What are camps and camp-like settings and who resides in them?

Worldwide, there are an estimated 89.3 million people who have been forcibly displaced from their homes and are living in camps, camp-like settings or informal settlements. These settlements include planned camps put in place by national governments or international agencies; self-settled camps developed by affected populations; transit camps used by people travelling through a country or region, and collective centres where an existing building is repurposed. Populations in camps and camp-like settings can typically be defined as refugees, internally displaced persons (IDPs), asylum seekers, stateless people, and/or people in refugee-like situations.

Evidence suggests that these crisis-affected populations are at an increased risk of epidemic diseases, namely respiratory and diarrhoeal diseases. This is in part due to health risks associated with forced displacement, overcrowding and inadequate access and coverage of WASH services. Numerous outbreaks of infectious diseases such as cholera, diphtheria, and COVID-19 have been reported from camps and camp-like settings. Preventing the spread of infectious diseases in these settings is important to protect populations who may be more vulnerable (e.g., populations who are clinically vulnerable or who may be more vulnerable to exclusion and discrimination) and the broader population within a country.

Additionally, these populations may also be neglected, stigmatized and have difficulties accessing health services that are available to the general or host population. Crisis-affected populations may therefore be at an increased risk of serious disease outcomes if they are unable to access health services. There is a strong public health and human rights rationale to extend all services to everyone, regardless of status and ensure inclusivity of the response. During infectious disease outbreaks, health services should be offered equitably to protect those disproportionately affected by consequences of the epidemic and the response.

This section relates to COVID-19 specifically, but principles can be applied to other diseases with similar transmission routes. In addition to the WHO’s standard infection prevention and control (IPC) guidelines, lots of guidance has been developed to inform COVID-19 responses in camp, camp-like or informal settlements specifically. The WHO and the Global WASH Cluster have collated a list of resources for humanitarian crises, including camps and camp-like settings. The Inter Agency Standing Committee (IASC), United Nations High Commissioner for Refugees (UNHCR), International Federation of the Red Cross / Red Crescent (IFRC), and WHO have also produced joint guidance on maintaining and scaling up COVID-19 response in crisis-affected populations. In the sections below, we summarise the relevant parts of the guidance for prevention of transmission according to three key goals of COVID-19 responses in camps and camp-like settings:

1. Reduce person-to-person transmission

2. Reduce contact exposure or surface transmission

3. Ensure individuals with COVID-19 symptoms (or those in close contact with symptomatic individuals) seek care and/or isolate when needed.

Access to and coverage of WASH services in camps and informal settlements should be increased to reduce the transmission of COVID-19. Frequent handwashing and respiratory hygiene (including respiratory etiquette and mask use) are some of the most important measures that prevent infection with COVID-19. WASH infrastructure and activities should enable greater frequency of hand washing by increasing access to soap, expanding access to handwashing facilities and using evidence-based strategies for hygiene behaviour change.

Expanded and adapted WASH services for camp and camp-like settings should include:

Increase water points: Fix any damaged water points and increase the number of taps per population and the number of water points. Where possible, construct water points that minimize hand contact with water infrastructure (e.g., pedal action taps or taps with sensors) and which allow physical distancing to be maintained.

Increase water quantity: Increased water quantity facilitates improved domestic hygiene practices. Ensure populations have sufficient water to meet their needs. This may mean increasing the number of litres per capita per day (LPCD) for the population and ensuring that these are in excess of minimum standards.

Maintain water quality: In centralised systems, maintain Free Residual Chlorine (FRC) of 0.5 mg/l in drinking water after at least 30 minutes contact time, and regularly clean water storage containers. If centralised systems are unavailable, provide or encourage the use of household water treatment technologies, such as boiling or using high performing ultrafiltration or nanomembrane filters, solar irradiation and, in non-turbid waters, UV irradiation and appropriately dosed free chlorine. For more on water treatment in relation to COVID-19, see this resource or the WHO guidelines.

Maintain sanitation services: Maintain access to improved sanitation and regularly clean communal toilets with detergents and ensure workers use appropriate personal-protective equipment (PPE). Safe faecal-sludge management (FSM) services should also be expanded to service the local population. For further advice on FSM in camps and camp like settings, see the Octopus and SaniHub resources.

Increase handwashing stations: Increase the number of and access to handwashing stations at homes, within blocks or clusters of households (e.g. at shared sanitation or entrance and exit points to camp regions), schools and public places (e.g. markets, health centres, child friendly spaces, places of worship, and transport centres) and ensure water and soap are available at all handwashing points. See our resources on handwashing infrastructure for further guidance.

Increase distribution of soap and WASH materials: People will require increased quantities of cleaning products at this time in order to adhere to preventative actions. Non-Food Items (NFIs) such as soap, sanitizer, cleaning products and masks could be included in hygiene kits. Enabling access to NFI kits should be done in line with existing guidance, (e.g. from Sphere) and be done in such a way that utilises the local market, minimises contact and the likelihood of transmission. At minimum, this includes setting up handwashing facilities at distribution sites. Expanding distributions and adjusting the timing of distributions should also be considered.

Promote hygiene behaviour change: Standard programme design processes should be followed for designing hygiene promotion activities in camps or camp like settings. This involves talking to, engaging with and learning from the population, in order to develop hygiene promotion activities that align with their circumstances, cultural norms and motives during this crisis. The Wash’Em process has been used to rapidly design handwashing promotion activities in camps and camp-like settings.

Adapt dead body handling and burial ceremonies: The risk of viral transmission while preparing the body of a person infected with COVID-19 is low and mainly occurs through contact with contaminated surfaces. Personnel who are interacting with the body, such as health care staff or the burial team, should use appropriate personal protective equipment (PPE), follow standard precautions and practice hand hygiene before and after interaction with the body, and the environment. People at high risk of severe illness, such as older people and those with pre-existing conditions, should be discouraged from participating in preparing the body, however, they do not necessarily need to be excluded from the mourning process. One of the key lessons from the Ebola outbreaks in Africa was that in addition to burials being safe and preventing disease transmission, they must also be culturally appropriate and dignified. The CDC has developed guidance on mourning and burial ceremonies and this includes specific recommendations for humanitarian settings and camps. Most governments have also developed guidance on how many people can attend funerals. However, it is important to work with populations to get funeral procedures right. In camps in Cox’s Bazar, they conducted a qualitative learning process to decide how to manage burial processes.

Considerations for the delivery of WASH services and products include:

Community engagement and learning: Work through existing structures to engage with the population to learn about perceptions related to COVID-19 and the community’s concerns. Note that for many crisis-affected populations, COVID-19 may not be their primary concern. Populations living in camps and camp-like settings may perceive themselves to be at a different level of risk of getting COVID-19 in comparison to the rest of the population. To counter this, it may be useful to normalise and share experiences of people who have had COVID-19 within the camp.

Use of a range of delivery channels: In camps and camp-like settings, the most common way of reaching people for hygiene promotion activities has historically been through face-to-face interactions. It is likely that this will need to be adjusted for COVID-19 response. During the pandemic, many countries focused on using digital media to reach populations, but displaced and crisis-affected populations did not always have high levels of access to mobile phones, the internet and mass media. To understand the best ways of reaching people, include an assessment of delivery channels as part of routine assessments and community engagement. If you are developing communication materials for camps, see this guide.

Ensure hygiene promotion staff stay safe: All staff who are conducting work in camps or camp-like settings should follow physical distancing recommendations, have access to sanitizer or handwashing facilities and wear masks. These measures are key for keeping themselves and the population safe. For more guidance on the measures to be taken by frontline staff, see this resource.

Align WASH actions with the national response, global standards and actions within other sectors: Activities within camps and camp-like settings should be aligned with the national coordinated response and continue to consider general guidance on environmental health in emergencies. There are also useful WASH checklists which have been developed by SPHERE and UNHCR. These include preparedness activities and how WASH intersects with other emergency response sectors, such as food distribution and community engagement.

Promote safe mask use: The WHO recommends that in community settings with known or suspected SARS-CoV-2 transmission, non-medical fabric face masks should be used by the population. Decisions about recommending fabric mask use in camps or camp-like settings should also be aligned to national government guidelines. If producing or purchasing fabric masks, make sure to consider the design, fabric used, and the number of layers of fabric. For specific guidance, see our article on masks. It’s also important to ensure people have access to sufficient numbers of fabric masks so that they can wear them safely and clean them regularly. We would recommend 3 per person. Make sure to teach people about safe mask use as part of hygiene promotion activities.

Physical distancing: Physical distancing in camps and camp-like settings can be challenging, given limited land availability and the density of populations. In the early stages of the pandemic, concerns related to the inability to physical distance caused many to speculate that camps and camp-like settings could easily become major sites for COVID-19 transmission. Indeed, we have witnessed outbreaks in camps settings throughout the course of the pandemic. For example, cases have been reported by the Rohingya refugees in Cox Bazar in Bangladesh.

Actions that should be considered to enable physical distancing in camps and camp like settings during COVID-19 outbreaks include:

Ensure protection of the population remains central to the response: Be aware of the broader impacts the COVID-19 pandemic is having on the lives of crisis-affected populations. Any measures introduced in response to COVID-19 may have adverse effects on other daily activities and programmes (e.g. closure of markets and schools, postponement of food distribution, limitation of free movement in and out of sites). Programmes should incorporate an assessment of their potential implications. This should consider gender, protection, livelihoods, well-being and psychosocial needs and other concerns. Programmatic plans may need to change and alternative modalities for providing services or assistance to individuals should be considered.

Community feedback: Where possible, utilise existing community feedback mechanisms or provide a hotline or process for the community to provide feedback and ask questions about COVID-19 and about response programming. All staff, from cleaners to health promoters to managers, should have knowledge of the feedback mechanism and feedback mechanisms should be actively promoted. This could include printing the hotline number on staff t-shirts or vehicles, or painting murals on walls with the number.

The hygiene of communal areas and facilities will need to be strictly maintained during outbreaks of infectious diseases such as COVID-19 and cholera. Cleaning and disinfection of surfaces at communal facilities, such as toilets, showers, water points and distribution points, should be done as frequently as possible or at least daily. It is particularly important to clean taps, door handles or other high-touch surfaces. In order to enable this cleaning, the following should be considered:

Surface-based transmission can also be reduced by increasing handwashing facilities at these communal points and putting systems in place to regularly replenish the soap and water. Similarly, cleaning solid waste from areas and maintaining existing rubbish management systems are important, particularly since people will be needing to dispose of used PPE.

For further guidance, see this guidance from the UNHCR and WHO, as well as our resource on PPE for sanitation workers.

Identifying and isolating probable and confirmed cases as early as possible are the most important measures to control the outbreak. In some regions, COVID-19 testing is unavailable or limited and testing shortages may be more likely to be experienced in camps and camp-like settings. If there is confirmed community transmission of COVID-19 in your region, then suspected cases (people with COVID-19 symptoms) who cannot be tested should isolate and/or seek care through established local mechanisms (e.g. in person at a health facility or via a phone-based health consultation).

Options for isolation or self-isolation will vary between contexts, and may include one of the following three scenarios:

1. Self-isolation in the home where individuals ARE able to isolate in a separate room: Suspected cases should stay in an individual room, use their own utensils and linens, and have no contact with anyone else but a caregiver who should wear a mask. If using a shared sanitation facility, the person should clean and disinfect all surfaces they use, including the toilet. After isolation, the room should be appropriately cleaned and disinfected before other household members use the room. The Social Science in Humanitarian Action Platform has developed a guide for ensuring that home-based care can be managed safely and acceptably and the WHO also provides guidance.

2. Self-isolation in the home where individuals ARE NOT able to isolate in a separate room: In addition to the recommendations mentioned just above in scenario 1, suspected cases should wear a mask and allow for space (at least 1 meter) between them and other members of the household throughout the day and night, where possible. If 1 metre distances are not possible in sleeping areas, consider adding a barrier between the suspected case and others or sleeping head to toe. Where possible, increase the airflow within the house by opening doors and windows. Visitors should be limited, and if the suspected case must leave the home, they should wear a mask and notify the health care facility (HCF) that they are coming and that they have tested positive for COVID-19, or have COVID-19-like symptoms.

Scenario 3 is required when individuals requiring isolation and treatment do not have an adequate shelter and should be prioritized for facility isolation.

3. Isolation in temporary facilities or HCFs: In most instances, there may not be sufficient space in HCFs to treat all suspected cases as well as confirmed COVID-19 cases. During COVID-19 outbreaks, HCFs also need to be preserved for the treatment of non-COVID-19 medical issues and health services. All efforts must be made to increase the capacity of any collective isolation facilities. In camps and camp-like settings, it is useful to identify empty spaces, ideally next to the local health facility, where a new (temporary) structure could be put in place for isolation and treatment. Temporary facilities may also include repurposing existing community facilities (i.e. community hall or sports area). Such facilities can be used for the isolation and treatment of mild and low to moderate risk cases as well as the isolation and monitoring of contacts of cases. If setting up new facilities, make sure to plan appropriately for human resources and equipment needed for the operation of these isolation facilities. See these WHO guidelines for further information on repurposing facilities for COVID-19 isolation.

Key considerations for all types of isolation include:

For further guidance on isolation and care-seeking in camps and camp-like settings during COVID-19 outbreaks, see resources from WHO, the Global WASH Cluster and the IASC.

To aid your community engagement and communication on isolation and care-seeking behaviours, the WHO has developed a message library for use with at-risk populations which can be adapted locally for populations in camps and camp-like settings. Adaptations should take into account the culture, literacy rates, preferred communication channels and other factors such as miscommunication, community perception and prevalence of rumours. See our resources on community engagement, developing materials and deciding on which channel to use for further guidance.

To encourage self-isolation and care-seeking behaviour, messages should:

For further information, see our resource on what works to change handwashing and hygiene behaviours, as well as this learning brief from WaterAid which reflects on lessons learned from their COVID-19 hygiene response.

Author: Lauren D’Mello Guyett

Reviewed: Miriam Harter, Nada Abdelmagid, Tara Vernon, Bruce Spires

Last update: 03.06.2023