Estimating the Burden of SARS-CoV-2 among the Rohingya Refugees

  1. Shaun A. Truelove
  2. Sonia Hegde
  3. Lori Niehaus
  4. Natalya Kostandova
  5. Chiara Altare
  6. V. Bhargavi Rao
  7. Julianna Smith
  8. Philipp du Cros
  9. Andrew S. Azman
  10. Paul Spiegel

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Abstract

Since the emergence of the COVID-19 pandemic, substantial concern has surrounded its impact among the Rohingya refugees living in the Kutupalong-Balukhali refugee camps in Bangladesh. Early modeling work projected a massive outbreak was likely after an introduction of the SARS-CoV-2 virus into the camps. Despite this, only 317 laboratory-confirmed cases and 10 deaths were reported through October 2020. While these official numbers portray a situation where the virus has been largely controlled, other sources contradict this, suggesting the low reported numbers to be a result of limited care seeking and testing, highlighting a population not willing to seek care or be tested. SARS-CoV-2 seroprevalence estimates from similar a timeframe in India (57%) and Bangladesh (74%) further sow doubt that transmission had been controlled. Here we explore multiple data sources to understand the plausibility of a much larger SARS-CoV-2 outbreak among the Rohingya refugees.

Methods

We used a mixed approach to analyze SARS-CoV-2 transmission using multiple available datasets. Using data from reported testing, cases, and deaths from the World Health Organization (WHO) and from WHO’s Emergency Warning, Alert, and Response System, we characterized the probabilities of care seeking, testing, and being positive if tested. Unofficial death data, including reported pre-death symptoms, come from a community-based mortality survey conducted by the International Organization for Migration (IOM),) in addition to community health worker reported deaths. We developed a probabilistic inference framework, drawing on these data sources, to explore three scenarios of what might have happened among the Rohingya refugees.

Results

Among the 144 survey-identified deaths, 48 were consistent with suspected COVID-19. These deaths were consistent with viral exposures during Ramadan, a period of increased social contacts, and coincided with a spike in reported cases and testing positivity in June 2020. The age profile of suspected COVID-19 deaths mirrored that expected. Through the probability framework, we find that under each scenario, a substantial outbreak likely occurred, though the cumulative size and timing vary considerably. In conjunction with the reported and suspected deaths, the data suggest a large outbreak could have occurred early during spring 2020. Furthermore, while many mild and asymptomatic infections likely occurred, death data analyzed suggest there may have been significant unreported mortality.

Conclusions

With the high population density, inability to home isolate adequately, and limited personal protective equipment, infection prevention and control in the Rohingya population is extremely challenging. Despite the low reported numbers of cases and deaths, our results suggest an early large-scale outbreak is consistent with multiple sources of data, particularly when accounting for limited care seeking behavior and low infection severity among this young population. While the currently available data do not allow us to estimate the precise incidence, these results indicate substantial unrecognized SARS-CoV-2 transmission may have occurred in these camps. However, until serological testing provides more conclusive evidence, we are only able to speculate about the extent of transmission among the Rohingya.

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    While both approaches and data sources have limitations, their results independently pointed to similar timing and magnitude of infections and deaths in this population; both approaches were in support of Scenario 3, that a large outbreak occurred early in the pandemic and was largely unidentified at the time due to limited and variable care seeking and test seeking. The suspected outbreak appears to coincide with Ramadan, which lasted from 25 April to 24 May 2020 (Figure 2B). Survey deaths started increasing three weeks after the start of Ramadan, which would place the time of infection for those deaths at the beginning of Ramadan. We know from anecdotal reports that the camps had largely been in lockdown up to Ramadan, but after pressure, mosques were allowed to reopen for the month. Additionally, during Ramadan, it is common practice for people to congregate in large groups to consume their evening meal and some travel to different mosques, all potentially contributing to increased population mixing, contact, and transmission during that time period. This estimated epidemic curve also corresponds well with that of the host community, which experienced a major outbreak during May-July 2020 9. Each of the data sources used in this analysis has strengths and limitations. The mortality survey provides a valuable resource for understanding potential unidentified COVID-19 deaths, from which transmission may be inferred. In a vulnerable population like this, where active efforts ...

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