Rapid Response

Rapid Guide to Support Health and Social Care Systems in Response to Beirut Explosion

A K2P Rapid Response responds to high priority areas and urgent requests from policymakers and stakeholders by synthesizing research evidence drawn from systematic reviews and from single research studies. K2P Rapid Response services provide access to optimally packaged, relevant and high-quality research evidence for decision-making over short periods of time ranging between 3, 10 and 30-days.

Rapid Response

K2P Rapid Response Rapid Guide to Support Health and Social Care Systems in Response to Beirut Explosion

Authors Lama Bou-Karroum, Racha Fadlallah, Mathilda Jabbour, Najla Daher, Fadi El-Jardali*

Acknowledgments Special thanks are due to the K2P team and affiliates for supporting the development of this Rapid Response document.

Merit Review The K2P Rapid Response undergoes a merit review process. Reviewers assess the summary based on merit review guidelines.

Citation This K2P Rapid Response should be cited as: Bou-Karroum L, Fadlallah R, Jabbour M, Daher N, El-Jardali F*. K2P Rapid Response: Rapid Guide to Support Health and Social Care Systems in Response to Beirut Explosion, Knowledge to Policy (K2P) Center. Beirut, Lebanon, August 12th 2020

*Senior author Contents

Key Messages ...... 1

Context and Implications of August 4th 2020 Beirut Explosion ...... 6

Section 1: Response Phase ...... 11

A. National Level ...... 11

B. Health sector level ...... 23

C. Community Level ...... 43

Section 2: Recovery ...... 48

Activating Lessons Learned ...... 51

References ...... 53

Key Messages

Background to K2P Rapid Response

Key Messages A K2P Rapid Response responds to urgent requests from policymakers and stakeholders by summarizing research evidence drawn from systematic Context and Implications of August 4th 2020 Beirut reviews and from single research Explosion studies. A systematic review is an overview of primary research on a → Over the past seven decades, more than 25 tragic particular question that relies on systematic and explicit methods to incidents happened in Lebanon resulting in identify, select, appraise and thousands of injuries and fatalities. synthesize research evidence relevant to that question. → Lebanon is still lacking a comprehensive, K2P Rapid Response services provide access to optimally packaged, relevant multidisciplinary approach and multi-sectoral and high-quality research evidence disaster / emergency preparedness plan. over short periods of time ranging between 3, 10, and 30-day timeframe. → On August 4th 2020, a massive explosion rocked the This rapid response was prepared in a Lebanese capital of Beirut and left 158 dead, 5,000 3-day timeframe and involved the following steps: injured, and 300,000 displaced. 1) Formulating a clear review question on a high priority topic requested by → Prior to the explosion, the system was already policymakers and stakeholders from struggling with a second wave of the COVID-19 K2P Center. 2) Establishing what is to be done in pandemic, in addition to economic and political what timelines. crises. 3) Identifying, selecting, appraising and synthesizing relevant research → The explosion severely affected the country’s health evidence about the question and social system with several hospitals rendered 4) Drafting the K2P Rapid Response in such a way that the research evidence un-operational, scarce medical supplies depleted is present concisely and in accessible and essential and life-saving medications language. destroyed. 5) Submitting K2P Rapid Response for Peer/Merit Review. → Local, regional and international community rushed 6) Finalizing the K2P Rapid Response based on the input of the peer/merit to support Lebanon. Yet, these uncoordinated reviewers. activities may result in inequities, inefficiencies and 7) Final Submission, translation into Arabic, validation, and dissemination duplications of efforts. of K2P Rapid Response → This document contextualizes evidence from The quality of evidence is assessed previous disasters worldwide and provides guidance using the AMSTAR rating which stands to inform interventions (and strengthen for A Measurement Tool to Assess Systematic Reviews. This is a reliable coordination) by policymakers, international and and valid measurement tool to assess national humanitarian agencies, health care the methodological quality of systematic reviews using 11 items. organizations, NGOs, civil society groups, AMSTAR characterizes quality of municipalities, and volunteer / youth groups. evidence at three levels: 8 to 11= high quality → The document focuses on informing the response 4 to 7 =medium quality and recovery to large-scale disasters. 0 to 3 = low quality

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 1

Response Phase

Recovery Phase

(local NGOs, international agencies, volunteers)

Activating Lessons Learned

Recovering from this massive disaster, authorities should capture lessons learned from Beirut explosion to ensure better preparation for any future disasters and develop and strengthen the country’s emergency preparedness plan. The plan can be promptly activated to guarantee early detection and evacuation, prompt rescue and treatment, coordinate communication and to swiftly address health and social needs of population.

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 2 الرسائل األساسية

سياق وتداعيات انفجار بيروت في 4 آب 2020

← على مدى العقود السبعة الماضية، ضرب لبنان أكثر من 25 كارثة، أسفرت عن عشرات اإلصابات وفي بعض الحاالت، المئات واآلالف من الضحايا.

← ال يزال لبنان يفتقر إلى منهجية شاملة وخطة تأهب متعددة اإلختصصات للكوارث / حوادث الطوارئ.

← في 4 آب / أغسطس 2020، هز انفجار هائل العاصمة اللبنانية بيروت وخلف 158

قتي ال و5000 جريح و300 ألف مش ّرد.

← قبل االنفجار، كان النظام الصحي مثقل بفعل الموجة الثانية من وباء كوفيد19-، باإلضافة الى أزمات اقتصادية وسياسية.

← أّث ر االنفجار على النظام الصحي واالجتماعي في لبنان، حيث تضررت أربعة

مستشفيات بشكل كبير ج ّراء اإلنفجار، ونفدت بعض اإلمدادات الطبية، واألدوية األساسية.

← سارع المجتمع المحلي واإلقليمي والدولي إلى دعم لبنان، ولكن إن لم يتم تنسيق هذه الجهود، فقد يؤدي ذلك إلى نتائج غير عادلة، غير كافية وضياع بعض الجهود.

← يهدف هذا المستند إلى ترشيد االستجابة لهذا الحدث المهول والوضع الحالي بشكل عام، إليجاد وتحقيق التوازن بدقة بين مختلف األزمات، وإدارة وتنسيق الدعم، وتلبية االحتياجات الصحية واالجتماعية للمواطنين، وستركز بشكل خاص على مرحلة االستجابة على المستوى الوطني، والقطاع الصحي والمجتمع المستوى، باإلضافة الى مرحلة التعافي.

ر ا س جاب

ر ا افي

)الجمعيات غير الحكومية، المنظمات الدولية والمتطوعون(

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 3 تف يل ا دروس ا مس خ ص

للتعافي من هذه الكارثة الهائلة، يجب على السلطات استخلص الدروس من كارثة انفجار بيروت لضمان االستعداد بشكل أفضل ألي كارثة مستقبلية وتطوير وتحديث خطة التأهب للطوارئ. يمكن تفعيل الخطة على الفور للكشف المبكر واإلخلء، وتنفيذ اإلنقاذ الفوري والمعالجة، وتنسيق التواصل، كما يمكنها تلبية احتياجات المواطنين بسرعة.

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 4 Content

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 5 Context and Implications of August 4th 2020 Beirut Explosion

Over the past seven decades, more than 25 tragic incidents happened in Lebanon resulting in thousands of injuries and fatalities. Yet, Lebanon is still lacking a comprehensive, multidisciplinary approach and multi-sectoral disaster/emergency preparedness plan.

Figure 1 Timeline of Disasters in Lebanon over the past seven decades (Note: We included man-made and natural disasters that resulted in at least 20 injuries (date: 1955-present). We also acknowledge that some of the numbers are estimates)

On August 4th 2020 a massive explosion rocked the Lebanese capital of Beirut and left 158 dead, 5,000 injured, and 300,000 displaced amidst a second wave of the COVID-19 pandemic (as of August 8, 2020) [6, 7]. In addition to the deaths and injuries resulting from this large-scale disaster, the health system was severely affected as four of its hospitals were severely damaged [2]. Hospitals across Beirut had to operate above capacity draining their already scarce medical supplies [3]. The Ministry of Health’s main warehouse providing drugs for chronic and life threatening diseases was severely damaged threatening the supply of essential drugs for the uninsured [4]. To worsen the situation, the explosion left the country’s main port un-operational threatening the replenishment of essential drug supplies and other supplies.

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 6 Prior to the explosion, the system was already struggling to control the spread of the second wave of the COVID-19 pandemic and was expected to reach full capacity by mid-august, 2020 [8]. The cumulative number of COVID-19 cases doubled in just one month triggering the government to impose another lockdown days before the explosion [9]. The number of COVID-19 cases continued to rise after the explosion reaching a new record of 295 new cases on the 10th of the same month [10]. The government is now faced with an enormous challenge to balance between the needs of both emergencies and an economic crisis amidst a wide riot reignited by the incident and public distrust [1]. The Lebanese and international community rushed to support the country in meeting these challenges by providing humanitarian assistance, in-kind, and financial support. Yet, if these efforts are not coordinated, they may result in inequities, inefficiencies and duplications of efforts [11].

Emergency Response Challenges [1-5]

→ Shortage in Hospital Bed Capacity

→ Shortage in Medical Supplies

→ Damage of Essential Drugs Warehouse

→ Damage of four main hospitals

→ Mental Health Crisis

→ Poverty Crisis

→ Increase in Proportion of Poor Population with Chronic Disease

→ Economic Crisis

→ Public Riot

→ Public Distrust

The tragic incident is expected to have further impact on already strained health and social systems and wrecked economy. The implications of large-scale disasters go beyond their direct casualties and result in increased rates of communicable and non-communicable diseases in the long-term. In similar large- scale disasters, poor living conditions of displaced individuals resulted in an increased risk of infectious disease outbreaks [12]. Furthermore, highly exposed pregnant women suffered from negative outcomes on their physical and mental health [13]. Multiple systematic reviews also documented the impact of previous large-scale disasters on the mental health of the general population with survivors exhibiting psychiatric and psychological disorders including new-onset disaster- related psychiatric disorders, exacerbations of pre-existing psychopathology,

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 7 psychological distress, stress-related and adjustment disorders, bereavement, major depression, substance use disorders, and post-traumatic stress disorder (PTSD) [14- 19]. On the longer-term, individuals exposed to disasters have higher rates of death from all causes, increased cardiovascular diseases and stroke risk, and negative implications on diabetes management [20, 21].

As such, this rapid response document aims to guide Lebanon’s response to this massive event and situation to delicately balance between multiple crises, manage and coordinate support, and meet its population’s health and social needs.

Selection Process

A search of the literature was undertaken to identify articles -systematic reviews and single studies- addressing the disaster preparedness, response, and recovery. A combination of free word and controlled vocabulary to combine the following concepts: emergency preparedness, disaster management, humanitarian setting, crisis management, risk management, risk reduction, emergency relief, emergency response. We searched Pubmed, Health Systems Evidence, and Social Systems Evidence. We also searched Google, Google Scholar and websites of relevant organizations. Last search was done on the 8th of August 2020.

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 8 We adapted the below framework from the European Commission Science Hub to organize our evidence synthesis [22]:

• Set stewardship and National Level Health sector level governance foundation Pre-hospital level: • Search and rescue • Strengthen information system • Activate response • Treat and care • Plan health workforce • Manage scene • Provide shelters deployment • Track, evacuate and rescue • Provide essential supplies • Secure medical supplies Preparedness • Assess needs and prioritize Response • Assess damages and support • Ensure financing needs • Treat and transport • Plan emergency service delivery • Manage communication • Manage resources • Prepare households • Optimize resource use • Prevent Secondary • Prepare community Hospital level: disaster • Maintain Social Security • Command and control Recovery • Manage foreign affairs • Manage communication • Coordinate efforts • Track and identify • Repair vital infrastructure • Optimize surge capacity • Ensure Continuity of Care Community Level • Expand human resources capacity (local NGOs, international • Operationalize site control and agencies, volunteers) security arrangements • Establish mass casualty triage system • Coordinate efforts • Reassess and Govern • Provide medical care • Identify unmet needs • Evaluate and update response • Manage logistics and supplies • Treat wounded plan • Control infections • Provide rehabilitative care • Provide social support Primary Healthcare Level: • Restore routine care • Ensure accountability and • Prevent emergency (mitigate • Reconstruct counter corruption outbreak threats) • Ensure continuation of routine care • Alleviate burden on overloaded hospitals • Manage diseases related to emergency • Engage community • Provide outreach services

Figure 2 Framework from the European Commission Science Hub

This document will specifically focus on the following:

→ Response phase

› National level

› Health Sector level

› Community level

→ Recovery phase

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 9 Section 1 Response Phase

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 10 Section 1: Response Phase

Effective response to large-scale disasters relies on implementing a comprehensive and cross-sectoral disaster risk reduction strategy that involves actors at the national, health organizations and civil society and community levels.

A. National Level

It is generally accepted that the primary responsibility for dealing with a mass casualty incident must rest with national government [23]. Based on a comprehensive review of the literature the roles of the national government in managing major incidents and disasters include:

Disaster detection, warning dissemination and activation of the Response System [23, 24]

→ For rapid and effective response, there usually needs to be a system for activating disaster management systems and resource organizations.

→ It is useful to implement activation in stages. These might be Alert, Stand-by, and Action. The benefit of this arrangement is that if, after the initial warning, the disaster does not materialize, activation can be called off. Thus, full mobilization of resources can be avoided with minimal disruption to normal life.

→ Disseminate response decisions and, as appropriate, broadcast warning information to the public through effective means.

Evacuation of threatened populations

[23, 24]

The evacuation of communities, groups or individuals is a frequent requirement during response operations. Evacuation is usually either:

→ Precautionary (in most cases undertaken on warning indicators prior to impact to protect disaster-

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 11 threatened persons from the full effects of the disaster). Or

→ Post-impact (to move persons from a disaster-stricken area into safer, better surroundings and conditions).

Search and rescue operations [23-28]

→ Ensure the deployment of rescue equipment to search and rescue victims

→ Locate lost persons and victims trapped in collapsed structures and provide immediate medical care.

→ Leverage grass-roots emergency teams and people’s self-help and mutual rescue

→ Leverage international disaster relief efforts in supporting the search and rescue activities

→ Ensure cooperation, coordination and communication between different rescue teams

→ Leverage social media platforms and mobile technologies that was shown to be effective in reducing the time of response and identifying the victims’ location. Social media allows to share emergency warnings by public health agencies and identify areas in need of relief operations or medical assistance by using self-reported location.

Treatment and care of victims [23, 26, 29]

→ Provide first aid to victims.

→ Deploy emergency medical teams to the scene to rescue victims.

→ Identify casualties and manage corpse.

→ Identify needs in terms of medical devices, drugs, medical treatment, hospitalization, and medical evacuation; and to attempt to address them accordingly.

→ Provide comfort and support to family of victims, to the injured and other affected people.

→ Ensure reunification of families through engaging with communities in the identification, tracing and reunification process.

→ Establish temporary health facilities (e.g. field hospitals) to replace damaged health facilities.

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 12 → Coordinate and distribute medical supplies in surrounding areas

→ Provide psychological assistance by adopting a multidimensional approach to psychosocial care such as social support, psychological first aid, assessment, and psycho-education, and target individuals with serious mental illness, direct disaster survivors and other at-risk groups.

Provision of emergency shelters for victims [23, 24, 30]

→ Provide shelters to homeless people within existing accommodation or community buildings such as schools

→ Establish and install emergency transitional shelters such as prefabricated houses, tents and/or tarpaulins.

→ Make urgent repairs to some housing

→ The selection of suitable sites for emergency temporary shelters post-disasters is a multi- disciplinary task and should consider the following criteria: size and location, season, weather conditions, number of affected people, shelter type and model, feasibility of the site, environmental and social aspects and expected time for response and recovery. Selection should involve rescue experts, environmental scientists, geologists, engineers, social workers, construction contractors and local residents, governmental and nongovernmental agencies. It can benefit from Geographic Information System (GIS).

Provision of emergency food, water supplies, sanitation and temporary

subsistence supplies [23, 24, 26, 31]

→ Organize and distribute relief materials to affected people and emergency workers.

→ Provide supplies such as clothing, disaster kits, cooking utensils, and plastic sheeting, to enable victims to subsist temporarily in their own area, thus helping reduce the need for evacuation.

→ Estimate damage to crops and food stocks.

→ Estimate food reserves (including un-harvested crops).

→ Providing potable water is often difficult, particularly in the early post- impact stages; water-purifying equipment may therefore have to be obtained and/or water-purifying tablets issued.

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 13 → Safeguard the health of people in the stricken area and maintain reasonable sanitation facilities.

→ Provision of unconditional cash transfers and vouchers can be effective and efficient ways to provide humanitarian assistance to people affected by the disaster in addition to in-kind contribution and food transfers.

Assessment of needs, damages and disaster effect through surveys and Information Management Systems [23, 26, 28, 32, 33]

It is impossible to carry out effective response operations without an accurate survey of damage and consequent assessment of relief and other needs. This can be done through:

→ Map affected areas to identify the needs and losses of the population to plan response and relief efforts accordingly.

→ Assess physical damage to infrastructure and physical assets in affected areas to guide recovery efforts (damage analysis)

→ Assess physical damage to health facilities partially or fully damaged, and physical damage to equipment and medical supplies

→ Survey and assessment needs to be carefully planned and organized beforehand. It usually calls for:

› Survey from the air

› Survey by field teams, and

› Accurate reporting from disaster management and other official authorities in or near the disaster area.

→ Ensure that information is correctly processed according to the proven cycle of:

› Acquisition of information

› Information assessment

› Decision making, and

› Dissemination of decisions and information.

→ In most cases, a general survey needs to be made as early as possible after impact, with follow-up surveys as necessary. This is necessary to ensure the accuracy of information which is collected. The information gathered through survey and assessment is, of course, vitally important for the implementation of immediate relief measures. However, much of the information is also required for the formulation of recovery programs.

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 14 → Use social media and mobile technologies and applications to communicate and share the needs of affected people and to increase the situation awareness.

→ Identify and prioritize vulnerable people, households and communities in humanitarian emergencies in order to identify target beneficiaries of humanitarian aid programs through:

› targeting by displacement status (internally displaced person or refugees)

› categorical targeting (targeting by demographic category such as gender, age, ability, health conditions, ethnicity)

› locally derived assessment tools

› pre-existing administrative data

› self-targeting

› community-based targeting

› a sampling frame

→ Establish a survivor registry for identification of high-risk groups and effective targeting of services.

Information release, management and communication [23, 34, 35]

→ Determine the party responsible for the release of disaster information

→ Use social media and communication and mobile technologies to increase situational awareness by acquiring disaster situational awareness information through sharing pictures, videos, and establish conversations almost in real-time, facilitating the dissemination of information and establishing communications between families and authorities and speeding up information diffusion.

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 15 → Include social media in the communication strategy to increase awareness of the emergency by non-affected stakeholders, such as disaster relief agencies and fundraisers.

→ Manage information overload, rumours and the dissemination of false information through provision of oversight of traditional and social media by stakeholders.

→ As with all aspects of disaster management, good communications are essential for effective response.

→ Reserve communications (with their own power supplies) are a necessary part of response arrangements. For instance, solar powered communications, especially under severe disaster conditions, can be considerable.

→ Re-establish essential radio, telephone, telex, and facsimile links as early as possible.

→ Keep the stricken community informed on what they should do, especially in terms of self-help, and on what action is on hand to help them.

→ Prevent speculation and rumour concerning the future situation.

→ Depending on cultural and other local circumstances, make arrangements for counselling and spiritual support of the stricken community. This may involve religious bodies, welfare agencies, and other appropriate organizations.

Media Cooperation [23]

→ To avoid possible misunderstandings and misinterpretations, it is important to give media representatives, appropriate opportunities for briefings and gather information as soon as possible after disaster strikes.

→ Delays may lead to some media representatives making their own news, which may not be in the best interests of the affected nation.

→ Good relations with the local media are also important and usually two- way benefits are involved. Not only do the local media benefit from good cooperation from the disaster management authority, but they can also perform valuable services in roles such as warning, evacuation, and public awareness.

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 16 → It is recognized that during urgent emergency response operations, disaster management authorities may regard media information as an area of lower priority. However, this should and can be avoided if proper arrangements are in place and appropriate use is made of specialist information staff.

Ensuring optimum use of resources against a carefully assessed threat [23]

In assessing resources, it is essential to consider the widest range of both government organizations and NGOs. It is also reasonable to take into account resources which are likely to be forthcoming from international sources.

→ Accurately identify resources

→ Correctly assess their capability

→ Allocate suitable roles to resource organizations.

→ Develop plans and procedures to use resource in a timely and effective manner.

→ Manage commodities, which involve reception, off-loading, cataloguing, storage, security, and distribution of international assistance commodities.

→ Obtain the various commodities from government stores, emergency stockpiles, commercial supplies, and international assistance sources.

→ Organize the distribution of these commodities according to the best possible orders of priority.

Prevention of secondary disasters [26]

→ Strengthen the monitoring and early warning of secondary disasters and prevent buildings collapses, fires, debris flows, etc.

→ Conduct investigation and assessment of dangerous situations in affected areas and transfer people from dangerous areas when necessary

→ Carry out investigation of hazardous chemicals production and storage places to avoid leak of oil or gas and take necessary safety precautions.

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 17 Maintenance of social security [26]

→ Protect affected areas against illegal and criminal acts such as theft, robbery, looting of materials and spreading rumours.

→ Set up temporary police stations to protect affected sites such as mass resettlement sites and material storage sites.

→ Security forces to work on resolving conflicts and clashes.

Foreign affairs management [26]

→ Large-scale disaster can overwhelm national capacity in particularly in fragile states so the government have to seek international assistance based on the needs and damages assessment.

→ Communication and information release to relevant organizations, countries and regions of the disaster situation.

→ Coordinate and arrange the entry of international rescue teams.

→ Receive and manage international assistance and relief materials.

Intergovernmental and inter-organizational coordination of response operations and delegation of tasks [11, 23-25, 36, 37]

→ Depending on the specific nature of the incident, various state agencies, private health care entities, civil society organization, local and international NGOs, United Nations (UN) agencies should be involved in Crisis response activities because no single agency or health or emergency response entity alone can be expected to handle the challenges presented by a mass casualty incident.

→ Coordination among local and international NGOs, United Nations (UN) agencies and governmental organizations working to provide humanitarian assistance and disaster relief can enhance the flow of resources and increase the accountability, effectiveness and impact of relief efforts.

→ Each level of government should ensure coordination and consistency in the active engagement of all partners in the emergency response system, including emergency management, public health, emergency medical services, public and private health care providers and entities, and public safety.

→ Activation of appropriate disaster management committees (usually at national, intermediate, and local government levels) are necessary to

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 18 ensure that, as far as possible, there is overall coordination in decision making and in the allocation of tasks.

→ Priorities for the implementation of response tasks are usually decided by the appropriate level of disaster committee. These priorities may have to be changed frequently and both disaster management authorities and resource organizations need to be capable of accepting and implementing such changes.

→ Different coordination models exist in the literature that can be applied to ensure effective coordination among local and international NGOs, United Nations (UN) agencies and governmental organizations. Models of coordination that can applied are detailed in the below table [36, 38, 39]:

Table 1 Models of coordination among local and international NGOs, UN agencies and governmental organizations

The Cluster Approach The Cluster establishes a clear system of international leadership and response to needs in 11clusters including health, food security, nutrition, water and sanitation, emergency shelter with a Cluster Lead Agency (CLA) assigned for each and includes multiple national and international agencies working together within each sector. The Sphere Project The Sphere Project creates interagency coordination at the site of the disaster which included: (1) principles of engagement and cooperation, (2) a protocol for assuming duties and responsibilities, (3) identification of gaps in the health sector, and (4) a summary of the components of the health sector. 4Ws “Who is Where, When, doing What” (4Ws) tool was developed by IASC to help in the coordination of responsibilities between the actors responding to the crisis. The tool maps: → Who are the participating actors (number and names of organizations)

→ Where, the geographic locations

→ When, the initiation and duration of activities

→ What, the types of MHPSS activities

Code of Conduct Code of Conduct is used as a tool and guideline for creating coordination for agencies which are engaged in humanitarian measures, including NGOs and making decisions regarding humanitarian measures. It seeks to maintain the high standards of independence, effectiveness, and impact to which disaster response NGOs and the ICRC Movement aspires. Decentralized and Decentralized and centralized approaches: systems and tools currently centralized approaches available to facilitate humanitarian coordination can be divided into centralized and decentralized categories in terms of the presence of one or more main players with authorization for directing relief operations. Recent

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 19 study suggests use of a decentralized approach, in which each organization independently makes decisions. To share its information, experts, and responsibilities with other organizations, it can utilize any of the decentralized approaches such as Inter-Agency Standing Committee and Inter-Agency Working Group. National Disaster National Disaster Management Authority (NDMA) is a mechanism that aims Management Authority to promote response during disasters. In fact, it is a disaster management (NDMA) tool in order to develop policy, plan, and guideline legislation at the national level. In Pakistan, this approach tries to address disaster risk and vulnerability to coordinate NGO activities at different levels Model of temporal The flat or horizontal structure promotes involvement of the staff in the coordination of disaster decision-making process with managers by decreasing the level of middle response managers. The coordination committee is responsible for coordinating with the other committees such as health and engineering committee. web-based application Web-based applications facilitate the receiving and sharing of information among organizations engaged in relief response and aim to create a shared operational picture of the status of relief for different agencies. 5x5 Model The five key “skill packages” aim to provide mental health-specific platform to apply algorithms for common disorders. These packages, consistent with the WHO mental health intervention, guide in non-specialist health settings and include: 1) case finding, engagement, follow-up, and psycho-education; 2) targeted psychological interventions; 3) medication management; 4) supervision and consultation; 5) quality oversight. The five “implementation rules” consist of the following: 1) assess context first; 2) identify priority care pathways; 3) specify decision-support tools, supervision, and triage rules; 4) use quality-improvement practices; 5) plan for sustainability and capacity building Model of Information Coordination between partners through the Internet and occasional ship-to- Coordination shore teleconferences. It was important to inform the emergency operations command about the psychosocial relief efforts through reports, critical resource documents on traumatic exposure metrics and intervention manuals with intervention mapping strategies. Coordination of funding National and international funding and monetary contributions can be and monetary coordinated and monitored through: contributions → Creating a reliable, transparent and cost-effective financial monitoring system for all stakeholders

→ Establishing a specific fund to pool contributions (pooled financing mechanisms) to the relief or reconstruction effort such as the case of Emergency Relief Response Fund (ERRF) in Haiti and Pakistan which are then allocated according to identified needs (under international mandate)

→ Requiring targeted funding and addressing constraints of pooled funding.

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 20 If planning and preparedness have been properly carried out, the majority of response tasks, have been designated beforehand to appropriate government departments and other resource organizations. For instance:

→ Public works department should estimate high-priority building repair and replacement requirements, closure of roads or bridges and to undertake debris clearance tasks.

→ Medical and health department should implement health and sanitation measures.

→ Police should maintain law and order, prevent looting and unnecessary damage and to assist with control of people and vehicles around the disaster area.

→ Red Cross and other emergency operation centers should carry out first aid and other emergency welfare assistance

→ Provide military resources to support logistical, medical, transportation, and security services.

→ State governments should authorize appropriate agencies to institute crisis standards of care in affected areas, adjust scopes of practice for licensed or certified health care practitioners, and alter licensure and credentialing practices as needed in declared emergencies to create incentives to provide care needed for the health of individuals and the public.

Immediate repair of infrastructure [26]

→ Re-establish water and power supplies, gas supply and communications or to make temporary arrangements for them.

→ Repair transport facilities such as airports, highways, bridges and tunnels.

Prevention and control measures in shelter homes to prevent infectious diseases transmission [40, 41]:

→ Conduct a rapid assessment within the first week of the disaster to quantify the risk of infectious disease transmission. Risk factors commonly associated with air-borne/droplet diseases such as COVID-19 in shelters are overcrowding and malnutrition.

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 21 → Establish a robust surveillance system for early case detection and treatment

→ Plan site construction based on international guidelines: allow 3.5 m2 per individual, build one toilet for every 20 individuals, build toilets 30 m away from shelter and 100 m from water supplies.

→ Ensure clean water, sanitation and proper waste management.

→ Educate on infectious disease control measures, encourage personal hygiene (such as frequent hand washing) and personal protection (such as facemasks and social distancing).

→ Promptly isolate and treat the sick.

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 22 B. Health sector level

The health sector level encompasses pre-hospital (emergency medical services), hospital and primary healthcare

i. Prehospital Care: Emergency Medical Services (EMS)

Prehospital care is provided by emergency medical services (EMS) responders, who are the initial health care providers at the scene of a major disaster. These licensed/certified personnel (emergency medical dispatchers, emergency medical responders, emergency medical technicians, and paramedics) may be the first to apply crisis standards of care (CSC), and are integral partners in local and state efforts related to the development and implementation of

coordinated and integrated CSC plans [33, 42-44].

Based on a review of the literature, the role for paramedic first responders to manage major incidents and disasters include:

Activation of Emergency response and responding to calls at dispatch centers [45, 46]

→ The prehospital system should encompass a national emergency hotline to be answered by the police and forwarded to an Emergency Medical Coordination Centers (EMCC), and to other ambulance services

→ Emergency operation centers may refer calls to or direct the public to call a number for specific information relative to a disaster since the routine communications systems will be overwhelmed.

→ Emergency operation centers shall prioritize calls according to potential threat to life; “pend” or decline calls without evident potential threat to life apparently non-life-threatening calls (note this requires a medically trained dispatcher)

Scene management [47]

Upon arrival to a mass casualty incident scene, the pre-hospital medical team has a responsibility to:

→ Assess risk and manage the scene, making it as safe as possible (Specifics vary with the nature of the environment and incident).

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 23 → Ensure the safety of not only the patients/victims, but also other emergency service members, and the public.

Tracking, evacuation and rescuing [33, 42, 48]

→ The primary aim is to deliver the pre-hospital care crew to the incident scene.

→ EMS personnel play a role in the evacuation of citizens from collapsed buildings in addition to the evacuation of patients at an affected health care facility and their transportation to unaffected health facilities or to alternate care sites.

Assessment and triage by medical providers [33, 49, 50]

→ Conduct early effective triage by senior clinicians

→ EMS personnel shall utilize disaster triage systems (sort, assess, life-saving interventions, treatment/ transport; simple triage and rapid treatment [START]; and JumpSTART triage methods) so they can assess patients within 60 seconds and categorize them for immediate or delayed care.

→ Major incident triage that involves mass casualties is different from normal clinical triage in a hospital setting since limited time and scarce resources cannot be tied up attending to casualties who are identified as being likely to die, as this will distract resources from those who are identified as being likely to live.

→ Major incident triage can be based on military battlefield triage that categorizes the patient into one of five distinct priorities:

› Priority 1 (immediate): Casualties requiring immediate life-saving procedures

› Priority 2 (urgent): Casualties requiring intervention within four to six hours

› Priority 3 (delayed): “Walking wounded” who do not require urgent treatment

› Priority 4 (expectant): Only used in major mass casualty situations. Casualties whose injuries are so severe that they cannot survive in the circumstances

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 24 › Priority 5 (Dead)

Treatment [43, 51, 52]

→ The pre-hospital phase of patient care is often time dependent and includes the application of simple techniques early in the course of a disaster and consequently alter injury progression avoid adverse outcomes.

→ The EMS personnel shall perform early diagnosis and clinical decision making, commencement of resuscitation, , administration of treatment and if needed procedural sedation and analgesia at the accident scene and in transit with additional measures to prevent secondary injuries.

→ Initiate treatment immediately and have another person work on immediate transfer to a hospital setting with potential for intensive care admission if needed

→ Intervention by emergency medical services is usually needed for advanced airway management, the treatment of reversible causes of cardiac arrest, and the reduction of hemorrhage. According to military scenarios, catastrophic hemorrhage is a greater preventable cause of death than loss of airway, hence priorities are re-aligned such that control of catastrophic hemorrhage is attended to before airway and breathing. In both civilian and military settings, management of external hemorrhage is the priority.

Patient Transport and handover to health facilities [33, 42, 43, 48, 50]

→ After triage and assessment, it is suggested to prioritize the transportation of victims with significant injury (according to guidance from EMS medical director)

→ After triage and assessment, transport patients to the closest appropriate facility (rather than the facility of the patient’s choice).

→ Multiple modes of transport can be used in mass casualty, after a proper triage has been done allocating the safest mode of transport for each patient. These include ICU ambulances equipped for resuscitation and smaller vans, “keke” tricycles could be good for ease of transportation but could be dangerous for a spinal cord-injured patient. Boats, private cars, and Hilux jeeps are other alternatives, depending on the terrain.

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 25 Helicopters and air ambulances are engaged under special arrangements.

→ Transfer patients promptly and strive to keep transfer and arrival time at the referral hospital within 20–30 minutes, after triage with ongoing resuscitation in transit.

→ Handover of patients to appropriate health facilities and maintain good flow in these facilities to avoid saturation of the receiving hospitals/facilities.

→ Continue to contribute actively towards care alongside the emergency hospital team after handover if possible.

Communication [33, 50]

→ Leverage pre-arranged disaster channels for timely communication and exchange of information

→ Ensure communication protocols are in place for communicating with public area authorities, such as schools and large buildings, Ensure availability of backup communication equipment to minimize disruptions and delays in communication of critical information to key stakeholders

Resources (Manpower and logistics) [33, 42, 52, 53]

→ Pre-hospital clinicians should be generalists with a broad understanding of medical, surgical, and trauma pathologies, who will often work from locally developed standard operating procedures, but who are able to revert to core principles.

→ EMS team should have adequate staffing (qualified medical and nursing personnel including a qualified emergency physician and a registered nurse certified in advanced cardiac life support and pediatric advanced life support) to meet the written emergency procedures and needs anticipated based on the nature of the incident.

→ Pre-hospital emergency team also requires specialized non-clinical abilities including conflict resolution, logistical and crew resource management, communication, and teamwork.

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 26 → Plan personnel safety, back-up from additional medical (physician or non-physician) teams or rescue resources and management of fatigue in prolonged missions.

→ Conduct regular checking of all equipment and transport vehicles (in most services, at the start of each shift)

→ Utilize the limited resources in an ambulatory facility to the fullest to stabilize the patient while transferring him/her to a higher-acuity facility if needed.

→ Modify resource assignments (e.g., only fire/rescue dispatched to motor vehicle crashes unless EMS are clearly required, single-agency EMS responses if fire agencies are overtaxed) and eek mutual-aid assistance from surrounding areas. Consider staffing configuration changes (e.g., from two paramedics to one paramedic plus one emergency medical technician).

Quality and governance [42, 52, 53]

→ Ensure policies and procedures are in place to transfer patients in need of a higher level of care to appropriate facilities; with the same standards as hospital-based EDs for quality improvement, medical leadership, medical directors, credentials, and referral policies

→ Emergency medical services usually adopt resource management techniques such as pre-procedure checklists and emergency action cards in order to minimize errors and maximize situational awareness.

→ Pre-hospital emergency medicine requires highly governed systems from kit maintenance to the audit and analysis of procedures and outcomes.

→ Ambulatory emergency response standardization through frequently scheduled simulation drilling could potentially optimize response in the setting of leaner resources

→ Difficulties raised can be used to refine protocols and provide an institutional learning memory.

ii. Hospitals

Hospitals play a critical role in disaster events by providing communities with essential medical care. Depending on the nature of disasters, the demand for healthcare services can rapidly increase. [54] Without sufficient planning, a disaster can overwhelm the functional capacity and safety of a hospital.

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 27 Based on a review of the literature, the roles and measures required to optimize hospital responses during disasters are highlighted below.

Activation of hospital incident command system [54-57]

→ Activate the hospital incident command system (if the latter is not available, establish an ad hoc group responsible for directing the hospital-wide emergency response)

→ Designate a focal point individual who will bear the responsibility for ensuring the response is carried out in an effective, efficient and, coordinated manner, and if needed, authorize evacuation.

→ Rapidly assess the impact of the crisis on the hospital operation and communicate the status to leadership in a situation report or a rapid needs assessment. Assessment should include:

› Extent and magnitude of the disaster and the scope and nature of casualties

› Status of operations and any disrupted critical services

› Impact of disruptions on operations and the ability to sustain operations

→ Designate a hospital emergency command center to convene and coordinate the hospital-wide emergency response activities and ensure it is equipped with effective means of communication.

→ Alert the in-charges of key departments/units who in turn notify the staff (medical / nursing / others staff) working in these areas to immediately reach the emergency command center and carry out their functions.

→ Allocate funding (as needed) for activation of disaster response

Operationalization of site control and security arrangements [54, 58]

During emergency situations, the healthcare facility may be overwhelmed by not only patients being brought in, but also other people including family members, by-standers and media which may block the entrance and other areas hampering the smooth functioning of the hospital.

→ Operationalize site control and security arrangements at a very early stage of the disaster.

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 28 › Ensure site control and security by assigning hospital staffs to key intersections, with well-marked signage that provides direction for those seeking care.

› Define the threshold and procedures for integrating local law enforcement and military in-hospital security operations.

→ Ensure all hospital personnel carry Identity cards

→ Carry out the following duties related to site control and security:

› Maintain order within and outside the facility

› Direct traffic so as not block the free access of patient-carrying vehicles to and outside the facility

› Protect key installation of the facility (Emergency Department, Hospital Working areas, Power Station/ Generators, Water Tanks/Water Supply etc.)

› Restrict and strictly control access to the facility

› Direct the entry for authorized persons to appropriate areas (ambulances to emergency, relatives to waiting area, media to media room etc.)

› Protect facility personnel and patients

Timely communication and exchange of information [33, 54, 56]

→ Clarify roles and responsibilities of staff within the incident response plan

→ Communicate decisions related to adapted admission and discharge criteria, triage methods, infection prevention and control measures to all relevant staff and stakeholders.

→ Establish mechanisms for timely exchange of information between hospital administration, department/unit heads and facility staff

→ Ensure procedures are in place to maintain situational awareness and communication with staff, patients, emergency medical responders, and public and private care providers through electronic, web-based, and hardcopy means. Additionally, ensure the facility is able to receive warnings and notifications from external agencies.

→ Appoint a credible expert to coordinate hospital communication with the public, the media and health authorities.

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 29 Designate a space for press conferences (outside the immediate proximity of the emergency department, triage/waiting areas)

→ Update staff notification information (phone contact numbers)

→ Ensure availability of primary and back-up communication systems (e.g. satellite phones, pagers, internet connections mobile devices, landlines, two-way radios, etc)

Establishment of mass casualty triage system with designated triage area [54, 56, 59-63]

This area is the first area of contact between hospital personnel and the incoming patients. Initial registration and triage should be done here.

→ Assign an experienced triage officer to oversee all triage operations. It is recommended that triage in mass casualty situations be conducted by highly experienced physicians, who possess the necessary skill set (e.g. a trauma or emergency physician).

→ Identify a contingency site for receipt and triage of mass-casualties

› Ensure areas for receiving patients (including waiting areas), are protected from potential environmental hazards and provided with adequate work space, lighting and access to auxiliary power.

› Designate an alternative waiting area for wounded patients who are able to walk (to the extent possible, maintain safe spacing between patients due to COVID-19)

› Ensure the triage area is in close proximity to key care services (e.g. emergency department, operative suites, intensive care unit).

→ Adopt a suitable and context-specific triage system/model:

› Align with the following principles of triage: classification and prioritization of injured people, speed of assessment (<1 minutes), and accuracy of the performance

› Ensure ethical principles guide patient prioritization during disaster triage. Measures to consider ethical patient prioritization in disaster triage include: medical (medical need, likelihood of benefit and survivability) and non-medical (saving the most lives, youngest first, preserving function of society, protecting vulnerable groups, required resources and unbiased selection).

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 30 › Establish a clear method of patient triage identification and ensure adequate supply of triage tags

→ For Chemical, Biological and Radiological (CBR) incidents, designate an area for decontamination and isolation with clearly marked “clean” and “contaminated/dirty” areas.

→ Separate COVID-19 triage area from regular emergency department area/ develop designated areas for COVID-19 examination and care

→ Ensure that adapted protocols on hospital admission, discharge, referral and operative suite access are operational when the disaster plan is activated to facilitate efficient patient processing.

→ Determine which of the following routes each patient should take:

› Referral to the appropriate place within the facility per disaster plan

› Referral to tertiary healthcare facilities following stabilization at the facility.

› Referral to tertiary healthcare facilities directly by emergency medical service without any additional stabilization at the facility.

› Referral for life-saving care and/or initial stabilization and then disposition

› Referral through the decontamination corridor of the triage area, prior to additional medical assessment.

→ To the extent possible, minimize gatherings around reception and triage area, maintain safe distance, impose strict entry into hospital, monitor temperature of staff, patients and family members, and ask people to wear masks (as well as provide masks to patients who are able to wear them).

Surge Capacity [54, 63-67]

→ Estimate the increase in demand for hospital services (using available planning assumptions and tools) and maximal capacity required for patient admission and care (beds, staff, resources, space)

→ Identify and implement different methods of expanding hospital inpatient capacity (taking into consideration personnel, equipment and supplies, and structure (facilities and organization)):

› Designate care areas for patient overflow (e.g. auditorium, lobby, hallways).

› Cancel or postpone elective surgeries according to available treatment capacity and demand

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 31 › Discharge patients with appropriate status

› Redesign physical space of departments in terms of arrangement of beds and equipment to create accessible space

› Expand portable hospitalized units

› Practice reverse triage for those patients for whom expedited discharge is safe and ethical (taking into consideration victims’ status and patients’ transfer hazard in emergencies and disasters)

→ Adapt hospital admission and discharge criteria as well as readjust referral/counter-referral policies to release additional capacity and contain hospital overload

→ Use adaptive measures to compensate for reduced staffing, such as additional shifts, changes in shift structure/time, provision of support to staff children, expansion of scope of practice, recruitment and credentialing of additional staffs and volunteers.

→ Establish plans to institute substitution, conservation, adaptation, reuse, and reallocation of scarce resources as part of efforts to optimize critical care resources available to a hospital during crisis.

→ Outsource care of non-critical patients to other health facilities (e.g. outpatient departments adapted for inpatient use) as well as leverage community-centered care to supplement the response and accommodate the surge

→ Verify the availability of vehicles and resources required for patient transportation.

→ Designate an area for use as a temporary morgue, ensure the adequate supply of body bags and formulate a contingency plan for post mortem care.

→ Consider utilization of technology (e.g., telemedicine) as an important adjunct to the delivery of critical care services in a disaster to serve as a force multiplier to support response to disaster events (as well as minimize direct contact with patients and staff which may be critical during pandemics).

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 32 Identification of alternative care sites [68-71]

→ A surge in the need for care may require communities to establish alternative care sites in non-traditional environments (e.g. hotels, schools, community centers, gyms). Selection of a site will be largely dependent upon the availability of structures or areas in a given community, and will change according to the type of event.

→ While alternative care site establishment and operation is the responsibility of local jurisdictions, when an incident creates medical surge exceeding the ability of several hospitals, or a community to handle it, the government has a responsibility to assist.

→ Coordinate with local authorities, municipalities and community leaders to identify additional alternative sites in the communities as well as to mobilize the workforce and volunteers willing to staff these sites, establish policies and manage it; coordinate operations with emergency medical services, the Red Cross, hospitals and other healthcare facilities, other key officials charged with emergency operations decision making; and finance it.

→ Adopt a well-organized incident command system to operate and manage an alternative care site. This approach encompasses the concept of “unified command”, which is important when more than one discipline (usually health, fire, law enforcement) has a major stake in the incident at hand. Organizational structure of site would have both Command Staff and General Staff positions

→ Decide on the use of the site, based on needs and facility’s structural, staffing, or logistical capabilities. Possible uses include the following (some develop as the situation progresses):

› Facility in which to quarantine or isolate patients

› Facility to house low-acuity patients from hospitals and nursing homes

› Ambulatory care/vaccination clinic

› Primary triage point to decide where and how patients can best be treated

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 33 › Acute care inpatient facility

› Place to provide palliative care for hospitalized patients

› Facility to house patients discharged from hospitals so that they can be released earlier than usual

› Combination of many or all the above functions

→ Forge agreements with health and medical service providers to supply personnel to help staff the site. Staff may also be off-duty providers from the primary facility, retired clinicians, military personnel, designated members of disaster response teams, or volunteers

→ Establish communication links with related organizations including the scene, the local emergency operations center and the local hospitals.

→ Ensure alternative care site can support implementation of recommended infection prevention and control practices:

› Physical infrastructure:

» Layout » Air conditioning and heating » Spacing between patients (particularly during pandemics) » Contamination prevention » Accessibility

› Services

» Food services » Environmental services » Sanitation » Laundry facilities » Pharmacy access » Diagnostics

› Patient care

» Staffing » Medical supplies » Personal Protective Equipment (PPE) » Hygiene

Human resource management and protection [54, 72-78]

→ Update the hospital staff contact list (as needed)

→ Identify the minimum skill sets needed to maintain operational sufficiency

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 34 → Prioritize staffing requirements and distribute personnel accordingly

→ Prepare a list of staffs who may be made available at a short notice and mobilize additional staff from non-critical areas.

→ Implement measures to mitigate preventable causes of staff shortage, including sheltering of staff and their families, measures to mitigate fatigue, access to transportation services, and maintenance of a safe working environment

→ Establish appropriate program to recruit and train additional staff (e.g. retired staff, reserve military personnel, university affiliates/students) according to the anticipated need.

→ Establish a safe and effective emergency volunteer program for recruitment of volunteers that includes the following elements:

› Describes how the permanent medical staff will be able to distinguish volunteers from hospital staff

› Outlines the role and process for supervising volunteers

› Outlines criteria that help staff determine, within 72 hours, whether responsibilities granted to volunteers should continue (this decision is based on the observation and supervision activities, as well as the risk of contracting infectious diseases like COVID-19)

→ Provide training (and cross-training of personnel) in areas of potential increased clinical demand (e.g. emergency, surgical, and intensive care units), to ensure adequate staff capacity and competency

→ Provide onsite disaster-worker training on potential hazards, organizational assets for monitoring hazard, and hands-on instruction on how to use of assigned protective equipment. Establish information and treatment protocols in conjunction with ongoing training opportunities for staff

→ Conduct pre-deployment medical review to ensure "fitness for duty", taking into consideration: personal risk factors; potential hazards associated particular field locations; and risks involved with assigned tasks (e.g., workload and pace).

→ Establish a clear staff sick-leave policy, including contingencies for ill or injured family members or dependents of staff.

→ Monitor attendance and absenteeism of staff and adjust staffing needs accordingly

→ Provide financial and non-financial support to improve morale and strengthen resilience of healthcare providers and staff

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 35 → Ensure availability of psychological support and mental health services for staff, family of staff and patients during the different stages of the crisis

→ Implement strategies to protect the health and safety of the staff, frontline workers, patients, and their families through proper infection prevention and control measures, trainings and education

→ Establish mechanisms to enable safety decisions implementation such as effective and rapid scene control (site access), personnel tracking, and safety enforcement.

→ Ramp up an incident-wide safety management, with implementation of scalable and coordinated plans for hazard assessment, data sharing, and real-time hazard control and communication strategies

→ Invest additional efforts to protect staff from other disease outbreaks that may be occurring simultaneously (e.g. COVID-19):

› Ensure staff protection by asking staff to stay home if they have respiratory symptoms and conducting COVID-19 tests when needed

› Train medical and non-medical staff on infection prevention and control, PPE measures, perform self-isolation if they were exposed and safe triage measures

› Ensure all staff wear protective equipment during interaction with patients and implement rigorous hand washing (require patients and their families to also wear masks as deemed necessary)

› Maintain physical distancing measures to the extent possible

› Redesign existing models of care and train health workforce to enable the use of telehealth to deliver remote acute and routine care if possible,

› Assign separate rooms and pathways for COVID-19 patients

› Minimize contact and rotation between staff treating COVID-19 patients and those being assembled to address the disaster.

Management of logistics, supplies and continuity of care [56, 79, 80]

→ Develop and maintain an updated inventory of all supplies, pharmaceuticals and equipment

→ Assess the consumption of essential and medicinal resources and identify those that are in short supply and for which increased inventory levels would be needed

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 36 → Establish contingency agreements with vendors to ensure the procurement and prompt delivery of equipment, supplies and other resources in times of shortages and disasters

→ Coordinate with authorities to ensure the continuous provision of medicines and essential supplies

→ Implement modified protocols, which limit routine use of affected medications and supplies and encourage use of alternatives when shortages are anticipated, and for which sufficient resupply may not be available in a timely manner

→ List the services of the hospital and prioritize the essential services

→ Establish a plan for the continuation of essential services, especially for critically-ill and vulnerable groups (children, elderly and disabled individuals)

→ Coordinate with authorities, neighbouring hospitals and communities to ensure the continuity of essential services

→ Ensure the availability of back-up arrangements for essential life lines, including water, power and oxygen

→ Develop a plan for the management and disposal of increased volumes of hazards and contaminated waste

→ Coordinate a contingency transportation strategy with prehospital networks and transportation services to ensure uninterrupted transfer of patients (as needed)

Patient tracking and identification [63, 81]

→ Establish a patient tracking system to:

› Record, track, and identify all patients

› Maintain pictures, descriptions, and locations of patients

› Facilitate reunification process

→ Ensure the system has the following capabilities:

› Tracking patients from their entrance to the healthcare system up to their discharges

› Identifying users of the system who have appropriate permissions to access the electronic system

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 37 › Accessing patient tracking mass data from the prehospital emergency and hospitals

› Observing rules and regulations concerning patient confidentiality

› Integrating by the national patient tracking system

→ Collect the following minimum primary data (to the extent possible): patients' unique numbers, names, gender, dates of birth, health conditions, location identifier, identifiers of arriving or leaving locations, and dates of arriving or leaving locations. Additional required data elements include transportation, specific medical needs, decontamination state, and security needs, IDs for joining members of a family to each other, attached files such as medical files and images, particular communication needs, and disposition from the healthcare system.

Hospital evacuation considerations [82-84]

→ In case of damage to a hospital building, ensure that a comprehensive structural integrity and safety assessment is performed. Common factors affecting hospital emergency evacuation decision-making can be classified into 4 categories: Threat (e.g. hospital size; disaster severity; level of risk); Hospital infrastructure consequences (e.g. loss of electricity and water); External factors (e.g. physical access; transportation; destination capability); and Internal factors (e.g. resources; experience background). The most commonly used subcategories for decision-making are:

› Level of risk

› Loss of electricity and water,

› Communication and transportation,

› Resources such as staff,

› Removing patient devices

→ If sheltering-in-place with sufficient resources is not guaranteed, evacuation could be a reasonable option if performed in a well-planned manner with satisfactory arrangements for appropriate transportation and places to safely evacuate.

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 38 → If evacuation is required, ensure the following perquisites for hospital evacuation are in place: support, equipment, human resources, information management, communications, removing patient devices, transportation, resources such as staff and inter-sector and inter- institutional coordination

→ Ensure the existence of a systematic and deployable evacuation plan that seeks to safeguard the continuity of critical care (including, for e.g. access to mechanical ventilation and life-sustaining medications)

→ Ensure patients’ records/documents are incorporated into the evacuation and eventual relocation.

→ Determine the time and resources needed to complete repairs and replacements before the facility (or affected department/unit) can be reopened.

iii. Primary healthcare

The primary healthcare (PHC) approach plays a critical role in providing primary care and essential public health functions, preventing disease outbreaks with effective public health measure, identifying and managing emergency cases, reducing unnecessary admissions, relieving the hospital system and engaging communities, for more context-specific responses [85, 86]. Yet, the PHC system remains underutilized and overlooked as part of the health sector response during disasters.

1. Role of PHC system

A review of the literature highlighted the following roles for PHC during disaster responses:

Emergency prevention (mitigation of outbreak threats following a disaster) [85, 86]

Continuous provision of primary health care during disasters creates an environment that is alert, recognizes health risks and manages local challenges, thus preventing emergencies:

→ Primary prevention interventions such as community water, sanitation and hygiene (WASH) or vaccination programs are important for reducing the risk of outbreaks following a disaster

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 39 → Surveillance systems through PHC facilities are essential for rapidly detecting disease outbreaks following a disaster before they spread and become difficult to control

Continuation of routine health services [85-88]

→ Primary healthcare providers have better knowledge of the local population and the special needs categories, thus enabling the PHC system to play a crucial role during emergencies in understanding health needs and identifying vulnerable groups in disaster-affected communities.

→ Primary care can act as a buffer against disruption of service delivery and ensure continuity of care including medications, particularly among vulnerable groups such as diabetes patients and elderly. For example, non-communicable diseases (NCDs) pose major health issues after large-scale disasters, necessitating the need to establish strong countermeasures against interruption of treatment and surveillance systems to ascertain medical needs for NCDs

Alleviation of burden on overloaded hospitals (hospital surge) [85, 86, 89]

→ Primary healthcare centers can act as a community-level triage system— treating those with minor illness (thus reducing unnecessary admissions) and referring those with more serious disease to help alleviate pressure on health systems while expanding the availability of beds for more critical patients

Management of diseases related to health emergencies [85, 86]

→ Primary healthcare centers can play a critical role in managing and treating diseases and conditions directly resulting from disasters including mental health and chronic disease interventions, skin-related diseases, hemorrhagic fevers, respiratory tract infections, foodborne and waterborne diseases and meningitis

Community engagement [85, 86]

→ Primary healthcare centers can use culturally appropriate messages to communicate risk, share timely information, and counter rumours which is essential for more effective emergency risk management.

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 40 → Primary healthcare centers can engage and empower local communities which enables improved surveillance, increases trust in services, improves utilization during emergencies, and ensures that response activities are appropriate to local context.

Outreach services [85, 90]

→ Primary health staff can be organized into small teams and directed (as forward teams) to different residential areas in conjunction with other emergency services to:

› Define the special needs and vulnerable population.

› Supply chronic medications to the needed

› Define affected individuals and conduct baseline life support interventions.

› Contact health authority or hospitals for patients who require transfer to higher level of care

→ PHC staff can mobilize mobile clinics to provide non-communicable disease interventions, mental health services, sexual and reproductive health services, and multiple primary health care services to vulnerable and heard to reach populations. To enhance feasibility and effectiveness of mobile clinics during humanitarian crisis: ensure mobile clinics are designed to complement clinic-based services; improve technological tools to support patient follow-up, record-keeping, communication, and coordination; avoid stigmatized labelling of services; enhance referral to psychosocial and mental health services; partner with local providers to leverage resources; and ensure strong coordination to optimize continuum of care [90].

2. Activation of PHC Response [64, 73, 85, 86, 91]

→ Change the layout of the facility and the patients’ flow (as needed) to permit faster management of patients with acceptable standards

→ Secure basic infrastructure requirements including WASH facilities, an isolation room to facilitate quarantine, and a waste management plan and facilities, including an incinerator.

→ Ensure facility has infection, prevention and control supplies to ensure patient and provider safety, including personnel protective equipment for health personnel such as gloves and goggles.

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 41 → Ensure basic diagnostic equipment and facilitated referrals to the secondary care level

→ Enable proper supply management to ensure a stock of essential medicines and products , as well as electricity and network supply

→ Ensure staff have access to occupational health services (as well as mental health support) if they experience a work-place exposure or become ill

→ Call the staff who are off duty to join work in the facility (if needed)

→ Postpone non-urgent appointment and patient visits

→ Contact local health authority and nearby hospitals to liaise about the situation and work distribution.

→ Make special documentation for the patients and other related issues like questionnaires, asking about needs, relatives, etc.

→ Implement sick leave policies for staff/employees that are flexible and non-punitive

→ Leverage telemedicine systems to address the needs of low-acuity patients with disease exposure concerns or minor illnesses, while mitigating overcrowding in emergency departments, urgent care clinics, and primary care clinics as well as provide a new window of care to overcome shortages of specialized staffs in disaster and remote areas

→ Ensure additional measures are in place to protect against COVID-19 (wearing protective equipment, training on infection control and PPE measures, clear referral channels and equipped transportation to hospitals that are treating COVID-19 patients, adequate spacing and physical distancing in waiting room, spate waiting rooms for patients with respiratory symptoms.

3. Integration and Coordination of response [92-94]

For PHC to be effective, the Ministry of Health must be committed to its role of coordinating the emergency health system, mobilizing resources and promoting inter-sectoral co-operation and inter-agency collaboration [94].

→ Integrate primary care into disease outbreak or pandemic preparedness and disaster response plans.

→ Clarify the roles and responsibilities of primary healthcare facilities and providers in local and national response, including the lines of reporting through the health system and the linkages between the health system and community health actors

→ Equip PHC workers and facilities with the required tools and infrastructure and a well- defined plan to guide referral. This includes designation of the health facilities responsible for clinical management, as well as logistics and transportation

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 42 → Establish communication plan for adequate notification of critical personnel and exchange of information within and across health facilities to inform distribution of support and resources in a timely manner

→ Ensure flexible health financing arrangements to enable PHC to remain functional in emergency situations (to finance the surge in activities during an emergency)

→ Coordinate receipt and distribution of medical/medication supplies. A centralized structure for receiving supplies and medications, but a decentralized access model with patients retrieving medications at multiple community sites is a recommended standard for the management of international drug donations.

C. Community Level

Local and international NGOs, community members and ordinary citizens have a remarkable role in providing humanitarian services during disasters in cooperation with governmental organizations and agencies. However, for an effective response at the community level, the concerned parties should consider the below:

Community engagement and volunteering activities [95-99]

Organize, guide and coordinate volunteers’ activities:

→ Ordinary citizens are usually first on the scene in an emergency or disaster, and remain long after official services have ceased; they can provide invaluable assistance to official agencies and represent an immense resource for emergency and disaster management.

→ It is vital that emergency services and organizations are prepared to cooperate with volunteers and coordinate their activities. This is necessary to ensure effective responses and avoid duplication of effort, but also to prevent volunteers from being in situations where they may harm themselves or others.

→ Aligning volunteering activities with needs and priorities and organize donations receipt and distribution, and use through sharing and coordination of information.

→ Mobilize student volunteer centers in schools and universities

→ Mobilize people living in non-affected areas to provide support to the people in disaster areas.

→ Support volunteers to provide psychological support to survivors as a means of increasing psychological resilience and facilitating personal recovery

→ Organize volunteers into support roles that match the volunteer’s capacity and the authority’s need.

→ Categorizing and allocating tasks during disasters: 1) tasks that do not need instructions nor prior training necessary; 2) Tasks that spontaneous volunteers can assume after brief training; 3) Tasks to be fulfilled by volunteers with specific

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 43 qualifications, verification of proper qualification necessary and 4) Tasks to be fulfilled only by trained and skilled emergency personnel.

Organize fast and flexible local help

→ Local residents can help by providing assistance as individuals, usually in the early stages of a disaster through first aid activities, starting search and rescue actions in destroyed buildings, by clearing debris or by helping to find shelter and housing for affected populations.

→ Anticipated individual volunteers that fulfil the general expectations of society on an individual basis, such as physicians or nurses may volunteer to aid of victims on the ground.

→ Individual citizens may choose to volunteer and join a regular disaster organization such as a volunteer fire brigade or the Red Cross, and whose participation is expected and planned for.

→ Individual citizens may choose to formally create an ad hoc organization for dealing with the circumstances of the specific disaster

→ Individual citizens may use their pre-existing, non-disaster organization for disaster work only once an emergency or disaster has occurred.

Make the best use of new technologies

→ Typically crisis mapping is initiated by active members of the public who have recognized the potential of local actors to provide emergency-related information for their peers in real time. Once established, the wider public can also contribute information to the platforms.

→ Volunteered geographic information (VGI) involves the sharing and mapping of spatial data through voluntary information gathered by the general public.

→ A potential means of formalizing or institutionalizing the practice and technology associated with crisis mapping is in the establishment of Virtual Operational Support Teams (VOSTs). VOSTs are known for their activities in social media monitoring, situational awareness support, countering rumours, and the amplification of official crisis communication.

→ Use of social media and mobile technologies to share information on people’s needs and required to align volunteering activities with people’s needs

Role of local and international NGOs [100-108]

Coordination of fundraising activities and volunteers

→ Collaborate with other entities to raise funds

→ Open up portals for individuals and institutions who are willing to donate relief materials and essential commodities

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 44 → Provide oversight and management of the collection, transportation, and distribution of volunteers and donations (money and goods)

Provision of support to government in identifying unmet needs and managing logistics

→ Collaborate with government to identify resource gaps in areas such as logistics and human resourcing

→ Conduct assessments of community needs, transported or distributed supplies, or warehoused supplies

→ Engage in and support transportation and logistics services

→ Coordinate with municipalities and/or other entities to support in assessment of needs and damages, in provision of relief materials including food, water, medical supplies and hygiene kits and provision of temporary shelters.

Provide direct medical care for patients and ensure infection control

→ Local and international NGOs have a role in providing direct medical care for patients through field hospitals and mobile clinics.

Provision of social support and care to affected communities and vulnerable populations

→ Provision of relief materials including food, water, medical supplies (medications, masks, gloves) and hygiene kits to affected individuals or families

→ Provide financial support for families in need and whose work was interrupted

→ Provide mental and psychosocial support and care services

NGO Networking and collaboration

→ Collaborate, create networks and coordinate with other NGOs (both national and international) to minimize duplication of efforts, maximize outreach activities and amplify impact of response

Contribution to social solidarity

→ Report unfair trade practices by retailers who may exploit residents by selling essential commodities at inflated prices

→ Support community initiatives to prevent hoarding of essential commodities.

Accountability and anti-corruption in relief [109-111]

During large-scale disasters, there is a substantial flow of resources by international governments and humanitarian aid organizations. This creates room for corruption and illegal profiteering through the inequitable distribution of aid, the diversion of relief materials, and substandard reconstruction of physical

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 45 infrastructure. Tackling corruption and ensuring accountability in humanitarian aid is a key to ensure effective and equitable humanitarian assistance. In this regard, humanitarian aid organizations need to evolve robust control mechanisms by:

→ Ensuring civil society involvement and community participation and strengthen the role of community feedback mechanisms through establish complaints mechanisms and avoid channelling them though ‘gate-keepers’. This involves empowering by increasing the awareness of local communities of their entitlements.

→ Strengthening accountability systems within humanitarian aid agencies through improving transparency in contractual arrangements and checking fast spending and the use of common audit and logistics tracking systems. Audits should include direct supervision and monitoring of relief and reconstruction efforts.

→ Ensure allocation of funds to respond to the needs of people and not on political basis and enforce mechanism to ensure aid is delivered to needy people.

→ Eliminate monopolies in managing humanitarian aid

→ Humanitarian community, donor governments, United Nations agencies and NGOs should ensure that accountability through regular internal and external evaluation and monitoring. Strengthening monitoring and evaluation during humanitarian aid can be achieved through engaging local people in planning, implementation, and reporting of malpractice in aid delivery.

Coordination between Nongovernmental organizations (NGOs) [36, 38, 39]

→ Coordination of information and actions between different parties facilitates the provision of equitable assistance and the implementation of effective interventions.

→ Models of coordination that can applied among NGOs and civil society organizations are detailed in the table 1 in section 1.

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 46 Section 2 Recovery

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 47 Section 2: Recovery

Following the disaster response, government, local and international organizations, and communities should collaborate together to ensure a well governed and coordinated disaster recovery phase that can cater to the affected community’s health and social needs and guarantee a sustainable and equitable reconstruction plan.

Governance Provision of and Rehabilitative Coordination care

Provision of Reconstruction Routine Care

Figure 3 Framework for Recovery

Governance and Coordination [112-114]: → Develop a multi-sectorial recovery team including humanitarian agencies

→ Identify and sequence recovery needs (immediate versus long term needs)

→ Establish context specific funding management to optimize the use of finances and direct them to prioritized recovery needs

→ Establish multi-partner recovery fund

→ Establish a monitoring and evaluation system to assess the strong points/weak areas of the recovery

→ Use a list of health related indicators to assess the health status of the population and needs after the disaster.

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 48 → Evaluate disaster response and update regulations to enhance future emergency preparedness.

Provision of Rehabilitative care [13, 15, 65, 115-117]: → Establish a framework for mental health case finding, triage and treatment

→ Establish a mitigation strategy to decrease the impact of the pandemic on the mental health of medical responders (high risk group).

→ Prepare mental health services that can meet the needs of older adults

→ Assess and respond to the physical and mental health needs of the highly exposed pregnant women.

→ Provide comprehensive occupational and physical rehabilitative models providing regular and coordinated interventions to achieve optimal rehabilitative outcomes.

→ Start physical and psychological rehabilitation immediately after the disaster extending to months after it.

→ Decrease the dependency on external funding and international support for the provision of rehabilitative services.

Provision of Routine Care [114, 118, 119]: → Restore service delivery and increase capacity to ensure access to routine services

› Build health workforce capacity to meet new health needs and provide incentives for deployment to disaster affected areas

› Replenish medical supplies and encourage local production of medications

› Address financial barriers for service access and consider removing co-payment shares for affected population

› Remove other barriers to access for affected vulnerable population (repair roads leading to services, provide services that can cater to the vulnerable populations’ specific needs…)

→ Adjust hospital surge capacity to guarantee cancer patient routine care in the aftermath of the disaster.

→ Establish measures to prevent the interruption of routine care for non- communicable diseases.

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 49 Reconstruction [120-124]: → Establish a timely, and coordinated reconstruction plan with clear roles, accountabilities, and expectations

→ Prioritize the reconstruction of infrastructure, essential cultural assets, and emergency management resources.

→ Develop plans, tools, and regulations that can balance between market flexibility, donation management, and government interventions (such as price restrictions) in reconstruction resourcing.

→ Establish a link between government, non-governmental organizations, and the community from the beginning of the reconstruction process.

→ Incorporate government and community in all aspects of planning and execution of reconstruction, as government-community relationship is more sustainable than NGO-community on the long-term.

→ Involve the community in the decision-making and prevent the re- establishment of inequitable construction plans.

→ Leverage this opportunity to construct housing that are more sustainable and can withstand future hazards.

→ Reconstruct the health system infrastructure and strengthen surveillance system.

→ Leverage this opportunity to modernize and rationalize the health system

→ Build temporary structures or mobile units to provide services provided by destroyed health structures (that may take years to rebuild)

→ Re-build resilient health system infrastructure that can withstand future disasters: adhere to international building codes when building hospitals and train hospital staff for future response including the management and treatment of mass casualties

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 50 Activating Lessons Learned

Recovering from this massive disaster, authorities should capture lessons learned from Beirut explosion disaster to ensure better preparation for any future disasters and develop and update its emergency preparedness plans to address the following main dimensions [73, 125, 126]: stewardship and governance, information management systems, human resources, medical products and supplies, financing (dedicated contingency fund), service delivery and community preparedness. Such plan can be promptly activated to guarantee early detection and evacuation, prompt rescue and treatment, coordinated communication and can swiftly address populations’ needs.

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 51 References

K2P Rapid Response Rapid Guide to Support Health & Social Care Systems in Response to Beirut Explosion 52 References

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