COVID-19 Case Investigation and Contact Tracing among Refugee, Immigrant, and Migrant (RIM) Populations: Important Considerations for Health Departments
Who are RIM Populations?
RIM stands for Refugee, Immigrant, and Migrant populations and includes individuals living in the United States who were born in another country. RIM populations include diverse groups originating from all over the world, speaking hundreds of languages, and with different immigration status, occupations, and years of residence in the United States. Important factors to consider when interacting with RIM populations include cultural beliefs, language barriers, unfamiliarity with the United States healthcare system, and levels of knowledge regarding mitigation measures such as wearing a mask, social distancing, handwashing, case investigation and contact tracing.
Why are RIM Populations at Increased Risk for COVID-19?
While COVID-19 is a public health threat to the entire U.S. population, there is growing evidence that the outbreak disproportionately affects certain groups, including RIM populations. Long-standing systemic health, economic and social inequities have put many people from racial and ethnic minority groups at an increased risk of becoming seriously ill and dying from COVID-19. Due to social and economic conditions, RIM populations may face many of these same challenges that lead to poorer health outcomes. These communities also face unique risks for COVID-19 infection. Many RIM populations face economic, cultural, geographic, and legal barriers to health care, including lack of health insurance compared to the U.S.-born population. Critical infrastructure industries, including the food, agriculture, and hospitality sectors, often rely on large numbers of RIM employees as essential workers and may include work environments that present challenges to social distancing.
What Factors Affect Prevention Interventions in RIM Populations?
RIM communities often live in multigenerational and high occupancy shared housing, which present both benefits and challenges for public health. Multigenerational and high occupancy housing can act as a great social resource, providing help and mutual support (including childcare and shared household duties) that would be valuable to a family member or coworkers in quarantine or isolation. Multigenerational households may include individuals at differential risk for severe COVID-19 due to their status as an older person, someone with an underlying medical condition, or a pregnant person.
- In some households, there may be multiple people at higher risk for exposure or severe illness. Prevention interventions can be challenging to implement in multigenerational or crowded households due to physical distancing measures necessary for isolation and quarantine. Temporary housing may be offered by state or local governments or industries to help control the spread of COVID-19 by ensuring safe and successful completion of isolation and quarantine. This temporary housing has reportedly been declined by many RIM individuals. Acceptable, alternative approaches may be needed.
- Some migrant farmworkers live in isolated, employer-provided housing. Also, some employers in meat/poultry processing plants have been reluctant to provide public health authorities with access to their employees. Some farmworkers travel from abroad and within different geographic areas in the United States for seasonal work. These situations provide opportunities for transmission of SARS-CoV-2 and may limit access to public health interventions and medical care for those with or exposed to COVID-19.
- RIM communities are culturally and linguistically diverse and often include individuals and households with limited English proficiency and varying levels of health literacy. Effective case investigation and contact tracing requires culturally and linguistically appropriate health communications. Close collaborations with the community-based organizations (CBOs) who serve specific RIM populations can facilitate prevention interventions through effective communication.
- Fear of immigration enforcement and distrust of government agencies may be a barrier to obtaining accurate information from RIM individuals, even among legal residents and U.S.-born family or community members.
- Concern for immigration enforcement may also limit RIM populations from seeking care if they become ill due to COVID-19. Community engagement and education of RIM populations regarding access to clinical services is essential.
How Can Health Departments Conduct Effective Case Investigation and Contact Tracing Among RIM Populations?
It is important to remember RIM populations may come from societies with differing cultural and societal norms in terms of what is and is not appropriate to discuss in public or with someone they do not know. In addition, it is natural to be suspicious of governmental agencies and representatives when someone has suffered oppression, violence, genocide, ethnic cleansing or civil war at the hands of a government or other authorities in their country of origin. RIM populations may continue to be negatively impacted by some policies after resettlement.
To aid in the process of case investigation and contact tracing, health departments should plan to:
- Address concerns related to confidentiality and stigma
- Overcome language barriers
- Engage affected communities and build key partnerships
- Educate RIM populations regarding mitigation measures, including testing, case investigation, and contact tracing
- Support successful completion of isolation (cases) and quarantine (contacts)
- Consider travel risks
Address Concerns Related to Confidentiality and Stigma
Consider that some RIM populations, especially refugees, have been separated from family members for extended periods before arriving in the U.S. They may fear never seeing their loved ones again and distrust government agencies that propose to isolate or quarantine family members. RIM populations face stigma related to immigration and citizenship status. There is a need to build trust and reduce further stigma around COVID-19. These experiences can compromise participation in public health interventions. The following actions can be considered to address concerns related to confidentiality and stigma to improve engagement with COVID-19 prevention measures.
- Reassure RIM individuals who test positive for COVID-19 that names and other personal information for themselves and their contacts will be kept confidential.
- Share information with RIM individuals regarding how the information they provide will be used, why it is important, and how it can protect the ones they love and their communities.
- Reassure undocumented migrants and individuals concerned about their immigration status that participation in COVID-19 mitigation strategies will not result in deportation or repercussions for use of government resources.
- Address concerns of primary caregivers about being separated from family. RIM individuals may not have other options for assuring their family members’ safety and care if they need to quarantine or isolate.
Overcome Language Barriers
Language barriers and cultural or societal challenges can result in misunderstanding or misapplication of COVID-19 mitigation measures. Activities to reduce language barriers include the following:
- Seek to recruit bilingual staff from the RIM community to fill roles as contact tracers, community health workers, patient navigators, and use of certified interpreters should be prioritized. Not only are these individuals fluent in the language of the population, but they are trusted and knowledgeable about cultural practices and societal norms, thus best able to communicate effectively.
- Make professional language interpretation services available in the individuals’ preferred language throughout the process of case investigation and contact tracing. This includes when conducting interviews, notifying or monitoring contacts, and connecting contacts with services they need during the quarantine period.
- Provide training to case investigators and contact tracers working with RIM populations that incorporates cultural competency as well as the procedures for use of language interpretation services (e.g., community interpreters or phone lines).
- Avoid using bilingual children as interpreters. It is inappropriate to assume that proper translations can occur with minor children who may be unfamiliar with the concepts and context surrounding the conversations to be translated. In addition, the topics of economic supports, isolation, and quarantine may not be appropriate content for children. It is unlikely that a child would be able to translate the information effectively and accurately. Doing so can cause misunderstanding of key information as the message is screened through a child’s understanding and vocabulary.
- Address necessary accommodations for people with disabilities using interpretation services and educational communications.
Engage Affected Communities and Build Key Partnerships
Community-based participation can facilitate uptake and application of prevention measures for COVID-19 among RIM populations. Partnerships with organizations working with RIM populations can facilitate timely development of relevant and effective messaging regarding participation in public health interventions to prevent COVID-19. The following describes proposed activities for these types of engagement:
- Identify and work with resettlement agencies, CBOs, trusted community leaders, and local healthcare providers serving the RIM community to develop and distribute appropriate messaging on isolation of cases and quarantine of contacts.
- Provide background information for public health staff to understand key demographic, language, immigration, mobility patterns, cultural, and health characteristics of specific RIM groups and health care considerations for these populations, such as CDC’s Refugee Health Profiles, CDC’s Refugee Health Guidelines and Ethnographic Guides.
- Work with healthcare entities and community partners to identify strategic locations within RIM communities to offer free or low-cost COVID-19 testing, such as mobile testing or testing within workplaces and faith-based institutions.
- Partner with resettlement agencies and CBOs to help individuals understand what contract tracing is, why public health workers need to find people who have come into contact with someone who has COVID-19, how information will be protected so individuals will not be harmed, and what successful contact tracing requires.
- Work with community partners to identify and resolve barriers to successful case investigation and contact tracing efforts.
- Collaborate and share information with other health departments about multijurisdictional RIM cases (e.g., migrant agricultural workers or refugees resettling in a new locality). The Department of Health and Human Services, Office of Refugee Resettlement provides a list of key state contacts who can connect to these partners.
Educate RIM Populations Regarding Mitigation Measures, Including Testing, Case Investigation, and Contact Tracing
Information needs to be shared with RIM populations in a timely manner. If they are not given the guidance promptly, these groups may be at greater risk of loss to follow up and unfavorable outcomes concerning implementation of prevention recommendations.
- Share information about available testing sites (e.g., community health centers), procedures to follow between time of testing and awaiting testing results (3 Key Steps to Take While Waiting for Your COVID-19 Test Results pdf icon[350 KB, 2 pages]), the implications of testing results, and information for health departments and health care providers.
- Share COVID-19 resources that are culturally sensitive and accessible for community, work, school, and home settings.
- Use plain language health education materials or low literacy materials that can be employed to convey key messages, using trusted sources (e.g., local ethnic media and community or religious leaders as spokespersons) and in a format that is preferred and easily accessible to the RIM community. CDC’s Communication Toolkit for Migrants, Refugees, and Other Limited-English-Proficient Populations provides current messaging, information in plain language and translated COVID-19 materials in 34 languages. This toolkit also provides guidance and additional resources pertaining to COVID-19 and RIM populations.
Support Successful Completion of Isolation (Cases) and Quarantine (Contacts)
RIM populations may need financial, social and economic support to adopt COVID-19 mitigation measures, including isolation and quarantine. RIM populations in low-income jobs may not be able to afford to be absent from work without pay in order to isolate or quarantine. Support activities that can facilitate successful participation in public health prevention measures are included below.
- Connect individuals in quarantine or isolation to social support services, such as food delivery and temporary housing, available in your jurisdiction. Referrals may need to be made to social workers, local aid organizations, and CBOs.
- Connect with businesses who employ refugees (e.g., poultry plants, restaurants) and discuss adopting mitigation measures as well as incentives or policies such as sick leave policies (for individuals themselves) or family leave policies (for individuals who must take care of ill family members).
- Ensure that individuals who are separated from their family or friends using temporary housing facilities can communicate with loved ones and that their basic needs are supported.
- Support RIM populations in isolation and quarantine to maintain housing and provide food during these periods. This assistance may be needed to ensure successful completion of isolation and quarantine.
- Work with resettlement agencies and community partners to anticipate what the population needs to support isolation and quarantine measures.
- Develop and share messaging regarding isolation and quarantine that reflects the importance of the strong sense of community and collectivism in RIM communities, as well as the experience of living in multigenerational households.
- Prepare to initiate contact tracing measures in congregate settings, around religious and social gatherings, and in multi-family homes.
- Plan to provide counseling and referrals to individuals who may encounter issues with their mental health over the course of isolation and quarantine.
Consider Travel Risks
RIM populations may need to travel for seasonal work or to be near family members. This travel may increase risk of transmission of SARS-CoV-2. To help reduce this risk, consider the following:
- Advise RIM individuals in quarantine or isolation to delay planned travel until they are cleared by public health officials.
- Identify concerns related to travel. If travel is still a concern, local and state health departments may request federal public health travel restrictions, which prevent listed travelers from boarding commercial airplanes and trigger public health notification, to support state- or locally-mandated quarantine or isolation.
- Request support as needed with federal public health travel restrictions by contacting the CDC quarantine station with jurisdiction for the area.
- ASTDR Principles of Community Engagement
- Why Refugees May Be at Higher Risk During COVID-19 Outbreak
- COVID-19 Public Service Announcements (PSAs) are available in many languages
- COVID-19 in Newly Resettled Refugee Populations
- NIH: Cultural Competencyexternal icon
- CDC COVID-19 Communications Toolkit for Health Departments (available in English and Spanish)
- CDC Contact Tracing Resources
- Resolve to Save Lives COVID-19 Contact Tracing Playbook external icon
- Living in Close Quarters
- Guidance for Large or Extended Families Living in the Same Household pdf icon[529 KB, 5 pages]
- Reaching At-Risk Populations in an Emergency
- CDC’s Stress and Coping Resource Page