus were abundant in bird nests, including chicken coops and P. howardi associated with rats in piles of bricks, in the peridomicile. Triatomine infestation was characterized by high rates of colonization, especially in peridomicile. Flagelates infection was detected in only 12% of the samples by microscopy and Trypanosoma cruzi infection in 42% of the examined triatomines by PCR (n = 372). The most important risk factors for house infestation by R. ecuadoriensis were ecological zone (w = 0.99) and presence of chickens (w = 0.96). Determinants of secondary importance were reporting no insecticide applications over the last twelve months (w = 0.86) and dirt floor (w = 0.70). On the other hand, wood as wall material was a protective factor (w = 0.85)., Conclusion/significance: According the results, approximately 571,000 people would be at high risk for T. cruzi infection in Manabí province. A multidisciplinary approximation and the adhesion to a periodic integrated vector management (IVM) program are essential to guarantee sustainable preventive and control strategies for Chagas disease in this region.

Effective control of Chagas disease vector populations requires a good understanding of the epidemiological components, including a reliable analysis of the genetic structure of vector populations. Rhodnius ecuadoriensis is the most widespread vector of Chagas disease in Ecuador, occupying domestic, peridomestic and sylvatic habitats. It is widely distributed in the central coast and southern highlands regions of Ecuador, two very different regions in terms of bio-geographical characteristics. To evaluate the genetic relationship among R. ecuadoriensis populations in these two regions, we analyzed genetic variability at two microsatellite loci for 326 specimens (n=122 in Manabí and n=204 in Loja) and the mitochondrial cytochrome b gene (Cyt b) sequences for 174 individuals collected in the two provinces (n=73 and=101 in Manabí and Loja respectively). The individual samples were grouped in populations according to their community of origin. A few populations presented positive F IS, possible due to Wahlund effect. Significant pairwise differentiation was detected between populations within each province for both genetic markers, and the isolation by distance model was significant for these populations. Microsatellite markers showed significant genetic differentiation between the populations of the two provinces. The partial sequences of the Cyt b gene (578bp) identified a total of 34 haplotypes among 174 specimens sequenced, which translated into high haplotype diversity (Hd=0.929). The haplotype distribution differed among provinces (significant Fisher's exact test). Overall, the genetic differentiation of R. ecuadoriensis between provinces detected in this study is consistent with the biological and phenotypic differences previously observed between Manabí and Loja populations. The current phylogenetic analysis evidenced the monophyly of the populations of R. ecuadoriensis within the R. pallescens species complex; R. pallescens and R. colombiensis were more closely related than they were to R. ecuadoriensis., (Copyright © 2017 Elsevier B.V. All rights reserved.)