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Vulnerability of Syrian refugees in Lebanon to COVID-19: quantitative insights

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Fouad M. Fouad, Stephen J. McCall, Houssein Ayoub, Laith J. Abu-Raddad & Ghina R. Mumtaz

Abstract

Lebanon, a middle-income country with ongoing political turmoil, unstable economic situation, and a fragmented and under-resourced health system, hosts about one million Syrian refugees since 2011. While the country is currently experiencing substantial COVID-19 epidemic spread, no outbreaks have been reported yet among Syrian refugees. However, testing of this population remains limited and exposure levels are high given dire living conditions and close interaction with the host community. Here, we use quantitative insights of transmission dynamics to outline risk and contextual factors that may modulate vulnerability of Syrian refugees in Lebanon to potentially large COVID-19 epidemics.

Syrian refugees live in close contact with the host community, and their living conditions are favorable for epidemic spread. We found that the high levels of crowding within Syrian refugee households and among those in informal tented settlements, the inadequate water supply and sanitation, limited use of masks, inadequate access to health care, and inadequate community awareness levels are vulnerability factors that directly impact important parameters of transmission dynamics, leading to larger epidemic scale. Poverty, stigma, and fear of legal consequences are contextual factors that further exacerbate this vulnerability. The relatively high prevalence of non-communicable diseases in this population could also affect the severity of the disease among those infected. Mathematical modeling simulations we conducted illustrated that even modest increases in transmission among Syrian refugees could result in a large increase in the incidence and cumulative total number of infections in the absence of interventions.

In conclusion, while the young age structure of the Syrian refugee population might play a protective role against the scale and disease-burden severity of a potential COVID-19 epidemic, the epidemic potential due to several vulnerability factors warrants an immediate response in this population group. Local and international actors are required to mobilize and coordinate efforts to prevent the transmission of COVID-19, and to mitigate its impact amongst the vulnerable refugee populations globally.

Background

Since the start of the conflict in 2011, over 5.5 million people have fled Syria seeking refuge in neighboring countries [1]. Lebanon hosts the highest per capita number of refugees worldwide with approximately one million officially registered Syrian refugees [1]. Only 20% of those have legal residency, which complicates an already challenging situation in terms of housing, securing livelihood, and access to health care, among others [2]. About half of households live in extreme poverty and a large fraction continue to live in substandard settings [2]. Due to Lebanon’s non-encampment policy, Syrian refugees are widely dispersed throughout the country, both in urban and rural areas. The majority live in residential (69%) and non-residential (11%) structures in the host community, while the remaining 20% reside in informal tented settlements [2].

The protracted hosting of large refugee populations has placed additional strains on a middle-income country like Lebanon with ongoing political turmoil, unstable economic situation, and a fragmented, highly privatized, and under-resourced health care system. Since October 2019, Lebanon has been witnessing a popular uprising amidst an unprecedented economic crisis, which was further exacerbated by the emergence of the coronavirus disease 2019 (COVID-19) pandemic. In fear of a rapidly growing epidemic for which the health care system is largely unprepared, the government imposed early population lockdown which successfully suppressed the epidemic until July 2020 when infection spread resurged following rapid easing of restrictions. The August 4 Beirut port blast, which shattered the city and caused a large number of casualties, added further complexity to an already fragile situation. Several hospitals with large COVID-19 units were destroyed and the others were flooded with the injured, overstretching health care infrastructure and capacity. As of February 28, 2021, there were over 375,000 confirmed COVID-19 cases and 4,692 deaths, with hospitals in the country working near or at full capacity.

Despite substantial scale-up of the country’s testing capacity over time, testing of Syrian refugees has remained limited. As of July 10, 125 positive cases were confirmed among Syrian refugees, all of whom were identified in urban areas through contact tracing in clusters that were found among the local population [3]. Since the majority of the refugees live in the host community, their level of exposure is high due to close interaction with the wider population who is currently experiencing large epidemic expansion with a positivity rate close to 15%. Except for one national campaign conducted by UNHCR in informal settlements and collective shelters in June and where no cases were identified [3], there is no systematic testing of refugees living in these settings. While they may be relatively shielded due to lower contact with the host community and higher concentration of humanitarian efforts in the settlements, their living conditions create favorable context for a potentially large outbreak if the virus is introduced into these settings.

Refugees worldwide have been shown to have an increased vulnerability to infectious disease outbreaks compared to host populations [4], and COVID-19 is expected to be no exception. Despite some recent commendable efforts by UNHCR in scaling up preparedness plans [5], the response among the Syrian refugee population remains insufficient, particularly in terms of surveillance. In this commentary, we use quantitative insights of transmission dynamics to outline risk and contextual factors that may modulate vulnerability to potentially large COVID-19 epidemics among Syrian refugees in Lebanon.