COVID-19 in Newly Resettled Refugee Populations

Refugees to the United States, especially those who are recently resettled, may experience living arrangements or working conditions that put them at greater risk of getting COVID-19. Some refugees also have limited access to health care, as well as certain underlying medical conditions that put them at increased risk of severe illness from COVID-19, compared to the rest of the U.S. population.

A refugee is someone who has been forced to flee their country because of a well-founded fear of persecution for reasons of race, religion, nationality, or political opinion. Nearly 750,000 refugees resettled in the United States from 2008 to 2019, and thousands more have resettled since then.

Refugees are eligible for U.S. government-funded resettlement help, including healthcare benefits such as short-term health insurance for up to 8 months after arrival, and a medical exam within 90 days of arrival.

The impact of COVID-19 on the lives of resettled refugees remains unknown, as COVID-19 is a new disease. Meeting the healthcare and everyday needs of refugees, especially during health emergencies, can help keep communities safe.

Guidance for Refugees Upon Arrival in the United States

Refugees come from diverse regions of the world, and professionals working with them need to understand the health risks, including the risk of COVID-19, in the countries from which they are departing. One resource is CDC’s Travel Health Notices, which are resources for travelers, including refugees, to help understand the risk of COVID-19 in destinations around the world. Learn how CDC determines the level of a destination’s COVID-19 Travel Health Notice.

Public health professionals, community organizations, resettlement agencies, and healthcare providers can assist refugees arriving in the United States by providing them with information they need to protect themselves from COVID-19.

• CDC’s Welcome Booklet for Refugees pdf icon[PDF – 8 pages] provides important information to help refugees and their families stay healthy during the COVID-19 pandemic after arriving to the United States. When talking with newly arrived refugees, local refugee health partners and resettlement agency staff should reiterate concepts in the Welcome Booklet and provide them with local and state COVID-19 information and contact information for healthcare providers.
• CDC’s After Arrival recommendations for inbound international travelers provide useful information for arriving refugees.

What Can Be Done for Refugee Health During the COVID-19 Pandemic

Groups that want to help refugees and those who already serve refugees can share culturally sensitive resources on COVID-19 prevention, symptoms, and self-management. The Department of Health and Human Services, Office of Refugee Resettlement (ORR) provides a list of key state contactsexternal icon who can connect to these partners.

Public health professionals can:

• Collect data about the sociodemographic and clinical characteristics of refugees who have COVID-19 to understand risk.
• Share information and available resourcesexternal icon about COVID-19 with partners. Work with resettlement agencies and other partners, such as employers, healthcare systems and education, faith-based, transportation, and housing organizations to find ways to break down social and economic barriers to COVID-19 prevention efforts.
• Identify and secure funding for services to support refugee communities during the pandemic, such as wrap-around services for refugees in quarantine or isolation (e.g., temporary housing and child care), mobile testing, health education, and contact tracing.
• Create health promotion audio and visual materials that are tailored to refugee populations. Consider featuring trusted members of the community. Create materials in different languages that are appropriate for a variety of cultures and literacy levels. Disseminate information through various channels, including via messaging apps, local radio stations, and social media, based on what is appropriate for local refugee groups.
• Ensure contact tracing programs reaching refugee populations are culturally competent and incorporate training on the use of medical interpretation services. Community health workers and patient navigators familiar with working with refugees should be integrated into contact tracing programs.
• Communicate (translate as needed) information about services available to refugees during the pandemic, such as food and rental assistance, and information that will impact refugees, such as school or business re-openings and executive orders.
• Work with health systems and community partners to identify strategic locations within refugee communities to offer free or low-cost COVID-19 testing, such as mobile testing or testing within workplaces and faith-based institutions. These events can be promoted by trusted community leaders to encourage participation. Ensure either in-person or phone interpretation is available at testing sites.
• Provide background information for healthcare professionals and health systems to understand key demographic, cultural, and health characteristics of specific refugee groups resettling in the United States and health care considerations for these populations, such as CDC’s Refugee Health Profiles and CDC’s Refugee Health Guidelines.

Community organizations and resettlement agencies can:

• Share COVID-19 resources that are culturally responsive for community, work, school, and home settings. Verbal education, such as through phone or video calls, and/or communication via radio or text messages, are effective communication methods.
• Engage trusted individuals within the refugee community, such as community leaders and community health workers, to support health education efforts and to deliver key prevention messages. Virtual community group meetings that integrate health education and question-and-answer (Q/A) sessions may be useful ways to convey information.
• Work with refugees and explain what contact tracing is and why public health workers need to find people who have come into contact with someone who has COVID-19.
• Work with community health workers in refugee communities to educate people about COVID-19, discuss strategies on how to safely isolate or quarantine within the household when needed, and link refugees to free or low-cost services.
• Work across different businesses and services to connect refugees who become sick or test positive for COVID-19 with support in completing applications for unemployment benefits, food benefits, and rental/utility assistance, if needed, as well as with services such as grocery delivery or temporary housing. Ensure that refugees who are separated from their family or friends while in temporary housing facilities are able to communicate with loved ones and that their cultural needs are supported.
• Work with partners to connect refugees with the healthcare and community resources they need when refugees become sick or test positive for COVID-19, including medicines, healthcare providers, and mental health services.
• Help refugees get access to items to help prevent the spread of COVID-19, such as masks, soap, hand sanitizer, or household cleaners.

Employers can:

• Review and put into practice guidance for businesses and employersexternal icon, reminding managers to ensure that best practices are followed.
• Maintain flexible leave policies. Allow employees who are sick or who must care for others to stay home without fear of being fired or other punitive actions. Additional flexibilities might include giving advances on future sick leave days and allowing employees to donate sick leave to each other.
• Allow employees to use sick leave and return from sick leave without a doctor’s note or a COVID-19 test.
• Provide employees with COVID-19 prevention messages and trainings that are tailored to employees’ languages, literacy levels, and cultures.
• Provide masks, hand sanitizers, handwashing stations, and personal protective equipment as appropriate.
• Establish fair policies and practices for all employees to maintain physical distance between each other and customers, as possible.
• Train employees at all levels of the organization to identify and interrupt all forms of discrimination; provide them with training in implicit biasexternal icon.

Healthcare systems and healthcare providers can:

• Ensure providers show awareness of and respectexternal icon for cultureexternal icon when providing COVID-19 testing and care.
• Provide language interpretation services in all relevant settings, such as phone triage and intake, inpatient units, and outpatient services.
• Learn about patients’ barriers to COVID-19 prevention, testing, and control, and then work with resettlement agencies and other partners to reduce them.
• Reach out to patients and gather their updated contact information, preferred method of communication, and a plan for staying in contact if someone in their home gets sick with COVID-19.
• Where possible, incorporate telemedicine into healthcare settings if refugees have the means and are able to participate in virtual clinic visits. Support clinical staff, such as patient navigators, can assist with educating refugees about how to use virtual telemedicine applications.
• Share resources and materialsexternal icon that use a culturally sensitive approach and educate patients about COVID-19, including: symptoms and potential impacts on health, transmission (including asymptomatic transmission), how to protect oneself and others, the purpose and process of contact tracing, and how to get testing and care when needed. Where possible, reinforce key prevention messages, such as at triage.
• When a patient is referred for testing, provide instructions on procedures (e.g., quarantine, isolation) to follow until they receive test results. Educate patients on what test results mean and when to discontinue quarantine or isolation. Again, this should be done with interpretation services.
• Connect newly arrived refugees who have underlying medical conditions to community partners that can help them develop and continue with their care plans and help them get needed supplies and medicines.

Supporting Resettled Refugee Populations in Receiving a COVID-19 Vaccine

Resettlement agencies and community organizations, vaccination providers, state refugee health coordinators, health systems and providers, and health departments should work together to facilitate refugees’ access to COVID-19 vaccines as states implement their rollout plans.

• Ensure availability of culturally and linguistically appropriate vaccination materials tailored for refugee populations such as translated emergency use authorization fact sheets about the vaccines, and medical interpretation services at vaccination sites.
• Offer COVID-19 vaccination where people live, work, learn, pray, and play, such as through mobile vaccination units. Community members can help to identify these locations. Encourage participation in vaccination events by having trusted community leaders, such as leaders from faith-based institutions, promote them.
• Refugees who received a COVID-19 vaccine not currently authorized in the United States may be offered revaccination with an FDA-authorized vaccine:
  • COVID-19 vaccines not authorized by FDA but authorized for emergency use by WHO
    • Refugees who completed a COVID-19 vaccination series with a vaccine that has been authorized for emergency use by the World Health Organization (WHO) do not need any additional doses with an FDA-authorized COVID-19 vaccine.
    • Refugees who are partially vaccinated with a COVID-19 vaccine series authorized for emergency use by WHO may be offered an FDA-authorized COVID-19 vaccine series.
  • COVID-19 vaccines not authorized by FDA or not authorized for emergency use by WHO
    • Refugees who completed or partially completed a COVID-19 vaccine series with a vaccine that is not authorized by FDA or not authorized for emergency use by WHO may be offered an FDA-authorized COVID-19 vaccine series.
• Develop partnerships with community organizations such as local pharmacies, community centers, apartment complexes, and schools, to host vaccination events together.
• Provide refugees with transportation to and from vaccination sites.
• Identify trusted members of refugee communities, such as community health workers, through partnerships with community organizations to serve as local COVID-19 vaccine champions and proactively link individuals to relevant resources and vaccination appointments.
• Share and disseminate culturally sensitive resources and materialsexternal icon about vaccination.
• Educate refugee communities about COVID-19 vaccines, including information about how the vaccines work, benefits of getting vaccinated, when someone is considered fully vaccinated, potential side effects and how and when to contact healthcare providers, and the need to continue to follow prevention recommendations (such as wearing masks and maintaining physical distance) after being fully vaccinated. Provide additional education about the type of information that may be collected at vaccination sites, state or local requirements for receiving vaccination (e.g., need to bring a form of identification), that vaccination is free of charge for all people living in the United States, regardless of immigration or health insurance status, and the importance of keeping vaccination cards in a secure location. Resettlement agencies, community groups, state refugee coordinators, and healthcare providers can use available translated health communication resources and materialsexternal icon to support education efforts.
• Identify mechanisms such as weekly meetings with stakeholders to remain informed about and address vaccination questions and needs of refugee communities.
• Learn about individual and community-level barriers to COVID-19 vaccination—including limited access to vaccination information and sites, distrust of systems based on historical experiences, challenges in navigating vaccination registration sites, language barriers, work conflicts, cultural and religious beliefs, and misinformation about vaccines—and then work with partners to reduce them.

Additional recommendations on creating and delivering COVID-19 vaccine messaging for refugee communities are provided in other sections below.

At medical visits, healthcare providers can:

• Provide education about COVID-19 vaccines, share resources, and address any questions or concerns about COVID-19 vaccination for refugees who have not been vaccinated.
  • Provide counseling and education about COVID-19 vaccines at the domestic medical examination, which is available to populations eligible for benefits available under the United States Refugee Admissions Program.
• Where possible, reinforce key messages about COVID-19 vaccines at vaccination sites and provide education about the purpose of and how to use post-vaccination monitoring systems such as v-safe, when applicable.

Why Refugees May Be at Increased Risk During COVID-19 Pandemic

Due to social and economic conditions, resettled refugees face many of the same challenges that lead to poorer health for some racial and ethnic minority groups in the United States.  Refugees also face the challenges of a new healthcare system and finding health information they can understand.

Living conditions and personal circumstances

For many resettled refugees, their living conditions may make it hard to prevent getting sick with COVID-19, or to seek treatment if they do get sick.

• Several generations residing in one house can make it hard to protect older family members, as well as those of any age who have certain underlying medical conditions, such as diabetes or asthma. This may also make it difficult to isolate those who are sick, especially if living space is small, such as an apartment or a small house.
• Living in neighborhoods (urban or rural) that are far from health care, grocery stores or pharmacies can make it harder to get care if sick, and more difficult to stock up on medicines or other supplies.
• Lack of personal transportation such as a car can make it difficult to get to healthcare facilities, work, or stores. Refugees rely on public transportation such as buses, ride share, and trains, which are limited in some areas, especially during the current pandemic.
• Lack of access to television, radio, or Internet can make it difficult to get information about COVID-19. Refugees may not be able to read or understand English, and some refugees may even have limited literacy of their native language.
• Not yet being integrated into the community can limit potential support and links to friends, religious leaders, or community organizations.

Work circumstances

With the help of resettlement agencies, refugees often work in entry-level jobs, where the type of work, and workplace policies, can increase the risk of getting sick with COVID-19. Two factors may increase risk:

• Being a critical worker: The risk of infection may be greater for refugee workers in essential industries, such as meat-packing plants, grocery stores, and factories. These workers often are required to be at the job site despite outbreaks in their communities, and many can’t afford to stay home. Some of these kinds of jobs require public contact and close contact among fellow workers, increasing the risk of getting or spreading COVID-19.
• Not having sick leave: Refugees without paid sick leave may be more likely to keep working when they are sick or be exposed to someone who is sick with COVID-19—which means that they are more likely to spread COVID-19 to other workers, including other refugees who oftentimes work in the same facilities.

Underlying medical conditions and lower access to care

Some refugees have underlying medical conditions and face barriers to healthcare, which may put them at increased risk of COVID-19. These include:

• Lack of health insurance: Refugees can access healthcare in the early resettlement period, with the help of resettlement agencies. However, after their short-term health insurance expires, up to 50% of refugees may be uninsured.
• Language barriers: Language barriers can affect healthcare access at every stage, from making an appointment, to relaying health concerns, to filling a prescription, or to taking medicine as prescribed. Language barriers may also prevent refugees from getting COVID-19 information that is not written using common everyday words with visuals and culturally relevant. Healthcare providers, clinics, or community groups can provide interpretation services to help fill these gaps.
• Underlying medical and mental health conditions: Compared to the general U.S. population, refugees may have certain underlying medical conditions (for example, diabetes) that put them at increased risk of more severe illness from COVID-19, as well as mental health conditions (e.g., post-traumatic stress disorder and depression). These conditions may be poorly controlled due to many years without regular preventative care.
• Stigma and perceived discrimination: These issues may prevent refugees from seeking testing or care or being honest with their healthcare providers about their health needs.

Despite these barriers, refugees have the support of resettlement agencies, community groups, state refugee coordinatorsexternal icon, and healthcare providers. State, local, and community response to COVID-19 should include working with these resource groups in their COVID-19 response efforts, who are trusted members of refugee communities.

What Providers Working with Newly Resettled Refugees Need to Know about COVID-19

Getting vaccinated is the best protection against COVID-19, but you can take more steps to protect yourself and your clients even if you and your client are fully vaccinated.

• Wear a mask.
  • You should wear a mask when working with a client regardless of your vaccination status, especially if you are in an area of substantial or high transmission.
  • You may not know if a client has a weakened immune system or if they have been fully vaccinated. Wearing a mask is even more important if you or your client are at increased risk for severe disease, or if someone in your or your client’s household has a weakened immune system, is at increased risk for severe disease, or is unvaccinated.
  • You should also wear a mask where required by laws, rules, regulations, or local guidance.
• Encourage your client to wear a mask.
  • Wearing masks may be difficult for people with sensory, cognitive, or behavioral issues. Masks are not recommended for children under 2 or anyone who has trouble breathing or is unconscious, incapacitated, or otherwise unable to remove the covering without help.
• When possible, stay at least 6 feet away from clients and others in their home.
• Wash your hands often with soap and water for at least 20 seconds or use a hand sanitizer that contains at least 60% alcohol.
• If you or your client have symptoms of COVID-19 or test positive for COVID-19, cancel your in-person appointment or meeting unless you are an essential caregiver or aide.
• If you or your client have been exposed to COVID-19 and either one of you have not been fully vaccinated, cancel your in-person appointment or meeting unless you are an essential caregiver or aide.
  • If you and your client are fully vaccinated, you may follow guidance for people who are fully vaccinated.