Introduction:
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.
Methods:
We constructed a globally representative sample of 802 genomes,
including 46 samples from patients inside or with a travel history to
Iran. We then performed a phylogenetic analysis to identify clades
related to samples from Iran and estimated the start of the epidemic and
early doubling times in cases. We leveraged air travel data from 36
exported cases of COVID-19 to estimate the point-prevalence and the
basic reproductive number across the country. We also analysed the
province-level all-cause mortality data during winter and spring 2020 to
estimate under-reporting of COVID-19-related deaths. Finally, we use
this information in an SEIR model to reconstruct the early outbreak
dynamics and assess the effectiveness of intervention measures in Iran.
Results:
By identifying the most basal clade that contained genomes from
Iran, our phylogenetic analysis showed that the age of the root is
placed on 2019-12-21 (95 % HPD: 2019-09-07 - 2020-02-14). This date
coincides with our estimated epidemic start date on 2019-12-25 (95 %CI:
2019-12-11 - 2020-02-24) based air travel data from exported cases with
an early doubling time of 4.0 (95 %CI: 1.4-6.7) days in cases. Our
analysis of all-cause mortality showed 21.9 (95 % CI: 16.7-27.2)
thousand excess deaths by the end of summer. Our model forecasted the
second epidemic peak and suggested that by 2020-08-31 a total of 15.0
(95 %CI: 4.9-25.0) million individuals recovered from the disease across
the country.
Conclusion:
These findings have profound implications for assessing the stage
of the epidemic in Iran despite significant levels of under-reporting.
Moreover, the results shed light on the dynamics of SARS-CoV-2
transmissions in Iran and central Asia. They also suggest that in the
absence of border screening, there is a high risk of introduction from
travellers from areas with active outbreaks. Finally, they show both
that well-informed epidemic models are able to forecast episodes of
resurgence following a relaxation of interventions, and that NPIs are
key to controlling ongoing epidemics.
COVID-19; Excess mortality; Non-pharmaceutical interventions (NPIs); Phylogenetics; SEIR modelling; Under-reporting.