Objective To guide clinicians working in a range of primary care clinical settings on how to provide effective care and support for refugees and newcomers during and after the coronavirus disease 2019 (COVID-19) pandemic.The described approach integrates recommendations from evidence-based clinical guidelines on refugee health and COVID-19, practical lessons learned from Canadian Refugee Health Network clinicians working in a variety of primary care settings, and contributions from persons with lived experience of forced migration.The COVID-19 pandemic has amplified health and social inequities for refugees, asylum seekers, undocumented migrants, transient migrant workers, and other newcomers. Refugees and newcomers face front-line exposure risks, difficulties accessing COVID-19 testing, exacerbation of mental health concerns, and challenges accessing health care, social, and settlement supports. Existing guidelines for clinical care of refugees are useful, but creative case-by-case strategies must be employed to overcome additional barriers in the context of COVID-19 and new care environments, such as the need for virtual interpretation and digital literacy skills. Clinicians can address inequities and advocate for improved services in collaboration with community partners.The COVID-19 pandemic is amplifying structural inequities. Refugees and newcomers require and deserve effective health care and support during this challenging time. This article outlines practical approaches and advocacy priorities for providing care in the COVID-19 context.This article is eligible for Mainpro+ certified Self-Learning credits. To earn credits, go to www.cfp.ca and click on the Mainpro+ link. This article has been peer reviewed.# 
 A large proportion of refugees have faced forced migration, precarious isolation, substandard living conditions, and limited health care. Layered onto pre-existing trauma and a multitude of postmigratory stressors, the coronavirus disease 2019 pandemic has brought about further loss of access to settlement services, loss of employment and income, and prolonged social isolation, each of which exacerbates mental and social strain.
 Many refugee patients have struggled to access their health care providers and familiar social supports during the coronavirus disease 2019 pandemic, and continue to grapple with navigating a constrained health system. Obstacles include limited in-person visits and a transition to virtual care and online services compounded by existing language barriers, inconsistent access to and familiarity with technology, and a range of social stressors. Clinicians must remain alert for depression and anxiety and ensure a range of care options and platforms are available, and can help patients connect to social and community programs to address underlying social and economic stressors.
 Overcoming barriers requires new and creative solutions; dynamic interdisciplinary teams, perhaps within more specialized or alternatively funded clinics; and caseby-case approaches. Innovations should be codesigned with patients to ensure strategies are responsive to their needs and priorities.
T he coronavirus disease 2019 (COVID-19) pandemic has exacerbated inequities related to health and socioeconomic status for refugees and newcomers around the world. 1 Box 1 defines some categories of migrants and clarifies the health and social support to which they are entitled. 2,3 Despite comprising approximately 25% of the population, refugees and newcomers accounted for 43.5% of Ontario's COVID-19 cases in the first half of 2020. At the same time, rates of COVID-19 testing in Ontario were lower for refugees (3.4%) compared with Canadian-born individuals (4.4%). 4 Employment in front-line work with limited job protection and safety measures, high-density housing situations, and greater reliance on public transportation put refugees at higher risk of contracting COVID-19. 5 Temporary foreign workers and undocumented migrants may be at even greater risk, given their precarious work, living, and immigration circumstances. 6 Indeed, COVID-19 has had a disproportionate impact on the ealth of refugees and newcomers 7 and left many ndocumented migrants without access to health care. 8 Refugees have long faced individual, institutional, nd systemic barriers to care. These include financial onstraints, language barriers, pre-existing trauma, sysemic racism, and care coordination challenges. 9,10 Public ealth's redistribution of resources to address the panemic is often at the expense of refugee health prioriies, including screening for and management of both nfectious and chronic diseases (eg, tuberculosis, hepaitis B and C viruses, hypertension, diabetes), immunizaions, and mental health care. Public health restrictions or COVID-19 have also increased barriers to health care nd core resettlement services and have resulted in broen service connections. 11 Notable COVID-19 outbreaks n meat processing facilities 12 and among agricultural orkers 13 have highlighted the vulnerability of newcomer 

# Sources of information
The authors, all with the Canadian Refugee Health Network, shared clinical COVID-19 experiences, reviewed literature such as the eCOVID-19 guidelines and refugee health guidelines, and interviewed people with lived experience of forced migration (Box 3). 9,  Main message   21 periods of mandatory self-isolation or quarantine for newly arrived refugees by assisting with medical needs through virtual care and through partnerships with settlement organizations to address social needs.
Promote access to COVID-19 testing, care, and immunization. Even with lower testing rates among refugees and other migrants, secondary data analysis has found disproportionately high COVID-19 infection rates. 4 Exposure risks related to work, housing, and public transportation are compounded by a variety of barriers to testing. As well, varying levels of trust in health care institutions, often rooted in past and recent experiences of discrimination, exclusion, and systemic racism, may also hinder access to care. 22 Indeed, compared with Canadian-born residents, 3.2-fold fewer foreign-born residents obtain access to comprehensive primary health care. 23 Our experience also suggests health care providers can help patients to overcome barriers, including assisting with booking tests and arranging transport to testing locations. Further advocacy is required to ensure testing is truly accessible in priority communities by addressing this range of barriers. Additionally, it is important that vulnerable patients who have positive test results for COVID-19, or who otherwise require isolation, receive wraparound support and links to community resources to enable their safe isolation, with measures ranging from virtual clinical support to food deliveries to income support. Increasingly, trusted primary care providers, alongside community members and community leaders, are helping provide information and answer questions about COVID-19 vaccine recommendations. 15 Moreover, linked database studies suggest refugees and migrants must be considered among priority groups for COVID-19 vaccines. 4,24 Support women, children, and families. Historically, through economic, environmental, and epidemiologic crises, women have borne a disproportionate burden of detrimental impacts. 25 Lockdowns and self-isolation measures for COVID-19 have deepened pre-existing inequalities and vulnerabilities in social, political, and economic systems 26 when, globally, women already earn less, have greater job insecurity, and have a greater likelihood of being informally employed. 27 As with Canadian-born families, family tension may mount in this context, coupled with loss of community contacts, and evidence-based guidelines remind us to be alert to domestic violence in any population. 9,26 Within Canada, refugee women who generally provide essential care for families, often also must work in front-line jobs that increase their risk of exposure to COVID-19.
Refugee children often excel in their host neighbourhood school environment, learning local languages and cultures and making new friends. Social integration of refugee children early in the resettlement period is critical for their well-being. 28 Our clinical experience has shown that, for a variety of reasons, some refugee families have elected to keep their children home for virtual learning, rather than attending in-person classes. Virtual environments lack many of the social and academic supports of in-person schooling, and therefore clinicians should discuss school attendance with appropriate public health prevention measures, and can play a role in alleviating many parental concerns. They can also advocate for appropriate technology, language, and cultural support for children and families to enable their participation in educational activities.
Address stress and mental health. A large proportion of refugees have faced forced migration, precarious isolation, substandard living conditions, and limited health care during deadly epidemics in refugee camps. Layered onto pre-existing trauma and a multitude of postmigratory stressors, the COVID-19 pandemic has brought about further loss of access to settlement services, loss of employment and income, and prolonged social isolation, each of which exacerbates mental strain. 6,9 Primary care providers report frequent concerns of headaches, vision problems, and requests for sick notes and disability among patients, signaling underlying mental distress. 11 Sleep, anxiety, and mood have worsened for many, as individuals may have had more time to reflect upon and re-experience their past trauma without the distractions of daily life to help provide structure. Clinicians must remain alert for depression and anxiety and ensure a range of care options and platforms are available and responsive to patient needs and priorities 9 (for some, virtual care may facilitate access to care, whereas for others, in-person appointments may be a critical form of support). Health care providers can also help patients connect to available social and community programs to address underlying social and economic stressors. 29 From a trauma-informed, strengths-based approach, clinicians can support patients in focusing on their lived experience, learnings, abilities, internal resources, and resilience in overcoming challenges (see Traumainformed: the Trauma Toolkit). 16,30,31 Recognize the potential, but also the limitations of virtual care with refugees. In the face of COVID-19, primary health care and mental health services dramatically shifted to virtual care. Limitations, including technologic barriers, communication challenges, and privacy concerns, 32 make these services less accessible to many refugee patients. Most virtual platforms require patients to have laptops, cell phones with data plans, or access to Wi-Fi, and the digital and health literacy to navigate complex systems.
High-quality interpretation services are critical for health care delivery and should be considered a right when there is language discordance between providers and patients. 33 With increased reliance on an accurate history, virtual care is also highlighting the foundational role of professional interpretation in providing safe, equitable care. Ideally, clinicians should integrate interpreters into virtual platforms and employ in-person and telephone interpretation when desirable and accessible. Experience shows that clinicians can advocate for their patients to gain access to the appropriate technology to facilitate virtual care and for platforms designed for those with limited digital literacy and proficiency in English or French. Furthermore, safe options for in-person care must remain available, given these barriers to virtual care.
Stay alert to particular social needs, advocate for individual needs and system-level change, and encourage return to community and resettlement programs. Refugees often need support to connect to essential legal and social services, such as housing, language classes, and employment training, as well as for food security. Health providers should remain vigilant for signs of unmet social needs, such as housing instability and income insecurity, 19 explored in a sensitive, nonjudgmental way, and documented in patients' electronic medical records to ensure ongoing follow-up. Although many familiar social and settlement supports have been curtailed owing to pandemic restrictions, clinicians can help link refugees to community and resettlement programs as they become available, including in new virtual forms. A recent systematic review on homeless migrants 19 suggests screening for safety in the home and navigating and advocating for local social supports are essential components of care, guided by the priorities of patients themselves. 29 

# Case resolutions

# Conclusion
The COVID-19 pandemic is amplifying structural inequities, and one culturally and linguistically diverse group-refugees and newcomers-is among the special populations that need effective and case-bycase care, support, and advocacy at this time. This article outlines practical COVID-19-appropriate interventions for refugee care and some concrete examples of advocacy for refugee patients.

# Contributors
All authors contributed to the literature review and interpretation, and to preparing the manuscript for submission.

# Competing interests
None declared Correspondence Dr Neil Arya; e-mail narya@uwaterloo.ca