Lebanon, a small country in the Middle East, remains severely affected by the coronavirus disease 2019 (COVID-19) pandemic. The COVID-19 pandemic poses a significant threat to national and international healthcare security, particularly in Lebanon, a developing nation. Weak healthcare systems, inadequate monitoring, and a lack of disaster preparedness exacerbate the socioeconomic impact of the disease. Despite these challenges, the Lebanese government implemented stringent public health and social measures to slow the increase in cases and hospital admissions. The Lebanese government has relied heavily on the World Health Organization and non-governmental organizations for medical equipment and supplies. This review aims to explore the lessons learned and obstacles impacting the response and recovery of COVID-19 in Lebanon.

Coronavirus disease, Lebanon, Pandemic, Severe acute respiratory syndrome coronavirus 2, World Health Organization.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the virus that causes the highly contagious coronavirus disease 2019 (COVID-19.[1] SARS-CoV-2 spread quickly worldwide after the first instances of this primarily respiratory viral disease were recorded in Wuhan, Hubei Province, China, towards the end of December 2019.[2] Because of this, on March 11, 2020, the World Health Organization (WHO) declared it to be a global pandemic. With over 6 million deaths globally, COVID-19 has had a devastating impact on humanity. The first case of COVID-19 in Lebanon was reported on February 21, 2020, marking the initial incidence of the novel coronavirus in the country. Since then, reports of around 1 221 225 confirmed cases and 10 740 deaths have been made.[3]

Lebanon faced unique challenges in preparing for the emerging pandemic due to its dense population. With 6.9 million residents, 87.2% living in urban areas, including 2 million displaced persons and 500,000 migrant workers, all within a compact 10,452 km² area.[4,5] This made the already precarious healthcare system even more vulnerable and added to the pressure on the country’s economy.[6] Lebanon has been experiencing a serious and ongoing economic and financial crisis since October 2019, which was made worse by the COVID-19 epidemic.[6] The Spring 2021 Lebanon Economic Monitor predicts that the country’s economic and financial crisis is among the most severe crises globally since the mid-19th century. Lebanon’s GDP fell from $55 billion in 2018 to $20.5 billion in 2021, with a 37.1% fall in real GDP per capita. Monetary and financial turmoil continues to drive the crisis, with the US banknote rate depreciating by 68% and inflation averaging 131.9% in the first six months of 2021. The share of the Lebanese population under the US$5.50 international poverty line is expected to rise by up to 28 percentage points by the end of 2021.[7] The Lebanese pound has also dropped significantly, losing more than 90% of its value against the US dollar.[8] Due to the depletion of foreign exchange (FX) reserves, the banking sector has implemented informal capital controls over the past few years. Lebanon has experienced a significant decline in basic services due to the global pandemic, unable to import essential medications and medical devices.[9,10] The Lebanese government lacks funds to supply hospitals with necessary resources, leading to hospitals relying on the World Health Organization and non-governmental organizations for basic medical equipment and supplies.[11]

COVID-19 had a more detrimental socioeconomic impact on developing nations, such as Lebanon, mostly because of these nations’ flimsy healthcare systems, inadequate monitoring systems, and a dearth of thorough disaster preparedness and response strategies. Developing nations like Lebanon were far less able to recover from COVID-19, even though the global economy began to rebound with a 5.6% increase in 2021.[12] The purpose of this manuscript is to advance the evolution of COVID-19 epidemiology in Lebanon as well as gaps and challenges in the management of and response to the pandemic.

Issues with Lebanon’s COVID-19 pandemic response
The Lebanese government has been battling the pandemic since SARS-CoV-2 was discovered there by implementing sporadic lockdowns and other mitigating measures to lessen community transmission.[11] A spreading epidemic is eroding the already precarious healthcare system, and the explosion of the Beirut port on August 4, 2020, affected half of the capital’s medical facilities.[13]. Decades of political unrest and, more recently, an economic crisis have increased the likelihood of mental illness in Lebanon. Healthcare personnel and the public experienced significantly higher levels of stress and anxiety as a result of the combined effect of the COVID-19 lockdown tactics.[11]

The UN-backed COVAX initiative and the World Bank provided funding for vaccines. However, vaccine hesitancy and global vaccine shortages caused the vaccination effort to slow down.[14] Furthermore, the scientific community was not actively involved in assisting decision-making due to a lack of coordinated efforts between academics and national stakeholders and a deficiency in information-sharing mechanisms.[11] The Lebanese people were inundated with information from many media sources, much of which lacked credibility and proper sourcing.[15] Lebanon has the highest per-capita number of refugees, with 1.5 million Syrians and 13,715 from other countries.[5] Nine out of ten Syrian migrants live in extreme poverty due to the COVID-19 pandemic [16], the Beirut bombing, and the socioeconomic downturn. The drop in legitimate Syrian refugees makes it difficult for them to obtain civil documentation and essential services.

Population characteristics
According to the 2020 United Nations International Children’s Emergency Fund (UNICEF) study, a variety of criteria may have been considered while assessing the spread of COVID-19 infections in Lebanon.[16] Based on the nationality of the sample, 78% were Lebanese, 13% were Syrian, and 9% were Palestinian. Most of the respondents, who were Syrian and Palestinian, lived in host communities. The remaining participants were housed in Palestinian refugee camps, which were mostly in the North, South, and Mount Lebanon, and Syrian camps, which were in Akkar, Baalback-Hermel, and Bekaa.[16] The gender split was roughly even, with 49% males and 51% females. However, Syrian females were significantly more than. There are 28% of the Syrian respondents who are underrepresented. The age group of 25–44 accounted for 39% of the responses[16], while the 44–64 age group made up 29%. A minority of the sample was made up of the youngest age group (19%) and the elderly (14%). The majority of respondents (47%) were educated. Graduates and younger people were more likely to take part. University degrees are more common than older ones. Most of the respondents lived in Mount Lebanon (41%), followed by South Lebanon (13%), and North Lebanon (13%). The remaining governorates, including the capital Beirut, had less than 10% each.[16] In line with this study, a variety of criteria may have been taken into account while assessing the spread of COVID-19 infections in Lebanon.

Variability in the manifestations and severity of COVID-19 disease has been observed among individuals in Lebanon. According to the World Health Organization, the most common symptoms of COVID-19 are fever, fatigue, and a dry cough. Some patients may also experience a runny nose, a sore throat, nasal congestion, aches and pains, or diarrhea. Several people report losing their sense of taste and/or smell. In Lebanon, about 80% of individuals who contract COVID-19 experience a mild case, roughly equivalent to a common cold, and recover without the need for any specialized treatment.[16] One in six people will become seriously ill. Senior people and people with underlying medical problems, such as high blood pressure, heart problems, diabetes, or chronic respiratory conditions, are at a greater risk of serious illness from COVID-19. The overwhelming majority of respondents (97% to 99%) were female.[14] The elderly (92%) are at risk of serious illness, while 76% correctly identify individuals with preexisting health conditions. A significant proportion, 20% of respondents, consider pregnant women at risk of severe symptoms, while 13% express concern about children developing severe symptoms.[16]

Clinical manifestations, molecular diagnostics of the viral genome by real-time polymerase chain reaction (RT-PCR), chest x-ray or computed tomography (CT) scan, and serology blood tests are used to diagnose COVID-19. Patients with positive RT-PCR have the most common laboratory abnormalities, including lymphopenia, leukopenia, thrombocytopenia, elevated C-reactive protein (CRP) and inflammatory markers, decreased albumin, and abnormal renal and liver function. The Rafik Hariri University Hospital was the only hospital that admitted and cared for COVID-19 patients at the beginning of the pandemic.[17] Other major academic hospitals were able to establish COVID-19 units after the first national lockdown. Other public hospitals and healthcare facilities across Lebanon were equipped with personal protective equipment and ventilators to provide care for hospitalized patients during this period.[17] The nationwide lockdown implemented between March and May 2020 also resulted in the readiness of 47 laboratories nationwide for COVID-19 testing, 1366 hospital beds for patients, and a ratio of 21 beds per 100,000 for critical care, in addition to the increase in the number of ventilators to a total of 1424 (20%).[15] The average rate of positivity was 1.2% between April and May 2020.[18] The low positivity rate could be attributed to the lockdown, the low number of laboratory tests performed, and the lack of national mass testing programs during a national economic crisis. The Lebanese government allowed a five-phase plan to reclaim the country following a lockdown aimed at limiting the coronavirus epidemic by the end of April 2020. The first phase, which started on April 27, 2020, resumed the most priority and least dangerous economic activities, including food and agriculture, small and retail shops, hotels, factories, electricity, and water sectors.[15] The second phase, which started on May 4, 2020, included the opening of remaining factories, restaurants, cafes, children’s parks, sports courts, barber and hairdressing shops, and car repair shops.[15] The third phase, which started on May 11, 2020, involved the reopening of nurseries, institutions for special needs, Casino du Liban, and car agencies. The fourth phase, which started on May 25, 2021, has resumed Brevet and Baccalaureate classes at schools, universities, malls, and shopping centers. The final phase, starting on June 8, 2020, began with the reopening of various facilities, including nurseries, schools, and entertainment centers.[18]

Human coronavirus serotypes in Lebanon
The first strain of the human coronavirus (HCoV) was identified as B814 in 1965. About thirty other varieties of HCoV strains have been discovered in the years that ensued.[19] Seven strains of HCoV are known to be prevalent in the human population. These include two alpha-CoVs (HCoV-229E; HCoV-NL63) and five beta-CoVs (HCoV-OC43; HCoV-HKU1; MERS-CoV; SARS-CoV, including novel SARS-CoV-2). These strains are primarily responsible for cold symptoms and other respiratory diseases in healthy individuals.

In Lebanon, the strains B.1.398 (45%), B.1 (17%), and B.1.1.7 (17%) were the three most common Pango lineages. These lineages correspond to clades G, GH, and GRY, in that order. Furthermore, three strains—S3, S5, and S9—were found from clade O, a less well-defined group, while no strains were found from clades GV, L, V, or S.[19]

The vaccination strategy in Lebanon
The Access to COVID-19 Tools Accelerator (ACT-Accelerator) was launched in April 2020 to accelerate the development, production, and equitable access to COVID-19 diagnostics, therapeutics, vaccines, and health system improvement.[20,21] In January 2021, Lebanon launched its COVID-19 immunization program, which included an online vaccine registration platform and a tool for evaluating vaccine preparedness.[20] The BNT162b2 vaccination was initially given to Lebanon, followed by the ChAdOx1 vaccine.[21] Originally, the vaccination priority groups were categorized according to the following factors: risk of exposure and infection, risk of complications after infection, essential persons (e.g., workers in basic healthcare centers, front-line responders to the pandemic), and vaccine availability.[22] The vaccination campaign began on February 14, 2021, and only 6.3% of people received their first dose as of April 2021.[23] To increase vaccination coverage, the ministry of public health (MoPH) partnered with the business sector and Pfizer-BioNtech to supply vaccine doses for staff, instructors, and students.[24,25] Awareness campaigns, walk-in clinics, and vaccination marathons increased initial dosage coverage.[25,26,27] By October 2021, vaccination campaigns targeted students aged 11 and above in public and private schools.[26] Despite challenges, the nationwide vaccination program has effectively decreased cases and incidence rates.[16]

Refugees are facing challenges in accessing vaccinations
The World Bank is monitoring the Lebanese vaccination campaign, but legacy issues like mistrust, poverty, and lack of documentation are impeding the rollout. Refugees may avoid registration due to fear of harassment or detention.[30] The largest refugee populations are in the Bekaa and Baalbeck-El Hermel regions, and low literacy levels may limit their ability to register online. The government, private sector, World Bank, United Nations agencies, and non-governmental organizations (NGOs) are working together to address these challenges. A survey from the International Medical Corps (IMC) at MoPH revealed that 37% of non-Lebanese respondents believe the COVID-19 vaccine is unsafe, and 31% lack sufficient information about its effectiveness. Only 23% are willing to take the vaccine when available.[31] As of June 17, 2021, only 38,957 Palestinians and 45,195 Syrians had pre-registered for vaccination, indicating low confidence among refugees. The World Bank has approved a reallocation of $34 million from the Lebanon health resilience project, funded by the global concessional financing facility (GCFF), to support vaccines for all residents of Lebanon.[31] The World Bank is also mobilizing resources from the health emergency preparedness and response multi-donor trust fund for refugee vaccination deployment. The Lebanon experience highlights the importance of addressing the complex dynamics of the local context and ensuring fair and equitable access to vaccines for all. [31]

Socioeconomic impact of COVID-19 on Lebanon
The COVID-19 pandemic, despite Lebanon’s favorable health situation and low infections and fatalities, is expected to have catastrophic economic repercussions due to the weak economic climate. The pandemic has led to massive business closures, increased unemployment, poverty, limited access to foreign exchange and imports, and decreased remittance volume. The virus’s rapid spread has led to unprecedented disruptions to daily life, affecting mental health.[32] and causing anxiety, depressive symptoms, loneliness, and dangerous drug and alcohol consumption.[29] Depressive symptoms are higher in those working at home due to Lebanon’s economic crisis and lockdown measures, as the loss of the Lebanese pound and increased financial stress can lead to extensive worry and depression. Additionally, individuals who have contact with confirmed or suspected COVID-19 cases show higher depressive symptoms, as fear of infection is a significant factor associated with anxiety and depressive symptoms. In comparison to single individuals, married and divorced participants also displayed a higher level of fear of contracting the COVID-19 infection.[29] This can be viewed as an expected outcome, since married and divorced individuals may be more concerned about their loved ones (spouse and kids, for example).

Situation of COVID-19 in 2024
COVID-19 is no longer considered a public health emergency, but it remains a concern for public health that requires monitoring and response. Over 1.1 million new cases were reported worldwide over the 28 days from December 11, 2023, to January 7, 2024, a 4% rise over the previous 28-day period. With 8,700 new fatalities recorded, the number of new deaths fell by 26% over the previous 28-day period.[33] More than seven million deaths and over 774 million verified cases had been reported worldwide as of January 7, 2024.[33] During the reporting period, 640 new cases of COVID-19 and 4 related deaths were recorded in Lebanon. In Lebanon, the total number of cases remains below the threshold with less severity, fewer hospitalizations, and mortality related to COVID-19, even with a slight increase in new cases during the winter season. There was a positive rate of 5.2%. The WHO will continue to communicate with the Ministry of Public Health and its partners to monitor trends and variations in hospitals, with a 2% occupancy rate. This supports capacity building, and the relationship and network established to monitor respiratory disease surveillance.[33]

The COVID-19 pandemic exposed the vulnerability, gaps, and needs of the healthcare system in Lebanon, including epidemiologic surveillance, genomic surveillance, integrated and coordinated data sharing, diagnostic capacity, community mobilization, and risk communication. Massive efforts and actions were put in place to respond to the COVID-19 pandemic in Lebanon during a steadily worsening economic and financial situation. To ensure the safety and well-being of vulnerable individuals and prevent agency closures, humanitarian organizations must review and refocus their strategies. Death anxiety was identified as the most significant predictor of fear related to the COVID-19 pandemic. Future work should focus on exploring strategies to minimize the fear and death anxiety associated with pandemics.

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Corresponding Author:
Isabelle Basbouss-Serhal
Department of Pathology and Molecular Laboratory
Siblin Governmental Hospital, Lebanon
Email: isabellebasbouss@hotmail.com

Co-Author:
Fatima Fayad
Department of Molecular Biology
Siblin Governmental Hospital, Lebanon

All authors contributed to the conceptualization, investigation, and data curation by acquiring and critically reviewing the selected articles. They were collectively involved in the writing – original draft preparation, and writing – review & editing to refine the manuscript. Additionally, all authors participated in the supervision of the work, ensuring accuracy and completeness. The final manuscript was approved by all named authors for submission to the journal.

Not applicable

Not reported

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https://doi.org/10.63096/medtigo30622429

Isabelle B-S, Fatima F. A Literature Review: Impact of COVID-19 on Lebanon. medtigo J Med. 2024;2(4):e30622429. doi:10.63096/medtigo30622429 Crossref