This is a retrospective description of processes involved in repatriation of Lebanese citizens from various countries during the Covid-19 pandemic. The Mission was led by the NCC in coordination with the MOPH.
As per Lebanese expatriates appeal, Lebanese government developed a phased repatriation plan, while keeping safety and wellbeing at the forefront of this assignment. In addition, more elements were considered, such as medical history of the person and any accompanying family members. Length and ability to travel safely and further strains on elements of hardship for the repatriate (e.g., access to quality medical facilities, an underlying threat of political unrest, limited goods and services) were taken into consideration as well.
First of all, the Lebanese Ministry of Foreign Affairs initiated the coordination with embassies abroad to find out how many individuals want to return to Lebanon at their own expense. Then, each Lebanese citizen, living abroad and wishing to come back to Lebanon was requested to fill an identification form. It contained demographic and clinical information about the person in addition to a specialized part focusing on the availability and the suitability of appropriate quarantine location in Lebanon.
Before embarkation: Exit screening was conducted before departure for early detection of symptoms and corresponding results were shared with health authorities in Lebanon. Suspected cases, detected through exit screening are requested accordingly to delay their travel and to undergo further evaluation and treatment.
To accomplish this mission, the MOPH team was divided into four groups: the aircraft team, the airport team, the hotel team and the follow up team.
Aircraft team: The flight Team personnel consisted of two medical personnel, one physician and one health officer. Considering the limited number of human resources currently available at MOPH, volunteers have actively participated in the composition of this team All flight Teams trained personnel underwent briefing on in-fight safety procedures and use of personal protective equipment (PPE) and how to deal with suspected case of COVID-19 on board. Such procedures were pivotal to reduce exposure and limit transmission to other passengers or to aircraft crew. The non-medical crew of the aircraft were also appropriately instructed and outfitted, as well as conscious of the signs and symptoms that could appear on symptomatic COVID-19 cases. Upon boarding the flight, wearing face masks was compulsory for passengers as well as hands sanitization. At the entrance of the aircraft, the medical personnel performed visual triaging to identify those who appeared unwell or required special assistance. Seating was already arranged and mapped by MEA company based on the feasibility and the flight capacity in order to provide safe distance between repatriates. Such mapping was crucial for duly dealing with any passenger starting to show symptoms and requiring isolation and also for the identification of those in the immediate vicinity. The passengers were also divided into three categories (red, green and yellow) according to their health status. Passengers were asked to minimize their movement and to avoid eating during flight. Light meals were only offered for flight duration of more than five hours. All of these factors were crucial towards control of spread of COVID-19 during flight (14, 15).
Airport team: The airport Team personnel consisted of physicians, health officers and laboratory technicians. The team performed another triage using temperature screening and visual checking to detect and segregate symptomatic passengers. Hence, any passenger presenting symptoms was transported directly by the Red Cross to the hospital for testing and further evaluation. Given their health status revealed by the color of the worn wristband, the passenger debarkation process occurred in several groups starting by people with underlying health conditions followed by the healthy and asymptomatic passengers and lastly by the aircraft team. At the airport, repatriates undertook several processes including decontamination, health screening, swab screening and boarding of the bus that will ferry them to a designated hotel. Furthermore, unbreakable personal items were also sanitized. Screening swab test consisted of collecting nasopharyngeal swabs from each returning citizen to be tested using Polymerase chain Reaction (PCR) based technique except for newborns. The Flight Team underwent similar process as the repatriates. The airport team verified that each passenger has filled the identification form which included contact information and dedicated quarantine location details. Passengers were requested to sign a consent that obliged them to adhere to the requisite quarantine. In addition, health messages and brochures informing repatriates on Covid-19 symptoms, quarantine requirements and how to seek medical support in case of symptoms onset, were distributed to the passengers. The MOPH also shared with them the dedicated hotline of the COVID-19 in case they needed any further information. Asymptomatic passengers were transported by an assigned bus to the designated hotels.
Hotel Team: The Lebanese Government has assigned hotels to host returnees for 24 to 48 hours, which corresponds to the duration needed until the release of laboratory results for travelers. At the hotel, there was a MOPH team, called hotel team that coordinated with the hotel staff to ensure both safety of travelers and staff. Each traveler was requested to stay in his room and any further movement between rooms was forbidden. Based on the laboratory results, repatriates who tested negative were allowed to return to their home to finalize the mandatory quarantine for 14 days while the positive passengers were notified by the MOPH team who coordinated with the Red Cross as well to arrange their transfer to the hospital. It is noteworthy that all positive passengers, either showing symptoms or not, were transferred to Rafic Hariri University hospital to undergo a very clear medical assessment in order to ensure that their health status is stable enough and didn’t require a special attention. Positive cases with unstable health status and those having a condition hindering their ability to self-isolate were hospitalized, whereas asymptomatic cases and those with stable health status were discharged for home-based isolation.
Follow up team: The follow up team contacted the repatriates on a daily basis, whether present at home or facility quarantine, during the 14 days following their arrival to Lebanon, in order to monitor their symptoms. Besides, they were asked about their physical and psychological needs. Revealed physical needs, including appropriate accommodation and supplies were referred to the local authorities to explore with them the possibility to provide any support based on their capacities. Those starting to show symptoms were referred to the hospital for re-testing.
In addition to their role in monitoring symptoms among repatriates, the follow up team played a crucial role in raising awareness regarding measures and procedures to be followed during quarantine period and to provide emotional support in order to evade panic. They encouraged them to seek appropriate care when developing symptoms as well. Lastly, the follow up team reminded them regularly about the COVID-19 hotline in case they need any information.
The repatriation process was executed in 4 phases.
Phase 1: The time frame of the first phase was from 5th to 12th April 2020. MEA operated successive repatriation trips to evacuate Lebanese expatriates and nationals from abroad. It is mandatory to fill out the required medical form as a condition for boarding and send it back to MOPH.
Phase 2: Lebanon has suspended repatriation flights until April 27th in order to maintain the capacity of hospitals and hotels designated for isolation and to re-evaluate the implemented measures. The second phase of Lebanese repatriation started on April 28th, and extended until May 8th 2020. Newly detected COVID-19 cases in Lebanon included repatriated, and some returning expats who have flouted the requirement of quarantine, raising fears that the returnees could threaten progress made in controlling the virus. Fines and legal actions were taken to deter violators.
Phase 3: The phase 3 scheduled flights from the 14th of May till the 24th of May 2020 inclusive. The Phase 3 repatriation flights were subject to the following conditions: PCR test should be done three days before the departure in laboratories contracted with the Lebanese Embassy or in any laboratory recognized by the country of departure. In addition, the test result should not exceed 72 hours. However, PCR test cannot be replaced by a doctor’s report.
Phase 4: The fourth phase of Lebanese repatriation flights runs from 11th to 19th June 2020. Eighteen flights returning Lebanese nationals stranded abroad have been scheduled. Passengers departing from countries that can administer PCR tests were seated side by side on aircrafts.