Spread of Novel coronavirus by returning pilgrims from Iran to Pakistan

Abstract

Coronavirus disease 2019 (COVID-19), first reported on 31 December 2019 in Wuhan, China, has spread rapidly throughout the world, and was declared a global pandemic on 11 March 2020. As of 23 March 2020, 372 757 COVID-19 cases were reported to WHO with 16 231 deaths. In Iran, the first official announcement of deaths from COVID-19 was made on 19 February 2020. The Iranian officials also confirmed that the COVID-19 spread from Qom to other cities due to religious tourism.1 By 24 March 2020, Iran reported 23 049 cases and 1812 deaths.2 Iran was initially reluctant to close its borders with its neighbours as religious tourism is a big part of its revenue generation and the international community has already imposed economic sanctions over it due to its nuclear programme.3 Every year approximately 0.7 million Shia sect Muslims from Pakistan visit for a pilgrimage to various shrines in the cities of Iran that include Qom, Tehran, Tabriz and Mashhad. It has been estimated that there are over 8000 sacred sites in Iran alone and every year around 8 million foreigners visit these shrines (Figure 1). The pilgrimage mostly includes visits to cities like Karbala, Najaf, Kufa, Samara and Baghdad in Iraq and several places in Damascus in Syria. These religious visits peak around the birth and death anniversaries of various religious leaders. Besides these specific anniversaries, the early spring season is a favourable time for the pilgrimage to these holy shrines. From 19 February to 22 March 2020, thousands of religious tourists travelled from Pakistan, Afghanistan, Oman, Yemen, Qatar, Bahrain and other neighbouring countries to Iran and returned to their home countries. Map of Iran showing the most famous shrines in red colour map-icon-shrine. These shrines are the site of pilgrimage throughout the year. Pakistani pilgrims at Taftan border crossing, a gate between Pakistan and Iran border. (Courtesy of Ahlul Bayt (a.s) News Agency - ABNA). Initially, Pakistan did not stop these religious travellers, as the spread of COVID-19 in Iran was not clear due to a lack of testing and hence reporting. However, when COVID-19 infection was detected in two patients in the city of Karachi on 26 February 2020 and it was discovered that they had travelled to Iran, then the Pakistan government started taking precautionary measures at the Taftan border crossing area with Iran (Figure 2). However, by that time around 8000 pilgrims had returned to different cities of Pakistan. The initial precautionary measures taken by Pakistan at the Taftan border were thermal scanning of returning pilgrims. Later, a quarantine was imposed on incoming pilgrims from Iran by taking them to quarantine camps for 10 days, but secondary cases were already occurring as a result of those pilgrims before the institution of quarantine. Further, due to lack of facilities at the Taftan border, around 2000 returning pilgrims were shifted to their home cities quarantine centres while 2800 more returning pilgrims from Iran were received at the Taftan border. At this time in Dera Ghazi Khan city of Punjab in Pakistan, around 750 returning pilgrims are in a quarantine camp but have not yet been tested for COVID-19. Almost all provinces of Pakistan are reporting COVID-19 cases and the numbers are increasing. By 24 March 2020, Pakistan reported 990 cases and 6 deaths.2 Among these infected patients, 60% were pilgrims who travelled to Iran. The NIH institute in Islamabad Pakistan is the main laboratory that can test the COVID-19 while almost the rest of the country hospitals lack diagnostic facilities. Now the government is setting up temporary testing laboratories for COVID-19 across the country. Without extensive testing, new cases cannot be identified in a timely manner and prompt isolation and contact tracing cannot be conducted, both of which are the main strategies to contain COVID-19.4 The government of Pakistan has taken some precautionary steps like the closing of educational institutes, parks and wedding halls across the country including a lockdown of Karachi city. However, there is a shortage of personal protective equipment including face masks and lack of proper guidance for its citizens. Given the lack of extensive testing, it is highly likely that the disease is spreading and the exponential increase in cases will only be recognized by increasing hospital admissions. A country like Pakistan with a population size of 200 million is extremely vulnerable to COVID-19, further compounded by a weak health care infrastructure. A lockdown may be inevitable. A lockdown with enforced social distancing to reduce and even halt community transmission was successful in Wuhan, China.5 No funding was utilized for this work. All the authors declares that they have no conflict of interest.

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