Surveillance of COVID-19 Mortality in Lebanon

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Temporal distribution of confirmed COVID-19 cases and deaths

Between February 21, 2020 and September 15, 2021, a total of 614,069 confirmed cases of COVID-19 and 8,163 COVID-19 related deaths were reported to ESU. Figure 1 illustrates the epidemic curve of laboratory-confirmed cases in Lebanon from February 21, 2020 until September 15, 2021.

Figure 1

The epidemic curve of laboratory-confirmed cases of COVID-19 in Lebanon from February 21, 2020 to September 15, 2021.

The first death was reported on March 10, 2020. The death curve evolved in different phases (Fig. 2):

  • Phase A from March to mid-July 2020: few deaths per day with a daily average of 0.3, ranging from 0 to 4, and representing 1% of all deaths. This phase reflects the introduction of the virus and the detection of multiple clusters and the initiation of early containment measures. On February 21, the first case of COVID-19 was confirmed among travellers. The first cases were isolated in a designated hospital with contact tracing. On March 15, 2020, a state of emergency was declared with schools and businesses closed and movement restricted.

  • Phase B from mid-July 2020 to the end of December 2020: with a gradual increase in the daily count, a daily average of 10.6 deaths, ranging from 0 to 30, and representing 22% of all deaths. This phase reflects the progression towards community transmission after the opening of the airport in July 2020. During this phase, the explosion of the port of Beirut on August 4, 2020 contributed to the increase in the daily number of positive cases of COVID-19 and subsequent deaths. The explosion damaged many nearby hospitals, health facilities overcrowded with patients.

  • Phase C from January to mid-May 2021: corresponding to the big wave, with a daily average of 42.9, ranging from 10 to 98 (on February 4, 2021), and representing 70% of all deaths. This phase reflects the huge wave that followed the social events of late 2020 and the implementation of the second general lockdown. The wave lasted from January to mid-May 2021.

  • Phase D from mid-May to the end of July 2021: inter-wave period with a daily average of 3.7, ranging from 1 to 11, and representing 5% of all deaths.

  • Phase E from August 2021: new wave with a daily average of 6.8 deaths, ranging from 3 to 15, and representing 2% of all deaths.

Figure 2
Figure 2

Epidemic curve of COVID-19 deaths per day, Lebanon, February 21, 2020 to September 15, 2021.

Breakdown by age, sex and nationality

Among the 614,069 confirmed cases of COVID-19 included in our study, 21.1% occurred between the ages of 20 and 29 (Table 1). There was a higher proportion of male to female cases overall (1.06:1) and also in all age groups (Fig. 3a). The age pyramid of deaths shows the predominance of the elderly and in particular among men (Fig. 3b). The distribution of deaths by age group was as follows: 32.9% for those aged 80 and over, 28.2% for those aged 70–79, 20.4% for those aged 60–69, 10.4% for 50–59 year olds, 4.7% for 40–49 year olds, 2.0% for 30–39 year olds, 0.8% for 20–29 year olds, 0.3% for every 10–19 year old and 0 to 9 years old. The mean age of death was 72.4 years with a 95% confidence interval (CI) between 44 and 77 years. Regarding gender, 60.4% of deaths were men. The distribution by nationality of deaths related to COVID-19 was as follows: 93.9% Lebanese, 2.9% Palestinian, 2.7% Syrian and 0.2% Iraqi, 0.1% Egyptian, 0.1% Bangladeshi and 0.1% Ethiopian.

Table 1 Demographic characteristics of COVID-19 cases, deaths, mortality rate and case fatality by age group and sex in Lebanon from February 21, 2020, 2020 to September 15, 2021.
picture 3
picture 3

(a) Age-sex pyramid of confirmed COVID-19 cases (N=614,069) reported in Lebanon between February 21, 2020 and September 15, 2021. (b) Age-sex pyramid of deaths (N=8163) reported in Lebanon between March 10, 2020 and September 15, 2021.

Death by location: province of residence

Mortality rates showed variations between provinces. The highest cumulative mortality rate was recorded in the Bekaa (184.7/100,000), followed by Baalbeck-Hermel (136.8/100,000), Beirut (129.3/100,000), Mount Lebanon ( 121.2/100,000), North (106.6/100,000), Akkar (102.9/100,000), Nabatieh (100.2/100,000) and South (82.6/100,000) (Fig. 4).

Figure 4
number 4

Cumulative mortality rate/100,000 inhabitants by province in Lebanon (March 10, 2020 to September 15, 2021).

Mortality rate and case fatality rate

The cumulative mortality rate was 119.6/100,000, 95% CI 117–122. Deaths from COVID-19 varied widely by age, with the highest cumulative mortality rates being among the population aged 80 or older (2524.5/100,000) and the lowest among children aged 0. at 9 years (2.2/100,000). With regard to sex, the mortality rate was found to be higher in men (143.5/100,000) than in women (95.3/100,000) (p-value

The overall case fatality rate (CFR) in the Lebanese population was found to be 1.3%. When the data are stratified by age group, the CFRs appear similar for the age groups from 0 to 49 years, but the ratios increase significantly from the age of 50 and in particular for the 70-79 years (8.5 %) and those aged 80 and over. above (14.0%) (p-value

Comorbidities

Of the total deaths, 82.2% of deaths had at least one comorbidity (Table 2). Cardiovascular disease was the most frequently reported comorbidity among confirmed COVID-19 cases, both overall (59.1%) and as a single comorbidity (28.3%), followed by diabetes (37 .2%), kidney disease including dialysis (11%), cancer (6.7%) and lung disease (6.3%). Diabetes and cancer were reported as a single comorbidity in 6.1% and 3% of deaths, respectively. The overall CFR was 4.7% for patients with comorbidities. The CFR was 30.9% for kidney disease, 20.2% for cancer, 20.2% for lung disease, 18.1% for liver disease, 14.0% for diabetes, 12.2 % for cardiovascular disease, 8.5% for hematological disease, 8.2% for overweight, 5.1% for immunodeficiency, 3.4% for asthma, 2.4% for postpartum and 1.1% for pregnancy (Table 2).

Table 2 COVID-19 cases and deaths by comorbidities and case management in Lebanon, February 21, 2020, 2020 to September 15, 2021.

Case management

As of September 15, 2021, of the 8,163 deaths, 7,135 (87.4%) were admitted to hospital, 1,963 (24.0%) admitted to an intensive care unit (ICU), and 1,021 (12.5%) were required mechanical ventilation. Of all deaths, 84% occurred in health facilities and 16% at home. The CFR was 22.7% for COVID-19 patients admitted to hospital, 55.1% for ICU admission, and 68.3% for mechanical ventilation (Table 2).

Vaccination status

The MSP launched the national vaccination campaign against COVID-19 on February 15, 2021. Of a total of 3905 deaths related to COVID-19 that occurred between February 15, 2021 and September 15, 2021, 1.5% of cases died were fully vaccinated and 0.8% of deaths were partially vaccinated.

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