Crossing borders: one world, global health

Refugee Health During COVID-19 and Future Pandemics

Purpose of Review

This commentary summarizes recent literature pertaining to healthcare challenges and needs during the current pandemic among refugees and asylum seekers residing in a host country. We conducted a literature review to identify barriers to shielding these structurally marginalized populations from the impact of the COVID-19 pandemic.

Recent Findings

Many populations, including refugees, migrants, and asylum seekers, endure structural vulnerabilities in refugee camps and during their resettlement. These structural vulnerabilities include fear of contacting the healthcare system, cultural differences, housing insecurity, food insecurity, discrimination, lack of health insurance, health illiteracy and lack of readily available, and culturally appropriate educational materials. During pandemics, displaced persons suffer disproportionately from poorly managed chronic diseases, economic hardships isolation, and mental illnesses, in addition to the threats posed by the infectious agent.

Summary

Underserved groups, including refugee populations, shoulder a disproportionate burden of disease during pandemics. In order to mitigate the impact of preventable chronic illnesses and also reduce the spread of COVID-19 and other easily-transmissible and deadly viruses during pandemics, governments and public health authorities need to implement policies that allow refugees, asylum seekers, and displaced persons to be fully incorporated into their respective healthcare systems, so that they can be supported and protected and to reduce the amplifying networks of transmission.

Use of Oral Cholera Vaccine and Knowledge, Attitudes, and Practices Regarding Safe Water, Sanitation and Hygiene in a Long-Standing Refugee Camp, Thailand, 2012-2014

Oral cholera vaccines (OCVs) are relatively new public health interventions, and limited data exist on the potential impact of OCV use on traditional cholera prevention and control measures—safe water, sanitation and hygiene (WaSH). To assess OCV acceptability and knowledge, attitudes, and practices (KAPs) regarding cholera and WaSH, we conducted cross-sectional surveys, 1 month before (baseline) and 3 and 12 months after (first and second follow-up) a preemptive OCV campaign in Maela, a long-standing refugee camp on the Thailand-Burma border. We randomly selected households for the surveys, and administered questionnaires to female heads of households. In total, 271 (77%), 187 (81%), and 199 (85%) households were included in the baseline, first and second follow-up surveys, respectively. Anticipated OCV acceptability was 97% at baseline, and 91% and 85% of household members were reported to have received 1 and 2 OCV doses at first follow-up. Compared with baseline, statistically significant differences (95% Wald confidence interval not overlapping zero) were noted at first and second follow-up among the proportions of respondents who correctly identified two or more means of cholera prevention (62% versus 78% and 80%), reported boiling or treating drinking water (19% versus 44% and 69%), and washing hands with soap (66% versus 77% and 85%); a significant difference was also observed in the proportion of households with soap available at handwashing areas (84% versus 90% and 95%), consistent with reported behaviors. No significant difference was noted in the proportion of households testing positive for Escherichia coli in stored household drinking water at second follow-up (39% versus 49% and 34%). Overall, we observed some positive, and no negative changes in cholera- and WaSH-related KAPs after an OCV campaign in Maela refugee camp. OCV campaigns may provide opportunities to reinforce beneficial WaSH-related KAPs for comprehensive cholera prevention and control.

Safe water, sanitation, and hygiene (WaSH) are the primary measures for cholera prevention and control. Since 2010, oral cholera vaccines (OCVs) have been recommended as an additional tool for endemic and epidemic cholera prevention and control. Given the relatively new use of OCVs in public health programs, there is limited information on the impact of OCV use on traditional WaSH activities, i.e., can they serve as complementary tools, or will OCV use have a negative impact on WaSH-related behaviors? This study reports the findings of knowledge, attitudes and practices (KAP) surveys conducted before and after a preventive OCV campaign (2013) in a long-standing refugee camp in Thailand, where frequent cholera outbreaks had occurred in recent years. The surveys demonstrated high acceptability of the OCV campaign and several modest improvements in cholera and WaSH KAPs among the camp population. OCV campaigns may be used as opportunities to reinforce cholera and WaSH-related messaging towards strengthening comprehensive cholera prevention and control.