Paradoxes of Elimination and Persistence: Neglected Tropical Diseases in Ecuador Compared to Latin America and the Caribbean.

OBJECTIVE: To describe, from a comparative Latin American perspective, the progress and gaps in the elimination of neglected tropical diseases (NTDs) in Ecuador, integrating recent data on arboviruses, American trypanosomiasis, leishmaniasis, and structural determinants such as water, sanitation, and hygiene (WASH). METHODS: A narrative review with a descriptive comparison of secondary data based on secondary sources published between 2015 and 2026. Sources were identified through structured searches of PubMed/MEDLINE, the PAHO Institutional Repository for Information Sharing (IRIS), the WHO Global Health Library, and the WHO/UNICEF Joint Monitoring Programme (JMP) data portal, supplemented by targeted retrieval of official technical reports from WHO, PAHO, UNICEF, and Ecuador's Ministry of Public Health. Comparative indicators were constructed between Ecuador and the Region of the Americas or Latin America and the Caribbean (LAC) for: (a) burden and elimination of selected NTDs; (b) recent dengue dynamics; and (c) WASH service coverage. A synthetic two-panel table with key indicators was prepared, and an interpretive narrative analysis was conducted. RESULTS: Globally, NTD and malaria prevalence decreased 58% between 1990 and 2021, but the reduction in disability-adjusted life years was only 18%, with a disproportionate burden still in low- and middle-income regions. In the Americas, Ecuador was the second country to certify onchocerciasis elimination in 2014, following intensive mass drug administration (MDA) campaigns with ivermectin, with posttreatment surveillance confirming absence of transmission. The Region recorded a record dengue outbreak in 2024 with over 12.6 million suspected cases and more than 7700 deaths, concentrated in four large Latin American countries; through epidemiological Week 21 of 2025, more than 3 million cases had been reported, of which 23,623 corresponded to Ecuador. In 2020, 75% of the LAC population used safely managed drinking water and 34% used safely managed sanitation; nevertheless, 17 million people still lacked access to even basic water services and 72 million lacked basic sanitation. In Ecuador, basic drinking water-service coverage reached 95.7% in 2022, but only 41.6% used safely managed sanitation, and in rural areas, substantial proportions of unimproved water sources, surface water use, and open defecation persist. According to GBD 2023 data, the age-standardized DALY rate for NTDs and malaria combined was 193.8 per 100,000 in Ecuador (95% UI: 139.4-267.6), substantially lower than Bolivia (388.9) and Brazil (313.3). CONCLUSIONS: Ecuador illustrates a regional paradox that is primarily institutional and programmatic rather than biological. Vertical programs endowed with a dedicated external initiative, a donated single-dose drug, a verifiable elimination endpoint, and long-term technical accompaniment-as in onchocerciasis-can interrupt transmission of a historical NTD, whereas the persistence of structural determinants-poverty, precarious urbanization, and WASH gaps-sustains the burden of other NTDs and arboviruses. PAHO's Communicable Disease Elimination Initiative offers an opportunity to articulate elimination goals with rural water and sanitation policies, entomological surveillance, and intercultural territorial approaches. Sustained investments in WASH, integrated surveillance, and strengthened primary care are required to transform punctual elimination achievements into structural health equity gains.