Volume 5, Issue 3 (Spring-Special Issue on COVID-19 2020)                   Health in Emergencies and Disasters Quarterly 2020, 5(3): 139-144 | Back to browse issues page

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HabibiSaravi R, Saleh Tabari Y, Ghasemihamedani F. Measures to Control Covid-19 Epidemic in Public and Reduce the Patient Load in Hospitals: A Report From Iran. Health in Emergencies and Disasters Quarterly. 2020; 5 (3) :139-144
URL: http://hdq.uswr.ac.ir/article-1-298-en.html
1- Center for Disaster Management and Medical Emergencies, Mazandaran University of Medical Sciences, Sari, Iran.
2- Red Crescent Society of the Islamic Republic of Iran, Mazandaran Province, Sari, Iran. , fghasemihamedani@gmail.com
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1. Introduction
On December 31, 2019, China reported cases of pneumonia to the World Health Organization (WHO) caused by a novel coronavirus, subsequently named SARS-CoV-2 [1]. The disease has spread rapidly worldwide until it was topped by the WHO Secretary-General as a global concern and named as coronavirus disease 2019 (COVID-19) [2]. It was reported as a pandemic as the novel coronavirus has continued to rapidly spread worldwide [3]. At the date of writing this report, the COVID-19 has affected 192 countries and territories around the world and one international conveyance (the Diamond Princess cruise ship harbored in Yokohama, Japan) with the total affected cases of 341,529. In Iran, despite ongoing trade and travel between China and Iran, there was no reported case until two cases of COVID-19 deaths were reported in Qom city on February 19, 2020 [4]. The news of the emergence of the disease with two deaths caused great concern for the health system and the general public. In this report, we describe the current status of the COVID-19 response strategy for reducing transmission in public and patient load in hospitals in Iran and defects, as well. 
2. Current Status Report
Since the primary report, Iran has reported increasing numbers of cases and deaths caused by COVID-19. Health officials have identified evidence of transmission by Chinese cases who infected others in Qom. All patients had a history of traveling to China or were in contact with someone who had a history of traveling to China. At present (Mar 22, 2020), all 31 provinces of Iran are affected by COVID-19. The total number of 21,638 infected cases, 1,685 deaths, and 7,913 recovered cases have been reported (Figure 1).
3. Control Measures in Iran
The Iranian New Year is the largest annual mass travel event in the country coming soon at the end of March, in which there is a higher risk of spreading COVID-19. In response, provincial governments severely restricted traveling across Iran. Most authorities have closed public transit and restricted outbound transportation (airplanes, trains, private vehicles, and buses). Many provinces, such as Mazandaran province implemented fever check posts at the borders of the province with the cooperation of police and Iranian Red Crescent volunteers. After a preliminary examination, febrile persons are referred to the quarantine center if needed. Schools and universities were closed and all concerts and events with mass gatherings were canceled. All people were encouraged to stay at home except for buying the necessary supplies. The Ministry of Health and Medical Education (MOHME) sent regular and informative text messages to the public. Businesses that did not provide essential services have been closed and other offices’ working hours decreased by taking preventive measures and personal protective considerations.
Due to the existence of primary health services in the health network system as well as the establishment of a family physician system in some provinces, the first line of screening and identification of suspected cases was established. This strategy reduced the number of patients admitted to the second and third lines of the health system.
An online self-screening system was implemented by the MOHME at https://Salamat.gov.ir for decreasing unnecessary visits to medical services. On the other hand, the implementation of this system provides a relative estimate of suspected cases using the online syndromic surveillance system. Similar systems in each province were also set up by universities, such as the Mazandaran University of Medical Science to make it available to the general public for proper guidance and primary treatment measures (http://corona.mazums.ac.ir). In addition, the central hotline was provided in the MOHME as well as in provincial universities to answer public questions about COVID-19. 
The Iranian government announced 16600 billion Rials (US $395 million) to fund the response capacity and empower the health system. Rapid construction of one 1000 beds hospital in Qom as the primary focus was on the agenda. A specialized fever clinic (Corona Clinic) was deployed in cities to examine referrals from a first health level (Health centers or family physicians) as well as people who needed visiting a specialist in the initial screening by the web-based system.
Assigning dedicated pre-hospital emergency ambulance codes with proper personal and protective equipment to transfer suspected COVID-19 patients to the selected hospitals for hospitalization. For this purpose, triage guidelines developed by the Emergency Medical Organization were used. 
At early days of pandemic, Pasteur Institute was the only laboratory with needed facilities to evaluate samples of suspected patients. Subsequently, by sending necessary facilities to academic centers throughout Iran, it was possible to perform necessary COVID-19 lab exams elsewhere in Iran.
In each province, one or more hospitals were allocated in the early days for hospitalization and treatment of COVID-19 patients using special triage and treatment protocol (Figure 2). With the increase in the number of patients, other hospitals have also increased their capacity to accommodate patients with COVID-19 by discharging patients and canceling elective clinical practices. Private hospitals, charities, and military hospitals were also used. 
Numerous operational guides were provided to all occupational groups and the general public on decontamination and personal protection. Clinical and specialized guidelines for different levels of health care delivery were also developed using the experiences of China and the documentation provided by the WHO.
The potential capability of social media was used to prevent the spread of rumors and false news while informing the public at the right time. This strategy is very applicable to a penetration rate of over 90% of mobile Internet coverage in Iran. In addition, the appropriate informative and training programs were broadcast on all television and radio networks.
Despite informing the general population on the risk of COVID-19, unfortunately, due to the lack of proper collaboration of all affected areas, control measures were not successful. These included no closure of religious centers with public gatherings, such as Imam Reza’s shrine in Mashhad and Hazrat Masoumeh’s shrine in Qom. In addition, some religious leaders also put their audience and followers at risk for COVID-19 disease by expressing illogical and unscientific instructions in their speeches. However, subsequently, with the emergence of more cases of the disease and the deteriorating dimensions of its deterioration, the most prominent religious authorities in Iran emphasized the application of the principles of epidemic control.
Role of the WHO: The director-general of the WHO declared a public health emergency of international concern (PHEIC) for COVID-19 that poses a public health risk to other states through the international spread and requires a coordinated international response [5]. After the emerging and rapid progression of COVID-19 in Iran, and due to international sanctions imposed on Iran, it is not possible to purchase the resources and equipment from other countries. In this particular situation, WHO supported scientifically and Shipped personal protective equipment and laboratory kits to Iran that has been a very valuable act. 
4. Discussion
The most effective treatment for communicable diseases, especially those with high epidemic potential, is prevention [6]. Therefore, the priority of prevention over treatment needs to be removed from the slogan more than ever. A practical example may be found in China. The Chinese precautionary measures have included case finding everywhere, quarantining contaminated areas, and restricting traffic for millions of residents. Quarantining the Hubei province, as the center of the virus outbreak, establishing a curfew in the cities under quarantine, establishing central monitoring teams and sending them from the central government to the provincial capitals involved in the epidemic, mobilizing all facilities of government agencies and hospitals, increasing the length of Chinese New Year holidays, traffic control, cancellation of all communities, and strengthening public health education were the most important measures taken by the Chinese government to effectively deal with the virus. Therefore, they were able to gradually reduce the incidence of the new virus and its resulting mortality until they closed the newly established Wuhan Hospital.
South Korea was another country that experienced a significant spread of the disease in its early stages. Within a short period of mid-February, it implemented the most stringent quarantine measures for some cities and the northern Gyeongsang province. The closure of higher education centers and schools for a long period, the prohibition of mass gatherings, quarantining the places where the virus was rapidly spreading, the use of electronic maps to identify patients and their movements, the strict quarantine of patients, allocation of extra funds to combat coronavirus epidemic, raising national alert levels, and conducting public lab testing to identify even asymptomatic patients and carriers were among the most effective measures taken by Koreans.
Iran has also sought to capitalize on the successful experience of these countries and implement necessary measures to control the epidemic. However, some obstacles and problems, such as non-quarantine of Qom province, as the primary site of disease propagation, lack of public quarantine, lack of seriousness by some citizens and officials, lack of facilities and personal protective equipment needed for staff use, and restrictions on equipment purchases from other countries due to international sanctions, have served as obstacles to achieve good results.
5. Conclusion
The outbreak is currently not under control in Iran and worldwide. Managing outbreaks internationally requires the cooperation of all countries and the use of basic public health strategies. In Iran, with current actions, we hope to reach a stable condition in the emergence of new cases up to mid-April [7]. To achieve this end, we need to impose further restrictions on public contacts and unnecessary communications. Due to continued international sanctions, the WHO and many other international non-governmental organizations are expected to continue their supports for Iran in order to succeed in controlling the COVID-19 epidemic.
Ethical Considerations
Compliance with ethical guidelines
All ethical principles are considered in this article.
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors. 
Authors' contributions
All authors contributed in preparing this article
Conflict of interest
The authors declared no conflict of interest.

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Type of Study: brief report | Subject: Special
Received: 2020/03/3 | Accepted: 2020/03/22 | Published: 2020/04/1

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