COVID-19 Control in Low-income Settings and Displaced Populations: What Can Realistically Be Done?

Maysoon Dahab, Kevin van Zandvoort, Stefan Flasche, Abdihamid Warsame, Paul B. Spiegel, Ronald J Waldman, and Francesco Checchi

London School of Hygiene and Tropical Medicine, March 2020


The impact of COVID-19 on people living in low-income and crisis affected settings could be more severe than in high-income countries due to: (a) higher transmissibility due to larger household sizes, intense social mixing between the young and elderly, overcrowding, inadequate water and sanitation, and specific cultural and faith practices; (b) higher progression to severe disease due to highly prevalent co-morbidities; (c) higher case fatality due to lack of intensive care capacity; and (d) disrupted care for health problems other than COVID-19.

Key messages:

  • Containment strategies (border closures coupled with social distancing and quarantine measures) may, at best, buy some time to allow countries to better prepare. However, inadequate testing and contact tracing may initially obfuscate the extent of locally driven transmission. Moreover, social distancing and travel restrictions, if sustained over a long period, could be very harmful for fragile, export-dependent economies and stretch livelihoods beyond people’s coping ability.
  • Addressing higher transmissibility is more amenable to economically and socially feasible interventions, even in the most resource-constrained settings. However, population-wide social distancing measures would require most non-essential workers to work from home or not at all, and this would need to be sustained over a long period (until a vaccine or treatments are available at scale). Where dispersive strategies are difficult to implement and/or cannot be sustained, it would be more impactful and efficient to focus resources on protecting the most vulnerable.
  • It may be more impactful and efficient to focus resources on protecting those most vulnerable to the risk of serious illness, including people aged above 60 years and/or living with non-communicable diseases (TB, HIV, malnourished adults). The authors suggest three options for housing high-risk community members into transmission-shielded arrangements: (1) household-level shielding (each household demarcates a room or shelter for high-risk members); (2) street- or extended family-level shielding (neighboring households or members of an extended family within a defined geographic locale voluntarily ‘house-swap’ and group their high-risk members into dedicated houses / shelters); and (3) neighborhood- or sector-level isolation (sections of the settlement are put aside for groups of high-risk people). Option 3 would be applicable in displaced persons’ / refugee camps, where humanitarian actors can provide supportive services and smaller scale isolation is not possible. Stringent but realistic infection control measures should accompany any of the options, as should some social distancing within the ‘green zone’. It is essential that strategies are acceptable and well communicated to communities.

The authors suggest that the proposed approach might offer a realistic solution for allocating scarce resources in settings where scaling up treatment significantly is unlikely to be an option. Other feasible, high-yield interventions should be undertaken simultaneously, e.g. staying home if sick, limiting public transport use, reducing super-spreading events at funerals or other mass gatherings, promoting hand-washing, soap distribution and/or at least maintaining treatment coverage for risk-factor co-morbidities.