- Iran has confirmed 388 virus cases and 34 deaths, with dozens of cases in neighbouring countries linked to people who travelled to Iran
- Iranian outbreak comes ahead of the haj pilgrimage in late July, when millions of pilgrims annually visit the holy city of Mecca in Saudi Arabia
Iran's rising coronavirus death toll amid doubts over the government's reporting of cases is raising fears of mass contagion across the Middle East, months ahead of the most important mass pilgrimage in the Islamic calendar.
Iranian health authorities have confirmed 34 deaths, the highest death toll outside China, and 388 cases, most of them in the holy city of Qom, a popular destination for Shiite pilgrims and scholars.
After insisting the country was free of the virus as recently as the start of last week, health authorities confirmed the first cases on February 19, following the deaths of two elderly patients from the coronavirus, which causes the disease now officially known as Covid-19.
The Middle East is considered to be at major risk of a mass outbreak due to the constant movement of pilgrims and workers across borders, weak governance in many countries, and questions about the capacity of local health care systems to handle a surge in infections. Dozens of cases among people who have travelled to Iran have already emerged in Lebanon, Bahrain, Afghanistan, Oman, Iraq, the United Arab Emirates, Kuwait and Pakistan.
Due to Iran's geographical positioning as a crossroads in the Middle East, the Covid-19 virus has already spread to Iran's neighbouring countries, and if Iran doesn't act proactively, there is a big risk for the virus to travel more intensely far and beyondAsif Shuja
"Due to Iran's geographical positioning as a crossroads in the Middle East, the Covid-19 virus has already spread to Iran's neighbouring countries, and if Iran doesn't act proactively, there is a big risk for the virus to travel more intensely far and beyond," said Asif Shuja, a senior research fellow at the Middle East Institute at the National University of Singapore.
Turkey, Iraq, Kuwait, the UAE, Pakistan, Afghanistan and Armenia have all closed their borders to Iran or introduced restrictions on travellers.
Iranian President Hassan Rowhani this week ruled out quarantining affected cities and regions, but authorities have flagged restrictions at Shiite holy sites that attract millions of pilgrims each year.
Saudi Arabia, the location of the two holiest cities in the Islamic world, Mecca and Medina, which attract millions of worshippers each year, said on Thursday that it was temporarily suspending pilgrimages to halt the further spread of the virus.
Parvaiz A Koul, an infectious diseases expert at the Sher-i-Kashmir Institute of Medical Sciences in Srinagar, India, said he believed it was only a matter of time before the virus crossed borders in the Middle East on a grand scale with "disastrous consequences."
"Poor public health capacity, ill-compensated and uninterested health care workers, inappropriate emphasis on the right measures, wishful thinking, illiterate populace and the like seem challenges for the authorities and despite their efforts, the measures may simply not be enough," said Koul.
The growing fears of a major outbreak across the region come ahead of the haj, the annual Islamic pilgrimage to Mecca, in July. The pilgrimage last year attracted some 2.5 million pilgrims from all over the world, including nearly 90,000 worshippers from Iran.
"I believe if the cases do not abate in the countries from where pilgrims originate, it might call for a forced stoppage of the pilgrims from attending the haj," said Koul, who described the pilgrimage as the "ideal environment" for the spread of the virus.
This elevated fatality rate could be due to the strain put on their health infrastructure, but it is more likely that only the severe cases are being detected, in which case we may see continued spread throughout the country and regionJeremy Rossman
Although Iran has confirmed relatively few cases of the virus, the high fatality rate in the country " with about one in 10 people succumbing there compared to one in 50 in China, where more than 78,000 people have taken ill " has fuelled suspicion that the extent of the outbreak may be far greater than official figures suggest.
In a study published this week by medRxi, a website that publishes research which has not yet been subject to peer review, a group of Canadian scientists estimated the number of cases in Iran could be upwards of 18,000, basing their analysis in part on cases linked to Iran in other countries.
"This elevated fatality rate could be due to the strain put on their health infrastructure, but it is more likely that only the severe cases are being detected, in which case we may see continued spread throughout the country and region," said Jeremy Rossman, a lecturer in virology at the University of Kent. "It is too early to tell for sure at this point."
Rossman added that health care systems across the region appeared to be coping, but would struggle if localised transmission began emerging as it has in China.
The sudden spike in cases in Iran has led internet users in the country and outside observers to accuse authorities of mishandling and even covering up the extent of the outbreak, only weeks after thousands marched in Tehan to demand the resignation of Supreme Leader Ayatollah Ali Khamenei over the military's downing of an Ukrainian airliner and its initial denials of responsibility.
Critics have accused Tehran of downplaying the outbreak to avoid disruption to last week's parliamentary elections, which had the lowest turnout since the 1979 Islamic revolution " an outcome Khamenei blamed on "negative propaganda" about the virus by enemy countries" and bungling the opportunity to contain the virus by not immediately halting flights with China.
"The Iranian political elite were too busy in the parliamentary elections as they were worried about a lower voter turnout threatening their legitimacy and this may have caused them to overlook as well as underplay the threat due to Covid-19," said Shuja from the Middle East Institute at the National University of Singapore.
In a stark illustration of the government's credibility issues, deputy health minister Iraj Harirchi and vice-president Masoumeh Ebtekar, President Rowhani's deputy for women's affairs, are among seven government officials to have tested positive for the virus.
Harirchi earlier this week held a press conference while visibly ill during which he denied any attempt to cover up the outbreak, only to announce the following day that he himself had been infected.
Kamiar Alaei, an Iranian doctor and co-founder of the Institute for International Health and Education in Albany, New York state, noted that authorities had only announced the first cases of the virus after the death of two patients, "which means they had already been infected for a week or so, but the government didn't admit that they were infected."
"In the next several weeks, we will have a lot of new cases in Iran," Alaei added.
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