This study was conducted within the Dadaab Refugee Camp Complex, encompassing Hagadera, Ifo, Dagahaley camps and the surrounding host community. UNHCR provides overall operational oversight and coordination in the camp on behalf of the Government of Kenya. The healthcare implementing partners for these camps are the International Rescue Committee in Hagadera camp, the Kenya Red Cross Society (KRCS) in Ifo camp, and Médecins Sans Frontières in Dagahaley camp. Each of these camps is equipped with health posts that provide out-patient services exclusively, as well as a main hospital offering both inpatient and outpatient care, along with referral services for both refugees and members of the host community. The host community resides in areas around the three camps, spanning Fafi and Dadaab sub-counties, all of which are in Garissa County. The host community population in these two sub-counties is almost the same as the refugee population. The refugees can move freely between the camps and the host community, some host community members live within the refugee camp and even marry refugees and as a result there is no disparity in access to health care. In addition, the refugees sometimes travel back to their country of origin and return to the camp as re-entrants. Consequently, UNHCR and its partners conduct a household census every 6 months to determine the population in the camp that require services.

We calculated descriptive statistics, testing rates, attack rates (AR), and case fatality rates (CFR) using routinely collected data on COVID-19 in Dadaab Refugee Camp Complex from March 2020 to December 2022.

We also describe the interventions that were collaboratively implemented by UNHCR and the Government of Kenya. These interventions were aligned with national measures and aimed at delaying the introduction and mitigating the transmission of SARS-CoV-2 within the refugee camp. These interventions were periodically adjusted in response to evolving scientific knowledge about the virus and were strategically designed to minimize the adverse socioeconomic impact on the livelihoods of the refugee population.

We used four distinct SARS-CoV-2 data sets (Table 1), which were systematically maintained by various entities: UNHCR, Kenya’s National Public Health Emergency Operations Center (PHEOC), KRCS and the National Public Health Laboratories (NPHL). The criteria for eligibility for SARS-CoV-2 testing and type of test used is described elsewhere; notably testing was not available for everyone on a large scale [10].

A line list of SARS-CoV-2 positive cases reported from the refugee camp and nationwide was obtained from UNHCR and PHEOC respectively. All SARS-CoV-2 positive cases, compiled for each camp, was aggregated, and maintained by UNHCR, through the period May 2020 to December 31, 2022. This dataset captured cases reported among refugees and humanitarian workers but excluded members of the host community. Simultaneously, the PHEOC maintained a line list of all SARS-CoV-2 positive cases reported nationally, which included host community members though they were not categorized as such in the database. To estimate positive cases among the host community, we used PHEOC data to identify Kenyan citizens residing in Dadaab or Fafi sub-county who were not classified as a humanitarian worker. We combined the host data from the PHEOC to the UNHCR line list to obtain a complete set of SARS-CoV-2 positive refugees and host community members.

The NPHL maintained records of all SARS-CoV-2 testing (both positive and negative results) in Kenya from June 14, 2020, through October 24, 2021. Similarly, refugees, humanitarian workers and host community members were defined using multiple variables, as described above, since they were not explicitly identified in the national NPHL dataset. When testing capacity became available within the camp, from July 2021 through to December 2022, the test results for refugees and humanitarian workers from Dadaab Refugee Camp Complex were no longer submitted to the NPHL but were instead managed by the KRCS on behalf of all health care implementing partners across the camp complex. KRCS however couldn’t access the secure weblink for submitting SARS-CoV-2 testing data to NPHL because of a communication breakdown between the two organizations. We merged the two datasets to obtain complete testing data from June 14, 2020, through to December 31, 2022.

Statistical analysis was performed using R version 4.1.1. We used population data for the two sub-counties from the 2019 census and biannual camp population census data from UNHCR as a denominator to estimate the AR for the host community and Dadaab Refugee Camp Complex, respectively. These populations were extrapolated for each month and monthly ARs were computed. We compared ARs, CFRs, and testing rates between the refugees, the host community, and national rates. To compare rates among these three groups, we tested the null hypothesis that the proportions were the same using the Pearson’s chi-squared test statistic. Confidence intervals for the underlying proportions were computed with confidence level of 95 percent.

We employed locally weighted scatterplot smoothing (LOWESS), which involves localized weighted regression with a span of 20% of the nearest points. Additionally, we applied weights to points closer to it to effectively capture the prediction of the AR and testing rate trends. To avoid negative ARs because of smoothing caused by values closer to zero, we fitted them on a log-scale and then applied exponentiation to get results on the original scale.

This project was reviewed by the Kenya Ministry of Health and determined to be a non-research programmatic activity to inform public health prevention strategies and did not require local Institutional Review Board approval. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.

Two months after the initial introduction of SARS-CoV-2 in Kenya, on May 16, 2020, two distinct first-cases among refugees were simultaneously reported in Dadaab Refugee Camp Complex. One case was reported from Ifo camp, who was a re-entrant to the camp, and the other case was reported from Dagahaley camp, without a history of travel in the previous 14 days. The first case of SARS-CoV-2 infection was reported in the host population on April 29, 2020. By December 31, 2022, a total of 964 laboratory confirmed SARS-CoV-2 infections were reported from Dadaab Refugee Camp Complex and the surrounding host community. Among these cases, 700 (72.6%) were among refugees while 264 (27.4%) were reported among the host population. Of the 700 SARS-CoV-2 infections reported among refugees, 64 (9.4%) cases had travelled in the last 14 days. Similarly, among the host population there were no imported cases, while at least 256 (97.0%) were likely infected locally since they did not report travelling in the previous 14 days and 8 (3.0%) had an unknown recent travel status.

Notably, 57.4% of the refugee population were aged less than 18 years old but only 16.3% of SARS-CoV-2 infections among refugees occurred in this age group (Table 2). In contrast, 51.6% of the total host community population were aged less than 18 years old yet only 4.9% of SARS-CoV-2 infections in host community members were reported in this age group. Nationally 46.1% were under 18 years old with just 7.3% reporting SARS-CoV-2 infections. Most SARS-CoV-2 infections among refugees (64.1%) occurred in the age group 18-59 years, despite this group making only 38.7% of the refugee population. SARS-CoV-2 infections were reported in 17.7% of elderly (≥60 years) refugees, but elderly refugees represented only 3.9% of the total refugee population.

From June 14, 2020, to December 31, 2022, a total of 6,480 tests were performed among refugees and host community members. There was weekly variation in testing rates during the pandemic partly because of challenges in access to specimen collection and testing commodities. The average weekly testing rate for SARS-CoV-2 among host community members was 0.02/1000 population, among refugees it was slightly higher at 0.04/1000 population, and nationally it was 0.8/1000 population.

Overall, refugees and the host community had lower ARs compared to the overall national SARS-CoV- 2 infection AR of 721.1 (95% CI 718.7– 723.5) per 100,000 population (Table 2). This trend was observed even when SARS-CoV-2 infection ARs by age group and by week were compared (Table 2 and Figure 1). However, refugees had a SARS-CoV-2 infection AR of 228.3 per 100,000 population (95% CI 211.3-245.4; p-value <0.001)) which was significantly higher than host community members with a rate of 82.7 (95% CI 72.6 – 92.8). Of all age groups those aged ≥60 years had the highest AR among refugees, host community members, and nationally (Table 2). Refugees, in Ifo (AR 253.3: 95% CI 219.4 – 287.1: P value <0.001) and Dagahaley camps (AR 253.4; 95% CI 220.1 – 286.6: p value <0.001) had higher AR than those in Hagadera (AR 169.9; 95% CI 146.9 – 192.8) camps.

There were 52 deaths reported among refugees with a CFR of 7.4% (95% CI 5.4-9.4) while the host community had 4 deaths with a CFR of 1.5% (95% CI 0.15-3.18). Refugees had a significantly higher case fatality rate (p- value < 0.001) compared to Kenyans which had a rate of 1.76% (95% CI 1.71 – 1.80). There was however no significant difference in the CFR reported between the camps, despite the difference in AR. The CFR in Dagahaley, Hagadera and Ifo camps were 9.5% (95% CI 5.5-13.5), 8.3% (95% CI 4.4 – 12.2) and 5.4% (95% CI 2.2 -8.6) respectively.

Following reports of the first case of COVID-19 in Kenya on March 13, 2020, to ensure preparedness and delay introduction of the virus in the refugee camp, the Government of Kenya placed a gazette notice in April 2020 limiting movement between specific areas throughout the country, which included suspension of movement into the camps [11]. However, the limitation of movement into the camps presented challenges in service provision to the refugees and needed to be addressed. Due to the close interaction between refugees and host communities, strictly enforcing movement restriction between them was difficult. During the restricted movement period, to ensure a unified effort in preventing and controlling the spread of SARS-CoV-2, the Government of Kenya, UNHCR, and partners established a multisectoral coordination mechanism to address management of the camps during the pandemic. Below, we provide a timeline of the measures taken to mitigate the impact of the pandemic on refugees in Dadaab Refugee Camp Complex. These measures were consistent with those implemented at the national level as was officially communicated by the Government of Kenya and official notifications published on the Kenya Ministry of Health website [11].

April 2020

June 2020

September 2020

February 2021

March 2021

April 2021

May 2021

Throughout the pandemic, in addition to following national guidelines, continual measures were taken to protect the health of refugees at increased risk of infection and death due to COVID-19. These included prioritization for mask distribution, telemedicine to facilitate consultation, home visits to ensure refill of medications and established protocols to ensure continuation of essential services at health facilities. Health education was provided throughout the pandemic and refugees were involved in creation and reviewing informational materials that were developed in local languages understood by refugees.