The epidemiological trends of coronavirus disease (COVID-19) in Iran: February 19 to March 22, 2020 Dr. Farzan Madadizadeh Research Center of Prevention and Epidemiology of Non-Communicable Disease, Department of Biostatistics and Epidemiology, School of Public Health, Shahid Sadoughi University of Medical Sciences Reyhane Sedkar ( [email protected] ) Department of Biostatistics, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Research Article Keywords: Respiratory illness, Coronavirus disease 2019, Primary health care, Epidemiology Posted Date: May 18th, 2020 DOI: https://doi.org/10.21203/rs.3.rs-29367/v1 License: This work is licensed under a Creative Commons Attribution 4.0 International License. Read Full License Page 1/17 Abstract Background The Coronavirus has crossed the geographical borders of various countries without any restrictions. This study was performed to identify the epidemiological trends of coronavirus disease (COVID-19) in Iran during February 19 to March 22, 2020. Methods This cross sectional study was carried out in 31 provinces by using the daily number of newly infected cases which was announced by the Iranian health authorities from February 19 to March 22, 2020, we explore the trend of outbreak of coronavirus disease in all provinces of Iran and determine some inuential factors such as population size, area, population density, distance from original epicenter, altitude, and human development index (HDI) for each province on its spread by Spearman correlation coecient. K-means cluster analysis (KMCA) also categorized the provinces into 10 separate groups based on CF and ACF of the infected cases at the end of the study period. (ACF). Results There were 21,638 infected, 7,913 recovered and 2,299 death cases with COVID-19 in Iran during the study period. By March 22, CF shows that, most cases are attributed to Tehran province, while ACF shows that most are attributed to Semnan province. There was a positive signicant correlation between CF of the infected cases and province population sizes (r=0.45), HDI (r=0.58); province population density (r=0.47); a negative signicant correlation between the CF of the infected cases and distance from original epicenter (r=-0.47). KMCA results based on CF showed very high level of outbreak was in Tehran while KMCA based on ACF showed very high level of outbreak were in Semnan and Qom provinces. Conclusions Special attention is needed for the provinces nearer to the original epicenter which are high risk spots in terms of the severe prevalence of COVID-19. In the absence of denite treatment for this infectious disease, the effective solutions to reduce the transmission of the disease are early isolation of the cases, quarantine for close contacts both in families and community and observing personal hygiene. Background These days, a strange unwanted guest has drastically surprised the people in most of the countries all over the world. That is a 2019 novel coronavirus (2019-nCoV), which is a new member of coronavirus family mainly causes acute infection in the human respiratory system at early stages [1]. This new coronavirus rst emerged in December 2019 in China by identifying a cluster of pneumonia cases of unknown etiology and was identied from the throat swab sample of a patient on January 7 [2-3]. The International Committee on Taxonomy of Viruses (ICTV) called the newly described coronavirus as Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and the caused disease as coronavirus disease-2019 (COVID-19) [4]. Up to now, the world has witnessed the deadly and destructive outbreak of various coronavirus-related diseases including SARS during 2002-2003 and Middle East respiratory syndrome (MERS) in 2012 with a case fatality rate of 10 and 35.5%, respectively [5-6]. Researches have shown that the COVID-19 has a human to human transmission and its incubation period varies between 2-14 days [7-8]. Although, the transmission mostly occurs when a patient is symptomatic, the studies have indicated that it may also happen during the asymptomatic incubation period [9]. Clinical manifestations of this disease Page 2/17 include fever, cough, shortness of breath, and breathing diculties and other complications related to respiratory tract involvement so that, in more severe cases infection can cause pneumonia, severe acute respiratory syndrome, and even death [7-9]. Based on the warnings, older adults and people with serious heart disease, diabetes and lung disease may hurt severely from the COVID-19 [10]. Long infectious period, rapid increases in the number of cases and the absence of denitive treatment have made this disease a global challenge [11-12]. Until March 22, 2020, the total number of infected cases worldwide is 337,459, 14,640 of which have lost their lives. While china has the most total conrmed cases, the peak of mortality due to the COVID-19 has been reported in Italy with a total number of 5,476 deaths [13]. On 19 February 2020, the first death cases due to the COVID-19 were announced in Qom province (Iran), after that, the ascending trend of outbreak was started across the other provinces. According to the Ministry of Health and Medical Education (MHME) reports, up to March 22, 2020, there were 21,638 conrmed cases in Iran with 1,685 deaths and 7,913 remissions, and Tehran province has been reported to have the highest number of infected cases among the other provinces. Although the authorities have started to confront this epidemic by shutting down the schools and universities, refusing non-local travelers in some provinces, reducing working hours for some days, implementing forms of remote work by many companies for the employees, requesting the individuals to stay at home in self-quarantine, etc., still there is a quick increase in the number of infected cases [5]. According to the literature review, there are limited published papers on Iran's status in the outbreak period of the COVID-19 [5, 14-18]. Therefore, given the rapid outbreak of the COVID-19 in Iran, this study was conducted in order to identify the spreading trend of this disease in Iran and all its provinces from February 19 to March 22, 2020, using the recorded data from the MHME and also to nd similar provinces according to the disease spread using K-means cluster analysis (KMCA). Methods Data collection During the study period, from February 19 to March 22, 2020, the daily provincial distribution of the epidemic was closely tracked, extracted and collected through various sources including MHME and www.worldometers.info/coronavirus. The information included the daily number of newly conrmed cases, remissions and deaths due to the COVID-19 in all the 31 provinces of Iran within a 33-day interval. Based on the last population census conducted in 2016 in Iran, the population of Iran is about 79.9 million people. Table 1 presents the information on the cumulative frequency of the infected cases, population size, area, population density, distance from original epicenter (Qom province), altitude from sea level, and Human Development Index (HDI) for each province. According to Table 1, Tehran, Khorasan Razavi, and Isfahan are the most populous provinces, respectively. Kerman, Sistan and Baluchestan, and South Khorasan are the largest provinces, respectively. Tehran, Alborz, and Gilan have the highest population density, respectively. Tehran, Alborz, and Esfahan are the provinces with the highest HDI and Sistan and Baluchestan, Kurdistan, and North Khorasan are the provinces with the lowest HDI, respectively. Statistical analysis Page 3/17 Results regarding the descriptive statistics showed the trend related to the number of newly confirmed, recovered, and death cases for the COVID-19 during the study period through the plots provided in the Excel software. Also, the RStudio version 1.2.5042 software was used to map cumulative frequency (CF) and adjusting the cumulative frequency of the conrmed cases (ACF) with respect to population of each province (based on Iran's 2016 population census) in order to visualize the distribution of the epidemic. Furthermore, the spearman correlation coecient was calculated to assess the strength of the linear relationship between CF and the variables presented in Table 1. KMCA was also applied to identify the provinces with similar spreading pattern in terms of the COVID-19 outbreak. Cluster analysis is a method used to classify a sample of objects with different features into different groups so that, the objects in the same category (called a cluster) are more similar than those in other categories. In this study, K-means clustering technique was employed. It is a distance-based algorithm, where the distances are calculated to assign a point to a cluster. In this method, each cluster is associated with a centroid and the aim is minimizing the sum of distances between the points and their respective cluster centroid [19]. The number of iterations was set as 100 and the number of clusters was set as 10. Results Figure 1. shows the number of newly infected, death ,and recovered cases due to the COVID -19 from February 19 to March 22, 2020 in Iran. During the study period, maximum number of newly infected, death, and recovered cases were on March 14 with 1365 cases, March 19 and 20 with 149 cases, and March 20 with 890 cases, respectively. Qom province, as the seventh most populous city of Iran, with the geographical coordinates of 34.66 N, and 50.88 E was the rst province of Iran contaminated with the Coronavirus on February 19, 2020 with 2 cases and Bushehr province was the last province with ve cases on March 5, 2020. On March 22, 2020, 1028 new cases were reported in Iran that large number of them were from Tehran with 249 cases (24.22%), Isfahan with 87 cases (8.46%), Yazd with 84 cases (8.17%), Alborz with 60 cases (5.83%), and East Azerbaijan with 57 cases (5.54%) and also Bushehr, Kohgiluyeh and Boyer-Ahmad and Semnan provinces did not have any new case.