Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Migrant Health and COVID-19 Pandemic: A Cross-sectional Study of Characteristics, Clinical Features, and Health Outcome from Iran

Migrant Health and COVID-19 Pandemic: A Cross-sectional Study of Characteristics, Clinical... Background As the pandemic unfolds, major concerns remain with those in disadvantaged positions who may be dispropor- tionately affected. This paper aimed to present the characteristics of COVID-19 immigrant patients and investigate whether they were disproportionately affected by COVID-19 pandemic. Methods A cross-sectional study was performed using data on 589,146 patients diagnosed with COVID-19 in Iran. Descrip- tive analyses were used to summarize the study population’s characteristics. Chi-squared test and logistic regression model were applied. Results After accounting for possible confounding covariates, being an immigrant was significantly associated with increased risk of death due to COVID-19 (OR 1.64, CI 1.568–1.727). When compared to Iranian-born patients, the prevalence of low blood oxygen levels on admission was higher among immigrant patients (53.9% versus 47.7%, P value < 0.001). Moreover, greater proportions of immigrants who were diagnosed with COVID-19 were admitted to an ICU (17% versus 15.8%, P value < 0.001). Patients aged 65 and above were the largest age category in both populations. However, there was a significant difference between the age profiles of patients, with children under the age of eighteen presenting 16% of immigrant patients vs 6.6% of Iranian-born patients (P value < 0.001). In both groups, more men were affected by COVID-19 than women, yet the sex bias was more prominent for migrant patients (P value < 0.001). Conclusion The evidence from this study revealed that immigrant patients infected with COVID-19 were more likely to suffer from severe health outcome of the disease compared to Iranian-born patients. Keywords COVID-19 · Healthcare disparities · Health equity · Social determinants of health · Transients and migrants Abbreviations PCR Polymerase chain reaction SARS-CoV-2 Severe acute respiratory syndrome corona- ACE2 Angiotensin-converting enzyme 2 virus 2 COVID-19 Coronavirus disease 2019 WHO World Health Organization1 Background ICU Intensive Care Unit CVD Cardiovascular diseases The ongoing pandemic of the new disease caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has now affected the lives and mental health of all communi- * Ali-Reza Zali ties around the globe. The disease initially appeared in China drazali@sbmu.ac.ir in late 2019 and was named as coronavirus disease 2019 Community Medicine Department, School of Medicine, (COVID-19) by the World Health Organization (WHO) in Shahid Beheshti University of Medical Sciences, Tehran, early 2020 [1, 2]. By the time of writing, over 500 million Iran confirmed cases of COVID-19 have been recorded worldwide Social Determinants of Health Research Center, Shahid including over six million deaths [3]. In Iran, the outbreak was Beheshti University of Medical Sciences, Tehran, Iran first detected in a north-central province in February 2020. By School of Management and Medical Education, Shahid early March, the virus had spread to all regions of the coun- Beheshti University of Medical Sciences, Tehran, Iran try, making it one of the first hard-hit countries by corona - Functional Neurosurgery Research Center, Shahid Beheshti virus in the world [4]. To date, the country’s total number University of Medical Sciences, Tehran, Iran Vol.:(0123456789) 1 3 450 Journal of Epidemiology and Global Health (2022) 12:449–455 of COVID-19 confirmed cases has surpassed seven million, province of Iran. With over thirteen million residences, the and over 140000 confirmed deaths have been reported [5 ]. province is an important epicenter for COVID-19 epidemic The COVID-19 pandemic has had unprecedented health in the country [12]. The integrated COVID-19 registry was and social consequences for almost all populations. Yet, as established in the province in March 2020, and data on the pandemic unfolds, major concerns remain with those all patients diagnosed with COVID-19 were documented in disadvantaged positions who may be disproportionately ever since based on WHO case definition guidance [13]. affected. People who have been displaced, be it refugees, In this descriptive multi-center study, all patients with asylum seekers, migrants, or immigrants, represent one of SARS-CoV-2 infection (589,146 individuals) who were the most important groups who are vulnerable to epidem- seen in healthcare facilities across the province of Tehran ics. Generally, these populations live in overcrowded con- from March 2020 up to November 2021 were included. Of ditions and poor-quality housings, making them prone to those, 256,359 (43%) patients had positive PCR test results various communicable diseases. They often face challenges for SARS-CoV-2, and for the remaining, the diagnosis was in accessing healthcare services due to multiple barriers established based on chest CT findings and clinically epide- including linguistic differences, financial instability, lack of miologically criteria. Overall, data on demographic charac- legal status, and unawareness of their rights to healthcare teristics, clinical manifestations, underlying diseases, para- [6]. In addition, chronic comorbid conditions which are not clinical findings, and the health outcome of 589,146 patients appropriately cared for, such as cardiac diseases, diabetes, were extracted and anonymized from the records. and hypertension, may be more prevalent in them [7]. All these could pose a greater risk of morbidity and mortality 2.1 Variables on these populations at the time of pandemics. Iran hosts one of the largest immigrants, in particular Data included information on age, sex, smoking history, opi- refugee populations worldwide [8]. The great majority com- oids history, underlying diseases, clinical and para-clinical ing from Afghanistan (about 97%) with the remaining being findings, intensive care unit (ICU) admission, and the dis- mostly Iraqi nationals. About one million registered Afghan ease outcome. Underlying diseases included diabetes, hyper- nationals reside in Iran. However, estimates show that there tension, cardiovascular diseases (CVD), cancer, asthma, are additional 2.1 million undocumented foreign nationals chronic liver diseases, chronic kidney diseases, chronic (mostly with Afghan nationality) who live in the country [9]. neurological diseases, chronic hematological diseases, and Registered immigrants are included in the national health chronic immune deficiency diseases. Clinical manifesta- system. Meaning that they have access to primary health tions included fever, cough, muscle ache, difficulty breath- care services at no charge and are eligible for enrollment in ing, chest pain, loss of smell, loss of taste, loss of appetite, the national health insurance plans covering treatments and nausea, diarrhea, headache, vertigo, seizure, paraplegia, hospitalizations. However, in an inclusive response approach and skin lesions. Blood oxygen saturation level, polymerase to COVID-19 epidemic in the country, all foreign nationals chain reaction (PCR) test result, and chest CT scan report living in Iran, documented or undocumented, were provided were described as para-clinical findings. with free of charge COVID-19 testing and hospital services Age was categorized into 9 groups: 0–4, 5–11, 12–17, [10]. Yet, there are still several barriers in receiving effec- 18–24, 25–34, 35–44, 45–54, 55–64, and 65 years or more. tive health care for people living with foreign nationalities Sex was classie fi d as female or male. The blood oxygen satu - in Iran. Barriers, such as cultural beliefs, low health literacy, ration level was defined as being either higher than 93% or and hesitancy to access care out of fears about immigration 93% and lower, according to the National Coronavirus Con- enforcement, which could make them more susceptible to trol Operations Headquarter protocol. PCR test result was the infection and its negative consequences [11]. defined as negative, inconclusive, and positive. The chest CT Given the limited studies which have assessed the bur- scan report was divided into reports with positive COVID- den of the pandemic on displaced populations, this paper 19-related findings and those with no COVID-19 findings. aimed to present the characteristics of COVID-19 immigrant The disease outcome was described as survived or deceased. patients residing in Iran and investigate whether they were All other variables were dichotomized as yes or no. disproportionately affected by COVID-19 pandemic. 2.2 Statistical Analysis 2 Methods Descriptive analyses were used to summarize the study pop- ulation’s characteristics. Chi-squared test was performed to A population-based cross-sectional study was performed assess the differences in patients’ characteristics, clinical and using data form the registry database of Coronavirus Con- para-clinical findings, and the health outcome between the trol Operations Headquarter of Tehran, the most populated immigrant and Iranian-born patients. The logistic regression 1 3 Journal of Epidemiology and Global Health (2022) 12:449–455 451 model was applied to adjust for possible confounding effect the observed disparity in proportions of deceased patients of variables including demographic and existing comor- remained significant. Being an immigrant was significantly bidities on the health outcome of patients. Estimates were associated with increased risk of death with COVID-19 (OR examined with P value < 0.05 indicating a significant dif- 1.64, CI 1.568–1.727) when compared to Iranian patients ference and using IBM SPSS Statistics, version 27 (IBM (Table 3). Corp., Armonk, N.Y., USA). Since the information was documented by trained healthcare personnel, the rates of missing values were low across all variables used in this 4 Discussion study. Therefore, the impact of missing information on the statistical inferences drawn from the data was considered as The evidence from this study revealed that immigrant insignificant [14]. patients infected with COVID-19 were more likely to suf- fer from severe health outcomes of the disease compared to Iranian-born patients. The main findings indicated that being 3 Results an immigrant was significantly associated with increased risk of dying with COVID-19. More immigrant patients In this study, a total of 589,146 patients (20,992 immigrant presented with low blood oxygen levels on admission and patients, 568,154 Iranian patients) who were diagnosed required ICU care when compared to Iranians. with COVID-19 were included. The mean ± SD age was Overall, there were pronounced differences in health out- 42 ± 23.4 years for immigrant patients and 51 ± 20.9 for Ira- come between the two groups, with migrant patients having nian patients. Patients aged 65 and above were the largest higher rates of ICU admission and death due to COVID- age category in both populations. However, there was a sig- 19. After accounting for possible confounding factors, the nificant difference between the age profile of patients, with probability of COVID-19-related mortality was also higher children under the age of eighteen presenting 16% of immi- among immigrants compared to Iranian patients. The dispro- grant patients vs 6.6% of Iranian patients. In both groups, portionate burden of the disease found in this study confirms more men were affected by COVID-19 than women, yet the the results reported from other countries [15–18]. The poorer sex bias was more prominent for immigrant patients. The health outcome of people with migrant status is frequently prevalence of smoking was almost the same in both popula- attributed to multiple barriers which hinder their access to tions, while the proportion of patients using opioids was health care, and result in accessing care when the disease higher for immigrant patients. Comorbidities including dia- is more advanced compared to the host population. Barri- betes, hypertension, CVD, cancers, and chronic neurological ers are, such as differences in language and cultural beliefs, disorders were less prevalent in patients with foreign nation- lack of entitlement to health care, and reluctance to use ality residing in the country. However, no significant differ - health services out of fears about one’s legal status [19–21]. ence was observed for the prevalence of asthma, chronic However, immigrants in Iran are mostly from the neighbor- kidney diseases, chronic liver diseases, chronic immune ing country; Afghanistan; and share the same language and deficiency disorders, and chronic hematological diseases cultural values with Iranian-born population. Moreover, as between the two groups of patients. Significant differences of March 2020, all foreign nationals irrespective of their were noted in the distribution of the clinical manifestations legal status, were entitled to free of charge COVID-19 test- between the two groups, except for difficulty breathing and ing and hospital services in an inclusive approach to the paraplegia (Table 1). epidemic response [22]. Hence, the disparities in the health More than half of the immigrant patients had low lev- outcome between immigrant and Iranian patients which were els of blood oxygen saturation on admission. The rate was observed in this study, might point to more distant determi- significantly lower in patients with Iranian nationality. Of nants of health which could affect the course of the disease the immigrant patients, about a third had a positive SARS- and ultimately influence the outcome of patients infected CoV-2 PCR testing result, whereas almost half of the Ira- with COVID-19. Immigrants in Iran could generally be nian patients had positive PCR test results for SARS-CoV-2. characterized as low-income communities with poor overall More Iranian patients had chest CT reports indicating health status [23]. Many send most of their earnings to their COVID-19-related n fi dings compared to immigrant patients. home country to support their families, which leaves them However, higher rates of ICU admission and death due to unable to afford non-COVID-19 health services, therefore, COVID-19 were documented for foreign nationals when they often suffer from chronic conditions which are either compared to Iranians (Table 2). not diagnosed, or not properly managed. Moreover, most After accounting for possible confounding covariates labor migrants are day workers who would lose the day’s including age, sex, history of smoking, history of opioids, pay if left work to get tested or see physicians. All these and underlying diseases in the logistic regression model, could result in delayed diagnosis of SARS-CoV-2 infection, 1 3 452 Journal of Epidemiology and Global Health (2022) 12:449–455 Table 1 Characteristics and Characteristics Iranian patients Immigrant patients P value clinical presentations of patients infected with COVID-19, Iran, n % n % 2020–2021 Age (years) 0–4 25,262 4.4 2200 10.5 < 0.001 5–11 7408 1.3 717 3.4 12–17 4918 0.9 448 2.1 18–24 13,442 2.4 1359 6.5 25–34 56,466 9.9 2758 13.1 35–44 94,617 16.7 3106 14.8 45–54 95,896 16.9 3198 15.2 55–64 105,851 18.6 3139 15.0 65 and over 164,294 28.9 4067 19.4 Sex Female 270,578 47.6 9636 45.9 < 0.001 Male 297,576 52.4 11,356 54.1 Positive history of smoking 8618 1.5 290 1.4 0.11 Positive history of opioids 4434 0.8 268 1.3 < 0.001 Underlying diseases Diabetes 56,119 9.9 1224 5.8 < 0.001 Hypertension 64,053 11.3 1431 6.8 < 0.001 CVD 52,465 9.2 1031 4.9 < 0.001 Cancer 8891 1.6 225 1.1 < 0.001 Asthma 5927 1.0 215 1.0 0.79 Chronic liver diseases 2435 0.4 105 0.5 0.12 Chronic kidney diseases 9012 1.6 293 1.4 0.03 Chronic neurological diseases 4059 0.7 112 0.5 0.002 Chronic immune deficiency diseases 1547 0.3 43 0.2 0.06 Chronic hematological diseases 2562 0.5 95 0.5 0.97 Clinical presentations Fever 210,294 37.0 7267 34.6 < 0.001 Cough 295,532 52.0 9020 43.0 < 0.001 Muscle ache 191,694 33.7 5608 26.7 < 0.001 Difficulty breathing 240,796 42.4 8828 42.1 0.34 Chest pain 16,363 3.1 507 2.6 < 0.001 Loss of smell 14,365 2.5 257 1.2 < 0.001 Loss of taste 8393 1.5 182 0.9 < 0.001 Loss of appetite 45,292 8.4 1216 6.2 < 0.001 Nausea 36,046 6.7 1090 5.6 < 0.001 Diarrhea 19,052 3.5 785 4.0 < 0.001 Headache 48,991 9.1 1032 5.4 < 0.001 Vertigo 15,810 2.9 420 2.2 < 0.001 Seizure 1920 0.3 241 0.1 < 0.001 Paraplegia 717 0.1 21 0.1 0.36 Skin lesions 635 0.1 41 0.2 < 0.001 exacerbate the severity of the disease, and increase the risk [15–17]. This result is not particularly surprising given the of morbidity and mortality in the migrant population. fact that most foreign nationals in Iran are migrant workers. Overall, patients with non-Iranian nationality living in With respect to gender composition, patients were less fre- the country were younger than Iranian patients, which was quently women in both Iranian and non-Iranian populations in line with findings from immigrant populations who were which was consistent with reports around the world [15, 17, infected with COVID-19 in Kuwait, Italy, and United States 18, 24, 25]. However, the difference was more prominent 1 3 Journal of Epidemiology and Global Health (2022) 12:449–455 453 Table 2 Para-clinical findings and health outcome of patients infected for immigrant patients, which could be partly explained by with COVID-19, Iran, 2020–2021 the great proportion of labor migrants (mainly men) among non-Iranian patients. However, biological variations between Iranian Immigrant P value patients patients men and women which could make men more susceptible to SARS-CoV-2 infection, as well as differences in behavioral n % n % habits between the two sexes have also been mentioned in the PaO sat < 93% 270,811 47.7 11,314 53.9 < 0.001 literature to justify the sex bias observed in COVID-19 pan- Positive PCR test result 250,649 44.1 5710 27.2 < 0.001 demic [26, 27]. Chest CT with positive 375,468 66.1 11,369 54.2 < 0.001 The most prevalent underlying diseases were hypertension findings and diabetes in both groups which correlate well with those of ICU admitted 90,044 15.8 3576 17.0 < 0.001 other countries and further support the potential role of angi- Deceased 48,765 8.6 2127 10.1 < 0.001 otensin-converting enzyme 2 (ACE2) receptors in the corona- virus entry into human cells [28–31]. Yet the conditions were more prevalent in the patients with Iranian nationality. Higher Table 3 Logistic regression model of independent variables associ- prevalence of hypertension, diabetes, and several other comor- ated with COVID-19-related death, Iran, 2020–2021 bidities in Iranian patients compared to immigrant patients living in the country, could be attributed to the relatively older variable aOR 95% confi- P value dence interval age of patients with Iranian nationality. However, another pos- sible explanation for the observed discrepancy could be the Lower Upper underdiagnosis of chronic conditions in immigrant population. Age group In agreement with findings documented in previous studies, 0–4 1 in both groups, respiratory symptoms including cough and dif- 5–11 0.38 0.316 0.469 < 0.001 ficulty breathing were the most common complaints that have 12–17 0.71 0.595 0.858 < 0.001 prompted patients to seek medical care [32, 33]. However, it is 18–24 0.53 0.466 0.612 < 0.001 not completely clear why most symptoms are more prevalent 25–34 0.50 0.461 0.552 < 0.001 in Iranian-born patients compared to immigrant population. 35–44 0.84 0.786 0.914 < 0.001 However, our research might have limitations. First, data 45–54 1.49 1.387 1.600 < 0.001 on determinants, such as reason for relocation, migration 55–64 2.68 2.509 2.879 < 0.001 status, and length of stay in Iran, which could influence the 65+ 6.20 5.799 6.630 < 0.001 health outcome of immigrant patients infected with COVID- Sex 19 in the country, were not available to the researchers. Sec- Female 1 ond, since we did not have information on socio-economic Male 1.31 1.288 1.338 < 0.001 status of the patients, we have compared immigrant patients Nationality of whom mostly are from low socio-economic status with the Iranian patients 1 general population of Iran that has socio-economic diversity. Immigrant patients 1.64 1.568 1.727 < 0.001 If we assume that socio-economic status could impact the Positive history of smoking 0.80 0.740 0.865 < 0.001 health outcome of patients with COVID-19, then comparing Positive history of opioids 1.31 1.205 1.443 < 0.001 immigrant patients with Iranian patients from low socio- Diabetes 1.16 1.129 1.195 < 0.001 economic status might attenuate the observed disparity in Hypertension 1.04 1.012 1.068 0.004 the health outcome. As more comprehensive data become CVD 1.15 1.126 1.190 < 0.001 available, further research is needed to test this hypothesis. Cancer 2.21 2.097 2.339 < 0.001 Yet, using real-time and consistent data on a large multi- Asthma 0.91 0.842 1.001 0.05 center cohort of COVID-19 patients is the major strength of Chronic liver diseases 1.63 1.458 1.824 < 0.001 our study. This allows reliable extension of research findings Chronic kidney diseases 2.02 1.916 2.129 < 0.001 to the target population and makes this research of great Chronic neurological diseases 1.78 1.646 1.941 < 0.001 importance for policy-makers. Chronic immune deficiency diseases 1.28 1.084 1.527 0.004 Chronic hematological diseases 1.40 1.248 1.579 < 0.001 Constant 0.28 5 Conclusion The evidence from this study revealed that immigrant patients infected with COVID-19 were more likely to suf- fer from severe health outcomes of the disease compared to 1 3 454 Journal of Epidemiology and Global Health (2022) 12:449–455 permitted by statutory regulation or exceeds the permitted use, you will Iranian-born patients. The observed health disparity could need to obtain permission directly from the copyright holder. To view a be explained by several socio-economic health determinants copy of this licence, visit http://cr eativ ecommons. or g/licen ses/ b y/4.0/ . which require targeted public health interventions aimed at reducing the health inequalities. All in all, immigrants are among vulnerable populations who demand special consid- References eration from policy-makers in their response to COVID-19 pandemic. In addition to inclusive policies which ensure 1. World Health Organization. Timeline: WHO's COVID-19 their entitlement to COVID-19 healthcare, and their inclu- response 2020. https://www .who. int/ emer gencies/ disea ses/ no vel- coron avirus- 2019/ inter active- timel ine. Accessed 15 Apr 2022. sion in the national surveillance systems, it is particularly 2. World Health Organization. Naming the coronavirus disease important to address the socio-economic health determinants (COVID-19) and the virus that causes it 2020. https:// www. who. which affect the overall health status in this population with int/emer gencies/ disea ses/ no vel-cor ona virus-2019/ tec hnical- guida social services that are tailored to their needs. nce/naming- t he-cor ona virus-disea se- (co vid-2019)- and- t he-vir us- that- causes- it. Accessed 15 Apr 2022. 3. World Health Organization. Coronavirus disease (COVID-19) Acknowledgements The authors thank the Coronavirus Control Opera- pandemic 2020. https://www .who. int/ emer gencies/ disea ses/ no vel- tions Headquarter in the province of Tehran for their support and for coron avirus- 2019. making the original data available to us. 4. Takian A, Raoofi A, Kazempour-Ardebili S. COVID-19 battle during the toughest sanctions against Iran. Lancet. Author contributions Each named author has substantially contrib- 2020;395(10229):1035–6. uted to conducting the research and drafting this manuscript. Authors’ 5. World Health Organization. The current COVID-19 situation contributions are as followings: conceptualization: MRS, RA. Data 2020. https://w ww.w ho.int /coun tr ies/ir n/. Accessed 15 Apr 2022. curation: SJ. Formal analysis: MRS, RA. Funding acquisition: MRS. 6. Gil-Gonzalez D, Carrasco-Portino M, Vives-Cases C, Agudelo- Methodology: MRS, RA, SJ. Project administration: MRS, RA, ARZ. Suarez AA, Castejon Bolea R, Ronda-Perez E. Is health a right Visualization: MRS, RA, AM, ARZ. Writing—original draft: MRS, for all? An umbrella review of the barriers to health care access RA. Writing—review and editing: MRS, RA, AM, SJ, ARZ. faced by migrants. Ethn Health. 2015;20(5):523–41. 7. Shahul Hameed S, Kutty VR, Vijayakumar K, Kamalasanan A. Funding This work was supported by the Research deputy for research Migration status and prevalence of chronic diseases in Kerala and technology, Shahid Beheshti University of Medical Sciences, Teh- State, India. Int J Chronic Dis. 2013;2013: 431818. ran, Iran (Grant number 24229). There was no financial support for 8. Agency TUR. Refugees in Iran 2022. https:// www. unhcr. org/ ir/ authorship and publication of the article. refug ees- in- iran/. Accessed 17 Apr 2022. 9. ACAPS. AFGHAN REFUGEES 2021. https:// www. acaps. org/ Data and/or code availability The data that support the n fi dings of this count r y/ ir an/ cr isis/ afghan- r efug ees#: ~: te xt= Ir an% 20hos ts% study are available from Coronavirus Control Operations Headquarter 20one% 20of% 20the ,undoc ument ed% 20Afg hans% 20live% 20in% in the province of Tehran, but restrictions apply to the availability of 20Iran. Accessed 17 Apr 2022. these data, which were used under license for the current study, and so 10. UNHCR The UN Refugee Agency. Publications 2020. https:// are not publicly available. Data are however available from the authors www.unhcr .or g/ir/ wp- conte nt/ uploa ds/ sites/ 77/ 2020/ 05/ UNHCR - upon reasonable request and with permission of Coronavirus Control Month ly- Facts heet- IRAN_ Jan- Mar- 2020- Eng. pdf. Accessed 17 Operations Headquarter in the province of Tehran. Apr 2022. 11. Badrfam R, Zandifar A. Mental health status of Afghan immi- grants in Iran during the COVID-19 pandemic: an exacerbation Declarations of a long-standing concern. Asian J Psychiatry. 2021;55: 102489. 12. Presidency of the I.R.I Plan and Budget Organization. Statisti- Conflict of interest The authors have no competing interests to declare cal Center of Iran. https:// www. amar. org. ir/ engli sh/ Stati stics- by- that are relevant to the content of this article. T opic/ Popul ation# 288290- s t ati s tical- sur vey. Accessed 17 Apr Ethics approval and consent to participate This study was performed 13. World Health Organization. WHO COVID-19 Case definition in line with the principles of the Declaration of Helsinki. Approval 2020. https://www .who. int/ publi catio ns/i/ item/ WHO- 2019- nCoV - was granted by the Ethics Committee of Shahid Beheshti University of Surve illan ce_ Case_ Defin ition- 2020.1. Accessed 17 Apr 2022. Medical Sciences with a waiver of informed consent (Ethics approval 14. Dong Y, Peng CY. Principled missing data methods for research- number: IR.SBMU.RETECH.REC.1399.830). ers. Springerplus. 2013;2(1):222. 15. Fabiani M, Mateo-Urdiales A, Andrianou X, Bella A, Del Manso Consent to publish Not applicable. M, Bellino S, et al. Epidemiological characteristics of COVID-19 cases in non-Italian nationals notified to the Italian surveillance system. Eur J Public Health. 2021;31(1):37–44. Open Access This article is licensed under a Creative Commons Attri- 16. Khanijahani A. Racial, ethnic, and socioeconomic disparities in bution 4.0 International License, which permits use, sharing, adapta- confirmed COVID-19 cases and deaths in the United States: a tion, distribution and reproduction in any medium or format, as long county-level analysis as of. Ethn Health. 2020;2020:1–14. as you give appropriate credit to the original author(s) and the source, 17. Hamadah H, Alahmad B, Behbehani M, Al-Youha S, Almazeedi provide a link to the Creative Commons licence, and indicate if changes S, Al-Haddad M, et al. COVID-19 clinical outcomes and nation- were made. The images or other third party material in this article are ality: results from a Nationwide registry in Kuwait. BMC Public included in the article's Creative Commons licence, unless indicated Health. 2020;20(1):1384. otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not 1 3 Journal of Epidemiology and Global Health (2022) 12:449–455 455 18. Zhang M, Gurung A, Anglewicz P, Yun K. COVID-19 and immi- meta-analysis as a risk factor for death and ITU admission. Nat grant essential workers: Bhutanese and Burmese refugees in the Commun. 2020;11(1):6317. United States. Public Health Rep. 2021;136(1):117–23. 28. Rodriguez-Molinero A, Galvez-Barron C, Minarro A, Macho O, 19. Islam MN, Inan TT, Islam A. COVID-19 and the Rohingya refu- Lopez GF, Robles MT, et al. Association between COVID-19 gees in Bangladesh: the challenges and recommendations. Asia prognosis and disease presentation, comorbidities and chronic Pac J Public Health. 2020;32(5):283–4. treatment of hospitalized patients. PLoS ONE. 2020;15(10): 20. Jozaghi E, Dahya A. Refugees, asylum seekers and COVID-19: e0239571. Canada needs to do more to protect at-risk refugees during the 29. Du RH, Liang LR, Yang CQ, Wang W, Cao TZ, Li M, et  al. current pandemic. Can J Public Health. 2020;111(3):413–4. Predictors of mortality for patients with COVID-19 pneumonia 21. Chuah FLH, Tan ST, Yeo J, Legido-Quigley H. The health needs caused by SARS-CoV-2: a prospective cohort study. Eur Respir and access barriers among refugees and asylum-seekers in Malay- J. 2020;55(5):2000524. sia: a qualitative study. Int J Equity Health. 2018;17(1):120. 30. Fiorini G, Rigamonti AE, Galanopoulos C, Adamoli M, Ciriaco 22. Salmani I, Seddighi H, Nikfard M. Access to health care services E, Franchi M, et al. Undocumented migrants during the COVID- for Afghan refugees in Iran in the COVID-19 pandemic. Disaster 19 pandemic: socio-economic determinants, clinical features and Med Public Health Prep. 2020;14(4):e13–4. pharmacological treatment. J Public Health Res. 2020;9(4):1852. 23. Kiani MM, Khanjankhani K, Takbiri A, Takian A. Refugees 31. Fang L, Karakiulakis G, Roth M. Are patients with hypertension and sustainable health development in Iran. Arch Iran Med. and diabetes mellitus at increased risk for COVID-19 infection? 2021;24(1):27–34. Lancet Respir Med. 2020;8(4): e21. 24. GLOBAL HEALTH 5050. The sex, gender and COVID-19 pro- 32. Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epide- ject 2020. 2020. https://g lobalheal t h5050.or g/t he-se x-g ender-and- miological and clinical characteristics of 99 cases of 2019 novel covid- 19- proje ct/. Accessed 23 Apr 2022. coronavirus pneumonia in Wuhan, China: a descriptive study. 25. Bwire GM. Coronavirus: why men are more vulnerable to Covid- Lancet. 2020;395(10223):507–13. 19 than women? SN Compr Clin Med. 2020;2(7):874–6. 33. Bahl A, Van Baalen MN, Ortiz L, Chen NW, Todd C, Milad M, 26. Giagulli VA, Guastamacchia E, Magrone T, Jirillo E, Lisco G, et al. Early predictors of in-hospital mortality in patients with De Pergola G, et al. Worse progression of COVID-19 in men: is COVID-19 in a large American cohort. Intern Emerg Med. testosterone a key factor? Andrology. 2021;9(1):53–64. 2020;15(8):1485–99. 27. Peckham H, de Gruijter NM, Raine C, Radziszewska A, Ciurtin C, Wedderburn LR, et al. Male sex identified by global COVID-19 1 3 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Epidemiology and Global Health Springer Journals

Migrant Health and COVID-19 Pandemic: A Cross-sectional Study of Characteristics, Clinical Features, and Health Outcome from Iran

Loading next page...
 
/lp/springer-journals/migrant-health-and-covid-19-pandemic-a-cross-sectional-study-of-ZUaeaPDunm

References (40)

Publisher
Springer Journals
Copyright
Copyright © The Author(s) 2022
eISSN
2210-6014
DOI
10.1007/s44197-022-00063-3
Publisher site
See Article on Publisher Site

Abstract

Background As the pandemic unfolds, major concerns remain with those in disadvantaged positions who may be dispropor- tionately affected. This paper aimed to present the characteristics of COVID-19 immigrant patients and investigate whether they were disproportionately affected by COVID-19 pandemic. Methods A cross-sectional study was performed using data on 589,146 patients diagnosed with COVID-19 in Iran. Descrip- tive analyses were used to summarize the study population’s characteristics. Chi-squared test and logistic regression model were applied. Results After accounting for possible confounding covariates, being an immigrant was significantly associated with increased risk of death due to COVID-19 (OR 1.64, CI 1.568–1.727). When compared to Iranian-born patients, the prevalence of low blood oxygen levels on admission was higher among immigrant patients (53.9% versus 47.7%, P value < 0.001). Moreover, greater proportions of immigrants who were diagnosed with COVID-19 were admitted to an ICU (17% versus 15.8%, P value < 0.001). Patients aged 65 and above were the largest age category in both populations. However, there was a significant difference between the age profiles of patients, with children under the age of eighteen presenting 16% of immigrant patients vs 6.6% of Iranian-born patients (P value < 0.001). In both groups, more men were affected by COVID-19 than women, yet the sex bias was more prominent for migrant patients (P value < 0.001). Conclusion The evidence from this study revealed that immigrant patients infected with COVID-19 were more likely to suffer from severe health outcome of the disease compared to Iranian-born patients. Keywords COVID-19 · Healthcare disparities · Health equity · Social determinants of health · Transients and migrants Abbreviations PCR Polymerase chain reaction SARS-CoV-2 Severe acute respiratory syndrome corona- ACE2 Angiotensin-converting enzyme 2 virus 2 COVID-19 Coronavirus disease 2019 WHO World Health Organization1 Background ICU Intensive Care Unit CVD Cardiovascular diseases The ongoing pandemic of the new disease caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has now affected the lives and mental health of all communi- * Ali-Reza Zali ties around the globe. The disease initially appeared in China drazali@sbmu.ac.ir in late 2019 and was named as coronavirus disease 2019 Community Medicine Department, School of Medicine, (COVID-19) by the World Health Organization (WHO) in Shahid Beheshti University of Medical Sciences, Tehran, early 2020 [1, 2]. By the time of writing, over 500 million Iran confirmed cases of COVID-19 have been recorded worldwide Social Determinants of Health Research Center, Shahid including over six million deaths [3]. In Iran, the outbreak was Beheshti University of Medical Sciences, Tehran, Iran first detected in a north-central province in February 2020. By School of Management and Medical Education, Shahid early March, the virus had spread to all regions of the coun- Beheshti University of Medical Sciences, Tehran, Iran try, making it one of the first hard-hit countries by corona - Functional Neurosurgery Research Center, Shahid Beheshti virus in the world [4]. To date, the country’s total number University of Medical Sciences, Tehran, Iran Vol.:(0123456789) 1 3 450 Journal of Epidemiology and Global Health (2022) 12:449–455 of COVID-19 confirmed cases has surpassed seven million, province of Iran. With over thirteen million residences, the and over 140000 confirmed deaths have been reported [5 ]. province is an important epicenter for COVID-19 epidemic The COVID-19 pandemic has had unprecedented health in the country [12]. The integrated COVID-19 registry was and social consequences for almost all populations. Yet, as established in the province in March 2020, and data on the pandemic unfolds, major concerns remain with those all patients diagnosed with COVID-19 were documented in disadvantaged positions who may be disproportionately ever since based on WHO case definition guidance [13]. affected. People who have been displaced, be it refugees, In this descriptive multi-center study, all patients with asylum seekers, migrants, or immigrants, represent one of SARS-CoV-2 infection (589,146 individuals) who were the most important groups who are vulnerable to epidem- seen in healthcare facilities across the province of Tehran ics. Generally, these populations live in overcrowded con- from March 2020 up to November 2021 were included. Of ditions and poor-quality housings, making them prone to those, 256,359 (43%) patients had positive PCR test results various communicable diseases. They often face challenges for SARS-CoV-2, and for the remaining, the diagnosis was in accessing healthcare services due to multiple barriers established based on chest CT findings and clinically epide- including linguistic differences, financial instability, lack of miologically criteria. Overall, data on demographic charac- legal status, and unawareness of their rights to healthcare teristics, clinical manifestations, underlying diseases, para- [6]. In addition, chronic comorbid conditions which are not clinical findings, and the health outcome of 589,146 patients appropriately cared for, such as cardiac diseases, diabetes, were extracted and anonymized from the records. and hypertension, may be more prevalent in them [7]. All these could pose a greater risk of morbidity and mortality 2.1 Variables on these populations at the time of pandemics. Iran hosts one of the largest immigrants, in particular Data included information on age, sex, smoking history, opi- refugee populations worldwide [8]. The great majority com- oids history, underlying diseases, clinical and para-clinical ing from Afghanistan (about 97%) with the remaining being findings, intensive care unit (ICU) admission, and the dis- mostly Iraqi nationals. About one million registered Afghan ease outcome. Underlying diseases included diabetes, hyper- nationals reside in Iran. However, estimates show that there tension, cardiovascular diseases (CVD), cancer, asthma, are additional 2.1 million undocumented foreign nationals chronic liver diseases, chronic kidney diseases, chronic (mostly with Afghan nationality) who live in the country [9]. neurological diseases, chronic hematological diseases, and Registered immigrants are included in the national health chronic immune deficiency diseases. Clinical manifesta- system. Meaning that they have access to primary health tions included fever, cough, muscle ache, difficulty breath- care services at no charge and are eligible for enrollment in ing, chest pain, loss of smell, loss of taste, loss of appetite, the national health insurance plans covering treatments and nausea, diarrhea, headache, vertigo, seizure, paraplegia, hospitalizations. However, in an inclusive response approach and skin lesions. Blood oxygen saturation level, polymerase to COVID-19 epidemic in the country, all foreign nationals chain reaction (PCR) test result, and chest CT scan report living in Iran, documented or undocumented, were provided were described as para-clinical findings. with free of charge COVID-19 testing and hospital services Age was categorized into 9 groups: 0–4, 5–11, 12–17, [10]. Yet, there are still several barriers in receiving effec- 18–24, 25–34, 35–44, 45–54, 55–64, and 65 years or more. tive health care for people living with foreign nationalities Sex was classie fi d as female or male. The blood oxygen satu - in Iran. Barriers, such as cultural beliefs, low health literacy, ration level was defined as being either higher than 93% or and hesitancy to access care out of fears about immigration 93% and lower, according to the National Coronavirus Con- enforcement, which could make them more susceptible to trol Operations Headquarter protocol. PCR test result was the infection and its negative consequences [11]. defined as negative, inconclusive, and positive. The chest CT Given the limited studies which have assessed the bur- scan report was divided into reports with positive COVID- den of the pandemic on displaced populations, this paper 19-related findings and those with no COVID-19 findings. aimed to present the characteristics of COVID-19 immigrant The disease outcome was described as survived or deceased. patients residing in Iran and investigate whether they were All other variables were dichotomized as yes or no. disproportionately affected by COVID-19 pandemic. 2.2 Statistical Analysis 2 Methods Descriptive analyses were used to summarize the study pop- ulation’s characteristics. Chi-squared test was performed to A population-based cross-sectional study was performed assess the differences in patients’ characteristics, clinical and using data form the registry database of Coronavirus Con- para-clinical findings, and the health outcome between the trol Operations Headquarter of Tehran, the most populated immigrant and Iranian-born patients. The logistic regression 1 3 Journal of Epidemiology and Global Health (2022) 12:449–455 451 model was applied to adjust for possible confounding effect the observed disparity in proportions of deceased patients of variables including demographic and existing comor- remained significant. Being an immigrant was significantly bidities on the health outcome of patients. Estimates were associated with increased risk of death with COVID-19 (OR examined with P value < 0.05 indicating a significant dif- 1.64, CI 1.568–1.727) when compared to Iranian patients ference and using IBM SPSS Statistics, version 27 (IBM (Table 3). Corp., Armonk, N.Y., USA). Since the information was documented by trained healthcare personnel, the rates of missing values were low across all variables used in this 4 Discussion study. Therefore, the impact of missing information on the statistical inferences drawn from the data was considered as The evidence from this study revealed that immigrant insignificant [14]. patients infected with COVID-19 were more likely to suf- fer from severe health outcomes of the disease compared to Iranian-born patients. The main findings indicated that being 3 Results an immigrant was significantly associated with increased risk of dying with COVID-19. More immigrant patients In this study, a total of 589,146 patients (20,992 immigrant presented with low blood oxygen levels on admission and patients, 568,154 Iranian patients) who were diagnosed required ICU care when compared to Iranians. with COVID-19 were included. The mean ± SD age was Overall, there were pronounced differences in health out- 42 ± 23.4 years for immigrant patients and 51 ± 20.9 for Ira- come between the two groups, with migrant patients having nian patients. Patients aged 65 and above were the largest higher rates of ICU admission and death due to COVID- age category in both populations. However, there was a sig- 19. After accounting for possible confounding factors, the nificant difference between the age profile of patients, with probability of COVID-19-related mortality was also higher children under the age of eighteen presenting 16% of immi- among immigrants compared to Iranian patients. The dispro- grant patients vs 6.6% of Iranian patients. In both groups, portionate burden of the disease found in this study confirms more men were affected by COVID-19 than women, yet the the results reported from other countries [15–18]. The poorer sex bias was more prominent for immigrant patients. The health outcome of people with migrant status is frequently prevalence of smoking was almost the same in both popula- attributed to multiple barriers which hinder their access to tions, while the proportion of patients using opioids was health care, and result in accessing care when the disease higher for immigrant patients. Comorbidities including dia- is more advanced compared to the host population. Barri- betes, hypertension, CVD, cancers, and chronic neurological ers are, such as differences in language and cultural beliefs, disorders were less prevalent in patients with foreign nation- lack of entitlement to health care, and reluctance to use ality residing in the country. However, no significant differ - health services out of fears about one’s legal status [19–21]. ence was observed for the prevalence of asthma, chronic However, immigrants in Iran are mostly from the neighbor- kidney diseases, chronic liver diseases, chronic immune ing country; Afghanistan; and share the same language and deficiency disorders, and chronic hematological diseases cultural values with Iranian-born population. Moreover, as between the two groups of patients. Significant differences of March 2020, all foreign nationals irrespective of their were noted in the distribution of the clinical manifestations legal status, were entitled to free of charge COVID-19 test- between the two groups, except for difficulty breathing and ing and hospital services in an inclusive approach to the paraplegia (Table 1). epidemic response [22]. Hence, the disparities in the health More than half of the immigrant patients had low lev- outcome between immigrant and Iranian patients which were els of blood oxygen saturation on admission. The rate was observed in this study, might point to more distant determi- significantly lower in patients with Iranian nationality. Of nants of health which could affect the course of the disease the immigrant patients, about a third had a positive SARS- and ultimately influence the outcome of patients infected CoV-2 PCR testing result, whereas almost half of the Ira- with COVID-19. Immigrants in Iran could generally be nian patients had positive PCR test results for SARS-CoV-2. characterized as low-income communities with poor overall More Iranian patients had chest CT reports indicating health status [23]. Many send most of their earnings to their COVID-19-related n fi dings compared to immigrant patients. home country to support their families, which leaves them However, higher rates of ICU admission and death due to unable to afford non-COVID-19 health services, therefore, COVID-19 were documented for foreign nationals when they often suffer from chronic conditions which are either compared to Iranians (Table 2). not diagnosed, or not properly managed. Moreover, most After accounting for possible confounding covariates labor migrants are day workers who would lose the day’s including age, sex, history of smoking, history of opioids, pay if left work to get tested or see physicians. All these and underlying diseases in the logistic regression model, could result in delayed diagnosis of SARS-CoV-2 infection, 1 3 452 Journal of Epidemiology and Global Health (2022) 12:449–455 Table 1 Characteristics and Characteristics Iranian patients Immigrant patients P value clinical presentations of patients infected with COVID-19, Iran, n % n % 2020–2021 Age (years) 0–4 25,262 4.4 2200 10.5 < 0.001 5–11 7408 1.3 717 3.4 12–17 4918 0.9 448 2.1 18–24 13,442 2.4 1359 6.5 25–34 56,466 9.9 2758 13.1 35–44 94,617 16.7 3106 14.8 45–54 95,896 16.9 3198 15.2 55–64 105,851 18.6 3139 15.0 65 and over 164,294 28.9 4067 19.4 Sex Female 270,578 47.6 9636 45.9 < 0.001 Male 297,576 52.4 11,356 54.1 Positive history of smoking 8618 1.5 290 1.4 0.11 Positive history of opioids 4434 0.8 268 1.3 < 0.001 Underlying diseases Diabetes 56,119 9.9 1224 5.8 < 0.001 Hypertension 64,053 11.3 1431 6.8 < 0.001 CVD 52,465 9.2 1031 4.9 < 0.001 Cancer 8891 1.6 225 1.1 < 0.001 Asthma 5927 1.0 215 1.0 0.79 Chronic liver diseases 2435 0.4 105 0.5 0.12 Chronic kidney diseases 9012 1.6 293 1.4 0.03 Chronic neurological diseases 4059 0.7 112 0.5 0.002 Chronic immune deficiency diseases 1547 0.3 43 0.2 0.06 Chronic hematological diseases 2562 0.5 95 0.5 0.97 Clinical presentations Fever 210,294 37.0 7267 34.6 < 0.001 Cough 295,532 52.0 9020 43.0 < 0.001 Muscle ache 191,694 33.7 5608 26.7 < 0.001 Difficulty breathing 240,796 42.4 8828 42.1 0.34 Chest pain 16,363 3.1 507 2.6 < 0.001 Loss of smell 14,365 2.5 257 1.2 < 0.001 Loss of taste 8393 1.5 182 0.9 < 0.001 Loss of appetite 45,292 8.4 1216 6.2 < 0.001 Nausea 36,046 6.7 1090 5.6 < 0.001 Diarrhea 19,052 3.5 785 4.0 < 0.001 Headache 48,991 9.1 1032 5.4 < 0.001 Vertigo 15,810 2.9 420 2.2 < 0.001 Seizure 1920 0.3 241 0.1 < 0.001 Paraplegia 717 0.1 21 0.1 0.36 Skin lesions 635 0.1 41 0.2 < 0.001 exacerbate the severity of the disease, and increase the risk [15–17]. This result is not particularly surprising given the of morbidity and mortality in the migrant population. fact that most foreign nationals in Iran are migrant workers. Overall, patients with non-Iranian nationality living in With respect to gender composition, patients were less fre- the country were younger than Iranian patients, which was quently women in both Iranian and non-Iranian populations in line with findings from immigrant populations who were which was consistent with reports around the world [15, 17, infected with COVID-19 in Kuwait, Italy, and United States 18, 24, 25]. However, the difference was more prominent 1 3 Journal of Epidemiology and Global Health (2022) 12:449–455 453 Table 2 Para-clinical findings and health outcome of patients infected for immigrant patients, which could be partly explained by with COVID-19, Iran, 2020–2021 the great proportion of labor migrants (mainly men) among non-Iranian patients. However, biological variations between Iranian Immigrant P value patients patients men and women which could make men more susceptible to SARS-CoV-2 infection, as well as differences in behavioral n % n % habits between the two sexes have also been mentioned in the PaO sat < 93% 270,811 47.7 11,314 53.9 < 0.001 literature to justify the sex bias observed in COVID-19 pan- Positive PCR test result 250,649 44.1 5710 27.2 < 0.001 demic [26, 27]. Chest CT with positive 375,468 66.1 11,369 54.2 < 0.001 The most prevalent underlying diseases were hypertension findings and diabetes in both groups which correlate well with those of ICU admitted 90,044 15.8 3576 17.0 < 0.001 other countries and further support the potential role of angi- Deceased 48,765 8.6 2127 10.1 < 0.001 otensin-converting enzyme 2 (ACE2) receptors in the corona- virus entry into human cells [28–31]. Yet the conditions were more prevalent in the patients with Iranian nationality. Higher Table 3 Logistic regression model of independent variables associ- prevalence of hypertension, diabetes, and several other comor- ated with COVID-19-related death, Iran, 2020–2021 bidities in Iranian patients compared to immigrant patients living in the country, could be attributed to the relatively older variable aOR 95% confi- P value dence interval age of patients with Iranian nationality. However, another pos- sible explanation for the observed discrepancy could be the Lower Upper underdiagnosis of chronic conditions in immigrant population. Age group In agreement with findings documented in previous studies, 0–4 1 in both groups, respiratory symptoms including cough and dif- 5–11 0.38 0.316 0.469 < 0.001 ficulty breathing were the most common complaints that have 12–17 0.71 0.595 0.858 < 0.001 prompted patients to seek medical care [32, 33]. However, it is 18–24 0.53 0.466 0.612 < 0.001 not completely clear why most symptoms are more prevalent 25–34 0.50 0.461 0.552 < 0.001 in Iranian-born patients compared to immigrant population. 35–44 0.84 0.786 0.914 < 0.001 However, our research might have limitations. First, data 45–54 1.49 1.387 1.600 < 0.001 on determinants, such as reason for relocation, migration 55–64 2.68 2.509 2.879 < 0.001 status, and length of stay in Iran, which could influence the 65+ 6.20 5.799 6.630 < 0.001 health outcome of immigrant patients infected with COVID- Sex 19 in the country, were not available to the researchers. Sec- Female 1 ond, since we did not have information on socio-economic Male 1.31 1.288 1.338 < 0.001 status of the patients, we have compared immigrant patients Nationality of whom mostly are from low socio-economic status with the Iranian patients 1 general population of Iran that has socio-economic diversity. Immigrant patients 1.64 1.568 1.727 < 0.001 If we assume that socio-economic status could impact the Positive history of smoking 0.80 0.740 0.865 < 0.001 health outcome of patients with COVID-19, then comparing Positive history of opioids 1.31 1.205 1.443 < 0.001 immigrant patients with Iranian patients from low socio- Diabetes 1.16 1.129 1.195 < 0.001 economic status might attenuate the observed disparity in Hypertension 1.04 1.012 1.068 0.004 the health outcome. As more comprehensive data become CVD 1.15 1.126 1.190 < 0.001 available, further research is needed to test this hypothesis. Cancer 2.21 2.097 2.339 < 0.001 Yet, using real-time and consistent data on a large multi- Asthma 0.91 0.842 1.001 0.05 center cohort of COVID-19 patients is the major strength of Chronic liver diseases 1.63 1.458 1.824 < 0.001 our study. This allows reliable extension of research findings Chronic kidney diseases 2.02 1.916 2.129 < 0.001 to the target population and makes this research of great Chronic neurological diseases 1.78 1.646 1.941 < 0.001 importance for policy-makers. Chronic immune deficiency diseases 1.28 1.084 1.527 0.004 Chronic hematological diseases 1.40 1.248 1.579 < 0.001 Constant 0.28 5 Conclusion The evidence from this study revealed that immigrant patients infected with COVID-19 were more likely to suf- fer from severe health outcomes of the disease compared to 1 3 454 Journal of Epidemiology and Global Health (2022) 12:449–455 permitted by statutory regulation or exceeds the permitted use, you will Iranian-born patients. The observed health disparity could need to obtain permission directly from the copyright holder. To view a be explained by several socio-economic health determinants copy of this licence, visit http://cr eativ ecommons. or g/licen ses/ b y/4.0/ . which require targeted public health interventions aimed at reducing the health inequalities. All in all, immigrants are among vulnerable populations who demand special consid- References eration from policy-makers in their response to COVID-19 pandemic. In addition to inclusive policies which ensure 1. World Health Organization. Timeline: WHO's COVID-19 their entitlement to COVID-19 healthcare, and their inclu- response 2020. https://www .who. int/ emer gencies/ disea ses/ no vel- coron avirus- 2019/ inter active- timel ine. Accessed 15 Apr 2022. sion in the national surveillance systems, it is particularly 2. World Health Organization. Naming the coronavirus disease important to address the socio-economic health determinants (COVID-19) and the virus that causes it 2020. https:// www. who. which affect the overall health status in this population with int/emer gencies/ disea ses/ no vel-cor ona virus-2019/ tec hnical- guida social services that are tailored to their needs. nce/naming- t he-cor ona virus-disea se- (co vid-2019)- and- t he-vir us- that- causes- it. Accessed 15 Apr 2022. 3. World Health Organization. Coronavirus disease (COVID-19) Acknowledgements The authors thank the Coronavirus Control Opera- pandemic 2020. https://www .who. int/ emer gencies/ disea ses/ no vel- tions Headquarter in the province of Tehran for their support and for coron avirus- 2019. making the original data available to us. 4. Takian A, Raoofi A, Kazempour-Ardebili S. COVID-19 battle during the toughest sanctions against Iran. Lancet. Author contributions Each named author has substantially contrib- 2020;395(10229):1035–6. uted to conducting the research and drafting this manuscript. Authors’ 5. World Health Organization. The current COVID-19 situation contributions are as followings: conceptualization: MRS, RA. Data 2020. https://w ww.w ho.int /coun tr ies/ir n/. Accessed 15 Apr 2022. curation: SJ. Formal analysis: MRS, RA. Funding acquisition: MRS. 6. Gil-Gonzalez D, Carrasco-Portino M, Vives-Cases C, Agudelo- Methodology: MRS, RA, SJ. Project administration: MRS, RA, ARZ. Suarez AA, Castejon Bolea R, Ronda-Perez E. Is health a right Visualization: MRS, RA, AM, ARZ. Writing—original draft: MRS, for all? An umbrella review of the barriers to health care access RA. Writing—review and editing: MRS, RA, AM, SJ, ARZ. faced by migrants. Ethn Health. 2015;20(5):523–41. 7. Shahul Hameed S, Kutty VR, Vijayakumar K, Kamalasanan A. Funding This work was supported by the Research deputy for research Migration status and prevalence of chronic diseases in Kerala and technology, Shahid Beheshti University of Medical Sciences, Teh- State, India. Int J Chronic Dis. 2013;2013: 431818. ran, Iran (Grant number 24229). There was no financial support for 8. Agency TUR. Refugees in Iran 2022. https:// www. unhcr. org/ ir/ authorship and publication of the article. refug ees- in- iran/. Accessed 17 Apr 2022. 9. ACAPS. AFGHAN REFUGEES 2021. https:// www. acaps. org/ Data and/or code availability The data that support the n fi dings of this count r y/ ir an/ cr isis/ afghan- r efug ees#: ~: te xt= Ir an% 20hos ts% study are available from Coronavirus Control Operations Headquarter 20one% 20of% 20the ,undoc ument ed% 20Afg hans% 20live% 20in% in the province of Tehran, but restrictions apply to the availability of 20Iran. Accessed 17 Apr 2022. these data, which were used under license for the current study, and so 10. UNHCR The UN Refugee Agency. Publications 2020. https:// are not publicly available. Data are however available from the authors www.unhcr .or g/ir/ wp- conte nt/ uploa ds/ sites/ 77/ 2020/ 05/ UNHCR - upon reasonable request and with permission of Coronavirus Control Month ly- Facts heet- IRAN_ Jan- Mar- 2020- Eng. pdf. Accessed 17 Operations Headquarter in the province of Tehran. Apr 2022. 11. Badrfam R, Zandifar A. Mental health status of Afghan immi- grants in Iran during the COVID-19 pandemic: an exacerbation Declarations of a long-standing concern. Asian J Psychiatry. 2021;55: 102489. 12. Presidency of the I.R.I Plan and Budget Organization. Statisti- Conflict of interest The authors have no competing interests to declare cal Center of Iran. https:// www. amar. org. ir/ engli sh/ Stati stics- by- that are relevant to the content of this article. T opic/ Popul ation# 288290- s t ati s tical- sur vey. Accessed 17 Apr Ethics approval and consent to participate This study was performed 13. World Health Organization. WHO COVID-19 Case definition in line with the principles of the Declaration of Helsinki. Approval 2020. https://www .who. int/ publi catio ns/i/ item/ WHO- 2019- nCoV - was granted by the Ethics Committee of Shahid Beheshti University of Surve illan ce_ Case_ Defin ition- 2020.1. Accessed 17 Apr 2022. Medical Sciences with a waiver of informed consent (Ethics approval 14. Dong Y, Peng CY. Principled missing data methods for research- number: IR.SBMU.RETECH.REC.1399.830). ers. Springerplus. 2013;2(1):222. 15. Fabiani M, Mateo-Urdiales A, Andrianou X, Bella A, Del Manso Consent to publish Not applicable. M, Bellino S, et al. Epidemiological characteristics of COVID-19 cases in non-Italian nationals notified to the Italian surveillance system. Eur J Public Health. 2021;31(1):37–44. Open Access This article is licensed under a Creative Commons Attri- 16. Khanijahani A. Racial, ethnic, and socioeconomic disparities in bution 4.0 International License, which permits use, sharing, adapta- confirmed COVID-19 cases and deaths in the United States: a tion, distribution and reproduction in any medium or format, as long county-level analysis as of. Ethn Health. 2020;2020:1–14. as you give appropriate credit to the original author(s) and the source, 17. Hamadah H, Alahmad B, Behbehani M, Al-Youha S, Almazeedi provide a link to the Creative Commons licence, and indicate if changes S, Al-Haddad M, et al. COVID-19 clinical outcomes and nation- were made. The images or other third party material in this article are ality: results from a Nationwide registry in Kuwait. BMC Public included in the article's Creative Commons licence, unless indicated Health. 2020;20(1):1384. otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not 1 3 Journal of Epidemiology and Global Health (2022) 12:449–455 455 18. Zhang M, Gurung A, Anglewicz P, Yun K. COVID-19 and immi- meta-analysis as a risk factor for death and ITU admission. Nat grant essential workers: Bhutanese and Burmese refugees in the Commun. 2020;11(1):6317. United States. Public Health Rep. 2021;136(1):117–23. 28. Rodriguez-Molinero A, Galvez-Barron C, Minarro A, Macho O, 19. Islam MN, Inan TT, Islam A. COVID-19 and the Rohingya refu- Lopez GF, Robles MT, et al. Association between COVID-19 gees in Bangladesh: the challenges and recommendations. Asia prognosis and disease presentation, comorbidities and chronic Pac J Public Health. 2020;32(5):283–4. treatment of hospitalized patients. PLoS ONE. 2020;15(10): 20. Jozaghi E, Dahya A. Refugees, asylum seekers and COVID-19: e0239571. Canada needs to do more to protect at-risk refugees during the 29. Du RH, Liang LR, Yang CQ, Wang W, Cao TZ, Li M, et  al. current pandemic. Can J Public Health. 2020;111(3):413–4. Predictors of mortality for patients with COVID-19 pneumonia 21. Chuah FLH, Tan ST, Yeo J, Legido-Quigley H. The health needs caused by SARS-CoV-2: a prospective cohort study. Eur Respir and access barriers among refugees and asylum-seekers in Malay- J. 2020;55(5):2000524. sia: a qualitative study. Int J Equity Health. 2018;17(1):120. 30. Fiorini G, Rigamonti AE, Galanopoulos C, Adamoli M, Ciriaco 22. Salmani I, Seddighi H, Nikfard M. Access to health care services E, Franchi M, et al. Undocumented migrants during the COVID- for Afghan refugees in Iran in the COVID-19 pandemic. Disaster 19 pandemic: socio-economic determinants, clinical features and Med Public Health Prep. 2020;14(4):e13–4. pharmacological treatment. J Public Health Res. 2020;9(4):1852. 23. Kiani MM, Khanjankhani K, Takbiri A, Takian A. Refugees 31. Fang L, Karakiulakis G, Roth M. Are patients with hypertension and sustainable health development in Iran. Arch Iran Med. and diabetes mellitus at increased risk for COVID-19 infection? 2021;24(1):27–34. Lancet Respir Med. 2020;8(4): e21. 24. GLOBAL HEALTH 5050. The sex, gender and COVID-19 pro- 32. Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epide- ject 2020. 2020. https://g lobalheal t h5050.or g/t he-se x-g ender-and- miological and clinical characteristics of 99 cases of 2019 novel covid- 19- proje ct/. Accessed 23 Apr 2022. coronavirus pneumonia in Wuhan, China: a descriptive study. 25. Bwire GM. Coronavirus: why men are more vulnerable to Covid- Lancet. 2020;395(10223):507–13. 19 than women? SN Compr Clin Med. 2020;2(7):874–6. 33. Bahl A, Van Baalen MN, Ortiz L, Chen NW, Todd C, Milad M, 26. Giagulli VA, Guastamacchia E, Magrone T, Jirillo E, Lisco G, et al. Early predictors of in-hospital mortality in patients with De Pergola G, et al. Worse progression of COVID-19 in men: is COVID-19 in a large American cohort. Intern Emerg Med. testosterone a key factor? Andrology. 2021;9(1):53–64. 2020;15(8):1485–99. 27. Peckham H, de Gruijter NM, Raine C, Radziszewska A, Ciurtin C, Wedderburn LR, et al. Male sex identified by global COVID-19 1 3

Journal

Journal of Epidemiology and Global HealthSpringer Journals

Published: Dec 1, 2022

Keywords: COVID-19; Healthcare disparities; Health equity; Social determinants of health; Transients and migrants

There are no references for this article.