CASE STUDIES IN CLINICAL PRACTICE MANAGEMENT

Novel Screening and Triage Strategy in

Iran During Deadly Coronavirus Disease 2019
(COVID-19) Epidemic: Value of Humanitarian
Teleconsultation Service
Amir H. Davarpanah, MD, Arash Mahdavi, MD, Ali Sabri, MD, Taraneh Faghihi Langroudi, MD,
Shahram Kahkouee, MD, Sara Haseli, MD, Mohammad Ali Kazemi, MD, Payam Mehrian, MD,
Ali Mahdavi, MD, Farahnaz Falahati, MD, Abuzar Moradi Tuchayi, MD, Mehrdad
Bakhshayeshkaram, MD,Morteza Sanei Taheri, MD

THE PROBLEM 70% [3]. Therefore, effective exclusion radiological expertise because of the
The current outbreak of coronavirus of COVID-19 infection requires mul- complex morphological patterns of
disease 2019 (COVID-19) in at least tiple negative tests, possibly exacer- lung involvement that can change in
156 countries has been classified by bating test kit shortage. Early problems extent and appearance over time. The
the World Health Organization as a with distribution and performance of limited number of subspecialty-
global pandemic [1]. The long test kits laboratories in the United States trained thoracic radiologists hampers
incubation period and low disease and around the world have already been reliable interpretation of complex
severity in the early stage contributed reported. chest examinations in Iran and other
to rapid increase in case numbers. Diagnostic issues pose challenges developing countries, where general
The infection ranges from mild to for health systems over quarantine radiologists and occasionally clinicians
severe respiratory illness, potentially decisions, such as shortage of hospital interpret chest imaging. Furthermore,
progressing to acute respiratory beds and medical supplies, should the to reduce exposure in health care set-
distress syndrome in 17% to 29% of number of suspected cases exceed a tings during an epidemic, health ser-
patients [2]. Disease severity resulted certain threshold. The additional vices limit referrals to subspecialty
in global public health efforts to impact of recent outbreaks on the medical centers.
contain person-to-person viral spread global and state economies further The availability of radiology im-
by early detection. complicates decision making on ad- aging equipment is an important part
As of March 15, 2020, the total missions, given the high projected of high-quality patient care, particu-
number of infected cases in Iran has rates of hospitalizations and deaths. larly in developing countries. Iran, as a
reached 13,938, with 724 related Early lung manifestations of middle-income country with a popu-
deaths (highest numbers apart from COVID-19 infection consist of pe- lation of nearly 80 million, had
China and Italy). ripheral and basal predominant ground- 6.5 CT scanners per million people
Currently, COVID-19 infection is glass opacities progressing to organizing at the end of 2016 [5], distributed in
diagnosed by real-time reverse-tran- pneumonia pattern in the later stage the centers of 31 provinces. On the
scription polymerase chain reaction [2,4]. Notwithstanding that nearly 50% other hand, access to diagnostic
(rRT-PCR) analysis of nasopharyngeal of patients imaged in the first 2 days imaging equipment such as CT is
swab specimens. The rapidly expanding after the symptom onset had normal relatively universal for patients in the
number of cases could exceed laboratory chest CT [4], serial CT imaging is United States, which has 42.6 CT
testing capacity from potential testing valuable in assessing progression of scanners per million people [6].
kit shortages worldwide. Despite high lung abnormalities [2,4]. Despite this, adequacy of CT
specificity of rRT-PCR testing, the re- Accuracy of CT diagnosis of interpretations is quite variable,
ported sensitivity is as low as 60% to COVID-19 infection depends on potentially depriving a growing

Copyright ª 2020 American College of Radiology

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number of people from appropriate worldwide. We strategically imple- 2020, the Iranian Society of Radiology
screening during COVID-19 outbreak. mented social media to connect volun- (ISR), a nongovernmental, nonprofit
Teleradiology services eliminate the teer subspecialists in North America and organization representing more than
need to send patients to overpopulated the Iranian capital with undertrained 3,000 radiologists, assembled a
hospitals and provide near real-time clinicians throughout Iran for tele- second-opinion teleradiology group,
consultation from experts located radiology consultation. We describe the the Iranian Society of Radiology
around the country and the world to use of these teleradiology services deliv- COVID-19 Consultants (ISRCC), by
meet the local need. An increasing ered through a social media platform to inviting volunteer radiologists [7] on
number of health care professionals have provide diagnostic expertise for their WhatsApp open group. The 11
adopted social media for education COVID-19 in Iran. ISRCC volunteer participating
and information exchange in various radiologists (9 in Iran, 1 in Canada,
clinical settings. WhatsApp Messenger and 1 in the United States) all
(WhatsApp Inc. Mountain View, CA) is WHAT WE DID received subspecialty fellowship
a widely used messaging software In response to shortage of on-site training and have 4 to 24 years of
application with nearly 2.0 billion users thoracic radiologists, on February 18, experience in thoracic imaging.

Fig 1. Flowchart for triage of 2019 novel coronavirus disease in suspected cases in Iran. COVID-19 ¼ coronavirus disease
2019; CBC ¼ complete blood count; CHF ¼ congestive heart failure; CRP ¼ C-reactive protein; ESR ¼ erythrocyte sedi-
mentation rate; RT-PCR, reverse-transcription polymerase chain reaction.

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Fig 2. Schematic of the workflow process for remote consultations using social media and DICOM viewer.

Based on recent published litera- network coordinator (a physician reviewing submitted images. The
ture of present outbreak in Wuhan, assigned by ISR) using social media coordinator forwarded the final report
China, and short supply of test kits in messaging software, WhatsApp to the referrer via WhatsApp or e-mail.
Iran, the following triage strategy was (Fig. 2). Once a study (image files in Both lung and mediastinal win-
established [2,4,8] (Fig. 1). Patients JPEG format or cine clips in MP4 dows were submitted to facilitate
with early clinical and laboratory format) was submitted, the interpretation of JPEG or MP4 files.
findings suspicious for COVID-19 coordinator assigned a case number DICOM images were forwarded via e-
infection should undergo chest CT and posted images to the ISRCC mail in cases with suboptimal image
interpreted by a local general radiolo- private WhatsApp group. Then, one quality. Additional clinical informa-
gist. CT scans of patients with ab- of the available volunteers generated tion included the patient’s age, chief
normalities are referred to a a report using a standard format as a complaint, vital signs, physical exami-
teleradiology group as described later. comment on the post [7]. Access to nation, laboratory results, and the
An additional patient triaging algo- the private group was strictly limited course of care.
rithm depending on the results of the to the coordinator and volunteer
CT scan with or without rRT-PCR radiologists, who were instructed to OUTCOMES AND
testing is described in Figure 1. access information on their password- LIMITATIONS
Using the public website and protected devices to ensure the Between February 18, 2020, and
messaging service of ISR, physicians confidentiality of information. Dis- March 8, 2020, CT examinations
and general radiologists across Iran agreements on specific cases were from 1,138 patients (mean age, 53
were encouraged to submit abnormal resolved by consensus agreement years; range, 18 to 86 years; 664 men,
chest CT examinations for second through radiologists’ discussions in the 474 women) were uploaded to the
opinions. The teleconsultation system same post. Participation of expert ra- social media platform from more than
required referrers to submit anony- diologists in different time zones 65 cities (28 of 31 provinces; Fig. 3).
mized CT images to the volunteer allowed efficient time coverage for Nearly 43% (489 of 1,138) had

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print & web 4C=FPO

Fig 3. Distribution of number of remote consults across Iranian provinces between February 18, 2020, and March 8, 2020.
Circle size corresponds to number of cases.

imaging patterns suggestive of viral be interpreted in the context of pos- radiologists during a global health
pneumonia and were referred for itive exposure history and clinical crisis.
further rRT-PCR testing or isolation. symptoms, especially in epidemic
Another 41% (467 of 1,138) had areas with high pretest probability for ACKNOWLEDGMENTS
imaging patterns inconsistent with disease. Although we were able to We are grateful to many frontline med-
viral pneumonia and were referred for meet the current need using 11 vol- ical staff in Iran for their dedication in
management of underlying alternative unteers, the increased demand for the face of this outbreak, despite the
diagnoses. Approximately 16% thoracic radiology expertise might potential threat to their own lives and
(182 of 1,138) were categorized as exceed the capacity of traditional or the lives of their families. We thank
indeterminate and referred for obser- even social media–delivered tele- members of Iranian Society of Radiology
vation or CT follow-up. DICOM radiology services as the volunteers’ for their support and efforts to provide
images were reviewed in approxi- home countries experience an influx consult to the remote parts of Iran.
mately 19% of cases (216 of 1,138). of diagnostic cases and are themselves
The final reports were generated subject to infection. Despite the ad-
within 2 hours after initial posting in vantages of use of social media, we are REFERENCES
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100% of the cases. aware of disadvantages in health care
tor-General’s opening remarks at the media
Our study has limitations. We settings with respect to data security briefing on COVID-19—11 March 2020.
realize that using a broader definition and privacy protection, and usage Available at: https://www.who.int/dg/speeches/
of infection to include all positive requires meticulous and adequate detail/who-director-general-s-opening-remarks-
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Amir H. Davarpanah, MD, and Abuzar Moradi Tuchayi, MD, are from the Department of Radiology, Emory University School of Medicine, Emory
University Hospital, Atlanta, Georgia. Arash Mahdavi, MD, and Taraneh Faghihi Langroudi, MD, are from the Department of Radiology, Shahid Beheshti
University of Medical Sciences, Shahid Modarres Hospital, Tehran, Iran. Ali Sabri, MD, is from the Department of Radiology, McMaster University,
Ontario, Canada. Shahram Kahkouee, MD, Sara Haseli, MD, Payam Mehrian, MD, and Mehrdad Bakhshayeshkaram, MD, are from the Department of
Radiology, Shahid Beheshti University of Medical Science, Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and
Lung Diseases (NRITLD), Masih Daneshvari Hospital, Tehran, Iran. Mohammad Ali Kazemi, MD, is from the Department of Radiology, Tehran University
of Medical Sciences, Amiralam & Imam Hospitals, Tehran, Iran. Ali Mahdavi, MD, is from the Department of Radiology, Shahid Beheshti University of
Medical Sciences, Imam Hossein Hospital, Tehran, Iran. Farahnaz Falahati, MD, is from the Iranian Society of Radiology, Tehran, Iran. Morteza Sanei
Taheri, M, is from the Department of Radiology, Shahid Beheshti University of Medical Sciences, Shohada-e-Tajrish Hospital, Tehran, Iran.
The authors participated in this humanitarian program on a voluntary basis and state that they have no conflict of interest or involvement in any organization
or entity with any financial interest.
Amir H. Davarpanah, MD: Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA 30322; e-mail: [email protected] or
Morteza Sanei Taheri, MD: Shahid Beheshti University of Medical Sciences, Shohada-e-Tajrish Hospital, Tehran, Iran; e-mail: [email protected].

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