A narrative review of CBRN health sector preparedness in Lebanon

Abstract

Background

As chemical, biological, radiological, and nuclear (CBRN) events become increasingly recognised within international and national emergency preparedness efforts, this study aims to provide the first system-level overview of Lebanon’s preparedness capacities for CBRN-related health emergencies.

Methods

A narrative review of peer-reviewed and grey literature was conducted using a structured search strategy, with findings thematically synthesised to assess governance and operational CBRN preparedness capacities across eight health system domains in Lebanon.

Results

The review identified important advances in Lebanon’s preparedness for CBRN health emergencies, including engagement with international preparedness frameworks, development of governance structures, and implementation of coordination, training, and simulation initiatives. However, preparedness remains uneven and constrained by fragmented coordination, legislative gaps, limited surveillance and operational integration, shortages in material and human resources, and dependence on external support. Economic instability and workforce migration further challenge sustainability, while preparedness capacities and readiness levels vary across emergency response and healthcare institutions. Overall, strategic planning and governance capacities appeared stronger than operational response and surveillance functions.

Conclusion

While major efforts towards CBRN preparedness in Lebanon have been initiated, key aspects remain under-developed. Given Lebanon’s continued exposure to recurrent crises and regional instability, strengthening CBRN preparedness should be considered a critical component of broader health system resilience and national disaster risk reduction efforts.

Background

Lebanon is a small eastern Mediterranean country of approximately 6 million people [1], located along the eastern Mediterranean coast (Fig. 1), situated in a region marked by political instability and high exposure to diverse natural hazards [2]. Consequently, the country holds a position that both geographically and geopolitically thrusts the threat of chronic catastrophes upon its shores. Recent disasters include the 2020 Beirut Port Explosion [3], one of the most destructive chemical explosions in history, and the 2024 War, which involved the use of white phosphorous [4], caused approximately 4,285 deaths [5], and severely debilitated the capabilities of the health sector [6]. The threat of emergencies from the spread of communicable diseases has also garnered increased attention in recent years, with incidents such as the COVID-19 epidemic and 2022 cholera outbreak posing serious threats to public health [2].

Fig. 1.

Map of Lebanon in the Eastern Mediterranean region

Given Lebanon’s vulnerability to disasters, as well as recent fluctuations in regional stability, concerns over the risks posed by chemical, biological, radiological, and nuclear (CBRN) agents are mounting. Such concerns are global, and not without justification, with CBRN events being identified as one of the top three highest risks for the Eastern Mediterranean Region [7]. Alarmingly, inadequate preparedness in health facilities, particularly hospitals, is a global phenomenon [8], and for Lebanon such inadequacy in health system preparedness could be catastrophic for public health [2]. Lebanon, now classified as a lower-middle income state, faces disproportionately higher risks of economic and mortality losses from disasters [9]. Its economic deficiencies are particularly disadvantageous in the context of CBRN preparedness, which demands expensive infrastructure such as decontamination facilities and specialised personal protective equipment (PPE) [10].

These escalating risks underscore the need for structured, internationally guided approaches to disaster preparedness, particularly in vulnerable health systems. The United Nations Office for Disaster Risk Reduction calls upon countries to strengthen their disaster preparedness capabilities by having a systemic process to develop the knowledge and capacities that enable the state to effectively anticipate, respond to and recover from the impacts of disasters [11]. Disasters are defined as the consequence of state vulnerability, which, when interacting with a “potentially destructive agent or force”, disrupts the state’s ability to meet basic needs [12]. In this regard, the prevalence and consequences of disasters are exacerbated by weak governance and a lack of regulations mandating robust disaster risk management measures.

Despite growing global guidance on CBRN preparedness, Lebanon’s health sector lacks a comprehensive assessment of its readiness to manage such events. An overview of the current state of preparedness for CBRN incidents in Lebanon’s health sector is therefore a vital first step towards strengthening resilience and preparedness. To date, and to the best of our knowledge, no system-level review of Lebanon’s preparedness to CBRN-related health emergencies has been conducted. To fill this gap, this article provides an overview of the current capacities in health system domains fundamental to national CBRN preparedness. It first reviews the existing literature, before identifying key strengths, weaknesses, and opportunities for advancing CBRN health emergency preparedness in Lebanon.

Methods

The present study is a narrative review examining CBRN preparedness in Lebanon’s health sector. It aims to review national CBRN-specific emergency preparedness efforts across key health system domains. The methodological workflow is illustrated in Fig. 2.

Fig. 2.

Flowchat of the literature search and selection process

A comprehensive literature search was conducted in MEDLINE-Ovid to identify the relevant peer-reviewed articles published in English from 2000 to 2026. The search strategy incorporated Medical Subject Headings (MeSHes) such as “Lebanon,” and “Disaster Planning,” as well as keywords including “health sector preparedness”, and “CBRN.” Additionally, a manual search for grey literature was conducted using the Google search engine. Additional sources were reviewed through cross-referencing bibliographies of selected articles to ensure a broad and inclusive dataset. Studies were included if they tackled areas related to the management, preparedness, and response to CBRN hazards and incidents in Lebanon. Studies not referencing Lebanon were excluded. Data extraction focused on governance and operational CBRN preparedness measures, their reported implementation and performance, key challenges, noted limitations in their application, as well as the key domains covered.

The classification system of eight key health system domains was developed deductively from the World Health Organization’s State Party Self-Assessment Annual Reporting (SPAR) capacities and subsequently adapted through iterative thematic analysis to reflect the scope and evidence base of this narrative review. SPAR capacities provide an established and comprehensive structure for assessing national public health emergency preparedness, including capacities relevant to CBRN preparedness. During initial data extraction, findings were mapped to specific SPAR domains and indicators. To establish an appropriate level of analytical aggregation for a narrative review, related indicators were then consolidated where substantial conceptual and evidentiary overlap was identified in the included literature. For example, findings relating to financing mechanisms, equipment, supplies and other resource requirements were aggregated under the thematic domain of ‘Material Resources’. This approach resulted in a total of eight domains including: International Frameworks; National Bodies, Strategies, and Regulations; Coordination; Early warning, Alert and Response Systems (EWARS) and Information Management; Material Resources; Human Resources; Prehospital and Emergency Medical Services; and Hospitals.

Results

The Medline-Ovid search resulted in 87 peer-reviewed articles that were screened for inclusion. Additionally, the Google search yielded 36 sources. Three peer-reviewed articles and seven grey literature sources met the inclusion criteria, totalling ten sources for the final review. Table 1 summarises the findings.

Table 1.

Peer-reviewed and grey literature on CBRN health emergency preparedness in Lebanon

Title	Location (year of publication)	Aim of study	Methodology	Key Findings	Limitations	Health System Domain/s Addressed
Hospital CBRN preparedness in Lebanon: a modified Delphi-based assessment tool	Lebanon (2026)	Develop a specialized assessment tool for Lebanese hospital CBRN preparedness.	A modified Delphi study to develop a context based CBRN preparedness assessment tool	The tool emphasizes key categories for CBRN preparedness, introducing elements such as specialized response teams, comprehensive pharmaceutical management, and intensive training drills. Highlights the importance of gender-sensitive considerations in Lebanon, particularly regarding the application of decontamination protocols.	The reliance on a localized panel of Lebanese experts potentially limits the incorporation of global best practices. This tool is tailored specifically to Lebanon’s institutional and cultural environment. The lack of field validation.	Hospitals
Assessment of the Preparedness Level for Chemical, Biological, Radiological, Nuclear, and Explosive Risks in Emergency Departments in Lebanon: A Cross-Sectional Survey.	Lebanon (2026)	Assess ED staff level of preparedness for CBRNe hazards two years post-Beirut blast.	Descriptive cross-sectional survey	The study reveals a critical lack of CBRNe preparedness within Lebanese ED.	Reliance on self-reported survey data. Low institutional response rate limits the generalizability of the findings. The survey tool is adapted from European models.	Coordination; Material Resources; Human Resources; Hospitals
A closer look at the international health regulations capacities in Lebanon: a mixed method study.	Lebanon (2024)	Evaluate Lebanon’s IHR capacities, challenges, and refugee crisis impact.	Mixed-methods review of IHR data and semi-structured interviews.	Lebanon outperformed neighbouring countries and established CBRN and HAZMAT teamsLebanon suffers from significant vulnerabilities (resource shortage, governance challenges) The refugee crisis strained the health system and simultaneously triggered international funding	Incomplete milestone data. Small interview sample size (n = 9). The potential masking of specific weaknesses caused by equal indicator weighting	International Frameworks; National Bodies, Strategies and Regulations; Coordination; EWARS and Information Management; Material Resources; Human Resources; Hospitals
ARZ 2021 CBRN Field Exercise - Organisation and Implementation of a CBRN Counter-Terrorism Field Exercise: A Guiding Document	Lebanon (2021)	Provide a framework for organizing and assessing national CBRN counter-terrorism drills.	Guidance manual	Provided structured frameworks for objectives, scenarios, and evaluation metrics for national drills.	N/A	International Frameworks; National Bodies, Strategies and Regulations; Coordination; Pre-Hospital EMS
ARZ 2025 CBRN Field Exercise: A field exercise to counter CBRN terrorism	Lebanon (2025)	Outline the purpose, design, and objectives of the ARZ 2025 exercise.	Concept note	Describes objectives, structure, and expected outputs. No post exercise results reported.	N/A	International Frameworks; National Bodies, Strategies and Regulations; Material Resources; Human Resources
National Report related to the Convention of Nuclear Safety March 2023 Member State: LEBANON	Lebanon (2023)	Report on Lebanon’s implementation of Convention on Nuclear Safety (CNS).	National report	Lebanon maintains a strictly peaceful application of radiation sources, primarily in medicine, agriculture, and research, with no nuclear power installations or fuel storage on its territory. The country has established a robust regulatory framework led by the Lebanese Atomic Energy Commission (LAEC), which manages a comprehensive national register of radiation sources and performs regular inspections	N/A	International Frameworks; National Bodies, Strategies and Regulations; Human Resources; Pre-Hospital EMS; Hospitals
Public Health Emergency Operations Center Handbook	Lebanon (2023)	Establish guidance for operating a Public Health Emergency Operations Centre.	Technical manual outlining SOPs, organizational structures, and activation protocols.	Details the structured coordination system for health crises, emphasizing evidence-based response.	N/A	National Bodies, Strategies and Regulations; Coordination; EWARS and Information Management; Pre-Hospital EMS
Multi-Hazard Scenario Planning: Ensuring Effective Response in Complex Disasters and Crises	Lebanon (2022)	Showcase multi-hazard preparedness during overlapping crises.	Descriptive case study.	The Lebanese Red Cross (LRC) demonstrated that proactive contingency planning and long-term institutional trust were essential in responding to the 2020 Beirut explosion, even as it coincided with a pandemic and economic instability. It also highlights the LRC’s ability supported by a specialized CBRN unit and mobilization of volunteers	N/A	National Bodies, Strategies and Regulations; Material Resources; Human Resources; Pre-Hospital EMS; Hospitals
Case Study: Chemical Explosion Beirut Port: Technological and Biological (CBRN) Hazards	Lebanon (2020)	Document the (LRC) response to the catastrophic chemical explosion at the Beirut Port on August 4, 2020.	Descriptive case study.	Identified the blast as a large-scale chemical incident; highlighted gaps in specialized CBRN response.	N/A	National Bodies, Strategies and Regulations; Material Resources; Human Resources; Pre-Hospital EMS
SPAR 2024 Report	Lebanon (2025)	Assess Lebanon’s IHR core capacities.	Annual self-assessment using WHO SPAR tool.	The country capacity score was reported as 70 and is ‘approved’ as an IHR status.	N/A	International Frameworks; Coordination; EWARS and Information Management; Material Resources; Human Resources

The scope of analysis spanned multiple system levels. Two peer-reviewed sources (20%) focused specifically on hospitals, with both examining CBRN-specific preparedness. One study described the development of a hospital CBRN preparedness assessment tool built through multiple rounds of reviews by a panel of medical experts, otherwise known as a modified Delphi consensus process, while the other used a cross-sectional survey to assess emergency department preparedness for CBRNe incidents [13, 14].

Eight sources (80%) focused on the system level, addressing broader preparedness capacities. Among these, two sources evaluated national capacities to examine how well Lebanon meets global health security guidelines; one through a mixed methods academic research paper and the other through an official self-assessment report submitted to the World Health Organization (WHO) [15, 16]. Two grey literature sources focused on system-level structures and frameworks, including a national report on nuclear safety and radiation governance, and a handbook outlining how the country’s central health emergency response centre handles operational coordination [17, 18]. Four grey literature sources examined preparedness and response through applied and practice-based perspectives. Two documents (20%) addressed field exercises: one providing guidance on the organisation and implementation of a CBRN counter-terrorism exercise, and another outlining the design and objectives of a planned national exercise [19, 20]. In addition, two case study-based sources (20%) from the International Federation of the Red Cross and Red Crescent Societies analysed their participation in the response to the 2020 Beirut Port Explosion [3, 21].

Across all included sources, methodological approaches were diverse. Correspondingly, the objectives ranged from developing and applying CBRN preparedness assessment tools, evaluating facility-level readiness, and assessing national capacities, to providing operational guidance, documenting emergency response experiences, and outlining preparedness frameworks and system-level governance.

The findings are presented below according to relevant health system domains identified across the included sources.

International frameworks

CBRN health sector preparedness in nation-states is mandated at the international level by the International Health Regulations (IHR) of the World Health Organization (WHO), which requires state-parties to conduct “surveillance, reporting, notification, verification, response and collaboration” activities in the event of a public health emergency, including specific capacities for CBRN incidents. Lebanon ratified the IHR in 2007 and is supported by the WHO through the provision of guidance documents, capacity building initiatives and reporting mechanisms. In the 2025 IHR self-assessment, the national IHR focal point functions and emergency preparedness planning scored both an 80% grade [15, 16]. Lebanon also collaborates with European safety programmes which support partner countries in targeted efforts of CBRN risk mitigation and preparedness capacities by delivering technical assistance and facilitating international cooperation [17, 19, 20]. Individual components of CBRN are addressed through the ratification of international treaties, such as global nuclear safety treaties which oversee and monitor the regulation of radiological and nuclear agents [17].

National bodies, strategies, and regulations

CBRN governance in Lebanon is distributed across actors with varying preparedness, response, and regulatory responsibilities (Fig. 3). The national CBRN Commission, created in 2013, leads national preparedness efforts and plays an influential role through policy and planning instruments [15]. The Commission reports to the Prime Minister’s Office and is exclusively composed of governmental agencies, notably ministry representatives, technical agencies, and security forces, the Lebanese Atomic Energy Commission (LAEC) and the Lebanese Army. It does not include non-governmental actors that participate in CBRN incident response, such as the Lebanese Red Cross (LRC), private hospital representatives or other non-state entities [15, 17] The Commission’s work is operationalised primarily through action plans, regulations and strategies, much of which has been developed through external funding, due to domestic resource constraints [15, 20]. The Ministry of Public Health (MoPH) serves as the IHR focal point and oversees implementation of related health policies [15, 18]. The LAEC, established by decree-law 105/1983, serves as the national control authority for ionizing radiation and is housed within the National Council for Scientific Research. It mainly exercises regulatory functions including licensing, inspection and maintenance of the national source register [17].

Fig. 3.

CBRN governance in Lebanon

Incident response and management are heavily dependent on a wider set of actors, notably non-governmental entities and security forces. The MoPH is responsible for deploying a multi-agency Hazmat teams, while the Lebanese Army is responsible for nuclear source detection, in collaboration with the police, Red Cross and Civil Defence [15, 17, 19, 20]. Medical response is primarily provided by the Lebanese Civil Defense and Lebanese Red Cross volunteers, a non-governmental entity that provides basic life support services and transport. In large-scale events, the army can sometimes assist in inter-hospital transport [3, 21].

Operational radiological and nuclear response is delivered by a multi-agency team drawn from the Lebanese Army, Civil Defense, Beirut Fire Fighters, the Lebanese Red Cross and Police [17]. The Armed Forces also performs detection and source-search functions under supervision from the LAEC, whose operational role is confined to radiological and nuclear hazards, comprising environmental radiation monitoring, assistance during radiological or nuclear emergencies, and custody of orphan and out-of-regulatory-control sources [17]. In national exercise scenarios, both armed forces and the LAEC lead radiological source-search operations and provides radiation safety oversight rather than overall incident command [20]. Additionally, hospitals, notably private establishments, receive patients dispatched through the Public Health Emergency Operation Centre (PHEOC), housed at the MoPH [18]. Given the lack of public resources, emergency relief assistance from international donors is often needed, typically in the form of specialized equipment and, depending on the scale of the incident, first-response teams [3, 20, 21].

CBRN actors operate primarily through executive instruments (decrees, strategies, action plans, training activities), in the context of limited comprehensive legislative frameworks [15]. Some legal frameworks, such as those for the Convention on Nuclear Safety, have been adopted by the Lebanese Parliament [17]. Dedicated IHR legislation was drafted in 2016; however, it remains unratified [15]. All resources, actors, trainings and activities identified in the literature are mostly concentrated in the capital, Beirut [19, 20]. The review did not identify efforts to decentralize governance and capacities across the Lebanese territory.

Coordination

Strong multi-sectoral coordination mechanisms are stressed as a vital component of public health emergency preparedness, particularly in the context of increasing CBRN risks where the participation of non-health sectors is pivotal to public health risk prevention and control. [15] While the CBRN National Commission includes representatives from several sectors, assessments of multi-sectoral coordination for public health emergencies in Lebanon has highlighted an over reliance on the MoPH, noting limited participation from non-health sectors [15], with the national capacity scoring only 60% on IHR self-assessment tools [16]. The CBRN National Commission also conducts biennial EU-supported field exercise simulations called “ARZ” (Cedar in Arabic) to test multi-sectoral coordination for emergency response, regrouping national security forces, the LAEC, first responders, and hospitals (both private and public) [15, 19]. Further, a coordination hub at the MoPH was established to support coordination through watch, alert and response mechanisms, supported by the Epidemiological Surveillance Unit and the Disaster Risk Management Unit [18]. However, a 2026 study found that half of the responding emergency departments lack adequate communications with external agencies to facilitate coordination during emergencies [14].

EWARS and information management

Lebanon’s capacities for early warning, alert and response systems (EWARS) for public health emergencies achieved an overall surveillance score of 60% in 2024, including scores of 40% for early warning functions and 80% for event management mechanisms [16]. In 2014, Lebanon established the emergency operations centre and surveillance program, which included event-based surveillance that draws upon community reporting, social media and telephone hotlines, alongside data collection from medical field units [15]. Strengthening efforts have since included updated surveillance procedures, dissemination of surveillance guidelines to medical facilities, and workforce training on standard operating surveillance and response protocols [15]. These systems are managed by PHEOC, which serves as the ministry of public health’s central command hub for preparing and responding to health emergencies. PHEOC is responsible for managing health crises, infectious disease outbreaks, and mass casualty events through digital platforms connected to peripheral health facilities and the MoPH. It also works alongside the Epidemiological Surveillance Unit to perform national watch, alert, and response duties [18]. However, limitations in material and human resources have undermined the feasibility of employing surveillance and information systems consistently [15].

Material resources

Despite the relatively high scores submitted by the MoPH for financing IHR capacities (80%), and chemical event resource capacities (80%), material resource availability has been cited as a key weakness for CBRN health emergency preparedness in Lebanon, attributed predominantly to ongoing economic instability and crisis conditions [3, 15, 16, 21]. Chronic shortages of funding, essential supplies, and critical infrastructure, including electricity, fuel, and internet, have been highlighted as being particularly detrimental to the development and maintenance of preparedness capacities [15], with CBRN-specific resources being similarly affected [16]. Deficits encompass specialised CBRN infrastructure such as decontamination units and negative pressure rooms, as well as limited pharmaceutical stockpiles and reliance on imported medications [14]. CBRN-related initiatives, including IHR related activities, drills, and equipment acquisition rely predominantly on external support, including WHO and EU funding, and internationally donated equipment [15, 20].

Human resources

National efforts to strengthen human resource capacities have involved training programs in surveillance and response, radiological and nuclear emergency response, and CBRN emergency preparedness across health and non-health professionals [15, 17, 20]. Between 2013 and 2022, more than 340 trainees from first-responder agencies received radiological and nuclear response training delivered through international donor-funded projects [17]. The trained national radiological and nuclear emergency team is drawn jointly from the Lebanese Army, Civil Defence, Beirut Fire Brigade, Lebanese Red Cross and Police [17]. The Lebanese Red Cross contributes substantial human resources to response operations, mobilizing thousands of volunteer surge staff and maintaining a specialised CBRN team [1–3]. A medical hazardous materials team was established in 2017 and trained on CBRN response [15]. In its 2024 self-assessment, Lebanon reported a human resources capacity score of 67% [16]. Yet, increased migration of medical practitioners since the 2019 crisis has limited the sustainability of training initiatives, and recent data indicate that healthcare workers in hospital emergency departments report limited basic knowledge of radiation risks, with the large majority identifying unmet training needs [14, 15].

Pre-hospital emergency medical services (EMS)

Both Civil Defense and LRC teams constitute a central component of pre-hospital response, maintaining a large workforce of staff and volunteers, including a specialised CBRN unit, and providing ambulance services, first aid, triage, and patient transport, as demonstrated during the response to the 2020 Beirut Port Explosion [3, 21]. Their deployment is supported by the Lebanese Army and other security agencies, who provide additional logistical and human resources for first aid and transport. Transport is coordinated through PHEOC, which dispatches patients in relation to triage data and hospital readiness [18]. These first responders participate in national CBRN preparedness activities [17, 19]. Since the activation of PHEOC in 2024, first response preparedness mechanisms were enhanced with targeted trainings around facilitating communication, patient transfer, and synchronisation across agencies during emergencies [18].

Hospitals

Hospitals are identified as the primary sites for the management of CBRN casualties in Lebanon, undertaking triage, stabilisation, and clinical care within the emergency health system [13]. At the national level, hospitals are incorporated into preparedness frameworks, with defined responsibilities for maintaining preparedness plans, training healthcare workers, and ensuring the availability of medications and personal protective equipment, alongside the designation of 17 hospitals as reference facilities for chemical emergencies [15]. Some specific infrastructural and specialised capacities have been reported, including isolation rooms equipped with trained personnel and protective equipment, as well as regulated management of radiological materials and radioactive waste under national oversight [15, 17]. However, these capacities are variable, with 2022 assessments of CBRN preparedness in hospitals highlighting low levels of readiness and gaps across multiple domains, including training, surveillance, and reporting [14]. Hospital capacities are further weakening in light of the recurrent disasters that have occurred since 2019, including the Beirut Port Explosion, during which hospital infrastructure sustained significant damage [21].

Discussion

This review identified systemic efforts to strengthen preparedness for CBRN health emergencies in Lebanon, including engagement with international preparedness frameworks, multisectoral governance structures, and coordination and training initiatives. Conversely, it also demonstrated persistent structural weaknesses in preparedness sustainability and operationalisation, notably in constraints on material and human resources, coordination of medical response, and legislative functions.

Strengths

The findings demonstrate increasing institutional recognition of CBRN hazards as a public health concern. This is reflected in the establishment of national governance structures and Lebanon’s engagement with international preparedness initiatives, particularly through the National CBRN Commission and recurring ARZ exercises. These mechanisms have facilitated multisectoral coordination aligned with CBRN preparedness requirements. This broader trend is also reflected in Lebanon’s profile on IHR self-assessment tools, where the country reported comparatively strong scores for national IHR focal point functions and emergency preparedness planning (both 80%) [16]. Although dedicated IHR legislation remains unratified, reliance on executive instruments, strategies, action plans, and operational preparedness activities has allowed some CBRN-related preparedness work to continue despite slow legislative processes [15].

The presence of these governance structures has also provided a mechanism for capturing lessons learnt from recent emergencies with CBRN relevance, including technological hazards, conflict-related hazardous exposures, infectious disease outbreaks, and complex mass-casualty events. [22] This represents progress compared with earlier periods in which CBRN preparedness was less formally institutionalised within national emergency planning. The inclusion of experts, academics and health practitioners supports evidence-informed planning, while strong and consistent relationships with international partners, such as the EU and the WHO, have helped offset domestic financing constraints.

Weaknesses

Despite these efforts, major gaps remain in operational integration, resource availability, and institutional sustainability. These are exacerbated by the multiple crises the country has been grappling with, leaving persistent weaknesses in emergency response and public health [3, 15].

The actors playing central operational roles, namely the Lebanese Red Cross and receiving hospitals, are not represented on the body that sets preparedness policy (The National CBRN Commission). This separation is visible in the findings: pre-hospital providers are reported as delivering basic life support and transport, while hospitals are identified as the primary sites of CBRN casualty management yet report deficits in the decontamination infrastructure this role requires [3, 13, 21]. International guidance identifies decontamination before transport as central to limiting exposure among patients, responders and receiving facilities [10]. Although LRC and Civil Defense provide essential pre-hospital response capacity, their ability to deliver advanced on-site medical care and decontamination remains limited. The burden of decontamination eventually shifts to receiving hospitals, which increases costs and risks, and is administered according to individual resources and protocols [13]. Hospitals also face limited incentives to invest in CBRN preparedness due to inadequate funding, particularly in health systems that are highly privatised and where preparedness investments are rarely reimbursed or financially supported [23]. Even well-resourced private hospitals reported operational difficulties during the Beirut Port Explosion, due to limited stockpiles of medications and medical supplies, suggesting that private-sector capacity cannot substitute for state-led national planning [23, 24].

Regional self-assessment score comparisons suggest that such limitations are widespread across lower-middle income WHO EMRO states, with Lebanon scoring 40% for infection prevention control and chemical and radiation decontamination, compared to 60% in Jordan and Egypt and 20% in Morocco [16, 25–27]. These gaps are especially concerning given the concentration of preparedness activities in Beirut and the limited available assessment of readiness levels, training activities, and investments outside the capital. This is particularly relevant in areas where conflict exposure and socioeconomic vulnerability may heighten disaster risk [28].

Human resource limitations similarly emerged as a major barrier to preparedness, due in part to the migration of a significant proportion of healthcare professionals following the various catastrophic events that occurred over the past few years [15, 29]. Although continuous workforce development through training and simulation exercises is a requirement of the IHR Monitoring and Evaluation Framework [7], there is limited evidence to suggest that regular nationwide CBRN training programmes are being conducted for medical personnel in Lebanon. Ideally, technical training should be repeated every 6–9 months to address gaps in workforce knowledge, enhance operational competence, and ensure the safe and effective use of protective equipment, particularly for CBRN hazards which pose unique technical, operational, and safety challenges [14, 30].

Dependence of the Lebanese CBRN sector on non-state and international resources represents an additional vulnerability. Technical expertise, operational response, specialist training, and financial support are covered in majority by international partners, particularly through the EU CBRN Centres of Excellence initiative and the WHO [15, 20]. Local NGOs, such as the Lebanese Red Cross, provide substantial surge staffing and operational response capacity to compensate for the government’s lack of resources [3]. Heavy dependence on external assistance may undermine long-term preparedness sustainability, particularly where funding remains crisis-driven and response-oriented rather than focused on sustained prevention and mitigation capacities.

Finally, legislative development has lagged behind executive action. Draft IHR legislation prepared in 2016 remains unratified, and statutory coverage is partial and agent-specific, confined largely to nuclear safety instruments. Preparedness therefore rests predominantly on decrees, strategies and action plans, which are more readily revised or discontinued than statutory mandates. Notably, no legal instrument mandates domestic budgetary allocation for CBRN preparedness, which may help explain why the financing patterns identified above remain donor-dependent and crisis-driven rather than institutionally embedded [15].

Collectively, the findings suggest that while important developments have strengthened CBRN health emergency preparedness in Lebanon, persistent structural weaknesses continue to hinder the operational capacities and long-term measures required for effective preparedness.

Policy implications

This review identifies strengths and weaknesses of the current landscape of CBRN governance that can inform policy design and improve operational preparedness in Lebanon. First, including non-governmental actors that are central to CBRN response (ie Lebanese Red Cross and private hospital representation) within the national CBRN Commission should be considered. Their inclusion would allow CBRN policy and planning to better reflect operational constraints and improve coordination during emergencies.

Second, greater attention should be directed toward operational readiness outside Beirut. Regional CBRN actors should be included in local preparedness planning and recurring multisectoral exercises, with these efforts tailored to local hazards, capacities, and territorial characteristics.

Third, the government should diversify financing mechanisms for disaster preparedness within an all-hazards framework that includes CBRN-specific requirements. This would help reduce long-term reliance on crisis-driven external support. Including private hospitals in governance and financing arrangements may also support the development of on-site decontamination capacity through pooled resources and shared protocols.

Finally, ratification and implementation of the pending IHR-related legislation drafted in 2016 would place preparedness obligations on a statutory rather than administrative footing. Legislative instruments should nonetheless complement rather than replace existing executive mechanisms, which the findings indicate have sustained preparedness activity during periods of legislative inaction.

Limitations

No formal structured critical appraisal of source quality was undertaken, consistent with the narrative review design. The evidence base is heterogeneous in type and methodology and includes self-assessed national reporting; findings should therefore be interpreted as indicative of reported capacity rather than independently verified performance

Conclusion

Lebanon has undertaken important efforts to strengthen preparedness for CBRN health emergencies through engagement with international frameworks, the establishment of multisectoral governance structures, and the development of operational coordination and training initiatives. However, the findings show that national capacities remain uneven and constrained by fragmented coordination, limited operational integration, legislative gaps, shortages in material and human resources, and heavy reliance on external support. Advances in specialised technical capacities and governance mechanisms therefore coexist with broader systemic weaknesses affecting sustainability and implementation. Strengthening CBRN preparedness will require greater institutionalisation of preparedness measures, improved coordination between pre-hospital and hospital systems, sustainable financing, and more integrated multisectoral governance. Given Lebanon’s continued exposure to recurrent crises and regional instability, CBRN preparedness should be considered a critical component of health system resilience and national disaster risk reduction.

Abbreviations

ARZ

Name of Lebanon’s recurring national CBRN exercises

CBRN

Chemical, biological, radiological, and nuclear

CBRNe

Chemical, biological, radiological, nuclear, and explosive

COVID-19

Coronavirus disease 2019

ED (EDs)

Emergency department(s)

EMRO

Eastern Mediterranean Regional Office

EMS

Emergency medical services

EU

European Union

EWARS

Early warning, alert and response systems

Hazmat

Hazardous materials

IHR

International Health Regulations

LAEC

Lebanese Atomic Energy Commission

LRC

Lebanese Red Cross

MeSH (MeSHes)

Medical Subject Heading(s)

MoPH

Ministry of Public Health

NGO (NGOs)

Non-governmental organization(s)

PHEOC

Public Health Emergency Operation Centre

PPE

Personal protective equipment

WHO

World Health Organization

Biographies

Eveline Hitti

is Chairperson & Professor of Clinical Specialty, and Professor of Clinical Emergency Medicine at the American University of Beirut Medical Center. Dr. Hitti is board certified in emergency medicine (ABEM), with research interests in evidence-based health management, mass-casualty response in low-resource settings, and emergency medicine development and capacity building. Dr Hitti has overseen the Emergency Department’s mass casualty preparedness and response for 16 years.

Tharwat El Zahran

is Associate Professor of Clinical Emergency Medicine, Director of Clinical Operations for the Department of Emergency Medicine, and Co-Director of Toxicology Service, Emergency Department, at the American University of Beirut Medical Center. Dr. Zahran’s research interests lie in intentional/unintentional drug exposures, CBRN agents of opportunity, snakebites, and toxicological emergencies. Dr Zahran oversees the hospital’s CBRN preparedness and response plan.

Antoine Kallab

is an Advisor to the Lebanese Minister of Industry, a Public Policy Consultant and an Instructor of Environmental Policy and Strategy at the American University of Beirut. He holds a Masters’ in Architecture from the École Spéciale d’Architecture de Paris, an MSc in Urban Economic Development from University College London, a Masters’ in Geopolitics from IRIS Sup’ Paris, and a Masters’ in Public Administration from Université Bretagne Occidentale. His expertise covers public policy design, environmental policy, urban economic development, and disaster management governance.

Layla Farah

is a Research Assistant in the Emergency Medicine Department at the American University of Beirut Medical Center and holds a BA in History and International Relations from King’s College London. Her research interests centre on conflict and development in the Middle East and North Africa, with a focus on resilience and recovery in fragile and conflict-affected settings.

Author contributions

Conceptualisation: E.H & T.Z.; investigation: E.H., T.Z.; supervision: E.H, T.Z. & A.K.; visualisation: L.F., A.K., writing – original draft: L.F., A.K.; writing – review and editing: E.H., T.Z., A.K., and L.F. All authors have read and agreed to the published version of the manuscript.

Funding

Stimulus Funding 2024-2025 Award Number: 104605.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.