COVID-19 update, recommendations, and guidelines

Coronavirus pandemic: action plan for dealing with refugee camps

جائحة فيروس كورونا: خطة للتعامل مع مناطق مخيمات النازحين و اللاجئين

  • Authors: Dr. Mazen Kherallah, Dr. Fadi Al-Halabi, Dr. Tarek Abou Ghazala, Dr. Feras Fares, Dr. Khalid Al-Shabbagh, and Dr. Abdullah Sulieman Terkawi.

    Version 2 – March 24, 2020

    Background

    On December 29, 2019, the first case of an unspecified pneumonia epidemic was registered in the city of Wuhan, Hubei Province – China. The World Health Organization (WHO) was informed by the Chinese authorities On January 8, 2020. Soon after that, the virus was identified as one of the coronavirus family, and the name of the new/novel Corona virus 2019 was given. On January 30, 2020 the RNA sequencing of the virus was determined. The virus started to spread rapidly spread from China to the rest of the world. On March 11, 2020 the WHO declared the outbreak as a global pandemic. Home quarantine is one of the simple and effective methods used to combat the spread of infectious disease epidemics, however, it is difficult to apply in camps and crowded places for multiple reasons. In this review, we will explore the challenges which the refugee camps and poor and disorganized shelters are having to face this pandemic and will suggest a comprehensive plan to combat this pandemic at a different levels (e.g., community, local authorities, healthcare NGOs).

    What is unique about refugee camps

    Refugee camps are special communities that must be dealt with differently from other human settlements. These special considerations of refugee camps can be classified under 4 items:

    1. Crowded population: Camps are usually densely populated communities in which hundreds of thousands of people live in a narrow space that does not allow isolation or appropriate quarantine to prevent the spread of the epidemic. In addition, the tents/housing units are packed to each other, each unit by itself is crowded (average number of members per unit ~ 6-7 people.)
    2. Engineering complexity: This is due to the narrow distances between the housing units formed for the camp, whether they are tents or prefabricated housing structures, for example, the separation distance between tents is 100 cm or less. Also, the texture of the tents and the type of fabric poses a difficulty in applying the usual means of disinfection. Added to this is the lack of basic infrastructures, such as availability of clean water and sanitation, and participation in toilets and baths.
    3. Political considerations: Camps are often located in areas of political, racial and ethnical conflicts with devastating war, such as Syria, Yemen, Rohingya and others. This will cause an extra economic and cultural burden in the countries hosting these refugees.
    4. Economic considerations: Most camp residents usually live below the poverty line, relying mainly on humanitarian aid. (80% of the Syrian refugee population in Lebanon lives below the poverty line). This fact pushes many refugees out of the camp to seek livelihood, which means that it is difficult to practically control the movement of refugees in and out. This matter in conjunction with the first and second peculiarities will lead to a wild spread of a pandemic in the camp as well as outside it. It will be almost impossible if the epidemic spreads within the camp to prevent its transmission outside and thus infect population centres within the hosting country.

    These considerations make it necessary for us to work seriously and collectively to prevent the epidemic from entering the camps.

    Proposed policy to deal with the COVID-19 epidemic

    The best, and probably the only, successful plan is to suppress the epidemic by: preventing the entry of new – even any – cases; detecting and isolating existing cases; and preventing their spread inside the camps, and continuing that until the vaccine is available or the epidemic is contained. This policy will not take place without the collaboration of all stakeholders in the community (e.g., NGOs, local authorities and media, as well as public figures).

    A- Surveying the camps to determine cases:

    This is useful in determining the presence of any existing case that has not been detected yet. This may be done by a complete survey of the residents to ask about the presence of symptoms of illness or direct exposure to one of the proven cases in society. The local NGOs should hire social workers, train them, provide them with personal protection equipment (PPE), and provides them with the needed equipment for screening.

    B- Camps Lockdown:

    This serves to reduce the possibility of entering any case from outside the camps and preventing their spread inside. This is faced by that lack of governance inside the camp and the necessity of people to work to earn a livelihood. Teams of camp residents should be formed and enforced to implement this plan and control movement of people between inside and outside the camps until the pandemic is contained.

    C- Implementing Social Distancing:

    This will be done by enforcing all people inside the camp to follow a strict social distancing which mandates a change of known behaviours and ways of life:

    • Stop all events and group visits inside the camps
    • Stop children playing in the fields and between tents and corridors, and find alternative ways for every child inside the tent
    • Stop all congregational and Friday prayers
    • Stop the morning and evening meetings and food exchange
    • Stop the weddings, condolences, and the mass gathering of the funerals.
    • Adherence to the distance to at least one meter between people in all cases
    • Not to exchange clothes between brothers
    • Not exchanging things between family members due to the inability to purchase a piece for everyone
    • Do not use covers, blankets, and pillows among several people
    • Stop borrowing things from neighbours
    • Stop the hookah and not share it between people
    • Stop playing cards in groups

    D- Cleaning & Disinfection:

    • Cleansing and washing hands with warm water and soap for 20 seconds. Hand sanitizers solutions can be used but should containing at least 60% of alcohol for hands use, and at least 70% for surfaces use.
    • Covering the mouth and nose with a tissue when coughing and sneezing and throwing the tissue after. Clothes can be used if not tissue is available
    • Do not sneeze and cough in the air without a barrier (attributing the cause of coughing to smoking)
    • Disinfection of surfaces and commonly touched surfaces and tools
    • Avoid touching the face with two hands
    • Do not use a common family towel
    • Not eating from the same plate
    • Not to buy from street vendors

    E- Increase Awareness among Camp Residents:

    Through flyers, brochures, and videos, which can include the following awareness points:

    • Messages for people with chronic diseases who are at high risk to develop severe disease and carry higher death rate. These includes:
      • Older than 65 years old
      • Chronic heart diseases
      • Diabetes
      • Hypertension
      • Chronic lung disease
      • Immunocompromised patients
      • Cancers of all kinds
      • Chronic kidney disease
    • Informing everyone that the disease is very dangerous even for young and healthy people, as there is a relatively high morbidity rate among them, in addition to be a source of the spread of the epidemic
    • Raise awareness to commit to applying the cleansing methods
    • Raise awareness to commit to implementation of social distancing means
    • Other awareness issues:
      • Stopping the indiscriminate use of medicines for refugees.
      • Ask smokers to stop smoking.
      • No cooking within the tent and lack of ventilation
      • Good nutrition and adequate sleep
      • Do not use Ibuprofen and Diclofenac as an analgesic for all types of pain.
      • When dealing with a deceased person, who was confirmed or suspected to have COVID-19, it is important to note that the virus may still be contiguous for people who are dealing with the body (e.g., washing or burying the body). Therefore, we recommend taking the same precautions when dealing with alive patient (e.g., N95, eye shield, gloves, and gown).  

    F- Administrative and Service Matters:

    • Working to secure people’s basic needs for clean water, food and education. This calls for tireless work organized by relief and educational organizations to secure these needs and not to be interrupted. This also requires coordination with the relevant government agencies of the host country.
    • It is crucial to deliver in a regular basis the following: food (including baby milk and food), water, cleaning, disinfectant, warming materials, as well as the basic medications for people with chronic diseases (e.g., diabetes, hypertension, and asthma) for each individual in the camp. To make sure that they do not need to leave to work or get these supplies. Otherwise, it will be impossible to force these people to strictly stay in the camp.
    • In case any confirmed case appears in the camp, in top of isolating the infected patient, we recommend isolating the elderly people and those at higher risks in a separate shelters/tents, and strictly monitor them in a daily basis.
    • Serving the camps and maintaining hygiene
    • Organizing the camp’s relationship abroad.
    • Sterilizing what goes into the camps.
    • Completely block outbound to inside visits, and vice versa.

    Dealing with medical conditions:

    A- Definition of cases

    • Confirmed case: It is each case in which the coronavirus is screened positive by PCR method or a positive serological antibody test.
    • Suspected case: Any case with respiratory symptoms (cough and shortness of breath) with or without fever, and there is no clear laboratory diagnosis indicating infection other than Corona virus, even if the corona test is negative.
    • Ruled out case: a case of respiratory symptoms with or without fever, with a positive streptococcus or influenza test(s), or other respiratory viruses with a negative corona test.

    B- Lab Samples

    • The medical staff who will take care of the corona patient must have full personal protection equipment (PPE).
    • All cases to be examined when both the medical staff and patient wearing facemask
    • A sample must be taken from the nasopharynx or from the sputum with a special swab
    • The sample should be examined for influenza, streptococcus pharyngitis and COVID-19 as indicated.
    • The sample should be sent to the laboratory via the approved transport media.

    C- Dealing with medical conditions

    Confirmed cases:

    1. Isolate the patient in single tent or the special/dedicated isolation tent for confirmed cases
    2. Monitor the patient’s symptoms and follow up according to the attached protocol
    3. The patient should place a surgical mask and uses dedicated tools all the time
    4. The patient should remain in quarantine until three days after the symptoms are disappeared or two consequent negative PCR examinations, more than 24 hours apart. 
    5. Severe cases who require admission, to the word or intensive care, should only be admitted if there is an isolation room or ICU bed available. So other patients in the hospital does not get the infection.

    Suspected cases:

    1. Isolate the patient in a single tent or in a special/dedicated tent for suspected cases
    2. Monitor the patient’s symptoms and follow up according to the attached protocol
    3. The patient should place a surgical mask and uses dedicated tools all the time
    4. The patient remains quarantined until three days after the symptoms disappear

    Ruled-out cases:

    1. The patient is treated according to the specific diagnosis
    2. Infection control measures shall be conducted according to the case
    3. The patient can return to his tent and follow the usual infection control measures
    4. Monitor the patient’s symptoms and follow up according to the protocol for the case

    D- Management protocols:

    • Severe cases or progressing cases are dealt with separately and sent to hospitals if possible
    • Protocols for the screening and diagnosis of cases will be distributed to all health professionals.

    E- Healthcare centers recommendations:

    • Healthcare workers who are at the frontline with patients in triage area or dealing with admitted confirmed or suspected cases, should have full PPE (e.g., N95, eye shield, gloves, and gown).
    • All healthcare centers should cancel elective surgeries and procedures until the risk of the pandemic subside
    • Outpatient clinic close except for urgent cases
    • For the major healthcare center that continue to have inpatient admission and work as a referring center:
      • Should have a triage area outside the hospital, where the patient should have a temperature check and asked for any ongoing, or in the last week, cough or shortness of breath, or was recently traveling outside the country, or had an exposure to a patient with confirmed diagnosis,
      • If the patient raises any suspicion should be refer to an isolation area, outside the building, which can be a tent or shelter for example. This patient should be investigated as the available protocol (see attachment).
      • For big camps, we recommend sending a mobile clinic in a scheduled basis to minimize their need to leave the camp.

Public Education videos

Arabic COVID19 public education

Kurdish COVID19 public education

COVID19 Online Conference - Arabic lecture

Dr. Abdullah S. Terkawi: Anesthesia and perioperative approach and considerations

Dr. Yassen Rafee: COVID19 in the pediatric population

Dr. Mazen Kherallah: Pathophysiological approach on COVID19

Dr. Shahla Namak: Obstetric approach and considerations

Dr. Ahmad Rami Saltagi: ICU management of COVID19 patients.

Educational videos

English lecture for public audience:

English lectures for medical staff:

Suppression vs Mitigation of the COVID-19 Pandemic:

Aerosol & Surface Stability of SARS CoV2 & CoV1:

Herd Immunity and COVID-19 Pandemic:

Medical Respirators N95 Fitting Instructions 3M Health Care Respirators

Medical Respirators N95 Fitting Instructions 3M Health Care Respirators

فيديوهات تعليمية

استراتيجية التثبيط مقابل استراتيجية التخفيف في مواجهة وباء فيروس كورونا المستجد

القصور التنفسي المسبب بفيروس كورونا المستجد ونصائح استخدام التنفس الاصطناعي غير الباضع

فيروس كورونا المستجد: ماهو وماهي الجائحة وطرق الانتقال والاعراض وطرق الوقاية

حماية العاملين في المجال الصحي من فيروس كورونا المستجد‎

مناعة القطيع او المناعة الجماعية وتطبيقها في وباء فيروس كورونا المستجد

الوقاية الشخصية ووقاية الآخرين أثناء وباء فيروس كورونا المستجد

مدة بقاء فيروس كورونا حيا على السطوح وفي الحالات المنتجة للرذاذ الهوائي

تحديث على باثوفيزيولوجية مرض كورونا

الدلائل الطبية المتوفرة على استعمال دواء الكلوروكوين في مرض فيروس كورونا المستجد

Infographic

Guidelines

Extra References

SEMA Response

(1) Community education: تثقيف المجتمع

(2) Healthcare workers education: تعليم الكوادر الطبية

(3) Disinfectant and cleaning materials: تعقيم و تنظيف المراكز الصحية

(4) Personal protective equipment (PPE): توفير أدوات الوقايه للكوادر الصحية

(5) Screening triage areas with immediate temporal isolation shelters/tents: توفير مناطق مخصصة للمسح الطبي و أخرى للعزل المؤقت خارج المراكز الصحية

(6) Reorganize hospital schedules and provide hotlines for consultations: إعادة تنظيم ساعات العمل وإلغاء المعاينات والعمليات الباردة و توفير خط ساخن على مدار الساعة لإستشارات المرضى

(7) Increase the number and capacity of mobile clinics: تعزيز إمكانيات العيادات المتنقلة و دعمها بالأدوية

(8) Provide diagnosis kits: توفير اجهزة التشخيص المخبري

(9) Establish COVID-19 hospital for isolation and intensive care: إنشاء مستشفى خاص بالوباء لعزل الحالات المصابة مع وجود عناية مشددة مجهزه بشكل كامل

(10) Collect data to further advance the field of science: تجميع البيانات بشكل علمي منظم لتحليلها و رفد المجال الطبي بمعلومات و خبرات جديده

(11) Innovations to overcome resource limitations: إبتكارات للتعامل مع ضعف الإمكانيات

For inquiries, collaboration, and further information you may contact Dr. Abdullah S. Terkawi @ [email protected]

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