Introduction
Dealing with the COVID-19 is a newly-emerged global challenge in
infectious diseases management. The disease first spread in China and
Southeast Asia in late 2019 and gradually led to the death of a
considerable number of people worldwide, especially in Europe and then
the United States .1 Not only has this disease posed
the risk of infection-induced death, it has also brought unbearable
stress. 2 By May 13, 2020, there were 4,170,424
confirmed cases worldwide, and the death toll reached 287,399 people.
The World Health Organization (WHO) still assesses the COVID-19 a very
high-risk disease. 1
Countries have responded differently to the disease. According to global
recommendations, most countries have partially employed the three most
important strategies (mitigation, suppression, and containment) to
control the disease. 3-6 Meanwhile, countries such as
South Korea have been more successful in containing the epidemic,7 whereas most European countries are facing a
formidable challenge.1, 8
In all countries, general policies have usually been made by the
ministry of health or the state for public affairs such as job closure;
the instructions are then given to lower levels along with scientific
medical and health recommendations. In the treatment sector, the medical
staff (mainly doctors and nurses) are usually involved in the treatment
of patients exclusively; these staff are also exposed to the risk of
death. 9-11 The public health sector is responsible
for public education, case finding, contact tracing, and other health
cares. Finally, the research sector adopts a different approach to the
epidemic and takes valuable studies such as conduction of clinical
trials to determine the effectiveness of new drugs and development of
vaccines.
In Iran, the Ministry of Health and Medical Education benefits from
structural management centralization. The ministry is mainly responsible
for providing health, treatment and education services through 7
separate deputy named Health, Treatment, Education, Research and
Technology, Food and Drugs, Students and cultural, and Development of
Management and Resources. The Health deputy is responsible for providing
primary healthcare services for the community through an extensive
network of health centers across the country, whereas the Treatment
deputy is in charge of coordinating and controlling the provision of
services in public and private medical centers. Moreover, the Research
and Technology deputy is responsible for directing and supporting
health-related research. More than sixty medical universities in
different provinces and regions of Iran have been assigned to provide
health services. With a structure similar to that of the Health
Ministry, they provide services for the regions they cover. It should be
noted that integration and coordination of activities of the three
deputies of Health, Treatment, and Research can provide excellent
opportunities for controlling the epidemic. Fortunately, this has been
implemented at Shahroud University of Medical Sciences by proposing a
research-based model. This model was implemented on an approximate
population of 260,000 people covered by Shahroud University of Medical
Sciences (Shahroud and Miami Counties), with the highest incidence of
the COVID-19 in Iran, and the epidemic has been properly controlled.12 The specifications of this model and successful
experience are described below.
The University Headquarters for Prevention and Control of COVID-19 was
established right after the identification of the first confirmed
positive case of coronavirus in Iran on February 19, 2020. After the
responsibilities were declared, each deputy took proper measures to
provide adequate beds (including intensive care beds ) for the treatment
of patients, supply protective equipment for healthcare workers and then
for society, and provide public education. The Research and Technology
deputy employed the faculty members of clinical and basic sciences and
developed a pivotal research model in cooperation with the Epidemiology
department. The model led to the coordination of various academic
activities and their better effectiveness. The main specifications of
this model are described below.
1. Designing and presenting a systematic model for the registration of
data on suspected and confirmed cases of COVID-19 in hospitals and
outpatient clinics including contact information, disease symptoms and
their date of onset, results of CT scanning, PCR lab results, clinical
examinations, prescribed drugs, vital signs, caring methods, recording
cardiac monitoring, oxygen therapy in the ICU, and contact tracing.
2. Developing a proprietary software application for recording data and
the access of Treatment, Health, and Research deputies so that, besides
data confidentiality, patients’ data related to tests, radiographies,
drugs, etc. could be recorded in the system and could be entered into
the system from HIS and other existing systems. In fact, rapid
development of this comprehensive software application was the most
important step in controlling this epidemic. Unfortunately, multiple
systems are utilized, and duplicate information is sometimes registered
in these systems in most cities of Iran. Data entry into these systems
is very time-consuming and due to a large amount of missing data,
statistical analyses are inaccurate.
3. The Health and Treatment deputies are in contact via this system so
that, immediately after hospitalization of suspected or confirmed
patients, their personal, job, and contact information will be available
to the system users in extensive health centers. Based on the dates and
schedules defined in the system, these contacts are actively traced for
up to 14 days by healthcare providers, and in addition to recording the
disease symptoms, health education is provided for them. At the same
time, packages of protective equipment including masks, gloves, and
disinfectants are delivered to patients and their families.
4. In the active contact tracing program, the necessary tests and
treatment are performed on symptomatic individuals in contact with the
patient, and if necessary, they are referred to hospitals via the same
system. In this program, in addition to healthcare providers in
extensive health centers, 12 supervisors monitor the health care workers
activities and their records in the system. They also try to identify
cases of migration or with missing contact information. The purpose of
this model in the Health deputy is to target the activities and perform
them accurately in a timely manner. Within near three months of the
epidemic, 29,529 in-person and phone tracings were performed for 7,640
jobs and family contacts of 611 confirmed patients, a process which was
very effective in controlling the epidemic.
5. Establishment of the education ward in hospitals was another
important step in controlling the epidemic. In these wards, every
discharged patient, along with a next of kin, receives the necessary
consultations and educations for isolation up to 14 days after
discharge. The patients also receive training materials, masks, and
disinfectants. These trainings are also provided for the relatives of
patients who die in the hospital.
6. Availability of clinical and laboratory evaluations and follow-up of
the relatives, according to different levels of access, resulted in
clear provision of all health and treatment staff with the patients’
conditions, and honest presentation of this information led to better
and more accurate cooperation of employees.
7. The management dashboard of this software application in the Health
and Treatment deputies and senior managers of the university provided
the managers with accurate, fast, and timely information about the
epidemic for decision making.
8. Careful recording of data led clinical experts to evaluate the
results of their treatment comfortably and quickly and to make the
necessary changes in the treatment protocols timely. In addition, it
helped the decision makers to predict the required number of beds and
staff by examining the status quo and to manage regions with more cases
accurately.
9. Other research projects can be performed precisely by using the
accurate and systematic recorded data of this system. In this system,
patients are predicted to be followed up for 90 days after discharge. In
addition, data of two well-known cohort studies in Shahroud13, 14 can be employed to evaluate the relationship
between different exposures and the COVID-19.
10. Providing accurate and timely statistics for the society encouraged
people, organizations, and NGOs to give a large volume of donation
including masks and protective and required equipment. The epidemic was
controlled properly due to the increased participation of people, the
seriousness of health advice, closing jobs, and the staying at home
instructions eventually.
11. The resultant data were employed for inter-sectoral cooperation in
the first days of the epidemic before the national decisions, and all
schools, universities, mosques, Friday prayers, and congregational
prayers were shut down.
12. Systematic registration of data and preparation of a biobank from
hospitalized patients paved the way for future studies. In other words,
important investigations can be carried out in consistency to this
study.
13. This program can provide data required by senior managers inside and
outside of the Ministry of Health easily and accurately. Certainly,
these statistics are highly effective in making the right decisions.
14. Requesting the PCR test and its simple registration in all covered
centers, sending the sample quickly for testing, recording the results
in the system, preparing outputs to complete the data of other systems,
and exact registration of patients in the form of a registration program
and even a cohort study were among the other advantages of the system
and the joint action.
15. This system is an instrument for determining clinical severity,
transmission rate, and optimization of treatment options. Recording and
evaluating the symptoms in the relatives of patients gradually determine
changes in the symptoms of patients and sensitization of the health
staff to various symptoms.
16. The use of this system and its information can actually equip the
treatment sector and dedicate the largest and the best equipped hospital
in Shahroud exclusively for COVID-19 patients with the presence of the
most experienced specialized workers. In addition to providing the
non-COVID-19 patients with therapeutic requirements, this decision
minimized the risk of staff infection and prevented contamination of
other hospitals. Thanks to its physical size and structure as well as
efficient ventilation facilities, all of which were led to the optimal
and economic use of facilities.