My co-presenter was going to present. Diana is the one who starts, so she just ran to the restroom. She'll be here any second. I don't think, I'm going to, I'm just, I'll introduce myself and Diana, here she comes. Here she comes. If you guys want to come closer, since it's such a small group, but whatever is comfortable for you, so you do whatever you want. Sorry. You can hear us, okay? We didn't ask for so much to announce our conference. My name is Diana Rahmi. I am a family physician, and I am also an occupational specialist. I did my occupational medicine in France, and I'm from Lebanon with my colleague, Dr. Kareem Saar, who is the director of the employee health service in our university. So, today we're going to talk about the importance of hospitals' collaboration for pandemic preparedness, and the lessons we have learned from our project. So, first, allow me to ask you to bear with me, because I'm French-educated. I'm not English-educated, so excuse my English. Okay, so Dr. Saar and I, we don't have any conflict of interest to declare. Our project, however, was funded by the United States Agency for International Development, and we are currently also working on a project founded by the NIH, but it's different. So, before talking about our project, how we did during COVID-19, I would like to situate you in the context of our geographical part, Lebanon, and our institution, the American University of Beirut, and the American University Medical Center. Then I will talk slightly about what was happening around the time when we had the pandemic, because this will help you understand how we did with our project. Then we will talk about the project, the different phases, and what are the different lessons that we have learned. So, where do we come from? Lebanon. Lebanon, not in the city. Lebanon, the country. It's a very tiny country in the Middle East, so tiny that you cannot see its name on a world map. There's no place. This is somewhat good, because if there is a world war, they will not see us. They will mix us with the rest. Okay, so, and we came a long way. It is like 6,000 miles to reach Philadelphia from Lebanon. This is a closer look, and you can see Lebanon is in the Middle East. We have Syria at our north, and Israel at the south, and we have the beautiful Mediterranean Sea also. So, how big we are? We are 4,000, around 4,000 square mile, something like 80% of Connecticut, to have an idea. So, in the picture above, you can see my village. It's a northern mountain village. It is called Bishari. It is at an altitude of 1,500, and we have the mountain, and our mountain are famous for the cedars of Lebanon. The cedars of Lebanon, most probably you have heard about them. They figure, the name figure, like more than 300 times in the Bible. And in my village, it snows, and we do ski during winter time. And my village is also famous for a Lebanese-American poet, who is Gibran Khalil Gibran, if you know him. He has written the famous, the prophet, the book. So, here we are. And below, you can see an aerial picture of our city, Beirut. Now, how, we're not, we're not so, we are only 5 million, but we have more than 1.5 million Syrian refugees. So, more than 25% are refugees, imagine. And now, closer picture to our institution. We come from the institution called the American University of Beirut. It is known as the AUB, and the AUB was founded in 1866. It is governed by an autonomous board of trustees, and it is accredited by the Commission on Higher Education of the Middle States Association of Colleges and Schools in the US. Above, you can see a picture when it was founded. And down, this is a recent picture of our beautiful campus that is connected to the sea, too. We have the AUB beach, even. So, our mission is very well explained by our founder, Daniel Bliss, who said, we were not anxious to appear great, and we're still not anxious to appear great. But we were anxious to lay foundations upon which greatness could be built. So, we're trying to follow this till today. And more updated summary is by our current president, Dr. Fadlo Khoury, who is a Lebanese-American, too. For more than a century and a half, we have offered the world class education to the people of Lebanon and the region, cared for the sick and wounded at our hospital, shaped Arab intellectual and artistic movements, influenced political and civic life, and helped the most vulnerable among us. AUB has seven faculties, including, of course, obviously, medicine, nursing, engineering, architecture, agriculture, and so on. And we have more than 130 programs. We are more than 1,072 instructional faculty. And around 8,000 students are here every year. Among them, 22% are international students. So, this is how we start, the AUB, as a faculty. And then, they said, we want to do a medical center. So, the story of AUB Medical Center started 145 years ago in a small rented building in part of Beirut. So, in 1902, the college purchased a property across the street from AUB Medical Gate. And it established the first 200 bed hospital that provided, at that time, ancillary services. But soon, over the years, the need for continued expansion became very clear. And here, where we are now, we have like seven annexed buildings, thanks to donors from the MENA area to Lebanese expatriates. You know that we have like more than 12,000 Lebanese that are not living in Lebanon, that have other nationalities. Among them, my maternal family. Okay. So, the AUBMC is the first medical institution in the Middle East to have earned five international accreditations, mainly the JCI, the ACGMEI, and the MAGNET. We have 18 residency programs. All are accredited by the ACGMEI. And the AUBMC's impact on the medical sector and on improving people's lives is without equal in the Arab world. We have now 376 beds hospital. So, this is our geographical situation. Now, let us look about the beginning of the pandemic. What happened in Lebanon? So, like two to three months before the pandemic, this is what happened. Okay. Okay. We demand water, we demand education. One person here is begging to teach his son. We want to live in dignity. I want to fight corruption. I want to say to those in charge, you are living at a certain level and I'm running after bread. A spark to the anger on Thursday was a government announcement of a daily tax of 20 US cents on messaging applications, including WhatsApp. The government within hours backtracked and is now facing an uprising. As it discusses the 2020 budget, other taxes have been proposed including on tobacco and fuel. To rein in the country's colossal debt, which is the third highest in the world of 150% of GDP. So, this was on October 2019. So, like two or three months. And then after two months, we started hearing all over the world about COVID-19 in China and then the WHO said this is a pandemic. But our situation was really horrible in Lebanon. We had a rising political instability. We had a huge banking and financial crisis, an economic collapse that is still going on. And the currency started severe devaluation and is still going on. So, it was really a horrible year and it was best described by our president, AUB president, as an anus horribilis because it started with forest fires. Then we had the thorough, which means this is the uprising in Arabic. The devaluation, the default for the first time in 100 years, massive financial losses and deflation affecting AUB and other institutions and families, so on. And at the same time, we were hearing around the world about COVID-19 and we were expecting our first case. So, our first case arrived on February 21, 2020. She was a woman coming from Iran and she tested positive for COVID-19. So, this was the first case. In our institution, because we were already hearing what was going on around the world, so we were expecting that sooner or later we'll have COVID-19 cases. So, our response was very rapid. Directly, the AUB and AUBMC established an expert committee and Karine is the director of this committee. And the role of this committee was to adopt coordinated and evidence-based measures for containing the virus and mitigating its impact at AUB and in the community. Of course, our operations at AUBMC changed. So, we had trained all our healthcare workers. We chose the model train-the-trainer. We launched also the AUBMC telehealth. Of course, we restricted the visitors' access and we relocated some of our units and departments. So, as you can see, we created this building that you can see in the upper right picture is the PECC. So, it's the Pandemic Evaluation Clinic and Center. So, we removed the clinics that were in this building and the patients, et cetera. It was the psychiatry, I think. And we created this isolated comprehensive COVID-19 facility. In the basement, we had the testing, the outpatient COVID clinic, and then we had a regular floor, an ICU floor, an STU floor, and even an OR was created in this building so that we don't mix COVID-19 patients with others. And directly, our president launched a corona response fund to receive contributions from donors to support the care of these specific patients. I remind you that the uprising was a few months before the COVID-19. So, really, the money, the financial crisis was tremendously severe in Lebanon at that time. And thanks to the USAID, so we found our major supporter. USAID Lebanon has a great history with us. And it is committed to helping Lebanon to modernize and achieve long-term prosperity through programs that strengthen service delivery and create new jobs. So, USAID responded to our call. And if I just give you a brief history, in January 2022, for example, USAID provided like $40 million as additional humanitarian assistance to vulnerable people in Lebanon because we continued to confront the impacts of ongoing economic and financial crisis with the COVID-19 and with the refugees number that were increasing and so on. So, in April 2020, we were informed about a call for a COVID-19 project. So, it would be a national effort to respond to the pandemic. Of course, at AUB, we captured this opportunity because we needed it and developed a proposal. Our goal would be to transmit our expertise and expand our outreach to the entire country because we were really prepared. We were expecting the pandemic and we were really prepared when it happened in Lebanon. So, we submitted our proposal to USAID in early April. And we were informed on April 24 that the proposal was accepted. So, this is the mail of our president when we submitted the proposal. You can see here the U.S. ambassador at that time with nearby our president. And Karine is here also. She was the president and director of this project. So, this is the mail when the project was accepted. So, we named this, we called this project a nationwide approach to respond to COVID-19 spread in Lebanon. The aim of this project was because we are an institution where everything is well-established. We have an infection control committee. We have the occupational team. We are well-organized and we have already our policies and our, in French, savoir-faire. So, we developed, we wanted basically to export all that knowledge to remote hospitals in the country. So, we would first assess and see what their level of preparedness is. And then, we will train for COVID preparedness and provide personal protective equipment and other needed equipment. And then, at the end, we will evaluate the post-training state of the hospital. So, now I will leave the floor to Dr. Karine. She's the mother of the project. Okay. So, as Diana was saying, we basically gathered a big team. And I really want to take, I mean, we are both presenting, but it really took a village. It was really a lot of people, core administrative staff. We had people from every section in the hospital to work on this project. So, we said, okay, great. So, what are we going to do? We're going to export what we have at the UBMC. We wanted to support remote hospitals. And by doing so, we would hopefully have them prepared. And this is all we didn't have. We're talking April. We had, like, very few cases in the countries. But we wanted to get ready before the cases started to rise. So, we decided to pick 10 hospitals. And because it's a small number, it's manageable, we would create 10 mini teams that would go to these places, train them, and provide support. We wanted to make sure we would cover the entire country. The country is small, but still. So, we wanted to make sure there's a good geographic spread. And we wanted to reach underserved areas with high concentration of refugees, as Diana was saying. The hospitals needed to be like 100 beds, give or take, not too big, not too small. Essential services to be present are emergency, lab, ICU, and they cannot be flagged, obviously, on any sanctioned lists for obvious reasons. So we reviewed all the private hospitals we had in Lebanon, came up with 15 of them. I'll show you the map in a second. Of the 15, we did internal vetting, brought them down to 10, and we visited them. We wanted to make sure they were okay working with us, so in the introductory visit, I was there, the dean of the medical school was there, and we had a doctor from the area, an AUB doctor, but if we're going to the north, a northern doctor would be with us, just like he knows the culture, he knows the people. It just facilitated the approach. So here they are. You can see our AUB, our medical center is in the capital in Beirut. We had one in Mount Lebanon, five in the Bekaa, and four in the north. We needed a validated tool. I don't know if anybody used the CDC hospital preparedness checklist. I don't know if you guys were involved in hospital preparedness pandemics. So there are some tools out there. The CDC has one, the European CDC has one, the WHO has one. We consolidated the three of them into one nice hospital preparedness checklist, and that was the tool that we were going to use. Pretty extensive, actually, and 20 sections. We were going to complete it at the beginning of the project before we did the training, and then we said we'll complete it at the end, and we will make comparisons to see how the intervention, what was the impact of the intervention. Different sections, I just circled a few of them. There's an occupational health section, an infection prevention and control section, moving patients in the facility section. So we're talking here. We haven't started the real training yet. We are in April. We're still having some cases, not too many, but this is pre-vaccination era. So we're doing those visits. Everybody has a mask on. When we could, we did the social distancing. It didn't work all the time. The first visit was just introduce ourselves to the hospital. We had, the team had one MD, one RN, one infection control officer, and an administrative person. We would go sit with the staff, complete this checklist that I just described. We were touring the hospitals to see where their COVID units were, what would be a nice place, actually, to have a testing area or the COVID inpatient area, and we assessed their needs for supply because, I mean, like everywhere else, I know that there were shortages in the US. We had some shortages in Lebanon as well. Still in phase one, before we started the training, we knew early on that communication was gonna be a big part of what we were doing. The hospitals needed educational material. Not everything was, I mean, the CDC had put a lot out there. Not everything was in English. So we developed a website. We put everything on the website, the posters, infographics, video. This is an example of a donning and doffing PPE. We made them in English and Arabic so they would access them, print them, and hang them all over the hospitals. So the phase two was like the bulk of the project. This is when we went and we did our training. It was a day-long training, and many of them, as I said, the mini team, the doctor, the nurse, the infection control manager, officer, I'm sorry. And these were the topics that were covered. Infection control practices, COVID-19 nursing practices, housekeeping, I mean, housekeeping was essential during COVID, PCR sampling, specimen collection, and we had the occupational risk assessment. When do you return people back to work? How long do you keep them out of work? And what was crazy was that the CDC guidelines were changing, so everything had to be updated at the same time. I'm sure you guys went through it as well. To assess the knowledge of the healthcare workers, we did like a small test, pre-training, post-training, and we compared them. We also asked the healthcare workers to complete a survey so that we know if they liked, I mean, basically we wanted them to grade the content and the trainer. And we also did a webinar for physicians. It was over one week. Every day there was a different topic. We did them online so that everybody from Lebanon could access them. And the topics covered were anesthesia, infectious disease, pulmonary, critical care, pretty detailed, very technical as well. And this is just like a snapshot of what the training, I'm sorry, the knowledge assessment looked like. So you can see that when we compared pre-training to post-training knowledge, I mean, things moved in the right direction. The housekeeping group did not improve much. The sample was small. We also suspected some language barrier because not all of them were literate. So this was something to keep in mind. The content and the trainer were evaluated pretty good. So we had a high of 93% for one and 97% for one. So that was pretty good. And after we completed the trainings, this is when we started delivering PPE and equipment. Each hospital received one ventilator and one high flow nasal cannula. They were welcome. I don't know how much of Middle East news you guys follow. So I don't know if anybody heard about the August 4th blast. So I'm gonna play a short video. It's a one minute video, just to give you an idea of what happened on that day in Beirut. There was a massive explosion. I mean, something that really shocked this city like I've never seen before. And I've been through wars here in Lebanon and this is something unheard of. I'm looking at the buildings all around me. Many windows are also smashed. There's lots of grass and other debris in the street. So the final number of victims, I mean, it's not finalized yet because some people went missing, but we're talking about more than 230 people who were killed. Thousands of people were wounded. So it was very, very big. So it's kind of reminded us of, for me at least, it reminded me of September 11th. And when big events like this happen, everybody remembers the event, but you also remember where you were and what you were doing on that day. I don't know if I ask you, where were you on 9-11? I'm sure you will remember, right? So on that day, actually, interestingly enough, Diana was at the medical center. That was a regular clinic day for her. This is the clinic and office building. And this is the road that she drives to return home. So around 5.40 p.m., she was right in front of the port, right in front of there. And 6.07, this is when the blast happened. I was in the north, and interestingly enough, I was working on this project. So I was visiting hospitals in Tripoli. That night, we had a wedding northern of Beirut. So I didn't come to Beirut until really late that night. And this is a picture of my apartment. You can see how the big window panel was completely, it didn't break though, which was surprising. And the entrance door was smashed. And this is my son, actually, at the wedding. We didn't enjoy the wedding that much. He was terrified. But when things like this happen, I mean, the last thing that you have on your mind is PPE use and using your mask. I mean, we all remember firefighters from 9-11. They didn't have respirators on. They were not wearing personal protective equipment. So at the medical center and in many hospitals in Beirut, the scenes were horrific because the hospitals themselves were damaged. And still, you're taking care of the wounded. So people forgot that they were in a pandemic. Sure enough, after the blast, we started to see the cases go up. So this is the daily cases of COVID in Lebanon. First case February, nothing. And things start creeping up here. And when people get sick, healthcare workers get sick at the same time. We're part of this population. So we looked at that, actually, and this is a paper that we just published, actually, in JOEM last week. We correlated the big curve is Lebanon, cumulative cases. And this is our medical center after the blast. The correlation is like 99%. So that was expected. Still, we continued with the project. And this is when we were doing our post-training assessment visit. And we were happy to see that things were moving in the right direction. The same checklist, as I mentioned, we completed it after the training. That was a few months later, just so that we can see. And we did one-on-one interviews. We sat down with hospital directors, infection control managers, to get really, just to get further input on their experience with this capacity-building project. So the checklist, I'm not going to bore you with details. It's already late. But basically, it's 186 checkpoints. The maximum you can score is 372. And we divided them. We categorized them. So pre-training, very good, we're at 50%. Excellent was 40%. Things got better after the training. 80% of the hospitals were excellent. 20% were very good. And if we look at them by hospital, they all showed the increase that we like to see. Everything moved up some places more than others. And then if we look by chapter, by category, we also saw that for most cases, things changed in the right direction. I mean, for some things, training didn't matter. Like, for example, continuity of essential healthcare services, training is not going to change that. People were not going to the hospital anyway. I mean, they were scared of the pandemic. You would not go to get your mammogram to get, things were not happening. So that was totally independent of the project. And while we're in phase three, this is when vaccines started becoming available in Lebanon. So our first vaccine was on February 14, 2021. I think the US was a few months ahead of us. I'm not sure if all of you come from here or from other parts of the world. So February 14 was the first day we started inoculating. The president called it V-Day. What we did, we also reached out to our partners to make them vaccination sites so that we can increase the outreach as well and reach those vulnerable population that Diana was telling you about a few minutes ago. So we also trained and we launched the vaccination campaigns with the remote hospitals. So this basically wraps it all up. So August, this is when the cases start to rise. There was another rise and that was the end of 2020. So we haven't started vaccination yet. The financial situation was bad. So the government, the authorities decided to open up the country. So restaurants were open. I see some nodding. So it did happen in other places. Also restaurants were open. The airport was open. So we were expecting really something bad. And sure enough, cases skyrocketed. We lost so many people in that period of time. Now, the good thing is that when this happened, we were already done with the training. So the hospitals we collaborated with, they were ready at that time. Afterwards, we were delivering PPEs and we continued with the vaccination campaign. So as of May 31st, 2022, which is pretty much when we wrapped up the project, we had administered 233, give or take 1,000 doses at our center, 14,000 in the partner hospitals, and 2.5 million pieces of PPE were delivered to AVMC and to the partner hospital. The numbers might look small for some of you, but still, this is a small country. And I will end showing you this video that summarizes it all. Actually, it's a one-minute video as well. The USAID response was immediate. USAID supported AUB to open the Pandemic Evaluation Center. Throughout the pandemic, it's been almost two years now, close to 2,000 patients were able to receive inpatient care in this clinic. AUB was able to partner with 10 collaborating hospitals located in the north, the Bekaa, and in Mount Lebanon. Training on COVID-19 preparedness and treatment was provided to almost 325 health care workers. In addition, four webinars were presented to more than 30 physicians. This is our medical center. That's AUBMC. This is the day of the blast. That was actually the medical school. We witnessed a severe rise in the number of COVID-19 cases. That's the entrance of the ER. That's the ER. This is our ER. The severe economic crisis, along with the sudden departure of a large number of health care workers, created an additional burden on the health care system in Lebanon in general, and at AUBMC in particular. USAID supported the AUB COVID-19 vaccination campaign. Through this campaign, we were able to immunize close to 110,000 individuals. Those campaigns were taking place at AUBMC, in collaborating hospitals, as well as in mobile clinics all over Lebanon. The number is smaller. More than 99% of the AUB community were vaccinated. And this allowed the campus to open its doors for in-person learning in October 2021. We're all in this together. And with this instrumental support, we are confident we will come through this crisis. I mean, just to end on a positive note, we were very proud of the 99%, by the way. We were extremely happy with the 99%. And we didn't have the choice, because we needed to open campus. So what did we learn? Collaborations during pandemic do work. I mean, I think this was the only way out, especially we were going through many, many crises, as Diana described. We validated the train-the-trainer model. This is what we used at our institution, and this is what we used with the collaborating hospitals. By doing what we did, we decreased the burden on the big academic centers in Beirut, because now we had satellite treatment all over the country. For them, obviously, the support was- I mean, training takes money and time. So just us going there and training those hospitals was a great plus. PPE, as we mentioned already. It's a two-way street. I mean, it was the pandemic. We didn't know. I mean, everything was new. Everybody's fighting this new virus. So we were exchanging knowledge. Shortages, for example, of N95. How are you sterilizing, et cetera, et cetera. It was a great collaboration. And by distributing COVID cases between us and them, we improved patient outcomes, and we decreased transmission by leaving the cases in their respective regions. So this is a quote, actually, that was mentioned two days ago. It was one of the TED speakers, and I thought it fits well here. Before I end, I just want to make sure that, I think we acknowledge already, USAID, wonderful people to work with. I mean, they really supported us tremendously. The team in Beirut worked really, really hard, so I want to acknowledge them as well. If you have any questions, and thank you so much for you guys for staying. If you have any questions, we'll take them. No questions. Yes, please. For your question, I can't think that you allowed religious exceptions. Religious? So we did not have, so all, actually, I knew that question was going to be asked. So people were allowed to apply for waivers. People were allowed to apply for waivers, and all the waivers were reviewed by the occupational medicine folks. So me, Dr. Rahmi, and we have another doctor with us, the chairperson. So we did not, interestingly enough, we did not have religious waivers. There were some allergies. We had some pregnant women who did not want to get vaccinated whatsoever. What else did we have, Diana? Some breastfeeding women did not, and- Anxious, anxious people. Yeah, a lot of anxious people, but anxious people, they didn't get a waiver. But this is what we got. But it was a lot of wreck, because in the medical center, what made it easier was that the government pseudo-mandated it. So if you, I mean, like what the French people did, right? If you want to be taking care of healthcare workers, you have to be vaccinated, unless you have a medical reason not to. So the waivers were granted for, I cannot tell you how many hours I spent on the phone with moms, because the students needed to be vaccinated as well. So we were talking to the moms of the students. We were talking to students who didn't want to get vaccinated. So yeah, that was the vaccination piece. And if they didn't receive vaccination, they had to do a PCR every three days, and it was quite expensive. So this was like a push. That was a deterrent. That was for the hospital. Yeah. This is what was mandated by the government. Students had to, we didn't allow it. Students, they couldn't enter the campus. Yeah, that was a deterrent for the students. No campus access. I mean, you can not get vaccinated, but you won't have access to the campus. And we had power shortages. The internet was not working all the time. So that's why we really needed that campus to open. Actually, it wasn't a luxury. It was necessary. Sure. Safe flight or train or whatever for you guys. Thank you. Thank you.

hospitals collaboration

pandemic preparedness

Lebanon

United States Agency for International Development

American University of Beirut Medical Center

COVID-19 training

vaccination campaign

positive impact