COVID-19 Rehabilitation in Vulnerable Populations

Original Editor - Jess Bell Top Contributors - Jess Bell, Stacy Schiurring, Kim Jackson, Tarina van der Stockt, Lucinda hampton, Aminat Abolade, Admin and Olajumoke Ogunleye

Introduction

COVID-19 poses a severe threat to all communities, but refugees/displaced people and those living in low-income areas face even greater challenges.

The United Nations High Commission for Refugees found that in 2018, over 70.8 million people worldwide were forcibly displaced, which is the highest figure of population displacement ever recorded. 41.3 million of these individuals were internally displaced people (ie they remain within their country’s borders), 3.5 million were asylum seekers (ie have crossed international borders but are awaiting decisions to determine their refugee status) and 25.9 million were refugees (ie have fled their home, but been granted refugee status in another country).

Because of their past experiences, these individuals often present with various complex health issues and have a greater prevalence of comorbidities, including both non-communicable and communicable diseases. However, they generally face administrative, financial, legal and language barriers which impact on their ability to access health services. For example, in Greece a recent study reports that around 62% of the 80,000 undocumented migrants living in over-crowded camps have unmet health needs. 53% had major difficulty accessing health services due to barriers such as cost and long waiting lists.

Moreover, refugees/displaced people are often living in camps or camp-like settings where living conditions are inadequate. They are:

• Often overcrowded
• Lack of basic amenities, including clean running water and soap
• Have insufficient access to healthcare professionals and poor access to health information. For instance, in Greece, there is only one public physiotherapist available for every 12,852 people and many people report that they queue for hours to access medical services at both public and NGO clinics, only to be turned away unseen at the end of the day.

Thus, basic prevention measures like social distancing, hand hygiene and self-isolation are more difficult to implement in these settings. These individuals may, therefore, be more heavily impacted by COVID-19.

It is important to note that while these groups are more vulnerable to COVID-19, evidence suggests that they have a low risk of transmitting communicable diseases to host countries as they are effectively isolated from the wider community. Aid workers who visit the camps are the most likely vectors for transmission of COVID-19 into camps. The World Health Organisation highlights the importance of communicating to communities that migrants and refugees do not pose an increased risk in comparison to other travellers, but they are more vulnerable and need additional support, particularly in relation to preventive and care services.

Impact of COVID-19 on Vulnerable Populations

There are three key reasons why COVID-19 will likely have an even greater impact on refugees/displaced people:

1. There will likely be a higher transmission of COVID-19 in camps/camp-like settings due to larger household sizes and overcrowding in camps, as well as certain cultural/religious practices such as mass prayer gatherings, large weddings and funerals.
2. There will be higher infection-to-case ratios and progression to severe disease due to COVID-19’s interaction with comorbidities, including non-communicable diseases, under-nutrition, tuberculosis and HIV.
3. There is also a lack of intensive care capacity in these settings, which will lead to higher fatality rates. The extreme pressure on health services can reduce access to other services, thus adversely affecting health outcomes related to other conditions.

Ways to Address these Issues

Low-income countries and areas affected by the crisis are, like higher-income nations, attempting to prevent COVID-19 from entering through border closures and introducing social distancing and quarantine measures. These measures are, however, resource-intensive, and it is argued that they are not easily replicated in lower-income/crisis settings. This is because it is more difficult to introduce adequate surveillance and testing in these areas. Thus, it is harder to determine levels of community transmission of COVID-19.

In order to reduce the transmission of COVID-19 in the community, it has been found that most non-essential workers need to work from home. However, this strategy is not well suited to many low-income settings. Moreover, it needs to be sustained long term until either vaccination or treatment (or both) is available.

Measures such as travel restrictions can be harmful to export-dependent economies. This quickly has an impact on individuals’ livelihoods, which reduces the likelihood a community will adhere to control measures. Thus, these strategies may work for a limited time and provide a window to prepare a response to COVID-19 but may fail long term.

As mentioned, COVID-19 appears to have a more significant impact on individuals with certain comorbidities. Thus, one measure to reduce the impact of this virus could be to maintain existing health services that focus on non-communicable disease, TB and HIV detection and management. Non-essential services can also be postponed to free up health service capacity.

It is unlikely in low-income or camp-like settings that intensive care services can be increased to the levels required if there is a large outbreak of COVID-19. Similarly, isolating patients with COVID-19 in general wards may not be clinically beneficial or reduce transmission of the virus. Without adequate training and infection control supplies, these sorts of facilities could generate increased risk for health workers - this is significant as there is often a scarcity of workers in low income and crisis settings.

Shielding

Because of these issues, a report by Favas for the London School of Hygiene and Tropical Medicine/Health in Humanitarian Crisis Centre have suggested that a more targeted approach focused on “shielding” high-risk individuals may be an option in these settings - it should be noted that this is not the only approach and may not be adopted in all areas.

Shielding in the context of COVID-19 is, essentially, a reversal of the approach taken in Ebola epidemics where unwell individuals are isolated into contaminated ‘red zones’, so that healthy individuals are protected. In COVID-19, a green zone is created for at-risk individuals. In this zone, these individuals can be shielded from the transmission of COVID-19 and cared for if they need to isolate.

While there is no one approach that will fit all settings, shielding aims to protect those who are most vulnerable from infection by helping them to live safely, but away from their families and neighbours for an extended period of time, until treatment or vaccinations are available.

Who Should Be Shielded?

The risk from COVID-19 appears to increase with age, particularly those aged over 70 and/or those who have non-communicable diseases and other immuno-suppressing conditions. It has been suggested that in low-income/crisis-affected settings, the high-risk definition should be extended to include:

• Individuals aged 60 and above
• Individuals  living with TB or HIV
• Malnourished adults

Types of Shielding

There are three main shielding options

1. Household-level shielding (where a room/area in a house is demarcated as a green zone).
2. Street or extended family level shielding (a specific shelter/group of shelters within a small camp area - for a maximum of 5-10 households)
3. Neighbourhood or sector level isolation (eg in displaced persons’/refugee camps - ideally located at the periphery of camps, comprising of a specific group of shelters in a camp for up to 50 high-risk individuals, with infection control/social distancing)

Implementation of Shielding

Ideally, the selection of shielding measures should be community-led (although this may not always be possible). Decisions to consider include:

• Deciding which household members meet the inclusion criteria for shielding
• Who should be moved to each green zone
• Which shelters should be vacated/swapped
• What provisions (such as beds and supplies) need to be transferred

Managing Symptomatic Residents of the Green Zone

It is essential that there is an alert system, so that if/when an individual develops symptoms of COVID-19, s/he will be immediately isolated (and tested where possible). Isolation measures will vary depending on the context.

Health Service Provision

Where possible, it is important that health services are as close as possible to the green zones. This will reduce the amount of movement of individuals outside of the green zone. There are various options to provide these services, including the use of mobile clinics.

People with Disabilities

It is important to note that COVID-19 presents even greater risks for refugees/displaced people living with disabilities. It is estimated that 15% of the world’s population have disabilities. However, these figures may be higher in areas where there is a conflict or humanitarian crises. For instance, it is estimated that 30% of the population aged 12 and above in Syria are people with disabilities.

People with disabilities will face higher health risks as a result of COVID-19 - they may be more susceptible to getting the virus and having significant sequelae. They also face various challenges due to changes in their environment, including reductions in services, such as social support, rehabilitation or protection service. These changes further exacerbate the impact of COVID-19 on these individuals, leading to poorer health outcomes, including permanent impairments and reduced function. Thus, it is essential that both people with disabilities and their relevant support organisations are actively involved in COVID-19 planning to ensure that their needs are considered.

Rehabilitation Planning for Refugees/Displaced People

Specific rehabilitation for COVID-19 is discussed here. Shortages of PPE have been highlighted elsewhere in all settings, so it is important to ensure that you are aware of local requirements/standards for infection control. Standard infection control practices are discussed here. Read more about the mental health challenges of refugees here. However, there are some considerations, which are specific to working with refugees/displaced people.

Healthcare for refugees and displaced people often takes place in difficult social, political, and economic contexts and no universal rehabilitation model exists to meet their needs. However, certain key points should be considered when planning rehabilitation services:

• Each individual should be individually evaluated and their rehabilitation needs should be considered.
  • Measures such as the International Classification of Functioning, Disability and Health (ICF) and adopting the biopsychosocial method can be useful in this context.
• Management should be holistic and consider physical, psychological, social and cultural dimensions. Some interventions, such as manual therapy, may not be appropriate for all cultures. Similarly, some communities may be more collectivist in nature, so group interventions of those that engage family members may be more beneficial for some individuals. However, it is important to note that all management plans and modifications based on culture should be considered an individual basis to avoid cultural stereotyping.
• Barriers, including cultural differences, language and limited information available contribute to poor outcomes. WHO advises that refugees and migrants should be involved in the creation of readiness/response plans/strategies, which may help to address some of these issues.
• When assessing children, it is important to remember that they are at increased risk of various physical, behavioural and developmental health issues. Understanding each child's immigration history will enable the healthcare team to carry out appropriate screening for infectious diseases and determine any other exposure risks (including trauma).
• A lack of understanding of the complexities of health issues faced by refugees/displaced people on the part of the health provider will also contribute to poor outcomes. Disparities in health outcomes for patients from different cultural/linguistic backgrounds have also been documented. Physiotherapists must, therefore, have an understanding of refugee health and be able to provide culturally appropriate care. This goes beyond the use of an interpreter; physiotherapists need to be familiar with the common beliefs and practices held by the communities they work with. They must be able to recognise that there is always intra- and inter-cultural variation. Moreover, they must reflect on their own personal/professional culture and any associated biases.

Summary

• Refugees/displaced people and those living in low-income areas will face significant additional challenges during the COVID-19 pandemic.
• They must, therefore, be actively involved in planning their community’s response to ensure it meets their needs.
• Many refugees/displaced people have significant long-term, pre-existing health conditions which may increase their vulnerability to COVID-19 and the related alterations/reductions in existing healthcare services.
• It is important that rehabilitation services for refugees/displaced people are holistic and all domains are considered.