How Iran Has Approached the Pandemic:
According to a recent census in 2020, the estimated population of Iran was   83 992 949 . (2) The Iranian Ministry of Health and Medical Education (MoHME), conducted almost 1,557,872 polymerase chain reaction (PCR) tests. 19.2 PCR tests per 1000 people have been performed since the beginning of the pandemic in Iran. The relative comparisons of the cumulative number of tests performed per 1000 people in the region is demonstrated in figure1. By June 29, 2020, more than 10 000 PCR-confirmed deaths had been recorded among patients with COVID-19; accordingly, 2593 and 122 people per 1,000,000 people were infected and subsequently died from COVID-19, respectively. The highest number of newly diagnosed patients was recorded on March 30, 2020 (3186 patients), and a declining slope was observed consequently.
By in large, many infected patients remained undiagnosed up until the date of the first official report, which dated February 19, 2020., This was due to lack of awareness of the viral virulence, proper diagnostic measures, and insufficient warnings. Indeed, some physicians and specialists around the country have been on record as stating that they encountered a series of patients with presentations of pneumonia and computed tomography (CT) scan findings similar to those in patients with COVID-19 which were stated prior to official reports. Retrospective evaluations of the CT scans or body fluids from those patients, if available, would have helped to clarify the real figures. Nonetheless, this diagnostic negligence prior to the declaration of the World Health Organization (WHO) concerning “global pandemic warnings” is similar scenario across the world.
The abovementioned data should be interpreted in light of the following points:
  1. After the first surge of the pandemic, the government not only banned public and religious events but also closed schools, universities, shopping centers, bazaars, and holy shrines. Serendipitously, the 2-week Iranian New year’s (Nowruz) holidays, which start on the first day of spring, fell within the period of the restrictions of social activities, allowing policymakers more time to contain the spread of the virus and to avail the impact of this pandemic.
  2. The shortage of laboratory diagnostics in the early period of the outbreak delayed the testing of COVID-19 extensively, compelling physicians to deal with patients with suspected infection by relying merely on physical examinations or chest CT scans, which were accessible across the nation. As is illustrated in Figure 1, Saudi Arabia and Turkey performed 45.7 and 39.5 tests per 1000 people, respectively, in comparison to 19.2 tests per 1000 people in Iran. Hence, the actual number of patients with COVID-19 may have been underestimated in Iran.
  3. As is the case of other countries, it appears that a majority of infected individuals are either asymptomatic or mildly symptomatic and have not been referred to hospitals and labs by frontline physicians. Therefore, the daily figures of diagnosed patients must have been underestimated and fatality rate may have been overestimated, consequently.
  4. The negative economic impact caused by the spread of COVID-19 in Iran coincides with the highest ever politically motivated economic sanctions against the country by the United States government. (3) The Iranian health sector, albeit among the most resilient in the region, has been affected because of the sanctions.
  5. On the basis of recent statistics, inpatient healthcare services in Iran are now provided by more than 900 hospitals nationwide, almost 85% of which are public hospitals under insurance coverage. (4) This number approximately equals 117 000 hospital beds, producing a density of 1.62 beds per 1000 people among the Iranian population. Hence, COVID 19 cases are being dealt on priority.
The Impact:
In the early stage of the pandemic, the MoHME announced that all public and private hospitals should cancel elective procedures and elective admissions from February 29, 2020. In conjunction with the decree for the postponement of elective procedures, each faculty and hospital were tasked to set up scientific and executive multidisciplinary committees. Additionally, all hospitals and clinics, except single-specialty tertiary centers, were to admit patients with COVID-19 including those requiring admission to general units or intensive care units (ICU).
Thanks to a nationwide network that was implemented decades earlier and was comprised of a referral system starting at primary care centers in the periphery going through secondary-level hospitals in the provincial capitals and tertiary hospitals in major cities, the healthcare system was able to resorb the increasing emergence of COVID-19 cases and provide primary response to the current crisis.
With the exponential rise in the number of patients affected, internists, hematologists, nephrologists, general surgeons, and thoracic surgeons joined the multidisciplinary framework. Cardiac surgeons were also involved in the implementation of extracorporeal membrane oxygenation (ECMO). These initial actions, accompanied by the restrictions laid down by the government, led to a steady-state curve of newly diagnosed patients in March 2020.
Domestic pharmaceutical and medical device companies accelerated the manufacturing of personal protective equipment (PPE), drugs, diagnostic kits, and essential supplies to overcome major shortages as a consequence of the international sanctions against Iran in the past years.
Currently, all hospitals providing care to patients with COVID-19 are equipped with PPE for healthcare personnel.