Healthcare system on the brink
The surge of COVID-19 cases in Lebanon First published online on August 7
The surge of COVID-19 cases in Lebanon
As of August 2, Lebanon has registered 4,885 cases (almost 80 percent of which are local) since the first case of COVID-19 was identified in Lebanon on February 21. At the time of writing, 3028 cases are considered “active”—of whom 110 are hospitalized, and while the majority (70 percent) are mild cases, still one in three hospitalized persons currently require intensive care treatment. The predominant majority of the active cases (96 percent) are in home isolation—not requiring hospital care. While that is unequivocally positive news, it is not entirely riskfree as the proportion committed to home isolation is far from 100 percent in some areas of Lebanon. According to the daily report published by the Disaster Risk Management (DRM) unit, self-reported compliance has been at 50 percent or less in areas such as the Bekaa, Akkar, and Baalbek, and suboptimal in Beirut (80 percent), the North (70 percent) and Mount Lebanon (60 percent). While reasons for non-compliance may vary and have not been investigated, repercussions of non-compliance are quite clear: the risk of transmission from an infected case to several healthy and possibly immunocompromised individuals.
IMPROVED TESTING,
BUT ALSO GREATER CASES
In the past few weeks, we have witnessed a surge in the number of positive cases detected on a daily basis. One may be tempted to attribute these higher daily numbers to the parallel significant rise in the number of daily tests conducted (the total PCR tests conducted as of August 2 is 308,735): 6,799 tests in March compared to about 50,000 in May and June each, to a total of 164,775 tests during the month of July alone. Indeed, the increased number of confirmed cases daily is a result of the higher number of daily PCR tests conducted. Nonetheless, the published data also points to a doubling in the positivity rate (number of cases/number of tests x 100), which was hovering around 1 percent in June versus about 2 percent in July (reaching 4.2 percent on July 12). Since July 1 marks the first day of reopening the airport at about 10-15 percent capacity (bearing in mind that four phases of repatriation had already occurred between April 5 and June 11), many may also be tempted to attribute the increased number of tests to incoming expats/tourists. Digging into the published numbers, however, the higher percentage of tests has been conducted among the locals and not at the airport (on August 1 for example, 6,666 PCR tests were conducted for locals in the preceding 24 hours versus 2,072 at the airport). Moreover, during the month of July the average positivity rate was 1.6 percent among locals (compared to 1.13 percent in June), in contrast to 0.86 percent among those tested at the airport.
While the majority of the hospitalized cases are mild (and 48 percent of all registered cases are asymptomatic), it is important to consider three additional statistics besides the positivity rate (which has doubled from June to July) when evaluating the current local COVID-19 situation. First, the number of cases requiring admission to an intensive care unit (ICU), which has quadrupled in a month from eight on July 1 to 34 on August 2. The second indicator is the number of deaths per month, which increased from seven in June to 25 in July, bringing the total number of coronavirus deaths to 59 at end-July (noting that the case-fatality rate is at 1.3 percent versus 3.8 percent globally). The third indicator is the percentage of cases that remain untraceable (an indicator of community transmission), and currently about 25 percent of registered cases remain “under investigation/of unidentified source.”
DANGERS OF LOCKDOWN FATIGUE
It is worth recalling that Lebanon by mid-March was in full lockdown with only about 100 confirmed positive cases. This aggressive containment early on was key to flattening the curve and building healthcare capacity to respond to COVID-19 cases. The high number of COVID-19 cases confirmed on a daily basis these past few weeks threatens to overwhelm Lebanon’s healthcare system. On July 30, after a series of record daily highs, Dr. Firas Abiad, director of the Rafic Hariri University Hospital warned: “Whether it is wearing face masks, social distancing, the financial situation, the blackouts, the drums of war, the sweltering heat, or the wretched lockdown, everyone is extremely drained and wants a break. #Covid19 is not listening.” Both public and private hospitals are threatened despite significant improvements since the start of the epidemic in terms of daily PCR tests, distribution of testing centers, available beds, ICUs, and ventilators. This is mainly because Lebanon is simultaneously battling an economic catastrophe, which is resulting in significant power cuts in
hospitals, laying off nurses and other hospital personnel, and translating to critical shortages in personal protective equipment (PPE), medicines, and other essential medical supplies.
Early in the epidemic, the Lebanese government initiated a “whole government response” and has since implemented several decisions, albeit some controversial such as the most recent partial lockdown that started July 30—which some health officials disagreed with, warning that only an enforced two-week full-lockdown could create any significant progress. The partial lockdown was also questioned by many precaution-taking citizens. Many wondered about the public health value of closing restaurants and holding instead banquets in home gardens, or closing of sports clubs and holding big birthday parties at home, or even necessitating PCR tests from arriving airline passengers if positive cases do not adequately home quarantine. Lockdowns have been perceived by the socially responsible as a punishment for the risky behaviors committed by the social butterflies who continued clubbing, partying, and not taking any precautions. What some local residents and incoming passengers fail to realize is that containing the second wave of COVID-19 in Lebanon requires shared responsibility—and the collective effort of multiple stakeholders—including them.
YOUNG, BUT NOT INVINCIBLE
At the end of July, the World Health Organization (WHO) warned that young people could be driving the surge in COVID-19 cases in some countries, as illustrated by a higher proportion of new cases among the younger demographic. In Lebanon, there are no clear demographic trends across time but the current demographic distribution of the cases shows that about 25 percent are in the 20-29 age group, and an additional 20 percent of the cases are in the 30-39 age group. This is in contrast to the profile of critical cases and deaths, which are predominantly among the 50+ year olds. Therefore, while young people are likely to experience a mild case of coronavirus and fully recover, they still pose a great risk to others in their community—by transmitting the virus to vulnerable groups including immunocompromised individuals (such as a sibling with asthma) and older adults with risk factors (such as parents who smoke or have a comorbid heart condition or cancer). One should be careful not to blame the younger popul ation— for one cannot determine the directionality of transmission (who infected whom) by looking at the age distribution of cases. Still, global researchers have shown that younger people do tend to react to the end of lockdown by socializing more, perhaps partially attributed to them misinterpreting the repeated messages they have been hearing about young people being less at risk. As such, there has been a recent shift in messaging and we have been hearing more and more that COVID-19 can affect any age group, and that young people are “not invincible.” It has always been the case, but with lesser precaution taking in the young and an increased risk of transmission to others, the thinking and messaging framework has shifted. The young must not only be warned but rather also be engaged in the process of re-flattening the curve as active agents of change. In the words of WHO Director-General Dr. Tedros Adhanom Ghebreyesu: “The pandemic does not mean life has to stop,” it just means we have to find ways to adapt to the “new normal”—including safer ways of socializing.
While individuals, across all age groups, play a crucial role in lowering the risk of transmission within their communities, they are only one of many stakeholders responsible for the mitigation of a “second wave.” Inter-ministerial coordination is key, and so are collaborations across various entities in Lebanon (community, healthcare facilities, municipalities, and non-governmental organizations [NGOs]) as they all have major responsibilities and must work collaboratively to implement advanced
The number of cases requiring admission to an intensive care unit quadrupled in a month from eight on July 1 to 34 on August 2.
structural measures. The government must balance Lebanon’s economic and public health needs and ensure the implementation of evidencebased measures and strategies as outlined in a newly published policy brief by the Knowledge to Policy (K2P) Center. The report stresses on the need for a comprehensive and cross-sectoral strategy, and outlines evidence-based measures at various levels to support the control of a second wave of COVID-19 in Lebanon.
Civic action and responsibility is necessary though not sufficient. Today, there is an unprecedented need for residents of Lebanon to join in the efforts aimed at containing COVID-19 locally—and that is by acting with heightened sense and sensibility. This does not preclude one from going to work to make a living in these incredibly stressed financial times, or sustaining small and close family and friends gatherings for mental health wellbeing. It simply necessitates that we all act responsibly and abide by international and national guidelines, otherwise, as Dr. Abaid warns, “if we falter, it will be a very steep fall.”
Dr. Lilian A. Ghandour is an associate professor of epidemiology at the Faculty of Health Sciences at the American University of Beirut. She is also a member of the executive committee of the Lebanese Epidemiological Association.