COVID-19: Projecting the Impact in Rohingya Refugee Camps and Beyond

Shaun Truelove, Orit Abrahim, Chiara Altare, Andrew S. Azman, Paul B. Spiegel

MedRxiv, March 20, 2020


An epidemic of COVID-19 in refugee settings with high population densities, poor access to water and sanitation, poor baseline health status, limited ability to isolate infected individuals, and inadequate capacity to surge health infrastructure and workforce could produce potentially devastating consequences. This paper examines the potential impact of the introduction of SARS-CoV-2 virus on the Rohingya refugees in the Kutupalong-Balukhali Expansion Site in Bangladesh, accommodating 596,000 people. The authors use a stochastic disease transmission model to estimate the number of infections, hospitalizations, deaths, and health care needs that might be expected. The authors also estimate an age-adjusted proportion of infections that might be expected to develop into severe disease. Three transmission scenarios (low, moderate, high) are modeled.

Main results:

  • A large-scale outbreak is highly likely after a single introduction of the virus into the camp. Following the introduction of the virus to the camp, an outbreak of at least 1,000 infections occur in 65 percent of simulations (low transmission scenario), 82 percent of simulations (moderate transmission scenario), and 93 percent of simulations (high transmission scenario).
  • In the first 30 days of the outbreak, infections are estimated to reach 119 (low transmission scenario), 168 (moderate transmission scenario), and 504 (high transmission scenario). After 12 months, infections reach 424,798 (low transmission scenario), 543,637 (moderate transmission scenario) and 591,349 (high transmission scenario).
  • Given the relatively young age distribution in Kutupalong-Balukhali camps, the proportion of infections that lead to severe disease and hospitalization could be approximately half of that estimated for China (3.6 percent versus 6.6 percent). However, it is likely that other co-morbidities such as malnutrition, concomitant diseases, and poor overall health status could cause more severe outcomes among these groups.
  • In almost all simulations in all scenarios, hospitalization needs far exceed available capacities. If existing hospital beds are used only for COVID-19 cases, the current 340-bed capacity will be exceeded within 2 to 4.5 months after the first introduction of the virus and depending on the transmission rate. With a surge capacity of 630 beds, the capacity would be overwhelmed 3-10 days later on average. In the absence of accurate recent estimate of the human resources currently available in the camps (doctors, nurses, midwives), it was not possible to estimate the number of health care workers that would be needed during a COVID-19 outbreak.
  • In the low transmission scenario, there could be 1,647 deaths at 12 months, rising to 2,109 with the high scenario.

The authors recommend finalizing and sharing, as quickly as possible, detailed advanced planning of healthcare capacities, triage procedures, and isolation strategies. Additionally, novel and previously untried strategies for social distancing and quarantine need to be considered. The authors caution that a major outbreak can easily disrupt an already precarious health system by diverting limited health resources from existing health services, including vaccination, obstetrical care, and emergency care, which may cause an increase in mortality due to diseases normally treated by the health system.