What are camps and camp-like settings and who resides in them?
Worldwide, there are an estimated 79.5 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.
Why are populations in camps and camp-like settings more at risk from COVID-19?
Evidence suggests that these crisis-affected populations are at an increased risk of epidemic 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 measles have been reported from camps and camp-like settings. Preventing the spread of COVID-19 in these settings is important to protect extremely vulnerable populations 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 severe COVID-19 or dying from COVID-19 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 the COVID-19 epidemic, health services should be offered equitably to protect those most vulnerable to the consequences of the epidemic and the response.
What actions should be implemented in camps and camp-like settings to reduce transmission of COVID-19?
Lots of guidance has already been developed to inform COVID-19 responses in camp, camp-like or informal settlements over the last months. 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:
- Reduce person-to-person transmission
- Reduce contact exposure or surface transmission
- Ensure individuals with COVID-19 symptoms (or those in close contact with symptomatic individuals) seek care and/or isolate when needed.
How can WASH programmes be adapted to reduce person-to-person transmission in camps or camp-like settings?
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.
Image: Newly constructed water points in Syria with taps that are spaced apart to enable physical distancing. ©ATAA
- 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 fecal-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 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. Distributing NFI kits should be done in line with existing guidance, (e.g. from Sphere) and be done in such a way that 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 and 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 recent 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 have focused on using digital media to reach populations but displaced and crisis-affected populations may 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.
What other COVID-19 preventative actions should be implemented to reduce person-to-person transmission in camps or camp-like settings?
Promote safe mask use: The WHO currently recommends that in densely populated settings, such as camps and camp-like settings, 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. Concerns related to the inability to physical distance have caused many to speculate that camps and camp-like settings could easily become major sites for COVID-19 transmission. Actions that should be considered to enable physical distancing in camps and camp like settings include:
- Utilising any vacant nearby land to increase spacing between shelters. This may require advocacy to national governments or camp management.
- Identifying sites within the camp where people may typically gather (markets, places or worship, schools and child friendly spaces, distribution sites and health care centres) and putting in place physical distancing measures such as cues and demarcations.
- Stopping any large group activities.
- Rolling out shielding measures to protect those who are older or have pre-existing conditions.
- Adapting shelters to make it easier for people to comfortably remain at home.
- Providing economic and livelihood support so that non-essential travel can be minimised and people can remain at home.
- Reducing non-essential access to camps and recording the details of those who enter.
- Set up communication systems so that people can stay in touch without in person interactions.
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.
Image: Men take note of a phone hotline service from a mural developed by Gram Vaani
How can contact exposure and surface transmission be reduced in camps and camp-like settings?
The hygiene of communal areas and facilities will need to be strictly maintained during the COVID-19 response as surfaces can contribute to the transmission of COVID-19. 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:
- Where cleaning teams exist within camps already, they may need to modify or increase their duties. This may necessitate increased payment, the need to employ more staff and the need to provide them with additional training.
- Where cleaning teams do not exist within camps, then other WASH-related committees or groups should be used (such as pump operators, water-user committees, sanitation cleaners, service crews, garbage disposal crews and waste management staff).
- A cleaning roster could be established or each individual user could be given the ability to clean surfaces after use.
- Cleaning staff should be provided with PPE such as gloves, boots, goggles, face masks/shields and have access to handwashing facilities or sanitizer.
- PPE should be used while cleaning and hand hygiene should be practiced before and after removing PPE. Clean reusable PPEs with disinfectant. Sterilize then safely dispose of greywater or water from washing PPE, surfaces and floors.
- All surfaces in communal toilets, bathrooms, and showers should be cleaned with detergent and 0.5% sodium hypochlorite at least once a day.
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.
How can we encourage individuals with COVID-19 symptoms (and their contacts) to self-isolate and seek care as needed?
Identifying and isolating probable and confirmed cases as early as possible are the most important measures to control the outbreak. In many 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. To limit contact, clean and disinfect around the person only when needed. If they are able, the person should clean the room themselves. 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 also developed a guide for ensuring that home-based care can be managed safely and acceptably.
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 (2 meters) between them and other members of the household throughout the day and night, where possible. If 2 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 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 health care facilities (HCF): In most instances, there may not be sufficient space in health facilities to treat all suspected cases as well as cases. Health care facilities also still 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.
Key considerations for all types of isolation include:
- Ample communication to community members to explain why isolation is needed and continued engagement with the community to understand and address their concerns about the approach.
- Preservation of family unity, particularly for young children, should remain a key principle in all isolation efforts. Where possible, children should be isolated together with a caregiver.
- Look for locally-adapted approaches to support cases and their families during isolation to ensure their safety and wellbeing. This may include facilitating communication (e.g. by phone) with family and friends who are not in isolation and providing access to activities to occupy people’s time in isolation (e.g. games, reading materials, videos or drawing facilities).
- Make sure there is a process for transferring cases to higher care facilities if symptoms worsen.
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 this guide for more details “What should be considered when designing Information Education Communication (IEC) materials?” and our summary report on “Community Engagement”.
To encourage self-isolation and care-seeking behaviour, messages should:
- Provide empowering behaviour-focused and forward-looking messages rather than messages that could instil fear, confusion or suspicion
- Be inclusive and representative in order for measures to be accepted, adopted and followed by the population
What other resources are there on working in camps and camp-like settings?
- Guidance for COVID-19 preparedness and response in humanitarian settings- A co-created document sharing public health and social measures for low capacity humanitarian settings (Updated May 2020)
- Global WASH Cluster Resource Centre- a library of technical documents, guidance and a help desk for responding to COVID-19 in humanitarian contexts
- UNICEF’s COVID-19 Resource Centre- a repository of useful documents and technical guidance for COVID-19
- WHO Guidance for Environmental Health in Emergencies
- SPHERE Standards for COVID-19- a repository of documents for humanitarian contexts
- WHO guide on WASH for COVID-19- a short guide on what WASH services to provide, expand and maintain across settings
- OXFAM’s COVID-19 Response Centre- a catalogue of resources developed by Oxfam
- Guide for self-isolation in the home- a WHO technical guide for home care of patients with mild COVID-19 and management of their contacts
- Guide for temporary isolation facilities- a WHO technical guide for the provision of temporary isolation facilities for care of patients with mild COVID-19 and management in dense areas
- OXFAM’s guide for quarantine centres for vulnerable populations- a WASH guide to supporting quarantine centres for COVID-19
- CDC’s guide for preventing COVID-19 transmission in densely populated areas
- Considerations for isolation of suspected COVID-19 cases- a WHO guide on quarantine and containment of cases
- IPC for safe COVID-19 burials- a WHO guide for safe burial practices for COVID-19 cases
- WHO Message Library for COVID-19 messages
- UNICEF’s RCCE Guidance – Provides an overview of key principles with links to other useful resources (Updated April 2020)
- UNHCR Technical WASH Guidance for COVID-19 Preparedness and Response - a breakdown of key WASH guidance for COVID-19 preparedness and response activities for camps and settlements
- UNHCR COVID-19 WASH Preparedness and Response Rapid Checklist - a rapid checklist of key WASH preparedness and response activities for COVID-19 for camps and settlements
Author: Lauren D’Mello Guyett
Last update: 19.9.2020