A framework for reconstructing transmission networks in infectious diseases.

In this paper, we propose a general framework for the reconstruction of the underlying cross-regional transmission network contributing to the spread of an infectious disease. We employ an autoregressive model that allows to decompose the mean number of infections into three components that describe: intra-locality infections, inter-locality infections, and infections from other sources such as travelers arriving to a country from abroad. This model is commonly used in the identification of spatiotemporal patterns in seasonal infectious diseases and thus in forecasting infection counts. However, our contribution lies in identifying the inter-locality term as a time-evolving network, and rather than using the model for forecasting, we focus on the network properties without any assumption on seasonality or recurrence of the disease. The topology of the network is then studied to get insight into the disease dynamics. Building on this, and particularly on the centrality of the nodes of the identified network, a strategy for intervention and disease control is devised.

Prevalence and correlates of burnout among Lebanese health care workers during the COVID-19 pandemic: a national cross-sectional survey.

BACKGROUND: The COVID-19 pandemic has harshly burdened the healthcare systems. Health care workers (HCWs) are at substantial risk of infection and confronted several stressors as well leading them to experience burnout. This study aimed to assess the prevalence of burnout among Lebanese health HCWs and to identify its associated factors. METHODS: A cross-sectional online survey was conducted between the first of November and the end of December 2020 among Lebanese HCWs working in all active hospitals operating across the country. Data were collected using an Arabic, anonymous, self-reported questionnaire comprising four sections: (a) basic sociodemographic characteristics, (b) exposure to COVID-19 covariates, (c) occupational factors, and (d) the measurements including the Copenhagen Burnout Inventory (CBI). CBI subscale cut-off score of 50 was used to assess the prevalence of burnout among HCWs. Multinomial logistic regression analyses were performed to examine the factors associated with the different aspects of burnout. RESULTS: Out of the 1751 respondents, personal burnout (PB) was detected in its moderate and high-level aspects among 86.3% of Lebanese HCWs. Moderate and high levels of work-related burnout (WB), and client-related burnout (CB) hit 79.2% and 83.3% of HCWs, respectively. HCWs who were females, married, physicians, having a poor health status and specific living conditions (dependent child, elderly at home, family member with comorbidities, and a low income) were more likely to exhibit a high level of PB compared to no/low burnout level. Moreover, frontline HCWs, those infected by COVID-19 or those having a colleague infected by COVID-19, and those exhibiting a high perception of threat were more prone to experience a high-level PB rather than a low/no burnout. Working in a public hospital, extensive working hours, and insufficient sleeping hours were also found positively associated with high PB. However, older age and altruism were negatively associated with high PB compared to no/low PB among HCWs. As for WB, similar factors were found either positively or negatively associated with a high level of WB except health status and living conditions factors (dependent child or family member). As for CB, older age of HCWs (> 30 years) and altruism were negatively associated with high CB compared to no/low burnout level. However, working in the frontline, high threat perception, extensive working hours, insufficient sleeping hours, and low income were positively associated with high CB among HCWs compared to no/low burnout. CONCLUSION: The prevalence of burnout among Lebanese HCWs during the pandemic was significant and alarming. Enacting and implementing preventive policies and effective interventions are urgently needed to cultivate wellness among HCWs.

COVID-19 mortality surveillance in Lebanon.

Since the beginning of the COVID-19 pandemic, the Epidemiological surveillance program of the Lebanese Ministry of Public Health has launched a rapid surveillance system for collecting COVID-19-related mortality data. In this study, we document the Lebanese experience of COVID-19 mortality surveillance and provide an analysis of the epidemiological characteristics of confirmed deaths. The implementation of the rapid COVID-19 mortality surveillance system, data sources, and data collection were described. A retrospective descriptive analysis of the epidemiological characteristics of confirmed cases occurring in Lebanon between February 20, 2020, and September 15, 2021, was performed. Epidemiological curves of Covid-19 confirmed cases and deaths as well as the geographic distribution map of mortality rates were generated. Between February 21, 2020, and September 15, 2021, a total of 8163 COVID-19-related deaths were reported with a predominance of males (60.4%). More than 60% were aged 70 years or above. Of all deaths, 84% occurred at hospitals and 16% at home. The overall cumulative mortality rate was 119.6 per 100,000. The overall case fatality ratio (CRF) was 1.3%. Of the total deaths, 82.2% had at least one underlying medical condition. The top reported COVID-19 comorbidities associated with COVID-19-related deaths are cardiovascular diseases including hypertension (59.1%), diabetes (37.2%), kidney diseases including dialysis (11%), cancer (6.7%), and lung diseases (6.3%). The CFR was 30.9% for kidney diseases, 20.2% for cancer, 20.2% for lung diseases, 18.1% for liver diseases, 14% for diabetes, and 12.2% for cardiovascular diseases. Considering the limited human and financial resources in Lebanon due to the economic and political crisis, the rapid mortality surveillance system can be considered successful. Improving this system is important and would contribute to better detection of deaths from emerging and re-emerging diseases during health crises.

The Role of Lebanon in the COVID-19 Butterfly Effect: The B.1.398 Example.

In the present study, we provide a retrospective genomic surveillance of the SARS-CoV-2 pandemic in Lebanon; we newly sequence the viral genomes of 200 nasopharyngeal samples collected between July 2020 and February 2021 from patients in different regions of Lebanon and from travelers crossing the Lebanese-Syrian border, and we also analyze the Lebanese genomic dataset available at GISAID. Our results show that SARS-CoV-2 infections in Lebanon during this period were shaped by the turnovers of four dominant SARS-CoV-2 lineages, with B.1.398 being the first to thoroughly dominate. Lebanon acted as a dispersal center of B.1.398 to other countries, with intercontinental transmissions being more common than within-continent. Within the country, the district of Tripoli, which was the source of 43% of the total B.1.398 sequences in our study, was identified as being an important source of dispersal in the country. In conclusion, our findings exemplify the butterfly effect, by which a lineage that emerges in a small area can be spread around the world, and highlight the potential role of developing countries in the emergence of new variants.

Prevalence and correlates of burnout among physicians in a developing country facing multi-layered crises: a cross-sectional study.

Burnout among physicians is a serious concern that cultivates its seeds during their education. This study assessed the prevalence of burnout among Lebanese physicians and explored its correlates and the combined effects of the pandemic and the economic crisis on burnout. A web-based cross-sectional study was conducted in December 2020 using a snowball sampling technique. Moderate and high levels of burnout hit 90.7% of the physicians where personal, work-related, and client-related burnout were detected among 80.4%, 75.63%, and 69.6% of them respectively. A strong association was found between the higher level of burnout and female gender, younger age, being single, having a dependent child, living with an elderly or a family member with comorbidities, and insufficient sleeping hours. Physicians' specialties, working in a public health facility, limited years of professional experience, lack of previous experience in a pandemic, and extensive working hours were also associated with increased burnout. Furthermore, low income, working in the frontline, higher threat perception, and fear of COVID-19 were contributing to higher burnout. The combined effect of threat perception and financial hardship significantly increased burnout levels. The alarming burnout level detected among physicians urges health authorities to take prompt actions to enhance the physicians' well-being.

Experience of field testing in Lebanon during the COVID-19 pandemic, January to August 2021.

Soon after detection of the first COVID-19 case in Lebanon, a testing strategy was developed aiming to early detect new cases and identify close contacts in order to implement isolation and quarantine measures, thus limiting disease transmission. Field-testing activities were initiated in March 2020, focusing on suspected cases and close contacts. The objective of this paper is to present data collected between the 1st and the 35th week of 2021 and discuss challenges and lessons learned. During the study period, testing activities were conducted in field sites covering all Lebanese districts and following a fixed schedule. Testing was provided free of charge for suspected/probable patients with COVID-19 and close contacts of positive cases. Nasopharyngeal specimens were collected and sent to designated laboratories for reverse transcription polymerase chain reaction testing. Results were received on a timely manner, within 48 hours. From the 1st to the 35th week of 2021, 1244 field-testing activities were conducted with an average of 37 testing activities per week. During this period, 71 542 samples were collected with an average of 2104 specimens per week. On average, activities covered 78% of the Lebanese districts. The average positivity rate for this period was 24% (15%-33%) in line with the virus circulation levels in the country. Timely development and implementation of a testing strategy is crucial during epidemics. The success of Lebanon's field-testing experience was mainly due to the timely adapted approach that covered all national territories, targeting all residents as well as high-risk groups in suburbs and remote areas.

Determinants of acceptance of Coronavirus disease-2019 (COVID-19) vaccine among Lebanese health care workers using health belief model.

Since Health care workers (HCWs) are at high occupational risk for COVID-19, they are prioritized for immunization. This study aimed to assess the acceptance rate of the COVID-19 vaccine among HCWs and to identify its determinants. A web-based cross-sectional study was conducted between10 and 31 December 2020 among Lebanese HCWs. The Health Belief Model (HBM) was used as a theoretical framework. Multivariable logistic analyses were carried out to identify the factors associated with the acceptance of the COVID-19 vaccine among HCWs. A total of 1800 HCWs have completed the survey. Around half (58.10%) of them were frontline HCWs and aged between (30-49) years old. Over two-thirds (67.33%) of the participants have received the seasonal influenza vaccine. The acceptance rate of the COVID-19 vaccine among surveyed HCWs was 58%. HCWs who were male (aOR = 1.99, 95% CI (1.41-2.80)), working in the frontlines (aOR = 1.61, 95% CI (1.17-2.21), and those who have received influenza vaccination for the current year (aOR = 1.38, 95% CI(0.99-1.92)) were more willing to get the COVID-19 vaccine. However, factors such as living in rural areas (aOR = 0.61, 95% CI (0.44-0.84)), and being previously diagnosed with COVID-19 (aOR = 0.66, 95%CI (0.45-0.96) were found negatively associated with vaccine acceptance. In terms of health beliefs items, concerns related to the novelty of vaccine (aOR = 0.42, 95% CI (0.25-0.71)), side effects/vaccine safety (aOR = 0.41, 95% CI (0.23-0.73), reliability of manufacturer (aOR = 0.43, 95% CI (0.30-0.63)), and the number of required doses (aOR = 0.58, 95% CI (0.40-0.84)) were also negatively associated with the willingness to get vaccinated against COVID-19. Remarkably, concerns such as the limited accessibility (aOR = 1.68, 95% CI (1.14-2.47)), and availability of vaccines (aOR = 2.16, 95% CI (1.46-3.20)) were associated with an increased likelihood of willingness to receive the COVID-19 vaccine. With regards to cues of action, receiving reliable and adequate information about the vaccine (aOR = 1.98, 95% CI (1.36-2.88)), recommendation by health authorities (aOR = 1.93, 95% CI(1.33-2.81)), and recommendations from health facilities (aOR = 2.68, 95% CI(1.80-3.99)) were also positively associated with vaccine acceptance. Lastly, perception of COVID-19 vaccine benefits by HCWs in terms of protecting them and their close contacts (patients, family members, and friends) from COVID-19 infection (aOR = 4.21, 95% CI (2.78-7.11)) was associated with an increased likelihood of vaccine uptake. The moderate acceptance rate of the COVID-19 vaccine among HCWs found in our study could have broader extents. Understanding and pointing out factors impairing vaccine acceptance such as concerns about the novelty of vaccine and manufacturers' reliability are required to reach a higher vaccination rate.

Prevalence and risk factors of burnout among Lebanese community pharmacists in the era of COVID-19 pandemic: results from the first national cross-sectional survey.

BACKGROUND: Community pharmacists (CPs) are increasingly facing occupational challenges as a result of the COVID-19 pandemic, putting them at high risk of burnout. This study aimed to assess the prevalence of burnout among Lebanese CPs during the COVID-19 pandemic and to identify its associated factors. METHODS: An online survey was conducted among Lebanese CPs between February 1st and March 30, 2021. Collected data included information on sociodemographic characteristics, exposure and work-related variables, the Copenhagen burnout inventory (CBI), and the COVID-19 threat perception scale. Prevalence of burnout was calculated. Multiple logistic regressions were performed to identify the factors associated with the three burnout domains. RESULTS: A total of 387 CPs participated in the survey. Of the total, 53.7% were females; and 43.2% were aged less than 40 years old. The prevalence of moderate-to-high personal, work-related and client-related burnout was 77.8%, 76.8, and 89.7%, respectively. Younger age, staff pharmacist, working more than 40 h per week, high perceived COVID-19 threat were associated with a moderate-to-high likelihood of burnout in all three domains. However, altruistically accepting the risks of caring for COVID-19 patients was the only variable that was associated with a lower likelihood of burnout in all three domains. CONCLUSION: An alarming prevalence of personal, work-related and client-related burnout was revealed among Lebanese CPs. This study has many implications for practice and provides a framework for establishing policy interventions to reduce burnout levels among Lebanese CPs. Preventive strategies and interventions on individual and organizational basis are recommended.

Retraction: Samaha et al. Effects of a Single Dose of Ivermectin on Viral and Clinical Outcomes in Asymptomatic SARS-CoV-2 Infected Subjects: A Pilot Clinical Trial in Lebanon. Viruses 2021, 13, 989.

The journal retracts the article, Effects of a Single Dose of Ivermectin on Viral and Clinical Outcomes in Asymptomatic SARS-CoV-2 Infected Subjects: A Pilot Clinical Trial in Lebanon [...].

Phased repatriation of Lebanese expatriates stranded abroad during coronavirus disease 2019 (COVID-19) pandemic.

BACKGROUND: The coronavirus disease (COVID-19) pandemic represents a serious worldwide threat. Stranded Lebanese citizens abroad appealed to the Lebanese government to embark on citizen repatriation missions. We aim to document the Lebanese experience in the repatriation of citizens during COVID-19 which allow us to disclose encountered challenges and lessons learned. METHODS: This is a retrospective description of processes involved in the phased repatriation of Lebanese citizens. The Mission consisted of 4 phases starting, April 5th until June 19th 2020. The prioritization of returnees was based on both medical and social risk assessment. The repatriation team was divided into four groups: the aircraft team, the airport team, the hotel team and the follow up team. On arrival, all returning citizens were tested using Polymerase chain Reaction (PCR) based technique, and were obliged to adhere to a mandatory facility quarantine for 24 to 48 h. Returning travelers who were tested positive for COVID-19 were transferred to the hospital. Those who were tested negative were urged to strictly comply with home-quarantine for a duration of 14 days. They were followed up on a daily basis by the repatriation team. RESULTS: Overall, 25,783 Lebanese citizens have returned home during the phased repatriation. The third phase ranked the uppermost in regard of the number of citizens repatriated. The total number of performed PCR tests at the airport upon arrival was 14,893 with an average percentage of around 1% positivity for COVID-19. On the other hand, more than 10,687 repatriates underwent external PCR requisite in the third and fourth phases. Two hundred seventy-two repatriates were tested positive for COVID-19 upon their arrival. CONCLUSION: Considering the limited human and financial resources besides the economic and political crisis, the overall repatriation mission could be considered as a successful experience. Such processes would not have been achieved without the professionalism of all involved stakeholders.

Pharmacists as immunizers in Lebanon: a national survey of community pharmacists' willingness and readiness to administer adult immunization.

BACKGROUND: Since the focus of healthcare has shifted toward prevention, pharmacists were highly encouraged to expand their practice to include immunization services. Our study aimed to assess the knowledge, attitudes and beliefs of community-based Lebanese pharmacists, in addition to their willingness to expand their practice scope to include vaccine administration. METHODS: A cross-sectional study was conducted during the phase preceding the arrival of the COVID-19 vaccine in Lebanon between 1 and 31st December 2020. Using a stratified random sampling method, data were collected from Lebanese community pharmacists (CPs) through an online survey that included information on socio-demographic characteristics, clinical experience, willingness to administer vaccines, knowledge about vaccination, attitudes towards immunization, reasons supporting utilizing pharmacists as immunizers and the requested elements to incorporate immunization in pharmacists' practice scope. Multivariable analyses were performed to identify the factors associated with knowledge. RESULTS: A total of 412 community pharmacists participated in this survey. Of the total, 66.5% of the surveyed CPs are willing to administer vaccines. The majority of them (89.8%) had an overall good level. Out of all, 92.7% showed a positive overall attitude score toward immunization, 95.4% agreed that community pharmacists can play an important role in advertising and promoting vaccination. The main needed elements for implementing immunization services in pharmacies listed by participants were: support of health authorities (99.3%), statutory allowance (82.8%), patient demand (95.4%), pharmacist's interest (96.1%) and continuous education and training workshops on immunization. Older CPs (50 years and above) [aOR = 0.703, CI 95% (0.598-0.812)] and those working in Bekaa and North have lower knowledge score than their counterparts. High educational level [aOR = 1.891, CI 95% (1.598-2.019)], previous experience in immunization [aOR = 3.123, CI 95% (2.652-4.161)] and working in urban areas [aOR = 3.640, CI 95% (2.544-4.717)] were positively associated with a good knowledge level. CONCLUSION: Most of Lebanese community pharmacists are willing to offer immunizations. The expansion of the pharmacists practice scope to include provision of immunizations required a national plan that encompasses strengthening knowledge, training, certification for eligibility to administer vaccines, enhancing pharmacovigilance and statutory reform.

Exploring determinants of community pharmacist-led influenza vaccination in a Middle Eastern country: a national web-based cross-sectional study.

BACKGROUND: Utilizing community pharmacists (CPs) as immunizers has being adopted in various countries as approach to boost influenza vaccination coverage. Our study aims to explore the Lebanese CPs' willingness to administer influenza vaccine, and to identify factors associated with this willingness. METHODS: This is a web-based, cross-sectional study, conducted over 2 months, from the 1st of November to the end of December 2020. Self-reported data were collected electronically from Lebanese CPs through an anonymous, questionnaire using google form. The collected data were analyzed using the statistical software SPSS (Statistical Package for Social Sciences). Bivariate and multivariable analyses were performed to examine factors associated with the willingness of CPs to administer influenza vaccine. RESULTS: A total of 412 CPs participated in this survey of which 76.9% are willing to administer influenza vaccines. More than 90% of them had a good overall knowledge score and 88.8% of CPs showed a positive overall attitude score, particularly towards involvement of CPs in influenza vaccine provision. Their willingness to administer vaccine was positively associated with the younger age (aOR = 3.12 with 95% CI (1.597-4.040)), higher education level (aOR = 2.02 with 95% CI (1.093-3.741)), previous experience in immunization (aOR = 2.72 with 95% CI (1.320-5.627)) and urbanicity of pharmacy (aOR = 1.542 with 95% CI (1.219-4.627)). Extensive working hours (aOR = 2.34 with 95% CI (1.131-4.845)), working in pharmacies that are operating round-the-clock, showing positive attitude towards immunization (aOR = 3.01 with 95% CI (1.872-6.422)) and towards provision of influenza vaccines (aOR = 13.72 with 95% CI (13.721-38.507)) were also positively associated to this willingness. Conversely, patient privacy (aOR = 0.55 with 95% CI (0.079-0.983)), time and cost for professional development (aOR = 0.55 with 95% CI (0.172-0.918)), limited patient's trust (aOR = 0.39 with 95% CI (0.203-0.784)), financial remuneration (aOR = 0.18 with 95% CI (0.088-0.377)), and requirement of formal certification in vaccine administration (aOR = 0.07 with 95% CI (0.020-0.279)) were negatively associated to this willingness. CONCLUSION: Addressing the unearthed concerns related to utilizing CPs as influenza immunizers through a concerted effort is a key to success in any future implementation of vaccination services in pharmacies.

Tracking the international spread of SARS-CoV-2 lineages B.1.1.7 and B.1.351/501Y-V2 with grinch.

Late in 2020, two genetically-distinct clusters of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) with mutations of biological concern were reported, one in the United Kingdom and one in South Africa. Using a combination of data from routine surveillance, genomic sequencing and international travel we track the international dispersal of lineages B.1.1.7 and B.1.351 (variant 501Y-V2). We account for potential biases in genomic surveillance efforts by including passenger volumes from location of where the lineage was first reported, London and South Africa respectively. Using the software tool grinch (global report investigating novel coronavirus haplotypes), we track the international spread of lineages of concern with automated daily reports, Further, we have built a custom tracking website (cov-lineages.org/global_report.html) which hosts this daily report and will continue to include novel SARS-CoV-2 lineages of concern as they are detected.

Effects of a Single Dose of Ivermectin on Viral and Clinical Outcomes in Asymptomatic SARS-CoV-2 Infected Subjects: A Pilot Clinical Trial in Lebanon.

OBJECTIVE: This study was designed to determine the efficacy of ivermectin, an FDA-approved drug, in producing clinical benefits and decreasing the viral load of SARS-CoV-2 among asymptomatic subjects that tested positive for this virus in Lebanon. METHODS: A randomized controlled trial was conducted in 100 asymptomatic Lebanese subjects that have tested positive for SARS-CoV2. Fifty patients received standard preventive treatment, mainly supplements, and the experimental group received a single dose (according to body weight) of ivermectin, in addition to the same supplements the control group received. RESULTS: There was no significant difference (p = 0.06) between Ct-values of the two groups before the regimen was started (day zero), indicating that subjects in both groups had similar viral loads. At 72 h after the regimen started, the increase in Ct-values was dramatically higher in the ivermectin than in the control group. In the ivermectin group, Ct increased from 15.13 ± 2.07 (day zero) to 30.14 ± 6.22 (day three; mean ± SD), compared to the control group, where the Ct values increased only from 14.20 ± 2.48 (day zero) to 18.96 ± 3.26 (day three; mean ± SD). Moreover, more subjects in the control group developed clinical symptoms. Three individuals (6%) required hospitalization, compared to the ivermectin group (0%). CONCLUSION: Ivermectin appears to be efficacious in providing clinical benefits in a randomized treatment of asymptomatic SARS-CoV-2-positive subjects, effectively resulting in fewer symptoms, lower viral load and reduced hospital admissions. However, larger-scale trials are warranted for this conclusion to be further cemented.

In vivo evaluation of the virucidal efficacy of Chlorhexidine and Povidone-iodine mouthwashes against salivary SARS-CoV-2. (preprint)

BackgroundThe oral cavity is potentially high-risk transmitter of COVID-19. Antimicrobial mouthrinses are used in many clinical pre procedural situations for prophylactic purposes. An evident-based investigation for an effective mouthwash solution against salivary SARS-CoV-2 is urgently required for the exposure reduction during dental procedures. AimsThis study aimed to evaluate in vivo virucidal efficacy of 2 mouthwashes: 1% Povidoneiodine and 0.2% Chlorhexidine as a dental preprocedural oral disinfection against salivary SARS-CoV-2. Materials and MethodsIn this randomized-controlled clinical trial, studied group comprised laboratory-confirmed COVID-19 positive patients through nasopharyngeal swabs. Participants were divided into 3 groups. For 30 seconds, group A gargled with 1% Povidone-iodine, group B mouthrinsed with 0.2% Chlorhexidine and control group C mouthrinsed with distilled water. Saliva samples were collected before and 5 minutes after mouthwash. SARS-CoV-2 rRT-PCR was then performed for each sample. Evaluation of the efficacy was based on difference in Ct value. The analysis of data was carried out using GraphPad Prism version 5 for Windows. Paired t test and unpaired t test were used. A probability value of less than 0.05 was regarded as statistically significant. ResultsSixty-one compliant participants (36 female and 25 male) with a mean age 45.3 {+/-} 16.7 years-old were enrolled. A significant mean Ct value difference (p < 0.0001) between the paired samples in group A (n = 25) and also in group B (n = 27) (p < 0.0001) was found. In contrast, no significant difference (p = 0.566) existed before and after the experiment in the control group C (n = 9). Moreover, a significant difference was noted between the delta Ct of distilled water wash and each of the 2 solutions 1 % Povidone-iodine (p = 0.012) and Chlorhexidine 0.2% (p = 0.0024). No significant difference was found between the delta Ct of patients using 1% Povidone-iodine and Chlorhexidine 0.2% solutions (p = 0.24). ConclusionChlorhexidine 0.2% and 1% Povidone-iodine oral solutions are effective preprocedural mouthwashes against salivary SARS-COV-2 in dental treatments. Their use as a preventive strategy to reduce the spread of COVID-19 during dental practice should be systematically implemented.