key: cord-0927419-c5iaaeqy
authors: Hintermeier, M.; Gencer, H.; Kajikhina, K.; Rohleder, S.; Santos-Hoevener, C.; Tallarek, M.; Spallek, J.; Bozorgmehr, K.
title: SARS-CoV-2 among migrants and forcibly displaced populations: a rapid systematic review
date: 2020-12-14
journal: nan
DOI: 10.1101/2020.12.14.20248152
sha: eda9490131518a6eb62163f61bc0f37d338922f9
doc_id: 927419
cord_uid: c5iaaeqy

The economic and health consequences of the COVID-19 pandemic pose a particular threat to vulnerable groups, such as migrants, particularly forcibly displaced populations. The aim of this review is (i) to synthesise the evidence on risk of infection and transmission among migrants, refugees, asylum seekers and internally displaced populations, and (ii) the effect of lockdown measures on these populations. We searched MEDLINE and WOS, preprint servers, and pertinent websites between 1st December 2019 and 26th June 2020. The included studies showed a high heterogeneity in study design, population, outcome and quality. The incidence risk of SARS-CoV-2 varied from 0.12% to 2.08% in non-outbreak settings and from 5.64% to 21.15% in outbreak settings. Migrants showed a lower hospitalisation rate compared to non-migrants. Negative impacts on mental health due to lockdown measures were found across respective studies. However, findings show a tenuous and heterogeneous data situation, showing the need for more robust and comparative study designs.

The COVID-19 pandemic poses economic and health threats to people worldwide, especially to migrants and forcibly displaced populations, such as refugees, asylum seekers and internally displaced persons (IDP).

[1] Policy measures taken to mitigate the spread of the severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) may exacerbate poor health conditions among these populations, or exacerbate conditions which create or add to pre-existing vulnerabilities. Especially low-wage labour migrants and forcibly displaced populations often live in crowded accommodations where they share rooms as well as cooking and sanitary facilities with a number of people outside their own household.

Physical distancing and recommended hygiene measures are not feasible in many such contexts. [2] Considering that 78 to 85% of human-to-human transmissions take place in family clusters and up to 10% on household level, these conditions are likely to increase the risk of infection and rapid dissemination among migrants and displaced populations. [3] Precarious working conditions may add to these vulnerabilities, mainly in manual labour jobs e.g., agricultural, or domestic work, that do not allow for protective measures like self-isolation, home-office, or physical distancing. [2, 4] This often leads to the loss of livelihoods due to the policy and lockdown measures taken, as it happened to many migrant workers in India under the national lockdown in March 2020. [5] While the COVID-19 pandemic poses a threat to migrants and displaced populations, evidence on risk of infection, progress of disease, and effective prevention strategies is still lacking. An emerging body of evidence showed racial and ethnic disparities, with higher SARS-CoV-2 incidence in ethnic minorities compared to white persons. [6, 7] However, there is only a small number of studies investigating these aspects in migrants and displaced populations.

This review aims to synthesise the empirical evidence on risk of infection, transmission, development of disease, and risk of severe course of disease among migrants, refugees, asylum seekers and IDPs. The secondary objective is to review the evidence on the effects of lockdown measures on their health, and effective policy strategies to avert risks and negative outcomes. We thereby seek to summarise valuable information to inform future research in this field.

We conceived a rapid systematic review (PROSPERO registration number CRD42020195633) based on recommendations by the Cochrane Rapid Reviews Methods Group. [8] To maintain quality while utilising resources efficiently, two underlying decisions have been made to accelerate the review process: the number of databases to search was restricted to two and the language of publication to English and German only. Conflicts were resolved through discussion or, where no agreement was reached, by a third reviewer. In the next step, full text screening for eligible records was conducted by following the same procedure as the title and abstract screening. Due to the novelty of the current pandemic and the conception of this project as a rapid review, references of eligible articles were screened, and, alongside journal articles, peerreviewed comments or letters to the editors were included, if they reported empirical data. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted December 14, 2020. ; https://doi.org/10.1101/2020.12.14.20248152 doi: medRxiv preprint focus groups, ethnography) analysing health outcomes or impact of lock-down measures and evaluation strategies that include refugees and migrants • Identified rapid or systematic reviews will only be screened for their included articles; meta-analyses will be included on their own.

Published peer-reviewed articles and preprints identified, as well as official reports from IOM or EUPHA websites.

Grey literature except for official reports on mentioned websites. 

No studies will be excluded based on geography.

Only studies published in English or German will be included (but searches will be conducted only in English).

Studies in other languages than English or German.

Studies published since December 2019 

The quality appraisal of included studies was carried out independently and in duplicate. Quantitative studies were assessed using the tool of the Effective Public Health Practice Project (EPHPP). Modelling studies were appraised using a self-developed instrument derived from existing tools. [10] [11] [12] [13] The Covidence software was used for the screening of titles, abstract, and full-texts as well as for quality appraisal.

Data extraction was performed in Excel 2016 by one reviewer (MH) using a piloted form and checked by a second reviewer (KB) for correctness and completeness of the extracted data. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted December 14, 2020. ; https://doi.org/10.1101/2020.12.14.20248152 doi: medRxiv preprint Primary outcomes were incidence risk of SARS-CoV-2 infections among migrant and forcibly displaced populations, and outcomes of infections (e.g. measured by hospitalisation, admissions to intensive care units (ICU), or mortality). Where reported, outcomes were extracted by subgroups (e.g. by nationality, or contextual information such as accommodation type). Secondary outcomes were the effects of lockdown measures on the health status of refugees, asylum seekers, IDPs and migrants, especially referring to mental health outcomes.

Extracted data was tabulated and summarised by narrative synthesis and, where applicable, by statistical meta-analysis. Numbers of SARS-CoV-2 cases and respective population size, including data on sub-groups, were visualised in a forest plot along with corresponding 95% confidence intervals calculated by the 'metaprop' command in STATA SE 15 (with the "nooverall" option to supress pooling of studies across subgroups due to high heterogeneity).

[14]

The review was performed in the scope of the Vulnerability Group of the Competence Network Public

Health Covid-19.

[15] No specific funding was received for this study. The corresponding author had full access to all the data in the study and the final responsibility to submit for publication. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted December 14, 2020. ; https://doi.org/10.1101/2020.12.14.20248152 doi: medRxiv preprint

The searches resulted in a total of 973 hits, and after duplicate removal, 715 studies remained for screening. Of these, 133 records were included for full-text screening and 13 met all the inclusion criteria.

Using the snowballing method, two further studies meeting the inclusion criteria were detected. In total, 15 studies were included in this review (Figure 1 ). Records screened (n=133)

Full-text articles assessed for eligibility (n=13)

Full-text articles excluded (n=120) is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted December 14, 2020. ; https://doi.org/10.1101/2020.12.14.20248152 doi: medRxiv preprint Almost half of the studies (n=7) reported data from high-income countries (HIC), five studies reported from upper or low middle-income countries (MIC), and three studies reported from low-income countries (LIC).

The studies covered the following migrant and forcibly displaced population groups: refugees, asylum seekers or IDPs (n=5), migrant workers (n=4), international students (n=2), and migrants with no further specification (n=2). The reported outcomes were incidence risks among migrant population groups, modelled transmission scenarios, physical health outcomes such as hospitalisation, ICU admissions, or mortality, and mental or social impact of the COVID-19 pandemic on peoples' health or well-being.

. CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.

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The copyright holder for this this version posted December 14, 2020. ; https://doi.org/10.1101/2020.12.14.20248152 doi: medRxiv preprint Using a WHO forecasting tool, this study has identified COVID-19 case load, according to severity, and potential health system needs in NW Syria, an area that has been subjected to severe levels of violence, displacement and health system disruption during the nine years of the Syrian conflict. The study models use three scenarios. The Camp-population Scenario describes a situation whereby unmitigated spread in crowded displacement camps will lead to total health system collapse within the first four weeks of an outbreak. Considering that such a scenario can occur concurrently with Scenario Two (or a worse All-population Scenario Three not presented here whereby doubling rates and clinical attack rates would be higher), the epidemic outcomes can be catastrophic I. Bojorquez This study revealed some specific sociopsychological experiences of respondents. However, it is also admirable that many of the international students were afraid during pandemic. This may be due to the fact that the respondents in affected areas paid more attention to the safety of their families [4] . Secondly, students with longer stay in China reported more concerns and consequences than the students who stayed for a short period of time. Camp residents report COVID-19 symptoms almost twice as frequently as members of the host community. We also document differences in self-reported non-COVID-19 symptoms, but these are not statistically significant. While this suggests that COVID-19 is much more prevalent in the refugee population, we cannot definitively exclude two alternative explanations. The first is that refugees experience higher rates of other common illnesses with overlapping symptoms. The second is that some refugees over report adverse life events and health outcomes, as some anecdotal evidence suggests. Findings of this study suggest the following recommendations for future interventions: (1) more attention needs to be paid to vulnerable groups such as the young, the elderly, women and migrant workers; (2) accessibility to medical resources and the public health service system should be further strengthened and improved, particularly after reviewing the initial coping and management of the COVID-19 epidemic; (3) nationwide strategic planning and coordination for psychological first aid during major disasters, potentially delivered through telemedicine, should be established and (4) a comprehensive crisis prevention and intervention system including epidemiological monitoring, screening, referral and targeted intervention should be built to reduce psychological distress and prevent further mental health problems. 

The incidence risk among the observational studies varied from 0·12% to 2·08% in non-outbreak settings [16, 17] , and from 5·64% to 21·15% in outbreak settings [18, 19] , showing a high heterogeneity across the studies. Modelling studies also showed a high heterogeneity, which is due to different scenarios and timeframes. Detailed estimates on migrants and forcibly displaced populations are plotted in figure 2. Studies with patient populations [17] report lower incidence rates compared to populations in congested settings [18, 19, [22] [23] [24] . However, the incidence risk varies among the different regions of origin of those infected (0·21-2·08%). [17] Compared to the incidence risk for the Spanish estimated at 0·7%, significantly higher rates were reported by a pre-print study for individuals from Sub-Saharan-Africa, Caribbean, and Latin America. [17] A high risk of bias study among migrants in transit in Mexico reports low incidence risks in two scenarios with 0·12% or 0·51% respectively. [16] The estimated cumulative incidence in two scenarios (with different sources for the population size of asylum seekers in the US) showed a higher number of suspected cases per 100 000 in the migrant group compared to non-migrants. [17] An ecological study investigating migrants in transit in Mexico found a higher Incidence Risk Ratio (IRR: 6•43, 95%CI, 4·41-9·39) for SARS-CoV-2 in state cluster populations with a higher proportion of migrants. [25] Contextual factors, such as dormitories, were associated with incidence risks in migrant workers in the range of 5·64% (95%CI, 5·56-5·72) to 19·43% (95%CI, 18·75-20·12) [18] and 21·15% (95%CI, 20·12-22·21) [19] .

Another study assessed SARS-CoV-2 screening campaigns in different shelters and accommodation centres of homeless people and asylum seekers in Marseille, France. No SARS-CoV-2 cases were found among the asylum seekers tested on a voluntary basis, while among the 411 homeless people, facing similar living conditions, tested in different shelters 9% (n=37) were tested positive. [26] 

Transmission scenarios were found to be slow in the beginning with a rapid increase of infections starting between the fourth week and the third month after start of simulated outbreaks. [22, 23] Irvine et al. found is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted December 14, 2020. ; https://doi.org/10.1101/2020.12.14.20248152 doi: medRxiv preprint the speed of transmission in confined detention centres to be dependent on the facility size, starting with five infected individuals at baseline, where smaller facilities of 50 detainees reach the peak of infections earlier (day 19) than larger ones of 1000 detainees (day 69), assuming a moderate reproduction number of R(0)=3·5. [24] This may be emphasised by the incidence risks of the modelling studies [22] [23] [24] [16] In contrast, the odds of interstate migrants was 1·36 (95%CI, 1·19-1·54) times the odds of hospitalisation than the reference (Mexican) population. [25] About 6·49% of all hospitalised SARS-CoV-2 cases in Mexico from 28th February until 21st April 2020 were interstate migrants. [25] However, the IRR for hospitalisation in state cluster populations with a higher proportion of migrants showed an inverse association (IRR: 0·65, 95%CI 0·58-0·74). [25] A study among patient populations in Spain reports a 3-, 6-, and 7-fold higher risk among patients from Sub-Saharan-Africa, the Caribbean, and Latin America, respectively, of being PCR confirmed cases or being hospitalised compared to the Spanish patients. [17] is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted December 14, 2020. ; https://doi.org/10.1101/2020.12.14.20248152 doi: medRxiv preprint 0·7% of the Rohingya refugee population. [23] Hariri and colleagues calculate with a doubling rate of 2·3 leading to 12 000 (1%) critical cases in need of ICU admission among IDPs in camps and tented settlements along the Turkey-Syria border. [22] Moreover, their scenario estimates a 50% overload of ICU capacity within the fourth week. [22] Only one study used empirical instead of modelling data to investigate the need of intubation within a patient population and reports that 12·5% of migrants need intubation.

However, due to a high number of missing values, these results are to be interpreted with caution. [16] Risk conditions in this specific study population seemed to be less among migrants except for the case of pregnant women. [16] 

Five studies address mortality as an outcome variable. Proportions of migrants with a fatal outcome in the studied populations vary from 0·48% to 6·0% across the studies. The modelling study of Truelove et al.

shows the lowest fatality rate with 0·48% (95%PI, 0·03%-1·5%) assuming that 10% of severe cases result in death. [23] The model of Hariri and colleagues predicts 1·6% (n= 18 751) deaths within the first six weeks upon infection. [22] The authors mention that numbers might be higher due to a lack of health facility capacity in northwest Syria for the treatment of severe and critical cases. [22] Non-modelling studies report a mortality rate among interstate migrants of 4·75% (95%CI, 4·06-5·43) with an odds ratio for fatal outcomes of 2·01 (95%CI, 1·46-2·76) compared to average state-cluster characteristics. [25] The IRR for lethality in state-clusters with higher proportions of migrants (IRR: 1·02, 95%CI, 0·98-1·02) showed a mild tendency to be higher in these populations. [25] Guijarro et al. investigate SARS-CoV-2 cases at a hospital in Alcorcón, Spain, finding 33% of severe cases in migrants (defined by country of origin) compared to 63% in the Spanish population. [17] Severe cases include death, critical care admission, and hospital stay longer than 7 days. Unadjusted mortality among severe cases was at 6% in the migrant and 25% among the Spanish population. [17] Motta et al. also found a lower mortality rate in migrants (2·3%, n=1, N=43) compared to non-migrants (26·9%, n=7, N=26) in the investigated study population of tuberculosis patients infected with SARS-CoV-2. [27] 

Mental and social wellbeing among different migrant groups was assessed in five studies. Kumar and colleagues found 73·5% out of 98 migrant workers in India to be screened positive for depression, anxiety, and/or perceived stress due to pandemic and lockdown measures measured by PHQ2, GAD2 and PSS-4

questionnaires. [28] In line with that, Qiu et al. assessed psychological levels of distress among Chinese people during the COVID-19 pandemic finding the highest level of distress among migrant workers compared to other, non-migratory occupation groups. [29] . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.

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The copyright holder for this this version posted December 14, 2020. ; https://doi.org/10.1101/2020.12.14.20248152 doi: medRxiv preprint Impact on social and socio-psychological wellbeing was assessed among international students in central China's Hubei province, showing that almost a quarter of the study population talked about the virus in regular conversations and almost half of the study population was unhappy due to the current lockdown condition.

[30] Moreover, migrant workers in India reported a deterioration of social-wellbeing with 63·3%

reporting increased loneliness and about half of the participants indicating a significant increase in negative feelings such as tension, frustration, irritability, and fear of death. [28] Reduction of sleep and social connectedness affected about one third of the participating migrant workers in the same study. [28] Another topic investigated by Lopez-Pena and colleagues were health behaviours of Rohingya refugees during the COVID-19 pandemic . [31] The authors focused on health providers chosen by persons that showed symptoms of SARS-CoV-2 and at trusted information sources such as friends, newspapers or nongovernmental organisations (NGO). A total of 42·3 % (95%CI 32·4-52·3) of symptomatic household members in refugee camps chose pharmacies as their first-choice health provider followed by health information providers in camps (35·8% (95%CI 26·0-45·6)). [31] Trusted information sources on COVID-19 prevention and advice among Rohingya refugees were friends, neighbours, and acquaintances (58·8% (95%CI 50·7-66·9)) followed by NGOs (53•5% (95%CI 45·6-61·3)) and informational campaigns on the streets (41•6% (95%CI 33·6-49·7)). [31] Rzymski and colleagues assessed prejudices against Chinese students studying at a university in Poland to assess social wellbeing. [32] According to the survey, 61·2% of participants said that they experienced prejudices in public transport, shopping or in restaurants and in health services due to the COVID-19

pandemic. [32] Racist behaviours were shown in preconceptions and rejective behaviours of others against Chinese international students resulting in negative impacts on their wellbeing. [32] . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.

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This systematic review has demonstrated a high heterogeneity of health consequences of the COVID-19 pandemic in migrant and forcibly displaced populations, who are in turn a heterogenous group exposed to a wide range of living conditions. Compared to various non-migrant reference groups, the incidence risks reported among migrant and forcibly displaced populations tend to be consistently higher, while hospitalisation rates and ICU admissions seem to be lower among migrants. However, most findings for the latter are derived from modelling studies and may thus only approximate reality as, e.g. hospital bed and ICU capacity were not always considered. As expected based on knowledge from studies in general populations, the different transmission scenarios in modelling studies show an exponential increase in SARS-CoV-2 cases after the start of transmission within a migrant population. There was no substantial gain in evidence regarding mortality rates as results were mixed. Crude mortality rates derived from observational studies were higher among patient populations compared to population-based studies, but overall were lower among migrants compared to non-migrant populations. In contrast, a population-based study at moderate risk of bias found a higher lethality in populations with a higher proportion of migrants when adjusted for age and gender. All migrant and forcibly displaces populations investigated by the included studies, were exposed to precarious living and working conditions and hence were at a higher risk of becoming infected or severe cases. In addition, the evidence consistently suggests that mental health is negatively impacted by the pandemic situation across all migrant groups considered by this review. Apart from the reduction in social connectedness, migrant workers no longer have job security and are therefore strongly affected by lockdown measures. However, as there is a lack of comparative studies assessing whether migrants and forcibly displaced populations suffer to a different extent from the pandemic measures compared to native reference populations, generalised conclusions cannot yet be drawn in this respect.

Overall, we found a heterogeneous and fragmented research landscape studying the health of migrants and forcibly displaced populations during the COVID-19 pandemic, few high-quality studies, and a scarcity of comparative designs.

There is a need for more analytical studies using robust comparative study design to monitor inequalities regarding exposure to SARS-CoV-2 or related pandemic policies. This requires a strengthening of health information systems, that however, due to weak capacities, are falling short of instantly generating and providing health information data on migrants, asylum seekers, refugees and IDPs. [33] Moreover, no qualitative studies were available at the time our search was conducted. Many researchers and organisations already called for the integration of vulnerable population groups such as refugees and migrants into national policy plans [34] [35] [36] and qualitative studies are instrumental to provide insights into . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.

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The copyright holder for this this version posted December 14, 2020. ; https://doi.org/10.1101/2020.12.14.20248152 doi: medRxiv preprint realities of migrant and forcibly displaced population groups during the pandemic. At structural level, and as long as medical remedies are absent, improving living conditions of these groups by ensuring preconditions that allow for self-isolation, physical distancing, and hygiene[37] appear to be the best preventive policy measures to protect migrants and forcibly displaced populations from being particularly exposed to SARS-CoV-2.

To our knowledge, and beyond a bibliometric analysis of SARS-CoV-2 research and migration [38] , this is the first review to investigate empirical data available on migrant populations at this stage of the COVID-19

pandemic.

The conception of this review as a rapid systematic review made it possible to conduct search, screening, quality appraisal, data extraction and synthesis in a timely manner. At the same time, we had to compromise by restricting the study languages to English and German, which poses a possible limitation to identify all empirical data available on this topic so far. The heterogeneity of studies did not allow for running a meta-analysis with pooled estimates to gain further knowledge about the incidence risk in migrant populations.

Furthermore, the body of evidence included is limited by a scarcity of high-quality studies and prone to a wide range of bias (hospital bias, diagnostic bias, selection bias, and misclassification bias) or residual confounding. Mortality studies, for example, did not always adjust for age and comorbidity when comparing migrants and non-migrants (see detailed risk of bias assessment: Appendix C). The inclusion of pre-prints, comments, or letters to the editor reporting empirical data was also a challenge for quality appraisal. Nevertheless, this was necessary in order to find as much empirical data as possible, at the early stage of the pandemic when our search was conducted. Given the dynamic number of SARS-CoV-2 related publications, updates of the rapid review will be required in regular intervals to synthesise and consider emerging evidence.

The summarised evidence in this first systematic review on SARS-CoV-2 among migrant and forcibly displaced populations shows high incidence risks among migrants, refugees, asylum seekers and IDPs, yet low hospital admission rates, and mixed mortality-related results. Due to the tenuous and heterogenous data situation on which the review is based on, results need to be interpreted with caution. In view of the general scarcity of health data on migrant and forcibly displaced populations, the pandemic might rather be a barrier than a facilitator to improve the body of evidence. More robust and comparative study designs are urgently needed to assess differences and inequalities in risk of infection, consequences of disease, is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted December 14, 2020. ; https://doi.org/10.1101/2020.12.14.20248152 doi: medRxiv preprint contextual risk factors, and impact of pandemic policies among migrants and forcibly displaced populations. This might include strengthening of health information systems and integration of these groups in notification and reporting systems at all levels of the healthcare system. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted December 14, 2020. ; https://doi.org/10.1101/2020.12.14.20248152 doi: medRxiv preprint manifesto. Nature Publishing Group is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

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None.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. 

The work has been conducted in the scope of the German Competence Net Public Health Covid-19. The authors state that they have no competing interests.

The study is based on published literature, no ethical clearance was required.