COVID-19 epidemiology and changes in health service utilization in Azraq and Zaatari refugee camps in Jordan: A retrospective cohort study

Abstract

Background The effects of the Coronavirus Disease 2019 (COVID-19) pandemic in humanitarian contexts are not well understood. Specific vulnerabilities in such settings raised concerns about the ability to respond and maintain essential health services. This study describes the epidemiology of COVID-19 in Azraq and Zaatari refugee camps in Jordan (population: 37,932 and 79,034, respectively) and evaluates changes in routine health services during the COVID-19 pandemic. Methods and findings We calculate the descriptive statistics of COVID-19 cases in the United Nations High Commissioner for Refugees (UNHCR)’s linelist and adjusted odds ratios (aORs) for selected outcomes. We evaluate the changes in health services using monthly routine data from UNHCR’s health information system (HIS; January 2018 to March 2021) and apply interrupted time series analysis with a generalized additive model and negative binomial (NB) distribution, accounting for long-term trends and seasonality, reporting results as incidence rate ratios (IRRs). COVID-19 cases were first reported on September 8 and September 13, 2020 in Azraq and Zaatari camps, respectively, 6 months after the first case in Jordan. Incidence rates (IRs) were lower in camps than neighboring governorates (by 37.6% in Azraq (IRR: 0.624, 95% confidence interval [CI]: [0.584 to 0.666], p-value: Conclusions COVID-19 transmission was lower in camps than outside of camps. Refugees may have been affected from external transmission, rather than driving it. Various types of health services were affected differently, but disruptions appear to have been limited in the 2 camps compared to other noncamp settings. These insights into Jordan’s refugee camps during the first year of the COVID-19 pandemic set the stage for follow-up research to investigate how infection susceptibility evolved over time, as well as which mitigation strategies were more successful and accepted. Chiara Altare and colleagues evaluate the COVID-19 epidemiology and associated changes in routine health services in Azraq and Zaatari refugee camps in Jordan. Author summary Why was this study done? There is a scarcity of information on the Coronavirus Disease 2019 (COVID-19) in humanitarian settings, including in refugee camps. Challenges specific to humanitarian settings have raised concerns over the ability to respond to the pandemic as well as to maintain essential health services. Crises often result in diverted attention and funding for health services that are critical to preventing excess disease and death from all causes. Evidence about the COVID-19 situation in humanitarian settings can help actors to make informed decisions about epidemic response and to appropriately prioritize services. What did the researchers do and find? We used observational programmatic data to describe the COVID-19 situation in 2 refugee camps in Jordan (Azraq and Zaatari camps) and evaluated changes in health services pre- and during COVID-19 periods. We found that there were lower rates of COVID-19 in the camps than at the governorate level by 37.6% (Azraq) and 40.2% (Zaatari) and at the national level by 59.7% (Azraq) and 63.3% (Zaatari). At the beginning of the COVID-19 pandemic, health service utilization declined for health consultations by 32.0% (Azraq) and 24.2% (Zaatari), for respiratory tract infection (RTI) consultations by 25.1% (Azraq) and 37.5% (Zaatari), and for family planning services by 47.4% (Azraq) and 47.6% (Zaatari). Health services for maternal healthcare and noncommunicable diseases (NCDs) did not show major changes between the pre- and during COVID-19 periods. What do these findings mean? The findings indicate that refugees did not pose a threat of spreading COVID-19 in the study locations, but may themselves have been affected by external COVID-19 transmission. There was a mix of health service performance in the first year of the pandemic, although services in the camps appeared to function better than in noncamp settings. Findings are limited by the challenges to conducting research in humanitarian settings including difficulties measuring health system performance and capturing external characteristics that could affect study results. The results set the stage for follow-up research on COVID-19 in humanitarian settings, including how infection rates may change over time, which mitigation strategies are appropriate, and how health services are affected.