It is not possible to live alongside COVID-19, as we have seen several countries go down this path, with the expected result of overwhelmed healthcare, resulting in considerably increased deaths from COVID-19 and other conditions unable to receive care. While a lockdown is necessary for Lebanon in the short-term, it cannot be maintained beyond a few weeks. What is to be done after the lockdown?

Green-zoning has been successful in different countries where it has been applied to various extents, particularly China, New Zealand, Switzerland, Argentina and Ireland. Correct design and implementation is crucial, otherwise we risk failure. Using green-zoning, China eliminated COVID-19 within 6 weeks, including at the outbreak epicenter in Wuhan. Switzerland was succeeding, but eased off before reaching zero cases, while Argentina is succeeding outside its capital.

So what does this mean? Basically, its breaking a larger problem into many small pieces, protecting successes and concentrating efforts on turning failures into successes. Also, with proper design, it can introduce skin-in-the-game for local people, and allow successful areas to have greater near-normality without having to wait for the whole country’s success.

We have 3 zones defined as follows:
Red zone = 1 or more cases in the past 14 days.
Yellow zone = Shares a geographical border with Red zone, but has Zero cases in past 14 days.
Green zone = Zero cases in the past 14 days.

Zero cases means zero community transmission. A zone does not change its status to red if a case is detected and rapidly isolated with all contacts centrally quarantined. In other words, yellow and green zones maintain their status so long as centralized isolation and centralized quarantine are rapidly applied to any new cases and avoiding unknown community transmission.

We use absolute cases, not rates (e.g. per 100K), not only because in Lebanon the denominator per area is unreliable (no census, refugee populations), but also because the main goal is not a matter of decreased concentration of cases, but to reach Zero cases. This is important, because we know that with its multiplicative potential, a few COVID-19 cases can result in hundreds or more within a few weeks. Whereas, zero cases cannot result in more cases. Don’t let small fires grow bigger again; put them out completely.

Each zone would have a different level of restrictions:
Red zone = Essential services open, closures of all other workplaces and educational facilities, ban on all indoor gatherings (except households).
Yellow zone = Non-essential services open, social gatherings of very limited size outdoors only (e.g.<20p).
Green zone = Greatest near-normality, social gatherings of limited size (e.g. outdoor<100p, indoor<50p).

However, all zones would have to maintain:
– Masking, especially in indoor settings.
– Avoiding 3Cs: closed spaces, crowded places, close-contact settings.
– Hygiene practices.
– Ban on indoor & outdoor mass-gatherings (e.g.>100persons) and potential super-spreading events.
– Special attention to facilities where people from different zones interact e.g. highway shops.

Travel restrictions would considerably increase effectiveness of green-zoning, decreasing the time needed to reach success. This means a ban on all non-essential transport from/to Red zones, to protect Yellow and Green zones.

What is needed from Central authorities?
1. Precise surveillance capacity teamed with rapid localized response. This means that authorities should gather and provide municipalities with daily information on COVID cases, such as name/ID, age, and location/context of infection (e.g. school). Municipalities and locals would then use this information to implement local response.
2. Central authorities are also needed to enforce travel restrictions, using police/army checkpoints.
3. Prioritize random and targeted testing in zones: Red > Yellow > Green.
4. Provide increased resources and guidance for Red zones struggling to reach Zero cases.

What is needed from Municipalities and locals?
1. Leadership and initiative. While central authorities will set the overall restrictions needed, it is for municipalities to lead the localized response, including tailoring action to be more effective (not less). The momentum has to be driven by locals, with the central authorities having set the minimum measures needed.
2. This may include measures such as door-to-door screening for symptoms/testing, transferring activities from indoors to outdoors, and engaging fellow locals to increasing masking.
3. Set up Isolation centers and Quarantine centers, especially in zones with high population numbers, and encourage confirmed cases and suspected cases to use these, both for their own benefit and to protect their own household. Maintain channel with health authorities and hospitals for transfer of moderate/severe cases.
4. Lessons learned at local level would be useful to share with all other municipalities, either directly through existing platforms, or indirectly through central authorities.

Communication between central authorities and municipalities has to be maintained, to provide feedback and modify ongoing measures where necessary.

Zones do not have to be on a per-municipality basis, but may include more than one municipality, particularly in smaller areas. However, coordination at the administrative level is necessary across municipalities grouped into one zone.

In cities such as Beirut, Tripoli and other high-density locations, zoning at the level of city districts or neighbourhoods should be applied, including travel restrictions. Otherwise, as an intermediate step, such locations should have lockdowns to drive to Zero cases. Applying zoning is necessary in the longer-term.

Upgrading and downgrading
Changes in zone status should be in line with the zone definitions above. However, if an individual case has been confirmed to be infected due to a cross-zone movement, and has been rapidly isolated along with all contacts, a short waiting period may be used before revising zone status.

Many lessons will be learned during practical application, and should be used to improve overall effectiveness of a green-zone approach, and allow locals to be as near to normal conditions as possible, without allowing COVID-19 to spread. This is about neighbourhoods, villages, towns and cities, altogether transitioning to a Zero-Covid-Lebanon.

Read more about Green-zoning:
A Green Zone Strategy for Ireland & Abstract
Toward a European network of “green zones” to avoid summer collapse