Associations with SARS-CoV-2 Positivity Among People in Refugee Settlements

Introduction. Limited SARS-CoV-2 testing capacity during the early COVID-19 pandemic required approaches to identify individuals at highest risk of infection for prioritized testing. We assessed the association between symptoms and exposures reported at the time of SARS-CoV-2 testing and test positivity among individuals referred for testing through an interactive voice response (IVR) platform in refugee settlements in Uganda. Methods. We used Dial-COVID, a multilingual, toll-free interactive voice response (IVR) platform to survey residents of refugee settlements in Uganda regarding COVID-19 symptoms, exposures, and comorbidities. Respondents reporting symptoms or exposures were invited for SARS-CoV-2 testing using nasal or oropharyngeal swab specimens. At the time of testing, an interviewer-administered questionnaire assessed symptoms and exposures occurring within the preceding two weeks. Log-binomial regression was used to identify factors associated with SARS-CoV-2 positivity. Results. Between February 2021 and March 2022, 6,913 of 15,467 Dial-COVID callers (44.7%) completed the IVR survey. Among survey respondents, 5,184 (75.0%) reported at least one symptom or exposure. Of these, 1,361 (26.3%) were invited for testing, and samples were collected from 751 (55.2%) within seven days of survey completion. SARS-CoV-2 test results were available for 741 individuals, of whom 48 tested positive (6.5%). Among symptoms reported at the testing visit, severe muscle pain (risk ratio [RR] 2.08; 95% CI 1.20–3.57) and unusual fatigue (RR 2.34; 95% CI 1.36–4.03) were associated with SARS-CoV-2 positivity in unadjusted analyses. After adjustment for sex, refugee status, hypertension, and diabetes, only unusual fatigue remained independently associated with a positive test result (aRR 2.10, 95% CI 1.20–3.67). Conclusion. Few self-reported symptoms were associated with SARS-CoV-2 positivity, highlighting the challenges of prioritizing testing based on symptoms alone. IVR-based platforms may provide a feasible approach for screening, surveillance, and linkage to testing in resource-constrained humanitarian settings.