The potential impact of COVID-19 in refugee camps in Bangladesh and beyond: A modeling study

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PLoS Medicine
http://www.plosmedicine.org/
(Accessed 20 June 2020)
Research Article
The potential impact of COVID-19 in refugee camps in Bangladesh and beyond: A modeling study
Shaun Truelove, Orit Abrahim, Chiara Altare, Stephen A. Lauer, Krya H. Grantz, Andrew S. Azman, Paul Spiegel
| published 16 Jun 2020 PLOS Medicine
https://doi.org/10.1371/journal.pmed.1003144
Abstract
Background
COVID-19 could have even more dire consequences in refugees camps than in general populations. Bangladesh has confirmed COVID-19 cases and hosts almost 1 million Rohingya refugees from Myanmar, with 600,000 concentrated in the Kutupalong-Balukhali Expansion Site (mean age, 21 years; standard deviation [SD], 18 years; 52% female). Projections of the potential COVID-19 burden, epidemic speed, and healthcare needs in such settings are critical for preparedness planning.
Methods and findings
To explore the potential impact of the introduction of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the Kutupalong-Balukhali Expansion Site, we used a stochastic Susceptible Exposed Infectious Recovered (SEIR) transmission model with parameters derived from emerging literature and age as the primary determinant of infection severity. We considered three scenarios with different assumptions about the transmission potential of SARS-CoV-2. From the simulated infections, we estimated hospitalizations, deaths, and healthcare needs expected, age-adjusted for the Kutupalong-Balukhali Expansion Site age distribution. Our findings suggest that a large-scale outbreak is likely after a single introduction of the virus into the camp, with 61%–92% of simulations leading to at least 1,000 people infected across scenarios. On average, in the first 30 days of the outbreak, we expect 18 (95% prediction interval [PI], 2–65), 54 (95% PI, 3–223), and 370 (95% PI, 4–1,850) people infected in the low, moderate, and high transmission scenarios, respectively. These reach 421,500 (95% PI, 376,300–463,500), 546,800 (95% PI, 499,300–567,000), and 589,800 (95% PI, 578,800–595,600) people infected in 12 months, respectively. Hospitalization needs exceeded the existing hospitalization capacity of 340 beds after 55–136 days, between the low and high transmission scenarios. We estimate 2,040 (95% PI, 1,660–2,500), 2,650 (95% PI, 2,030–3,380), and 2,880 (95% PI, 2,090–3,830) deaths in the low, moderate, and high transmission scenarios, respectively. Due to limited data at the time of analyses, we assumed that age was the primary determinant of infection severity and hospitalization. We expect that comorbidities, limited hospitalization, and intensive care capacity may increase this risk; thus, we may be underestimating the potential burden.
Conclusions
Our findings suggest that a COVID-19 epidemic in a refugee settlement may have profound consequences, requiring large increases in healthcare capacity and infrastructure that may exceed what is currently feasible in these settings. Detailed and realistic planning for the worst case in Kutupalong-Balukhali and all refugee camps worldwide must begin now. Plans should consider novel and radical strategies to reduce infectious contacts and fill health worker gaps while recognizing that refugees may not have access to national health systems.

Author summary
Why was this study done?
:: Forcibly displaced populations, especially those who reside in settlements with high density, poor access to water and sanitation, and limited health services, are especially vulnerable to COVID-19.
:: Bangladesh, which has confirmed COVID-19 cases, hosts almost 900,000 Rohingya refugees from Myanmar in the Cox’s Bazar district, approximately 600,000 of whom are concentrated in the Kutupalong-Balukhali Expansion Site.
:: The capacity to meet the existing health needs of this population is limited; an outbreak of COVID-19 within this population threatens to severely disrupt an already fragile situation.
:: We conducted this study to estimate the number of people infected, hospitalizations, and deaths that might occur in the Kutupalong-Balukhali Expansion Site to inform ongoing preparedness and response activities by the Bangladesh government, the United Nations agencies, and other national and international actors.

What did the researchers do and find?
:: Using a dynamic model of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission, we simulated how a COVID-19 outbreak could spread within the expansion site according to three possible transmission scenarios (high, moderate, and low).
:: Our results suggest that a large-scale outbreak is very likely in this setting after a single infectious person enters the camp, with 0.5%–91% of the population expected to be infected within the first three months and over 70%–98% during the first year, depending on the transmission scenario, should no effective interventions be put into place.
:: Hospitalization needs may exceed the existing hospitalization capacity of 340 beds 55–136 days after introduction.

What do these findings mean?
:: A COVID-19 epidemic in a high–population density refugee settlement may have profound consequences, requiring increases in healthcare capacity and infrastructure that exceed what is feasible in this setting.
:: As many of the approaches used to prevent and respond to COVID-19 in the most affected areas so far will not be practical in humanitarian settings, novel and untested strategies to protect the most vulnerable population groups should be considered, as well as innovative solutions to fill health workforce gaps.