key: cord-284477-3mspnc8q
authors: Kassem, Issmat I.
title: Refugees besieged: The lurking threat of COVID-19 in Syrian war refugee camps
date: 2020-05-05
journal: Travel Med Infect Dis
DOI: 10.1016/j.tmaid.2020.101736
sha: 
doc_id: 284477
cord_uid: 3mspnc8q

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No funding sources. deaths, respectively, as of April 9 th [1] . This perhaps casts shadows of doubt on the absence of outbreaks or cases in the camps. Indeed, there are suggestions that the refugees might not be reporting infections due to 1) lack of knowledge in regards to infection and symptoms, 2) lack of access to tests, which are already limited and insufficient for the needs of the hosting communities, and 3) fear of stigma which might lead to increasing restrictions and crackdown on the refugees. COVID-19 has ignited fears in many communities and reactions to patients or potential carriers of the virus are not always charitable. Furthermore, it is well known that certain hosting countries established curfews and implanted deportations of unregistered refugees even before the onset of the pandemic. Therefore, tackling the spread of COVID-19 in the refugee camps appears to be complicated and fraught with many complications.

A quick assessment of the nature of the disease can reveal the potential scope of threat to the refugees. It is known that COVID-19 is mainly transmitted via the respiratory route (spreads by close proximity), and that patients with comorbidities and those that are prone to recalcitrant and antibiotic-resistant secondary infections do not fair comparatively well. Additionally, the major current approaches to control the spread of COVID-19 in communities, include 1) social distancing, 2) close adherence to hygienic approaches (washing and disinfection), and 3)

protective gear (such as masks and gloves), 4) frequent testing and quarantines, and 5) maintaining a good health. These measures in any community have proven difficult, but they might be even more challenging in Syrian refugee camps. Indeed, it is widely known that many refugee populations that witnessed catastrophic events might be immunosuppressed and can carry multidrug resistant pathogens [2] , while the camps also host elderly refugees, which are particularly susceptible to COVID-19. Furthermore, populations of refugees live under crowded conditions in makeshift tents that provide little protection, while camps may share common services, which render distancing very difficult. Furthermore, the quality and availability of water (drinking and domestic) in many camps are insufficient; with intermittent access, shortages and documented contamination with bacterial indicators of fecal pollution and multidrug resistant pathogens [3, 4] . This obviously decreases the efficacy of hygienic practices that rely mainly on sufficient access to clean water and is more problematic in scenarios that also include shared latrines and vulnerable camp water cisterns. Additionally, shortages in-and monopolization and soaring prices of protective gear, disinfectants, virus tests and nutritious food mean that these items will be even more scarcely available for the refugees, which will adversely impact the maintenance a good health.

The situation is layered further with more complications and challenges. For example, Lebanon, a country that hosts an estimated 1.5 million Syrian refugees (distributed in makeshift camps and other dwellings) is currently facing a very severe economic crisis, civil unrest (decreased after the pandemic), and a COVID-19 outbreak. Lebanon is currently under a curfew in order to control the disease, and prices of food and medicine are soaring in a country that relies heavily on imports to meet its needs. The latter is becoming more difficult under restrictions imposed by the economic crisis as well as the spread of the disease. Consequently, allocating resources and much needed help to the refugees might be unavailable or scarce at best.

While the UN Refugee Agency (UNHCR) and other NGOs are attempting to provide support and awareness to the refugees, the realty is that significant funding is required, given the various needs and the high number of refugees. In that regard, the UNCHR has appealed for urgent funding to combat COVID-19 in refugee camps, but the results of this initiative remain to be seen [5] . In contrast, there are anecdotal reports of fears that foreign aid might withdraw from the camps due to the pandemic. The latter would have severe consequences, especially in case of an outbreak, which will leave the refugees besieged in their camps and facing a dire threat.

During these challenging times, we call for global and urgent support for these disenfranchised populations. The health of refugees is intimately linked to that of their hosting communities and beyond, which is more reason to protect the camps from COVID-19.

Consequently, an uncontrolled outbreak would result in significant morbidity and mortality that might not be confined to the camps. Therefore, transparent and thorough investigations along with preemptive and inclusive control measures are urgently required to prevent and/ or control the dissemination of COVID-19 in Syrian and other refugee camps worldwide.

The authors declare no competing interests.

Ethical approval: None was required.

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