A quantitative evaluation of the impact of vaccine roll-out rate and coverage on reducing deaths from COVID-19: a counterfactual study on the impact of the delayed vaccination programme in Iran (preprint)

Vaccination has been a crucial factor in the fight against COVID-19 because of its effectiveness in suppressing virus circulation, lowering the risk of severe disease, and ultimately saving lives. Many countries with an early and rapid distribution of COVID-19 vaccines performed much better in reducing their total number of deaths than those with lower coverage and slower roll-out pace. However, we still do not know how many more deaths could have been averted if countries with slower vaccine roll-outs followed the same rate as countries with earlier and faster distribution of vaccines. Here, we investigated counterfactual scenarios for the number of avertable COVID-19 deaths in a given country based on other countries vaccine roll-out rates. As a case study, we compared Iran to eight model countries with similar income brackets and dominant COVID-19 vaccine types. Our analysis revealed that faster roll-outs were associated with higher numbers of averted deaths. While Irans percentage of fully vaccinated individuals would have been similar to Bangladesh, Nepal, Sri Lanka, and Turkey under counterfactual roll-out rates, adopting Turkeys rates could have averted up to 50,000 more deaths, whereas following Bangladeshs rates could have led to up to 52,800 additional losses of lives in Iran. Notably, a counterfactual scenario based on Argentinas early but slow roll-out rate resulted in a smaller number of averted deaths in Iran, up to 12,600 more individuals. Following Montenegros or Bolivias model of faster per capita roll-out rates for Iran could have resulted in more averted deaths in older age groups, particularly during the Alpha and Delta waves, despite their lower overall coverage. Also, following Bahrains model as an upper bound benchmark, Iran could have averted 75,300 deaths throughout the pandemic, primarily in the >50 age groups. This study provides insights into future decisions on the management of infectious disease epidemics through vaccination strategies by comparing the relative performance of different countries in terms of their timing, pace, and coverage of vaccination in preventing COVID-19 deaths.

Prospects of COVID-19 Vaccination in Romania: Challenges and Potential Solutions (preprint)

The rapid advancement in vaccine development represents a critical milestone that will help humanity tackle the COVID-19 pandemic. However, the success of these efforts is not guaranteed, as it relies on the outcomes of national and international vaccination strategies. In this article, we highlight some of the challenges that Romania will face and propose a set of solutions to overcome them. With this in mind, we discuss issues such as the infrastructure of vaccine storage and delivery, the deployment and administration of immunisations, and the public acceptance of vaccines. The ways in which Romanian society will respond to a national COVID-19 vaccination campaign will be contingent on appropriate and timely actions. As many of the problems encountered in Romania are not unique, the proposed recommendations could be adapted and implemented in other countries that face similar issues, thereby informing better practices in the management of the COVID-19 pandemic.

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

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. 

Ongoing outbreak of COVID-19 in Iran: challenges and signs of concern (preprint)

Since the first outbreak in China, the Coronavirus Disease 2019 (COVID-19) has rapidly spread around the world. Iran was one of the first countries outside of China to report infections with COVID-19. With nearly 100 exported cases to various other countries, it has since been the epicentre of the outbreak in the Middle east. By examining the age-stratified COVID-19 case fatality rates across the country and 14 university hospitals in Tehran, we find that, in younger age groups, the reported cases on 13/03/2020 only capture less than 10% of symptomatic cases in the population. This indicates significant levels of under-reporting in Iran. Using the 18 full-genome sequences from cases with a travel history or link to Iran, as well as the one full genome sequence obtained from within the country, we estimate the time to the most recent common ancestor of sequences which suggests the likely start of the outbreak on 21/01/2020 (95% HPD: 05/12/2019 - 14/02/2020) with an approximate doubling time of 3.07 (95% HPD: 1.68 - 16.27). Also, based on known exported cases to Oman, Kuwait, Lebanon, and China, we estimate the outbreak size on 25 February and 6 March to be around 13,700 (95% CI: 7,600 - 33,300) and 60,500 (43,200 - 209,200), respectively. Knowing the size of the outbreak at two time points and the typical doubling times associated with the COVID-19 epidemics in countries across Europe and North America, we can independently verify that the likely start of epidemic in Iran is around 15/01/2020 (27/12/2019 - 24/01/2020). Our assessment of the fate of the epidemic based on current levels of non-pharmaceutical interventions implemented by the government suggests upward of 10 million cases (IQR: 6.7M - 18M) and 100,000 ICU beds required (IQR: 77K - 140K) during the peak of the epidemic with more than 100,000 cumulative deaths (IQR: 180K - 240K). We also predict a peak in demand for ICU beds on 21/04/2020 (IQR: 06/04/2020 - 23/05/2020). The large span of the peak of the ICU demand is a result of two separate peaks, with the first occurring at around 15/4/2020 and the second in approximately a months time. The latter is also expected to last longer and is based on the relatively relaxed social distancing measures in place. The exact magnitude and timing of the peaks strictly depends on levels of interventions and can change significantly upon new information or change of policy. We caution that a lack of, or relaxed, stringent intervention measures, during a period of highly under-reported spread, would likely lead to the healthcare system becoming overwhelmed in the next few months.

The Successes and Failures of the Initial COVID-19 Pandemic Response in Romania (preprint)

In the context of the COVID-19 pandemic, countries around the world varied in the strength and timeliness of their responses. In Romania, specific challenges were faced with regards to managing the spread and limiting the impact of the disease, ranging from healthcare infrastructure to demographic and sociocultural aspects. As the country has a sizeable diaspora, major difficulties were faced when large numbers of individuals from highly affected areas returned to Romania. However, the fast implementation of control measures successfully averted a surge in the number of COVID-19 cases. This delayed the overburdening of an already challenged healthcare system during the initial phases of the epidemic. Furthermore, early control was facilitated by the exploitation of communication channels that penetrated all layers of society, from ordinary citizens to governmental authorities and high-ranking religious figures. The management of the COVID-19 crisis in Romania illustrates the importance of a fast initial response which takes into account the role played by sociocultural aspects in the context of an epidemic. As the challenges faced by Romania are not unique, these results could inform future public health strategies worldwide.