In the Name of God

Evaluation Team Assessment of the Outbreak of Coronavirus in Qom

Final Report

Report Summary

The report examines the epidemiological evidence of the Qom outbreak and the possible origin
of the virus circulation processes. The structural weaknesses of Qom University of Medical
Sciences health system have been analyzed in the areas of crisis management of care system,
reporting, hospital treatment management system, laboratory structure, and health education.
The outcome of the 6-day investigation of the evaluation team is presented. To address system
challenges, it has been suggested that changes be made to the patient registration process, follow-
up of patient contacts, documentation of results and findings, and the university hospital crisis
management within the university system. The problems facing the university lab need to be
addressed forcefully. It is expected that the results of this assessment could also be helpful to
other cities in the country.

Table of Contents

Epidemiological report summary

Evaluation team
Objectives of Evaluation
Methods of Evaluation

A. Weakness of crisis management at the university level

B. Weak reporting and the Weakness of the Reporting System

Lack of attention to the syndromic care system
Required changes to patient registration and case definitions
Shortcomings in approach to patients and contact people
Tracking risk factors for Qom infection
Findings and Documentation of information

C Weaknesses in hospital treatment management system

The crisis facing hospital medical staff
Lack of hospital crisis management system
Failure to supply adequate personal protective equipment
Discharging of the patients with their consent
Failure to submit patient referral samples to laboratory

D Laboratory structure weaknesses

A. University Health Reference Laboratory
B. Private Booali Lab
Health education
Epidemiological Report Summary
Introduction
The first case of Covid 19 was reported in the country on Bahman 1, 1398 (Feb 19th , 2020), by
testing on samples obtained from two patients who were hospitalized and later died of severe
pneumonia in Qom. On Feb 20th, the Crisis Evaluation Team left for Qom. On February 26th
when the assessment process completed and the team returned to Tehran, the definitive number
of patients in the city had reached to 65, and 320 patients with suspected corona cases had been
admitted to two hospitals in Qom.
Qom traders work closely with their Chinese counterparts and the city of Qom is a sister city to
the (Yinchuan) Nin Shia city of China. Chinese businessmen are working in areas such as
Salafchegan Industrial City, Qom Slippers Factory, and the Qom-Isfahan Railway contractor is a
Chinese company with about 100 workers. Approximately 478 Chinese students study with their
family at Al-Mustafa University along with about 20,000 other foreign students.
During the evaluation process samples obtained from 5 of the 11 Chinese shoe workers and five
of the 18 workers of the Salafchegan free economic zone resulted in a positive detection of
Covid markers. In addition, two deceased persons of the shoe factory who passed away during
the evaluation period were showing evidence of Corona virus and one of the relatives also tested
positive as well. History of contacts of patients showed a close relationship with the Chinese
shoe workers in weeks prior to the death.

A majority of the shoe industry workers in Qom are of Afghan origin. Families of Afghan and
Pakistani workers live in various parts of town. They have a very close relationship together and
all live in below standard sanitary conditions. The occupants of one of the afflicted communities
in Qom were about 25% Afghan and 25% of Pakistani Descent.

In consideration to these observations, it was postulated that the illness was in correlation with
one of the Chinese merchants traveling to Iran and the Afghani and Pakistani Citizens played a
role in its distribution. A follow up analysis in the stored samples obtained during the months of
Dey and Bahman which were saved under the suspicion of Flu revealed five additional cases.
Sample which were positively identified were collected on or after February 9th. Access to
samples of prior dates were not possible since they were not saved in the respective sample
banks. Among the 186 patients associated with acute pulmonary syndrome (SARS1) who had
been hospitalized in Qom, 8 cases of death (3.4%) was observed. This compared to 0% observed
cases a year earlier.

Probable Chronology of Epidemic

In consideration to the evidence gathered and the fact that the death of primary patients were
identified towards the end of month of Bahman (Feb, 19th, 2020) it is probable to assume that the
virus was introduced to the City of Qom in the early Bahman period. If we accept the probability
that these patients were not necessarily the earliest cases of death, the propagation of the virus in
the city would be connected to the beginning of the month of Dey (December, 23rd). In this case
the virus had enough opportunity to distribute throughout the town and even other communities
in the country.

Suggestions
1. A follow-up process is undergoing to trace the locations and travel paths of the 20
identified patients. This process is done via tracing their mobile phones during the two
weeks period prior to their hospitalization. The objective is to assess and judge the extent
of contamination of various neighborhoods of the city and country.
2. Suggestions have been presented in the context of changing the procedures for
identification of patient cases. It is expected to validate the patient bedside care in
addition to a validated chest scan of an infected person.
3. In consideration to the estimates, it is expected that the cases in Qom will be increasing in
the next days and weeks. It is suggested to improve the facilities at the university lab in
the most expedient manner such that they can support the testing protocol by themselves.
4. It is suggested to strengthen the tracking mechanisms in the network of positively
identified patients and identification of the potential carriers within their communities
and families
5. In consideration to the recording of all the information at the urgent care facilities and
hospitals more support is needed to strengthen the communication and reporting tools of
these information systems.
Immediately after the reporting of the coronavirus epidemic in Qom, on February ***, the
Institute of Infectious Diseases Management at the Pasteur Institute in Iran sent a team to
evaluate the outbreak in Qom. This report addresses a brief summary of the findings of the team
and the list of activities that have taken place so far.

The Evaluation team

● Dr. Abdolreza Miroliaee- Expert in charge of the Center for Infectious Diseases
Management
● Dr. Ehsan Mostafavi- Epidemiologist and Head of the Pasteur Research Division of
Pasteur Institute of Iran
● Dr. Sina Eib-poosh- Epidemiologist and member of the Emergency Division of Infectious
Disease Response Team at the Pasteur Institute, Iran

Evaluation Objectives
● Evaluation of preventive and control measures taken
● Clinical evaluation of patients
● Investigation of possible origins of the Epidemic in Qom
● Assistance in the implementation and launch of Contact Tracing system
● Prediction of possible future trends of the disease

Evaluation method
During the evaluation process, the team held numerous meetings with the Honorable President
of the University, Director General of the State Crisis Management Team, the Deputy Director of
University Health System, and the deputies and experts responsible for the Health Department.
In addition, the team conducted visits to the hospital, al-Mustafa University Laboratory, the Holy
Masumah shrine, and the homes of the patients. The team evaluated the standard practices used
as well as the operations protocols, reviewed the evaluations forms, methods of care, as well as
the reporting of case histories in the context of the crisis management framework at the
university. After the process was completed, the results were reviewed and practical and
operational suggestions were presented to the university.
The main challenges and suggestions of this evaluation are as follows:
A. Weak crisis management at university level
The university's vice president of health care seems to be unable to manage the current crisis.
One of the challenges in this crisis is the involvement of senior and middle management in
unrelated affairs and, consequently, the neglect of quality management of health care delivery at
operational level.
It was determined that since the identification of the COVID-19 epidemic, the Risk Management
Office, at the Health Department has been active and has been conducting coordination
meetings. Evaluation of Operation Command Chart however revealed that despite appointing
Chart members and their successors, notification of issues relevant to personnel responsibilities
were not justified and explained by the description of assigned tasks.
Crisis Management has also been conducted outside the protocol and principles of (IOP).
In the current crisis, the components of the most important activities required in the form of an
operational plan has been designed. In this plan, the list of action items during the planning
period and the required answers in the preparation of response phase have been clearly listed. A
number of activities have been implemented, but some have not been operational since the start
of the epidemic.
After reviewing the performance of the designated components of the accident command chart,
the following corrective points were recommended to the colleagues in the field of health deputy
to improve the crisis management:
● A review of the ICS Chart of the Deputy Minister of Health
● Create a crisis management organization with a new corrective approach in the health
department.
● The emergency plan prepared by the provincial health center should be reviewed again
● Based on the scientific and practical experience of colleagues, the operational procedures
throughout the city need to be divided into smaller areas and one representative be
designated for each specific area.
● The Crisis Headquarters of the Deputy Minister of Health should hold a daily meeting in
the presence of the liaison among these areas and make the necessary interventions in
accordance with the received reports.
B. Weaknesses of the evaluation and reporting system
Lack of attention to the syndromic care system
● Had the syndromic care system was taken more seriously, it would be expected that such
an epidemic could be detected through the fever and pneumonia at least a few weeks
earlier in Qom and that the necessary follow-up would be performed to determine the
pathogen. Evidence suggests that the virus may have been in circulation as early as a
month prior to the first reporting of the disease. Despite the emphasis on the protocol of
Corona epidemic at a national level, reporting of inpatient pneumonia with an unknown
cause was suspected to be Corona but was not reported at the university level.

Required Changes to the process of registration and case definition

 ● During the past few days the main focus of colleagues has been solely on laboratory-
diagnosed patients. About 40 laboratory tests were reported by the time the report was
presented. However, about 300 clinical patients were exhibiting pneumonia symptoms in
Kamkar, Imam Reza, and Ali-bin Abitaleb hospitals. It was suggested that according to
China's experience and the limitations of laboratory diagnosis, the information of clinical
patients who were designated with the diagnosis based on chest graphics and the opinion
of an infectious disease specialist be added to the handwritten list of the patient
conditions.
● Following this requirement, a university statistician was appointed in charge of extraction
and managing hospital data. Using this approach, the Corona's designation list was
finalized with the university officials.
● In a meeting with the IT representative of the university, the required form of
identification of the Corona patients was finalized so that this information can be
extracted from the hospitals HIS database.

Shortcomings in treatment of people exposed to the patients

The observations of the evaluation team led to the fact that the 14-day isolation protocol for
those exposed to the patients was not implemented at the city level. Therefore, those people who
were exposed to the patient including family, friends and others were moving freely throughout
the city. Several others had travelled to other cities. Sufficient warning and consequences of the
inaction were presented to the University administration as well as those in charge.
There was no daily follow up of the health department with the relatives of patients in
accordance to the standard protocol. Lack of awareness, expertise, and inattention of the
evaluators in implementing these policies by means of person to person visits, sample collection,
and appropriate filling of the forms were below the expected standards. There were no forms for
contact tracing. The evaluation team instructed the fundamentals, expected outcomes, of the
process to the team of evaluators. The officials were warned by means of several reminders
about the consequences of inaction and on the 5th of Esfand (March **)) the entire evaluation
team was dispersed throughout the city to survey the identified homes.
Information regarding the previous topics that was provided by persons in charge to the
evaluation team in Qom were unfortunately untrue.
Tracing of the potential Source of Contamination in Qom
Shoe and slipper manufacturing is one of the main industries in the city of Qom. During the
month of Aban there was a shoe exhibition in Quanju China and about 50 business owners in
Qom attended this exhibition. About 15 of those in attendance travelled back to china in the
month of Azar and this time they visited several other cities and states in China. During the
months of Azar and Dey, several Chinese experts travelled to Qom as a follow up trip. On the 1st
of Bahman, there was an international slippers exhibition held in Qom and several Chinese
companies had booths at this exhibition. In addition to the above, a Chinese national named Mr.
Li has been operating in this industry in Iran for the past 10 years and employs Chinese workers.
He travels to China on a monthly basis. Two of the sons of deceased victims suspected of Corona
(Mr. Abolghasem Kermani and Haj Ali Shabanzadeh) were involved with the Chinese
businessmen and had travelled to China. The evaluations team sampling resulted in
identification of 5 of the 11 Chinese slippers factory workers who tested positive for COVOD-
19. In addition two of the deceased who were involved in the slipper manufacturing who died
during the initial recorded days exhibited bedside evidence of Corona. The test of one of the
relatives of them for COVID-19 was positive. In their chart history, the close connection to the
slipper manufacturing industry in China a few weeks prior to hospitalization was evident.
Many of the basic workers of the shoe and slipper industry in Qom are of Afghan descent and it
seems that this group can also be instrumental in spreading the contamination throughout the
town. Afghan and Pakistani families live throughout the town and are closely related. The
quality of sanitation in their neighborhoods are low and inconsideration to their low economic
standards. Without any health insurance, they have to cover all their health related expenses,
therefore they try to avoid health centers as much as possible. The residents of one of the main
nodes of this epidemic (Haeri Street in Qom) are 25% Afghan and 25% Pakistani. It was
postulated that this illness was brought to Iran through the Chinese connection and the migrant
workers of Afghan and Pakistani had a role in its propagation.
It was also determined that the Chinese residents of Qom are in two categories effectively.
Currently there are 478 Chinese students who live with their families and attend Jameh Al
Mostafa University alongside 20,000 other students. The University of Jameh Al Mostafa did not
cooperate with the evaluation team to the level expected. However, it was determined that
several students of this university had travelled to China in the previous months. Samples were
collected from several students. It is worth noting that one of the Professors of Jameh Al
Mostafa is among the verified positive samples of the laboratory results. In addition, about 20
Chinese workers are employed in the Salafchegan industrial park and they were also subjected to
testing by the evaluation team.
It was determined that about 600 foreign students attending the Al Mostafa in the City of Ashtian
and the religious center of Khatam Al Anbia in the city of Arak. These organizations have a
close connection to the Al Mostafa Organization in Qom such that the potential of transfer of
virus to Arak is worth investigating. On the third day of the evaluation team’s study, a positive
case at the Al Mostafa in Ashtiam was reported.
Based on the information provided on the roster, the location of the residence of the sick patients
was created on a map. It is worth noting that about 25% of the cases and the first laboratory
confirmed case was within a 1 km radius of the Kamkar hospital. In consideration to the lack of
appropriate air handling and air conditioning as well as the wind direction in the city of Qom, it
is postulated that the hospital was the site of propagation and dispersion of the virus throughout
the city.
The contractor for the construction of the IRGC’s Khatam Corporation’s Isfahan-Qom railroad is
a Chinese corporation which employs 100 Chinese workers. About two months ago the workers
travelled to China for vacation, however only few of them have returned. At the same time it is
reported that the Nuclear projects Ferdo and the Missile project in proximity to the Salt lake
employs several Chinese technicians and the potential that they were responsible for being the
initial carriers of the disease is also a possibility. It was not possible to get access to those
workers however.
In the evaluation process, samples of 5 of 11 Chinese workers of the Slipper factories and 5 of
the 18 workers of the Salafchegan free trade zone tested positive for the COVID 19.
Corona Virus tracing in the stored samples of Qom collected during the months of Dey and
Bahman have been followed by laboratory testing using the Flu exam. Five more cases who had
shown the symptoms after the 20th of Bahman were recorded. It was not possible to get access
to earlier samples from the sample bank since they were disposed of.
Among the 186 patients with the acute respiratory syndrome (SAR1) who were hospitalized in
Qum since Bahman, 8 cases of death representing 0.75% was observed. This measure in the
same month of previous year was 0%
Lack of Communication of the information and findings
Lack of information, improper documentation of findings and collection of information resulted
in a serious problems of crisis management and intervention aspects of the epidemic. The
conversion of the information to useable data and its evaluation could have resulted in proper
intervention and is regarded as a persistent problem. It was therefore not possible to present
relevant information to the higher authorities. One of the main challenges of the crisis
Management in the state is a list of recorded numbers and condition of the patients, which was
unavailable to the managers. Examples include listing of various illnesses by the specialist in
charge of those conditions, and the attention evaluators in filling out key identifiers and
conditions of the patient was unacceptable; meaning that the information collected lacked key
epidemiologic components, were basic, and were filled out without any specialized information.
During the days of visitation and support with the above-mentioned divisions, the importance of
data collection was presented by the evaluation team and the importance of these topics was
emphasized thoroughly.

C Weak Organization Management in the Hospitals

in consideration to the observations conducted in Qom, there should be more sensitivity in
choosing national hospitals that can be specialized to address Corona patients. Different
universities of the country should address the human resources, the equipment, and the
management of the hospitals so that we can have better experiences in other cities across the
country.
The hospitals of the University of medical Sciences in Qom is facing serious challenges and is
insufficient from an infrastructure as well as in the needed materials. These will limit the ability
to serve such an important role as it faces many serious challenges. For example the isolation
room did not have negative pressure and the CT scan was not available in any of those rooms.
Potential Organizational Collapse of the Medical Team
A majority of the hospital personnel are fearful, scared, and worried about own health and their
families. They seem very tired and many times they did not have proper information about the
seriousness and potential illness due to virus and the means of preventing it. A significant
number of the personal due to unrelated illnesses or pregnancy had been released from duties.
The number of the support forces, students, and some official employees with significant track
record were scared of showing up at their position. This resulted in additional workload for the
limited number of employees and this situation has resulted in a reduced efficiency, and loss of
their productivity throughout their work schedule. Within this situation, occurrence of illness
with similar signs among three of the hospital personnel resulted in a serious fear among the
personnel. It is important to support, empower, and provide emotional and mental support and
increase their awareness of the specific causes of this illness while providing sufficient
information to them. This situation should be a lesson for many other hospitals which will
eventually and probably face the same situation throughout the country. Proper prevention
methods should be adopted so the same experiences are not occurring at those sites.
A majority of healthcare workers felt that the virus was present had been identified much earlier
however for some reason there was never an official announcement regarding this situation.
This had created an anxiety and lack of trust towards the higher up Management Systems.
In a meeting with the president of the University, it was recognized that there is a need to address
Financial and mental support of the hospital personnel. After this issue was emphasized, he
promised financial rewards for the personnel in the following days.

Lack of Crisis Management in Hospitals

During the five days of visit, it was not possible to meet with a single one of the managers of
University hospital. Necessary warnings was given to the administrators of the University
though to beef up the crisis management at the Kamkar hospital and they were asked to increase
the attention paid to this task since other hospitals throughout the country would also will be
required to implement new educational process.
The situation of management at the emergency room was in such a way that once the patients or
their attending family became aware of the hospitalization need of their Corona patient they
preferred to transfer the patient to a different hospital. This situation can result in distribution of
the potential patients in other hospitals of the city as well as the other states.
All the beds available at the hospital were completely occupied. Isolation rooms from the
perspective of quality and quantity faced many serious challenges.
Lack of attention for providing personal protection and adequate devices
During the first two days of visitation almost all the personal complained about the lack of
personal protection devices in sufficient, and appropriate conditions. In majority of these cases
the personal were using industrial-type masks at the same time the personnel did not have
sufficient information about the level of personal protection
Some still did not know about the proper way of using the personal protection devices
There was no proper supervision in following the fundamentals of personal protection by the
patients, people accompanying patients, as there was no control of their attendance. This
situation can result in propagation of the disease in a very serious manner
Release from the hospital based on patience request.
The process of releasing patients based on their own demand needs to be addressed. This subject
of releasing patients in active conditions while they are suspect of serious and acute problems is
still permitted. This situation can create a serious situation in propagating the spread of the
disease throughout the country. There has to be an immediate policy installed to solve this
specific problem both in this hospital and in similar hospitals throughout the country.
Due to lack of facilities to maintain the condition of the patients such as availability of
ventilators many of the patients who are on an improving track record may be released from the
hospital by authorization of the medical team. This may result in propagation of the virus
throughout the city.
Lack of submittal of various patient’s samples for testing
UP to the present the laboratories efforts have only focused on testing samples from patients of
older age who have secondary type diagnosis. It was decided that submitted samples to the
hospitals should also include patients who are younger and without any secondary type illnesses
such that better judgment can be obtained from the collective number of patients.
D. the weaknesses in the Laboratory Facilities
A site visit to the laboratory facilities in the city of Qom was conducted.
A The Marjaa Salamat University Laboratory
The physical space of the laboratory was considered acceptable but the main challenge was the
the second floor of the laboratory was occupied by the children suffering from Asthma and
hemophilia. It is suggested that after the passing of this current crisis certain decisions regarding
the transfer of the location of the laboratory or the the hemophiliac Laboratory section be advised
so that there is a proper security for the patients.
One of the main problems of challenges of this laboratory is lack of qualified personnel. Support
by 2 groups of which were sent to the laboratory from Ministry of justice and Ministry of Labor
is not proportional to the sensitivity of the situation and the workload of 24/7 for them it's not
appropriate in these critical times.
In order to increase the capacity of the testing to 200 samples per day the operation is in serious
need of a real-time PCR obtained either from a rental unit or purchase situation.
Boo-Ali Private Laboratories of Qom
This laboratory is equipped with a multiplex kit and equipment to conduct as many as 360
simultaneous tests in an automated manner. The suggested cost for the laboratory for each test is
about 400,000 toomans and because of the current situation in the state there is flexibility for a
better pricing structure.
C Health Education
Fear that dominates the city of Qom is much more serious than the reality of the illness. It seems
that proper education for health workers as well as the general public in Qom and other cities are
extremely needed.
Additional consultation is necessary to be conducted with the state officials to decide about the
cancellation or continuation of schools, high schools, universities, social functions and
gatherings in public places as well as closure points of gathering such as religious, halls, and
exhibition spaces.
If the decision is made not to close the Shrine of Hazrat Masoumeh and other religious sites,
appropriate recommendations about the potential spread of the illness to the pilgrims, and
workers at these sites must be provided. These topics were clearly communicated with the
President of the university.