Doosti-Irani, A.

Haghdoost, A.-A.

Mansournia, M.A.

Mostafavi, E.

Nazemipour, M.

eprints Iran University of Medical Sciences

Global Epidemiology 2 (2020) 100035Contents lists available at ScienceDirectGlobal Epidemiologyj ourna l homepage: ht tps: / /www. journa ls .e l sev ie r .com/g loba l -ep idemio logyInternational PerspectiveChallenges for management of the COVID-19 epidemic in IranAmin Doosti-Irani a, Ehsan Mostafavi b,⁎,1, Maryam Nazemipour c,Mohammad Ali Mansournia d,1,⁎, Ali-Akbar Haghdoost ea Department of Epidemiology, School of Public Health and Research Center for Health Sciences, Hamadan University of Medical Sciences, Hamadan, Iranb Department of Epidemiology and Biostatistics, Research Centre for Emerging and Reemerging infectious diseases, Pasteur Institute of Iran, Tehran, Iranc Psychosocial Health Research Institute, Iran University of Medical Sciences, Tehran, Irand Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Irane Modeling in Health Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, IranThe epidemic curve of Iran followed a bimodal shape in the last sixmonths. It started on 19 February 2020, reached its first peak at theend of March (effective reproductive number, Re = 2.57), and after aone-month steep drop (Re = 0.95) the curve showed an increasingtrend with the second peak at the beginning of June. However, the epi-demic curve has had small fluctuations over the recent ten weeks(Fig. 1). To some extent, the same pattern was observed in the numberof daily reported deaths, with a two to four-week delay and a dominantsecondary peak (Fig. 2) [1]. A sharp decreasing trend in March wasmainly due to restrictions and lockdown.Iran is a vast country with variations in climate, cultures and sub-cultures, and socioeconomic status. Consequently, it is not comparableto many other countries in the world with regard to its challenges andresponses to the pandemic.Religious festivals and ceremonies, such as groupworship and regu-lar family parties, are among themain practices of the Iranian people. Atthe beginning of the outbreak, a substantial part of the populationchanged their behavior, supported by the advice of the governmentand main religious leaders. In addition, schools, universities, main mar-kets, sports centers, and even most of the governmental offices wereclosed soon after the detection of the outbreak.Forces from inside and outside of the country have affected theman-agement of the epidemic, perhaps more so than in other countries. Theepidemic curve of Iran peaked faster than in other countries andshowed a bimodal shape before the same pattern was observed inother counties. This issue caused high stress on the Iranian people andauthorities; Iran was even mistakenly identified by some as the sourceof the epidemic for other counties [2], but later it was found that thevirus, even before formal reporting of the disease in China, was in circu-lation in other countries [3,4]. There is no substantial evidence for theexact starting point of the epidemic in other countries, particularly inthe Eastern Mediterranean region. However, more than half of the reg-ular regional reports of the World Health Organization are about thescope of the epidemic in Iran, which shows higher transparency, andeven accuracy, of statistics in Iran. Therefore, early detection and⁎ Corresponding authors.E-mail addresses: mostafavi@pasteur.ac.ir (E. Mostafavi),mansournia_m@sina.tums.ac.ir (M.A. Mansournia).1 Both contributed equally and wish to be listed as co-corresponding authors.https://doi.org/10.1016/j.gloepi.2020.1000352590-1133/© 2020 Published by Elsevier Inc. This is an open access article under the CC BY-NCreporting of the disease in Iran and a higher rate of infection might beattributed to a functional surveillance system in the country [5].The second wave of the disease in Iran caused a new round ofpressures, since it was a unique pattern in the world at that time.Criticism was mainly around the impact of early reopening policies,which was attributed as the main source of reactivation of the epi-demic. The early reopening gave most people the impression thatthe situation had become somewhat normal, and they abandonedthe health considerations they had followed for several months.However, when the same bimodal pattern or extended epidemicwas observed in other parts of the world, the level of pressure di-minished significantly.Part of the high rate of reopening in Iran compared to other coun-tries was due to the country's economic problems, which had been al-ready exacerbated by sanctions. For the reopening, more than 2.3million small businesses, shops and industrial units were registered,and step-by-step reopening was accomplished. Mask mobile applica-tion was developed and used to facilitate the process. In this nationallyused application, a map of COVID-19 cases was available for all citiesand regions of the country, and people were alarmed to avoid enteringmore infected areas. People could also assess their probability of beinginfected by answering the app questions on symptoms and risk factorsof COVID-19 infection.There were some concerns in the management of the epidemicmainly because of the lack of experience to control such an extendedand vast epidemic caused by a novel virus, and the detrimental impactof the strict embargo against Iran.The strong embargo imposed by the US administration, backed by apolitical and mass media propaganda, diverted the type of pressurefrom a justified scientific form to a distorted format. For example, Irandid not have any access to its financial resources in the other countriesto purchase medicine, and laboratory equipment in this crucial pointof time [6,7]. Another challenge of the epidemic was to achieve a singledatabase for the disease. In the early months of the epidemic, differentdatabases were used for data entry and analysis by different medicaluniversities, in which the quality of data was not the same. Over time,this problem was somewhat resolved, and a more uniform with betterquality data was achieved.The variety of customs in different regions, such as mourningand wedding ceremonies, have been other challenges in the-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).Fig. 1. Daily reported cases of COVID-19 in Iran.Fig. 2. Daily reported deaths due to COVID-19 in Iran.A. Doosti-Irani, E. Mostafavi, M. Nazemipour et al. Global Epidemiology 2 (2020) 100035management of the epidemic in Iran. Besides, the pattern of the ep-idemic was not the same in all regions, and epidemic started with adelay in some provinces which was among the reasons of the secondwave of the epidemic in Iran.The control of the pandemic will not be achievable without the co-operation of all countries, and if they leave each other in such a situa-tion, managing pandemic will be difficult. The countries' experiencesin the management of the epidemic may be useful for others, thoughit may not apply to all due to differences in their situation. The epidemiccurve andmanagement of the epidemic in Iran are not comparable with2other countries. For a valid comparison of countries in managing theCOVID-19 epidemic, their conditions should be taken into account.Overall, the response of Iran to the epidemic, given its conditions, hasbeen somewhat plausible and defensible.Declaration of Competing InterestMohammad Ali Mansournia is a Senior Associate Editor on GlobalEpidemiology. Ali Akbar Haghdoost is the Deputy Minister of EducationofMinistry of Health andMedical Education (MOHME), and the directorA. Doosti-Irani, E. Mostafavi, M. Nazemipour et al. Global Epidemiology 2 (2020) 100035of the national committee of Epidemiology of COVID-19, in MOHME,Iran. The rest of the authors have no conflict of interest to disclose.References[1] Worldometer. Covid-19 Coronavirus Pandemic 2020. updated April 03, 2020 April 03.Available from https://www.worldometers.info/coronavirus/?isci=010702#countries; 2020.[2] Tuite AR, Bogoch II, Sherbo R, Watts A, Fisman D, Khan K. Estimation of coronavirusdisease 2019 (COVID-19) Burden and potential for international dissemination of in-fection from Iran. Ann Intern Med. 2020;172:10. https://doi.org/10.7326/M20-0696.[3] Deslandes A, Berti V, Tandjaoui-Lambotte Y, Alloui C, Carbonnelle E, Zahar J, et al.SARS-COV- 2 was already spreading in France in late December 2019. Int J AntimicrobAgents. 2020;55:106006. https://doi.org/10.1016/j.ijantimicag.2020.106006.3[4] La Rosa G, Mancini P, Ferraro GB, Veneri C, Iaconelli M, Bonadonna L, et al. SARS-CoV-2 has been circulating in northern Italy since December 2019: evidence from environ-mental monitoring. S Total Environ. 2020;15:141711. https://doi.org/10.1016/j.scitotenv.2020.141711.[5] Mounesan L, Eybpoosh S, Haghdoost A, Moradi G, Mostafavi E. Is reporting manycases of COVID-19 in Iran due to strength or weakness of Iran’s health system?Iran J Microbiol. 2020;12:73.[6] Aloosh M, Salavati A, Aloosh A. Economic sanctions threaten population health:the case of Iran. Public Health. 2019;169:10. https://doi.org/10.1016/j.puhe.2019.01.006.[7] Setayesh S, Mackey TK. Addressing the impact of economic sanctions on Iranian drugshortages in the joint comprehensive plan of action: promoting access to medicinesand health diplomacy. Glob Health. 2016;12:31. https://doi.org/10.1186/s12992-016-0168-6.

Challenges for management of the COVID-19 epidemic in Iran

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Challenges for management of the COVID-19 epidemic in Iran

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