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On February 21, 2020, the first case of coronavirus disease 2019 (COVID-19) was identified in Lebanon. This occurred amid a backdrop of political and economic turmoil that began in October 2019, when a banking crisis and a civil uprising led to a change in political leadership and pushed the country into an economic crisis. On January 31, approximately 2 weeks after cases started to emerge outside of China, the newly appointed government in Lebanon established a National Committee for COVID-19 (NCC) to oversee the COVID-19 national preparedness and response.
Lebanon had specific challenges preparing for the emerging pandemic: in addition to economic and political unrest, the country is densely populated, with 6.9 million residents—87.2% of whom live in urban areas—including 2 million displaced persons and 500 000 migrant workers, all within 10 452 km2 (approximately the size of the state of Connecticut or Kosovo). Households are largely multigenerational, averaging 5 persons per household. The health care sector is fragmented with hospitals of varying capabilities, 84% of which are private and mainly concentrated in large cities. Furthermore, 80% of the health care budget is spent on acute care in private hospitals, leaving the public health systems underresourced. In addition, Lebanon relies heavily on foreign supply chains and has no local manufacturing capability to produce essential COVID-19 supplies, including N95 masks and ventilators.
On February 21, with the confirmation of the first case of COVID-19, the government initiated a “whole government response” through a public-private partnership, with the NCC directing the strategy and the Ministry of Health (MoH)—alongside other ministries—overseeing the implementation. Given the significant resource challenges in the country, the approach was centered around early aggressive containment to allow for building capacity to respond to COVID-19 cases. On February 22, Lebanon shut down public transport and banned flights to countries that had experienced exponential growth patterns of COVID-19, including Iran, Italy, China, and South Korea. Six days after the first case (at 3 cases), day care centers, schools, and universities were closed. A week later (March 6; 22 cases), nightclubs, pubs, gyms, and theaters were closed. Soon after (March 11; 64 cases), all malls, restaurants, tourist sites, and public gardens also were closed. By mid-March, when the infection count reached 99 cases, the government declared “public mobilization,” issued stay-at-home orders, and closed the borders, with full lockdown of nonessential services.
After these measures, the average growth factor per week (defined as the number of cases on a given day compared with the prior day, averaged over 1 week) declined from a peak of 4.6 (week 2, February 28-March 5) to less than 1 (week 6, March 27- April 2). During this time, hospital preparedness, including securing personal protective equipment (PPE), purchasing additional ventilators, training staff, and developing testing capabilities, was increased from 1 to 15 COVID-19–ready hospitals. On April 27, with the growth factor value less than 1 and 710 confirmed cases, a phased reopening was initiated. This was based on risk of transmission and the effect on the economy matrix, whereby sectors with low risk for transmission and high effects on the economy were opened initially, followed by sectors with higher transmission risk and businesses with lower economic effects, separated by 10- to 14-day intervals between phases, leading up to airport reopening on July 1.
As of July 15, 2020, Lebanon has 2542 confirmed cases of COVID-19 (707 imported, 1455 recovered), 38 total deaths, and has completed 194 329 polymerase chain reaction (PCR) tests. Although no national surveillance testing has been completed and testing of illegal migrant workers remains a challenge, overall testing rates (17 per 1000 persons)1 compare with the global average of 15 per thousand, and the test positivity rate of 1.5% is less than the World Health Organization (WHO) benchmark of 3% to 12% for adequate testing.2 At 251 cases per million persons, Lebanon compares favorably with New Zealand (243 cases per million), South Korea (248 cases per million), and Australia (299 cases per million).2
Compared with other countries like Taiwan3 and South Korea4 that had successful containment strategies, Lebanon’s approach required much more aggressive measures, reaching a Government Response Stringency Index (a composite measure based on 9 response indicators including school closures, workplace closures, and travel bans; scale, 0-100) of 85 at its peak, compared with 57 and 22 for South Korea and Taiwan, respectively.2 This was deemed necessary, given the extensive resource constraints: while South Korea and Taiwan had local stockpiles and local production of PPE, Lebanon’s supply chain for N95 masks and ventilators relied entirely on imported products, competing in a market of global shortages in which low- and middle-income countries have little leverage.5 Tracing capabilities in these countries also relied heavily on technology unavailable in Lebanon, using unified health registries with mobile phone tracking and messaging as well as computerized tracking of travel. Also, while these countries had extensive preparedness expertise and experience from prior epidemics, including unified health response command, Lebanon had to build these capabilities as part of this current response. The strategy adopted thus necessitated buying much-needed preparation time through swift and aggressive lockdown. Several other initiatives, in a low-resource setting, were considered important aspects of the success of the containment strategy.
Designated Receiving Hospitals
During the initial phase, a single public hospital was designated as the testing, quarantine, and treatment site, after mobilizing a World Bank loan to secure the needed resources. This allowed the government to channel limited resources into a single area in addition to giving private hospitals time to prepare to receive patients. Additionally, this approach limited the exposure of unprepared hospitals, which were sources of community clusters in the initial weeks. The second phase involved preparing all major university hospitals until additional public hospitals across Lebanon were prepared. PPE, ventilators, and testing equipment, which were historically sourced primarily from Europe and the US, were purchased from a combination of WHO stocks, from Europe, and increasingly from China as governmental restrictions on exportation emerged in countries with surges. To date, 47 laboratories in Lebanon have COVID-19 testing capabilities and 1365 of the country’s 15 195 beds are COVID-19–dedicated and ready. In addition, ventilator capacity was increased by 20%, for a total of 1424 ventilators and a ratio of approximately 21 critical care beds per 100 000, compared with ratios of 20 and 53 per 100 000, the highest ratios reported for low- and middle-income countries and high-income countries, respectively.6
Testing and Tracing
Given resource limitations, a targeted testing approach was followed. Beginning February 22, all patients with symptoms from endemic areas as well as symptomatic/exposed patients were tested, with facility quarantine of all patients testing positive and home isolation of asymptomatic travelers. As small community clusters emerged, the transition to home isolation was made with an appropriate social assessment. Clusters were followed up by targeted surveillance testing of their respective communities, allowing for early containment. The MoH traced all cases manually in collaboration with municipalities, while enforcement of home isolation, in the absence of technological tools and a national health registry, was achieved through local municipalities and community efforts.
A national strategic communication campaign was launched 4 days after detecting the first case of COVID-19. The main strategy centered around flooding media outlets with information by health care professionals: talk shows hosted physicians and public health experts, and public service messages featuring physicians were streamed through social media and television outlets, in addition to governmental directives around “stay home” orders and prevention. This resulted in a high knowledge level on prevention and self-reported adherence with governmental recommendations including abiding by hand hygiene (96% adherence), avoiding crowds (90%), and abiding by stay-at-home orders (76%).7
In Lebanon, displaced persons and migrant workers constitute approximately 30% of the population, many of whom live in underserved, crowded camps with others dispersed among the host community. These vulnerable populations required a targeted approach to overcome concerns about working with governmental agencies out of fear of deportation as well as concerns around stigmatization. All initiatives including securing hygiene supplies, implementing a testing and surveillance strategy, and establishing isolation centers within the camps, were therefore implemented through the more trusted United Nations agencies working in Lebanon in collaboration with the government. While to date only small clusters have emerged in different camps across Lebanon, these communities remain a source of concern, given the access barriers to health care and underresourced living conditions.8
Repatriation has been a challenge for many countries, leading to spikes after periods of containment. Faced with mounting pressures to repatriate its citizens, the government developed a phased repatriation plan, working closely with its embassies to prioritize citizens based on both medical and social risk assessment. On arrival, all returning citizens are PCR tested, with mandatory facility quarantine for 24 hours pending test results. PCR-negative and stable positive individuals undergo a social assessment for home quarantine; all others are hospitalized. Between April 5 and July 1, approximately 26 000 individuals were repatriated, with 427 identified COVID-19 cases, which were the primary drivers of clusters prior to full border reopening.
In summary, while the aggressive containment strategy was essential for Lebanon to build up its health sector and public health capacity it came at a high economic cost, driving poverty levels from 30% to an expected 45% by end of 2020.9 Furthermore, while the community seroprevalence in other countries that have had less restrictive strategies is increasing, Lebanon’s community exposure level remains relatively low going into potential waves ahead.
Corresponding Author: Eveline Hitti, MD, MBA, Department of Emergency Medicine, American University of Beirut, PO Box 11-0236, Riad El Solh 1107 2020, Beirut, Lebanon (firstname.lastname@example.org).
Published Online: July 23, 2020. doi:10.1001/jama.2020.12695
Conflict of Interest Disclosures: Dr Khoury serves on the National Committee on COVID-19 (NCC) as special advisor on health to the Prime Minister. Dr Azar serves on the NCC as an infectious disease expert representing Saint George University Medical Center. No other disclosures were reported.
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Khoury P, Azar E, Hitti E. COVID-19 Response in Lebanon: Current Experience and Challenges in a Low-Resource Setting. JAMA. 2020;324(6):548–549. doi:10.1001/jama.2020.12695
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