Lack of drugs and vaccines for treating and preventing COVID-19, respectively, has led many countries to implement various non-pharmacological policies to reduce and control the disease (23). In addition to putting too much pressure on health systems, COVID-19 has also generated economic and political issues (24).
Iran is one of the countries with the highest morbidity and mortality rates for COVID-19 among the countries of the world. With the onset of the disease in Iran, there was initially an optimism about a quick response to the disease, but its prevalence increased rapidly (6). The coincidence of the severity of the disease outbreak and the beginning of the Nowruz holiday in Iran caused serious concern about the increasing prevalence of the disease among policy-makers (25). During the Nowruz holiday, many families have travelled to different cities to visit relatives and friends, and to see ancient and tourist sites (26). Nowruz holiday sounded as an alarm for health policy-makers in Iran. With the establishment of a national committee for the management of COVID-19, the Minister of Health, as the key person of the committee, decided to put prevention and control policies on the government's agenda (7).
Due to the lack of personal protective equipment such as masks, gloves and disinfectants, as well as sanctions and the inability of buying this equipment, Nowruz holiday has represented an opportunity for easy transmission of the disease in Iran (26). The increase in hospitalized patients and the lack of manpower caused the health system to experience more problems than other countries with a more resilient and robust healthcare system (27). The experience of implementing social distancing in countries such as China, Thailand, Hong Kong and New Zealand has shown that this policy can prevent further outbreaks of the disease (28, 29).
On March 27, 2020, the Iranian government implemented a policy of social distancing. The government banned all occupations (except some essential occupations) (6). Inter-city and inter-provincial travels were restricted. Attendance of parks, sports clubs and places of pilgrimage were banned. ITSA studies can assess the impact of implementing a given public health policy (15). Our ITSA findings showed that the implementation of this policy has reduced the number of new daily confirmed COVID-19 cases in Iran. Findings from studies employing ITSA and conducted in Italy and Spain (11), as well as in other countries (30) with high COVID-19 infection rate, showed that the implementation of social distancing has been an effective policy in reducing the incidence of this disease, which is consistent with the findings of our study.
Stay home orders, ban of gathering and avoiding crowded places are effective ways to reduce the transmission of the disease (29). The available body of evidence recommends the implementation of social distancing policy for reducing transmission (31).
Of course, in addition to the implementation of this policy in Iran, at the same time increasing the production of disinfectants and implementation of educational campaigns and hygiene interventions can also be one of the reasons for the decrease in COVID-19 cases. Also, treating patients with different (even though non-specific) therapeutics and increasing the number of tests, ensuring that more people have access to tests, enhancing the accuracy of laboratory tests, can be other reasons for this decrease.
After the implementation of this policy in Iran, the burden of hospitalizations was reduced as well as the pressure on the hospital staff members, who could increase the quality of services delivered to patients, being themselves less at risk (6).
With the decline in social activities, economy was highly disrupted. Many closed industries and factories needed to be reopened (32). The implementation of the policy of social distancing could not be on the agenda for a long time, and for this reason, the Iranian government issued economic licenses in two stages and reopened various jobs (33). COVID-19 has had a devastating effect on the economies of many countries and has created many problems for everyone (7).
Our ITSA findings showed that the resumption of social and economic activities led to the growth of newly confirmed cases of the disease. With the relaxing and easing of the policies in Iran, the transmission of the disease through social relations and contacts increased.
Health policy-makers have warned that the resumption of social activities could result in the resumption of the spread of the disease. However, economic issues, not only in Iran but also in other countries, forced governments to lift COVID-19 related strictures (6, 33). After the increase in cases, the Iranian government could not re-implement the policy of social distancing as in the past and decided to mandate the use of masks as a major intervention (34).
As a consequence, the production of masks and other preventive equipment in Iran increased and the conditions for providing this equipment were better than before. Our findings show that the implementation of this policy has also reduced the incidence of COVID-19 (35).
The use of masks in case of viral outbreaks can be a valuable intervention, although recommendations regarding its use of masks vary among countries. Available evidence suggests that SARS-CoV-2 can survive in the air for hours, and therefore the use of a mask can be effective in reducing the transmission of the disease (36).
The use of masks in the prevention of diseases such as SARS, avian influenza and swine flu suggests that wearing masks can be an important measure to control COVID-19 (35). Population density speeds up the transmission of COVID-19, so the mandatory use of a mask can be an effective policy to control the disease.
Wearing a mask is a crucial preventative measure, as many people with the disease may be asymptomatic (37). Singapore enforced the use of masks for the general public, a measure which was able to achieve good results. The South Korean experience also confirmed the use of masks as an appropriate strategy to reduce disease transmission (38).
Of course, it should not be forgotten that the mandatory use of masks can increase demand and cause shortages, so it can be a threat to health workers who are more involved in the management of the disease (37). Iran was able to solve the mask problem to some extent by establishing mask factories and also using the capacity of non-governmental organizations (NGOs).
The mandatory use of masks in public places can be a very effective way for reducing the transmission of COVID-19 (9). The long-term implementation of social distancing is practically unfeasible and unsustainable, and can have very disruptive effects on the economy, whereas the use of masks can help protect people against this disease (37). Even if there is a shortage of medical masks, it is recommended that people can use non-medical masks, which can be cost effective. Medical masks can be stored for healthcare and other frontline workers.
The present study examined the implementation of several COVID-19 related policies in Iran. The findings of this study showed that the transmission of the disease was reduced through social distancing and wearing a mask. Community cooperation to maintain proper distance and reduce unnecessary contacts and activities helps a lot to reduce the disease transmission. On the other hand, the need for resuming economic and social activities has resulted in an increase of cases.
Limitations of the study
This investigation is not without limitations. The major shortcoming is given by the short study period (2 weeks before and after the implementation of each policy), which is not enough to evaluate the impact and effectiveness of a policy. On the other hand, especially during an emergency situation like the ongoing outbreak, health policy- and decision-makers cannot wait long in that time is of paramount importance during a pandemic and even short-term data can be meaningful and helpful to inform and guide decision-making processes. Besides this main shortcoming, it should be emphasized that diﬀerent contextual factors and variables such as the quality of healthcare services in Iran, underlying co-morbidities, among selected sample, may contribute to explain the findings of the present study. Moreover, confirmed data could suffer from under-reporting bias or reporting delays. Finally, other measures implemented at similar time of the social distancing measures could also contribute to reducing the spread of the disease.