Ongoing outbreak of COVID-19 in Iran: challenges and signs of concern with under-reporting of prevalence and deaths

Hejazi

Karshenas

et al. 2020

Preprint

Self Cite

Many countries with an early outbreak of SARS-CoV-2 struggled to gauge the size and start date of the epidemic mainly due to limited testing capacities and a large proportion of undetected asymptomatic and mild infections. Iran was among the first countries with a major outbreak outside China. Using all genomic sequences collected from patients with a travel link to Iran, we estimate that the epidemic started on 21/01/2020 (95% HPD: 05/12/2019 – 14/02/2020) with a doubling time of 3 days (95% HPD: 1.68 – 16.27). We also show, using air travel data from confirmed exported cases, that from late February to early March the number of active cases across the country were more than a hundred times higher than the reported cases at the time. A detailed province-level analysis of all-cause mortality shows 20,718 (CI 95%: 18,859 – 22,576) excess deaths during winter and spring 2020 compared to previous years, almost twice the number of reported COVID-19-related deaths at the time. Correcting for under-reporting of prevalence and deaths, we use an SEIR model to reconstruct the outbreak dynamics in Iran. Our model forecasted the second epidemic peak and suggests that by 14/07/2020 a total of 9M (CI 95%: 118K – 44M) have recovered from the disease across the country. These findings have profound implications for assessing the stage of the epidemic in Iran and shed light on the dynamics of SARS-CoV-2 transmissions in Iran and central Asia despite significant levels of under-reporting.

Section: Evaluating Effectiveness Of Intervention Measures and The Dysupporting

confidence: 76%

Section: Introductionmentioning

confidence: 99%

Ongoing outbreak of COVID-19 in Iran: challenges and signs of concern with under-reporting of prevalence and deaths

Hejazi

Karshenas

et al. 2020

Preprint

Self Cite

“…We find that the corrected nationwide COVID-19-related deaths during each season is approximately 2.5 times higher than the number of confirmed deaths from MoHME and that both estimates follow a similar trajectory over time with particularly elevated levels of excess mortality during winter (i.e. approximately 2.8 times higher than the confirmed deaths at the time) which may indicate that a larger portion of deaths during the early stages of the epidemic were undercounted as also noted in our previous analysis [13].…”

Section: Estimating the Level Of Exposure Across The Populationsupporting

confidence: 77%

“…However, we find only 5 provinces with significantly higher levels of mortality in winter 1398 SH (22 December 2019 to 19 March 2020) (see Table 1). These provinces include Qom, Gilan (Guilan), Golestan, Mazandaran, and Qazvin which were reportedly hit the hardest by an early wave of the COVID-19 epidemic with a total of 3.48K (95%CI: 3.17K -3.78K) combined extra deaths [13]. This observation rejects any possible association between the excess mortality in fall and significant levels of undetected COVID-19-related deaths across the country.…”

Section: Did the Covid-19 Epidemic In Iran Start During Fall 2019?mentioning

confidence: 90%

“…Upon examining the seasonal trends in mortality during fall in our earlier reports [7,8], we noticed, for the first time, that there was a spike across the country in 1398 SH (from 23 September to 21 December 2019) compared to previous years. This was particularly unexpected as it occurred before the start of the COVID-19 pandemic in December [9,10] and its emergence in Iran during January [11] which led to some speculations about the cryptic transmission of the virus across the country in fall 2019.…”

Section: Did the Covid-19 Epidemic In Iran Start During Fall 2019?mentioning

confidence: 99%

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Excess deaths associated with the Iranian COVID-19 epidemic: a province-level analysis

Kadivar²

2020

Preprint

Self Cite

BackgroundThe number of publicly reported deaths from COVID-19 may underestimate the true death toll from the epidemic as they rely on provisional data that are often incomplete or omit undocumented deaths from COVID-19. In addition, these reports may be subject to significant under-reporting due to a limited testing capacity of a country to identify suspect cases. This study estimated the number of seasonal excess deaths attributable to the COVID-19 epidemic in 31 provinces of Iran.MethodsWe gathered the nationwide and provincial time series of the seasonal all-cause mortality data from spring 2015 to summer 2020 (21 March 2015 to 21 September 2020), in accordance with the Solar Hijri (SH) calendar, from the National Organization for Civil Registration (NOCR). We estimated the expected number of seasonal deaths for each province using a piecewise linear regression model which we established based on the mortality figures for the previous years and considered any significant deviations from the expectation during winter, spring, and summer of 2020 to be directly associated with COVID-19.ResultsOur analysis shows that from the start of winter to the end of summer (from 22 December 2019 to 21 September 2020), there were a total of 58.9K (95%CI: 46.9K - 69.5K) excess deaths across all 31 provinces with 27% (95%CI: 20% - 34%) estimated nationwide exposure to SARS-CoV-2. In particular, 2 provinces in the central and northern Iran, namely Qom and Golestan, had the highest level of exposure with 57% (95%CI: 44% - 69%) and 56% (95%CI: 44% - 69%), respectively, while another 27 provinces had significant levels of excess mortality in at least one season with >20% population-level exposure to the virus. We also detected unexpectedly high levels of excess mortality during fall 2019 (from 23 September to 21 December 2019) across 18 provinces. Our findings suggest that this spike cannot be a result of an early cryptic transmission of COVID-19 across the country and is also inconsistent with the molecular phylogenetics estimates for the start of the pandemic and its arrival to Iran. However, in the absence of appropriate surveillance data for detecting severe acute respiratory infections we were unable to make a determination as to what caused the spike in fall 2019.Conflict of InterestNone.

Excess deaths associated with the Iranian COVID-19 epidemic: A province-level analysis

International Journal of Infectious Diseases

Kadivar²

2021

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There has been no province-level data on the number of coronavirus disease 2019 (COVID-19)related deaths in Iran since the start of the pandemic. This study was performed to estimate the number of COVID-19 deaths and population-level exposure per province using seasonal all-cause mortality data. Methods: Time-series data were collected from the National Organization for Civil Registration on the seasonal all-cause mortality from spring 2015 to summer 2020 (from March 21, 2015 to September 21, 2020), in accordance with the Solar Hijri (SH) calendar, to estimate the expected number of seasonal deaths for each province using a piecewise linear regression model. A population-weighted infection fatality ratio was then applied to estimate the level of exposure per province during this period. Results: From the start of winter to the end of summer (from December 22, 2019 to September 21, 2020), there were a total of 58 900 (95% confidence interval 46 900-69 500) excess deaths across all 31 provinces, with 27% (95% confidence interval 20-34%) estimated nationwide exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In particular, Qom and Golestan were among the hardest-hit provinces, with nearly 57% exposure, while another 27 provinces showed significant levels of excess mortality in at least one season with >20% population-level exposure to the virus. Unexpectedly high levels of excess mortality were also detected during fall 2019 (from September 23 to December 21, 2019) across 18 provinces, unrelated and prior to the start of the COVID-19 pandemic. Conclusions: This study quantified the pattern of spread of COVID-19 across the country and identified areas with the largest epidemic growth requiring the most immediate interventions.