Abstract
Refugees in the United States are believed to be at high risk of COVID-19. A cross-sectional study design was utilized to collect anonymous, online surveys from refugee communities in the United States during December 2020 to January 2021. We invited bilingual community leaders to share the survey link with other refugees aged ≥18 years. We identified factors associated with COVID-19 infection and measured the distribution of contact tracing among those who tested positive. Of 435 refugees who completed the survey, 26.4% reported testing positive for COVID-19. COVID-19 infection was associated with having an infected family member and knowing people in one’s immediate social environment who were infected. Among respondents who tested positive, 84.4% reported that they had been contacted for contact tracing. To prepare for future pandemics, public health authorities should continue partner with refugee community leaders and organizations to ensure efficient programs are inclusive of refugee communities.
Keywords: Refugee, COVID-19, Infection, Case investigation, Contact tracing
Background
The SARS-CoV-2 virus causes COVID-19, a disease that is spread by breathing in droplets and small particles that contain the virus from an infected person [1]. There were approximately 20,715,564 cumulative COVID-19 cases and 375,004 cumulative COVID-19 deaths in the United States as of January 1, 2021 [2].
COVID-19 Risk Factors Among Newly Arrived Refugees
Previous research indicates that there are racial and social disparities in COVID-19 diagnoses based on structural inequality in the United States and suggests COVID-19 had a disproportionate impact on refugees during the first wave of the pandemic in early 2020 [3–5]. A refugee is defined as a person who is unable to return to one’s country because of persecution or fear of persecution for reasons of race, religion, nationality, political opinion, or membership in a particular social group [6]. More than 3.1 million refugees have arrived in the United States since the passing of the U. S. Refugee Act in 1980 [7]. Refugees are considered at increased risk of COVID-19 due to disparities in the built and social environment such as living or working conditions, limited financial and social support, social and racial discrimination, limited access to healthcare, and underlying health conditions [8, 9]. For example, refugees working in essential industries like meat-packing plants, grocery stores, and factories early in the pandemic are believed to have been at high risk for COVID-19 exposure [10, 11]. Language barriers, stigma, and experiences with discrimination can also lead to delays in accessing care and late presentations of chronic conditions, and increased risk for COVID-19 morbidity and mortality.
COVID-19 Contact Tracing Among Newly Arrived Refugees
To prevent further spread of COVID-19, case investigation and contact tracing (hereafter, referred to as “contact tracing”) has been employed as a core disease control measure by public health officials during the pandemic. During contact tracing, public health officials identify those who have come in close contact with an infected person, notify them of their exposure, and direct them to get tested and/or self-quarantine [12]. Barriers to contact tracing within refugee communities may include limited English proficiency, limited telephone access (e.g., due to work-related restrictions or cost), distrust of government agencies, fears about sharing personal information over the phone, or concerns about COVID-19 related stigma [13]. Previous research has outlined recommendations for healthcare settings and providers serving newly arrived refugees in the United States or Canada during the COVID-19 pandemic [9]. This includes developing refugee-specific outreach plans, identifying and partnering with trusted community leaders, and making every encounter count [9]. Additional recommendations include incorporating cultural competence training, partnering with individuals with expertise in refugee health (such as community health workers and patient navigators), ensuring adequate access and staff training on interpreter-mediated communication, and translating materials in a wide array of languages [10].
Study Purpose
Data regarding COVID-19 infection and contact tracing among refugees have not been prominent in national surveys. However, several qualitative studies with refugee leaders or healthcare providers have highlighted the difficulties that refugees have faced during the pandemic [9, 14–16]. Building on this body of research, we conducted a quantitative survey among refugees who came from various countries and currently reside in the United States to examine COVID-19 prevalence, factors associated with prior infection, and experience with contact tracing.
Methods
Study Design
A cross-sectional study design was utilized to collect anonymous, online surveys using snowball sampling from December 10, 2020 to January 20, 2021. Snowball sampling can be used to increase participation from those typically excluded from surveys [17]. We partnered with the Resettled Refugee Board of the Society of Refugee Healthcare Providers on recruitment. Recruitment was initiated with individuals from diverse backgrounds and broad networks within the community of interest to increase representation from the target population [18]. Twelve bilingual leaders from organizations working with refugees emailed or messaged the survey to refugees in their community who met the inclusion criteria. Participants completed an informed consent before completing the survey. The Ball State University Human Research Protection Office approved this study (IRB#: 1,605,425).
Participants
Participants included adults (age ≥ 18 years) who arrived in the United States as refugees and currently live in the United States. Participants were recruited from Afghan, Bhutanese, Somali, South Sudanese, and Burmese refugee communities in the United States. The communities included in this study represent three of the top ten countries of origin (Burma/Myanmar, Bhutan, and Somalia) for refugees who have arrived in the United States in the past decade [19], [20]. We translated the English questionnaire into Nepali and Somali, and participants completed the survey in English, Nepali, or Somali.
Measures
The primary outcome measure, COVID-19 infection, was based on two questions. If participants answered “yes” to the question “Have you been tested for COVID-19?” they were then asked “What was the result?” with the response options of “positive” or “negative”. The primary independent variables were self-reporting of having had a family member infected with COVID-19 (yes/no), knowing people in their immediate social environment (e.g., school, work, neighborhood) infected with COVID-19 (yes/no), and employment as an essential worker. Essential workers were defined as those with an occupation described as a COVID-19 essential worker by the United States Department of Homeland Security’s Cybersecurity and Infrastructure Security Agency; examples included jobs in health care, public health, food and agriculture, transportations systems, and commercial facilities [21].
We also included the following independent variables in the adjusted logistic regression model: sex (male, female), age group (≤ 30, 31–40, ≥ 41 years), country of origin (Afghanistan, Bhutan, Somalia, South Sudan, Burma/Myanmar, other), education level (secondary degree or less, associate’s degree, bachelor’s degree, master’s degree or higher), annual household income ($0-$25,000, $25,001-$50,000, $50,001-$75,000, >$75,000), current marital status (not married, married), years spent in the United States (measured in years), and the United States government response index (GRI) in each state in the United States. The United States GRI is based on the Oxford COVID-19 Government Response Tracker, which codes government policies numerically using a scale from 0 to 100, with a higher index indicating a stricter lockdown [22]. GRI includes the measures of policies in contamination, health, and economics. We used the United States GRI on January 1, 2021, the midpoint of our data collection. These independent variables are believed to be associated with COVID-19 infection from previous studies [10, 11, 23, 24]. Measures of some of these variables are consistent with our previous publication [25].
Statistical Analysis
Demographics and characteristics of survey participants were analyzed using count and percentage for categorical variables and mean and standard deviation for continuous variables. We then compared the characteristics of respondents who reported testing positive with COVID-19 and respondents who did not by using Pearson χ2 and Fisher exact tests (if 20% of expected frequencies are less than or equal to 5) for categorical outcomes and two-sample t-tests for normally distributed continuous variables. Normality was measured using the Kolmogorov–Smirnov test. Furthermore, we conducted an exploratory analysis applying adjusted logistic regression models to measure factors associated with COVID-19 infection. Additionally, we presented the distribution of contact tracing using count and percentage. We conducted the analysis using Stata/SE version 15.1 (StataCorp LLC). We used ArcGIS version 10.8 (Esri) to visualize the distribution of participants based on the zip code areas reported by our participants.
Results
Demographics
Demographic and COVID-19 related information are presented in Table 1. The geographic distribution of survey participants is shown in our previous publication (Figure) [25]. A total of 435 participants completed the survey, the response rate is unknown due to snowball sampling. from 32 states1 and Washington, DC, of whom 166 participants (38.2%) were from Bhutan, 113 (26.0%) were from Somalia, 68 (15.6%) were from Afghanistan, 39 (9.0%) were from South Sudan, and 34 (7.8%) were from Burma/Myanmar. Most participants (88.5%) completed the English-language survey and 11.5% of the participants filled the survey in Somali or Nepali (data not shown in tables). COVID-19 diagnoses were reported by 32.6% of respondents. Participants spent an average of 11.2 years in the United States. The average state GRI on January 1, 2021 was 58.2.
Table 1.
Demographic and COVID-19 related measures among refugees in the United States by their COVID-19 infection status, December 2020 - January 2021 (N = 435)
| Overall participants | COVID-19 Infection | |||
|---|---|---|---|---|
| N = 435 n (%d) |
No (n = 320; 73.56%) n (%e) |
Yes (n = 115; 26.44%) n (%e) |
p-value | |
| Family member infected with COVID-19 | ||||
| Yes | 114 (26.21) | 49 (42.98) | 65 (57.02) | < 0.001a |
| No | 318 (73.10) | 268 (84.28) | 50 (15.72) | |
| Missing | 3 (0.69) | |||
| People in immediate social environment infected with COVID-19 | ||||
| Yes | 312 (71.72) | 209 (66.99) | 103 (33.01) | < 0.001a |
| No | 119 (27.36) | 107 (89.92) | 12 (10.08) | |
| Missing | 4 (0.92) | |||
| Essential worker | ||||
| Yes | 309 (71.03) | 215 (69.58) | 94 (30.42) | 0.003a |
| No | 126 (28.97) | 105 (83.33) | 21 (16.67) | |
| County of Origin | ||||
| Afghanistan | 68 (15.63) | 63 (92.65) | 5 (7.35) | < 0.001b |
| Bhutan | 166 (38.16) | 124 (74.70) | 42 (25.30) | |
| Burma/Myanmar | 34 (7.82) | 27 (79.41) | 7 (20.59) | |
| Somalia | 113 (25.98) | 64 (56.64) | 49 (43.36) | |
| South Sudan | 39 (8.97) | 33 (84.62) | 6 (15.38) | |
| Others | 15 (3.45) | 9 (60.00) | 6 (40.00) | |
| Age (years) | ||||
| ≤30 | 130 (29.89) | 90 (69.23) | 40 (30.77) | 0.414a |
| 31–40 | 164 (37.70) | 124 (75.61) | 40 (24.39) | |
| ≥41 | 141 (32.41) | 106 (75.18) | 35 (24.82) | |
| Sex | ||||
| Male | 235 (54.02) | 164 (69.79) | 71 (30.21) | 0.053a |
| Female | 200 (45.98) | 156 (78.00) | 44 (22.00) | |
| Current marital status | ||||
| Not Married | 126 (28.97) | 86 (68.25) | 40 (31.75) | 0.117a |
| Married | 307 (70.57) | 232 (75.57) | 75 (24.43) | |
| Missing | 2 (0.46) | |||
| Education | ||||
| Secondary degree or less | 133 (30.57) | 106 (79.70) | 27 (20.30) | 0.033a |
| Associate degree | 93 (21.38) | 58 (62.37) | 35 (37.63) | |
| Bachelor’s degree | 143 (32.87) | 106 (74.13) | 37 (25.87) | |
| Master’s degree or higher | 66 (15.17) | 50 (75.76) | 16 (24.24) | |
| Household income | ||||
| $0 to $25,000 | 126 (28.97) | 98 (77.78) | 28 (22.22) | 0.304a |
| $25,001 to $50,000 | 153 (35.17) | 113 (73.86) | 40 (26.14) | |
| $50,001 to $75,000 | 87 (20.00) | 64 (73.56) | 23 (26.44) | |
| >$75,000 | 69 (15.86) | 45 (65.22) | 24 (34.78) | |
| Years spent in the U.S., mean (S.D.) | 11.18 (0.39) | 11.02 (0.39) | 11.62 (0.50) | 0.398c |
| COVID-19 government response indexf, mean (S.D.) | 58.24 (0.73) | 57.77 (0.49) | 59.61 (7.78) | 0.050c |
S.D. Standard Deviation
aPearson’s Chi-squared test
bFisher’s exact test
cIndependent t-test
dColumn percentage
eRow percentage
fThe United States government response index (GRI) is an indicator created by researchers at the Oxford University and is based on the Oxford COVID-19 Government Response Tracker, which codes government policies numerically using a scale from 0 to 100, with a higher index indicating a stricter lockdown. GRI includes the measures of policies in contamination, health, and economics. We used the GRI on January 1, 2021 as it’s the midpoint of our data collection (December 10, 2020 – January 19, 2021)
Respondents who had a family member infected with COVID-19 (57.0% vs. 43.0%), had someone in their immediate social environment infected with COVID-19 (33.0% vs. 10.8%), or were essential workers (30.4% vs. 16.7%) were more likely to test positive for COVID-19. Additionally, refugees from Somalia (43.4%) had the highest infection rate, followed by refugees from Bhutan (25.3%), Burma/Myanmar (20.6%), South Sudan (15.4%), and Afghanistan (7.4%). Those with an associate degree had the highest risk of infection (37.6%), followed by those with a bachelor (25.9%), a master’s level (24.2%), and those with a secondary degree or less (20.3%).
Factors Associated with COVID-19 Infection
Factors associated with COVID-19 infection are presented in Table 2. Family members infected with COVID-19 (AOR: 8.04; 95% CI: 4.52, 14.31) and having people in their immediate social environment infected with COVID-19 (AOR: 2.73; 95% CI: 1.29, 5.77) are associated with higher odds of COVID-19 infection. Compared with refugees from Afghanistan, refugees from Bhutan (AOR: 4.07; 95% CI: 1.17, 14.11) and Somalia (AOR: 12.58; 95% CI: 3.24, 48.90) had higher odds of COVID-19 infection. Those who were 40 years or older (AOR: 0.33; 95% CI: 0.15, 0.72) had lower odds of COVID-19 infection compared with those who were less than 30 years old.
Table 2.
Adjusted logistic regression to predict factors associated with positive COVID-19 testing results among refugees in the United States, December 2020−January 2021 (N = 435)
| Adjusted OR | 95% CI | |
|---|---|---|
| Family members infected with COVID-19 | 8.04*** | 4.52,14.31 |
| People in immediate social environment infected with COVID-19 | 2.73** | 1.29,5.77 |
| Essential worker | 1.42 | 0.75,2.69 |
| County of origin | ||
| Afghanistan (reference) | ||
| Bhutan | 4.07* | 1.17,14.11 |
| Burma/Myanmar | 1.72 | 0.31,9.62 |
| Somalia | 12.58*** | 3.24,48.90 |
| South Sudan | 4.93 | 0.92,26.43 |
| Others | 8.23* | 1.44,47.04 |
| Age (years) | ||
| ≤30 (reference) | ||
| 31–40 | 0.52 | 0.25,1.07 |
| ≥41 | 0.33** | 0.15,0.72 |
| Sex | ||
| Male (reference) | ||
| Female | 0.64 | 0.35,1.17 |
| Married | 1.38 | 0.62,3.08 |
| Education | ||
| Secondary degree (reference) | ||
| Associate degree | 1.46 | 0.69,3.09 |
| Bachelor’s degree | 0.83 | 0.38,1.79 |
| Master’s degree or higher | 0.45 | 0.16,1.31 |
| Household income | ||
| $0 to $25,000 (reference) | ||
| $25,001 to $50,000 | 1.07 | 0.52,2.21 |
| $50,001 to $75,000 | 0.99 | 0.42,2.29 |
| >$75,000 | 2.04 | 0.78,5.34 |
| Years spent in the U.S. | 0.97 | 0.92,1.02 |
| COVID-19 government response index | 1.03 | 0.99,1.07 |
We applied an adjusted logistic regression model to predict COVID-19 testing while controlling for the impact from family history of COVID-19 infection, COVID-19 infection among community members, being an essential worker, ethnicity, age, gender, education, household income, marriage status, year in the U.S., and the COVID-19 government response index
OR Odds Ratio; 95% CI 95% Confidence Interval
Significance: *p < 0.05, **p < 0.01, ***p < 0.001
Contact Tracing for Refugees who Tested COVID-19 Positive
The results of contact tracing were reported in Table 3. Among those who tested positive for COVID-19, 84.4% reported they were contacted by state/local public health department for contact tracing, 75.7% indicated that a state/local public health official informed their close contacts about the need to quarantine, and 83.5% had a state/local public health official ask them to inform their close contacts about the need to quarantine after they were tested positive for COVID-19. Among respondents who completed the survey in Nepali or Somali, 82.4% reported contact tracing; this is not statistically different compared with those who completed the survey in English (data not shown in tables).
Table 3.
Contact tracing among refugees who tested positive for COVID-19 in the United States, December 2020–January 2021 (N = 115)
| N = 115 | |||
|---|---|---|---|
| Yes (%) | No (%) | Don’t know (%) | |
| Were you contacted by your state/local public health department for “contact tracing” after you tested positive for COVID-19? | 84.35 | 14.78 | 0 |
| Did a state/local public health official inform your close contacts about the need to quarantine after you tested positive for COVID? | 75.65 | 14.78 | 8.70 |
| Did a state/local public health official ask you to inform your close contacts about the need to quarantine after you tested positive for COVID-19? | 83.48 | 11.30 | 3.48 |
Discussion
Around one-third of participants in this survey reported a prior positive test result for COVID-19. This number is higher than the reported number by a survey our team conducted in May 2020 among Burmese and Bhutanese refugees in the United States (6.9%) [11].
Essential Workers
Essential workers in the refugee community have a high risk of infection, especially at the beginning of the pandemic in spring 2020. During this time, many refugees worked as essential workers to maintain the country’s operations during the lockdown [10, 11, 24]. Many of those jobs did not provide sufficient protections and exposed them to a high risk of COVID-19 infection [24]. Additionally, our results suggest that infection among refugee workers subsequently increases the transmission of the virus within households. Finally, the community transmission of COVID-19 was widespread with the uplift of the lockdown policies.
Living Conditions Associated with COVID-19 Infection
In addition to refugees’ exposure at work, living conditions and language barriers could further expose them to the high risk of infection. Many refugees live in multi-generational housing where it can be challenging to quarantine or isolate after their family members are exposed or infected [8, 11]. It is also challenging to navigate updated information regarding COVID-19 among those who are not familiar with media resources in the United States and those with limited English proficiency. Further, those lacking private vehicles may need to rely on public transportation when seeking testing or treatment. In response, many refugee community organizations have acted to provide support and resources, e.g., by partnering with public health agencies to offer community-based vaccination programs.
COVID-19 Contact Tracing
In total, one in seven respondents who reported testing positive for COVID-19 did not recall being contacted by state/local public health departments for contact tracing. In contrast, among the general population in the United States during the period we collected data, only 48–76% of the COVID-19 cases received a case interview [26–28]. However, the majority of our participants speak English, so this finding may not represent the overall situation of the refugee community [13, 29]. Even among those who were contacted, contact tracing can be failed. For example, many people who were tested positive cannot provide details of their contracts and those who were contacted do not always follow the requirements of quarantine [30]. The process of contact tracing with refugees who speak languages other than English may be more challenging [13, 29]. Thus, promising practices, including working with bilingual, bicultural stakeholders and healthcare providers from refugee communities and healthcare facilities, are suggested to implement effective contact tracing among our target population [13].
Limitations
The study has several limitations. Participants do not represent all refugees residing in the United States. The majority of our participants completed the survey in English. Survey translation into languages besides English, Nepali, and Somali was limited by the desire to learn about COVID-19 quickly in order to respond to the community’s needs, the increased responsibilities of refugee community leaders during the COVID-19 pandemic, and the large number of languages spoken by refugee communities (e.g., over 100 languages are spoken in Burma/Myanmar). Results indicated higher self-reported household incomes and education levels compared to the overall refugee population [31, 32]. Thus, our study likely underestimated COVID-19 infection and overestimated the prevalence of contact tracing among refugees. Additionally, COVID-19 infection and policies regarding contact tracing have been changing rapidly. This study was a cross-sectional design, and the results are only representative of the population during this time period. Repeated cross-sectional or panel designs should be considered for future studies. Furthermore, we did not ask if the participants received reverse transcription polymerase chain reaction tests or rapid diagnostic tests (Ag-RDTs). We suggest researchers ask for the types of COVID-19 test received for future studies due to the concerns of false negative results of Ag-RDTs [33].
Conclusion
We found a high risk of COVID-19 infection among refugees in the United States. Among those who reported testing positive for COVID-19, one in seven did not recall contact tracing by a state/local public health department. In preparing for future pandemics, public health authorities should continue to partner with refugee community leaders and organizations to ensure efficient programs are inclusive of refugee communities.
Footnotes
Arizona, California, Colorado, Florida, Georgia, Iowa, Illinois, Indiana, Kansas, Kentucky, Massachusetts, Maryland, Maine, Mississippi, Minnesota, Missouri, North Carolina, North Dakota, Nebraska, New Hampshire, Nevada, New York, Ohio, Oregon, Pennsylvania, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, and Wisconsin.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Contributor Information
Mengxi Zhang, Email: mengxizhang@vt.edu.
Katherine Yun, Email: yunk@chop.edu.
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