The overall case fatality rate calculated in Ecuador (4,43%) till December 2020 is substantially higher than in other countries of the region and higher than the worldwide case fatality(21). When data were stratified by age group, the case- fatality rate in Ecuador appear very similar for age groups 1 to 19 years, but rates are higher in Ecuador among male individuals aged 50 or older; also in the population less than 1 year old. The distribution of cases is extremely different analyzed by gender with a higher infection rate on males than females. The cause of perceived reduced susceptibility of females needs further investigation in order to improve protective measures.
The demographic characteristics of the Ecuadorian population differ from other countries. By 2020, approximately 8% of the Ecuadorian population was aged 65 years or older(22). COVID-19 has proved to have higher rates of mortality in older patients, in Ecuador. The epidemiological analysis shows that males have a higher fatality rate compared by gender as seen in the study of Long-quan et al, the reason for it requires further investigation(23).
COVID-19 fatality rates are challenging to assess with certainty; data from China, United Kingdom and Italy report a death rate around 0,7 to 1,3% (21, 24–26).
One of the best ways to know the impact of COVID-19 is mortality. Mortality has a wide variability among each country that probably depends on the health system response regarding effectiveness on testing policies, health system capacity and efficacy of response to health emergencies(27). During the first reports made by Long-quan et al. the fatality rate among 1994 patients with COVID-19 was 5% (95% CI[0.01,0.11])(23).
The worldwide mortality rate is 3%. Salzberger el al. found a case fatality rate of 1,38% with their modell(28). However, this rate varies between countries (China:2,3; South Korea: 2,3; Italy: 13,1) related to population average age, age distribution and the health system capacity on diagnosis and epidemiological surveillance(21).
The mortality risk of COVID-19 shows higher rates related to aging; in China the mortality rate was less than 0,5% in patients younger than 50 years increasing to 16% in patients older than 80 years(6, 29–31). Elder patients, above 60 years show higher susceptibility to life-threatening complications derived from COVID-19 (32, 33).
Dong et al describe that children have a clinical progression and disease severity different from adults, as 90% have a mild or moderate disease; those who develop severe disease show having comorbidities that increase the mortality rate (34–36).
The CFR is not a constant epidemiological measure and it varies between populations, over time and it is modified by external factors like environment, treatments and quality of health care system(37). To report a worldwide CFR evolves multiple factors that need to be taken care of. Firstly, the capacity to diagnose due to the lack of sufficient laboratory test for COVID-19 patients. Secondly, the hessite of some COVID-19 patients to report their illness to the health system; the real values are difficult to get, and the data collection affects the fatality rate calculation(38).
In Italy the mortality was higher in patients aged 70–89(39), in Ecuador the highest mortality was around the same age but differs on the group of less than 1 year were the CFR is 4,02.
The highest rate of morbidity could be related to the surveillance strategy used in Ecuador, as the COVID-19 test are made only in symptomatic patients without the identification of patients with mild symptoms(38).
Regarding the preventive measures practice Bates et al. applied a binomial regression analysis which suggests that unemployed individuals, househusbands/housewives, or manual laborers, and individuals with elementary scholarity have lower levels of knowledge regarding COVID-19 which supports the correlation found between illiteracy and CFR by cantons and might be related to the access to official information about COVID-19(40).
During the early periods of COVID-19 in Ecuador Ortiz-Prado et al. found that men were at a higher risk of dying from COVID-19 and also it was higher in older individuals and the presence of comorbidities, as our study found the same relation regarding the sex and age(41).
Bolaño-Ortiz et al. found that the spread of COVID-19 through Latin America and the Caribbean region shows a correlation with socioeconomic indexes(42), the same correlation that we found in our study, the variables of poverty levels suggest that inequality is related to the spread of COVID-19.
Shammi et al. found a correlation of COVID-19 cases and deaths with economic indicators showing a significant correlation in between the urban poverty rate (r = − 0.77; p = 0.01) and the urban extreme poverty rate (r = − 0.79; p = 0.01), low poverty rates were related to higher rates of COVID-19 infection; explained by the people who have informal jobs in countries with lower Gini index values(43). It appears that there is a relation with inequality and heterogeneity in populations; Biggs et al. studied the impact on income level, inequality and poverty, health status depends on wealth distribution(44).
Poverty has proven to be a potential risk for COVID-19 and the incidence of infectious diseases are related to socioeconomic, environmental, and ecological aspects(45–47).
Education level, family income, occupation, ethnic and number of people living in a house have been considered socioeconomic factors with disparities in hospitalization for COVID-19(48).