Predicting COVID-19 Infection Among Older Syrian Refugees in Lebanon: A Multi-Wave Survey
Authors: Zeid Berthe Abi , El Khoury Tanya , Abdulrahim Sawsan , Ghattas Hala , McCall Stephen 
Published: January 2024

Background

Older refugees, exposed to a cluster of biological and social vulnerabilities, are more susceptible to COVID-19 infection and its complications. This study developed and internally validated a predictive model estimating COVID-19 infection risk among older Syrian refugees in Lebanon. Additionally, it described the barriers to PCR testing among those who reported a COVID-19 infection.

Methods

This was a cross-sectional analysis of a five-wave longitudinal study conducted between September 2020 and March 2022. Syrian refugees aged 50 years or older living in households that received assistance from a humanitarian organization were interviewed by phone. Self-reported COVID-19 infection was the outcome of interest. The predictors were identified using adaptive LASSO regression. The model performance and discrimination were presented using the calibration slope and the Area Under the Curve.

Findings

Of 2,886 participants (median [IQR] age: 56[52-62]; 52.9% males), 283 individuals (9.8%) reported a COVID-19 infection at least once. Six predictors for COVID-19 infection were identified: living outside informal tented settlements, having elementary and preparatory education or above, having chronic conditions, not receiving cash assistance, being water insecure and having unmet waste management needs. The model had moderate discrimination and good calibration. Nearly half of the cases were diagnosed through PCR testing. The main reasons for not testing were perception that the tests were unnecessary (n=91[63.6%]) or inability to afford them (n=46[32.2%]).

Interpretation

High-risk individuals should be targeted based on predictive models incorporating social determinants. Implementing awareness campaigns, screening measures, and cash assistance may reduce vulnerability in future pandemics.

Funding

ELRHA’s Research for Health in Humanitarian Crisis Programme and AUB University Research Board.

Research in context

Evidence before the study

A literature search was conducted in the databases PubMed and Google Scholar for studies published between February 1, 2020, and June 14, 2022, with the objective of developing a predictive model or examining the associated factors of COVID-19 infection among older adults or refugees. Different combinations of the following keywords were used in our research: “COVID-19 infection”, “SARS-CoV-2”, “Coronavirus”, “predictors”, “risk factors”, “refugees”, “migrants”, and “Syrian”. Previous evidence has shown that displaced populations are considered vulnerable groups highly susceptible to the impacts of COVID-19, due to their exposure to a combination of biological and psychosocial vulnerabilities. In Lebanon, Syrian refugees face an elevated risk of infection and its complications, mainly due to the deterioration of their living conditions resulting from the multiple crises burdening the country. The literature search featured the following potential predictors: age, gender, educational attainment, marital status, housing conditions, socioeconomic status, and presence of chronic illnesses. However, to date, no studies have developed predictive models of COVID-19 infection focusing on Syrian refugees in the MENA region. Additionally, there has been a scarcity of predictive models incorporating social determinants to assess the risk of infection among refugees or older adults in this context. Hence, identifying individuals who are highly susceptible to COVID-19 infection and its severity amongst vulnerable populations is important to inform better targeting of assistance in future outbreaks and to reduce the risk of infection and its complications.

Added value of the study

To the best of our knowledge, this is the first study that exclusively incorporates social determinants into a prediction model of COVID-19 infection among older Syrian refugees. Out of 2,886 participants, 283 individuals (9.8%) reported experiencing COVID-19 infection at least once. Six predictors of COVID-19 infection among older Syrian refugees were identified: living outside informal tented settlements, having elementary and preparatory education or above, having chronic conditions, not receiving cash assistance, being water insecure and having unmet waste management needs. Despite the efforts and the collaboration between UNHCR, several NGOs and the Lebanese Ministry of Public Health to cover the cost of COVID-19 testing and to raise awareness about COVID-19 symptoms and the necessity of testing, only half of the cases were diagnosed through PCR or lateral flow tests. The main reasons for not testing were perceptions that it was unnecessary or inability to afford the tests.

Implications of all the available evidence

The predictors identified in this study could be used to inform targeting efforts by humanitarian organizations to provide assistance to Syrian refugees at higher risk of COVID-19 infection or infections in future pandemics. In addition, it will be important for humanitarian organisations to continue outreach efforts outside of informal tented settlements into the community to reach the most vulnerable to COVID infection with interventions. Furthermore, intensifying awareness campaigns among Syrian refugees about testing availability and the importance of visiting a healthcare professional, and considering the implementation of free testing in primary healthcare centers and pharmacies will be essential to control infectious diseases in future pandemics.