The COVID-19 pandemic has forced us to reflect on our vulnerability, and it has thrown inequity among marginalized groups into sharp focus. Essential workers, like those in food service, maintenance and transportation service, are integral to the functioning of our economy and society. Many of these essential workers are refugees who are often required to risk exposure to make a living during the pandemic.

Recent studies have found that refugees face a higher risk of COVID-19 infection. Refugees, especially those with limited English proficiency, are more likely than U.S.-born workers to work in areas with low pay and high risk. In some industries, like food supply chain, there are limited worker protections, which has led to multiple outbreaks among workers in meat-packing plants, the majority of whom are refugees.

To better understand these risks and inequities, we conducted a cross-sectional study in May 2020 aimed at describing COVID-19-related risk factors among Bhutanese and Burmese refugees in the U.S. Bhutanese and Burmese refugees are among the largest refugee communities of Asian origin resettled in the U.S. in the past decade. They have high poverty rates, relatively low English proficiency and low bachelor’s degree attainment. Additionally, a high proportion of Bhutanese Americans live in multigenerational households. Because of these characteristics, these communities are less likely to have access to public health information, managerial or office positions that allow for work from home, or access to information about occupational health protections than the general Asian American population and the general U.S. population.

Of the 218 refugees in 23 states who completed the survey from May 15 through June 1, 2020, 40% were essential workers and almost 7% reported infection with COVID-19. Essential workers were over five times more likely to be infected with COVID-19 compared with non-essential workers. And having an infected family member and being female are also additional risk factors for infection. COVID-19 is of particular concern for immigrant essential workers in multigenerational households because younger essential workers may transmit infection to elders, who have the highest mortality risk among age groups. When working parents fall ill with COVID-19, it also increases the risk of infection for children in the household.

Given the vulnerability of low-income essential workers to COVID-19 infection and high levels of participation among refugees and immigrants in the essential workforce, there’s a clear need to increase public health attention to protect these populations during the COVID-19 pandemic. We echo many of the recommendations laid out in a recent PolicyLab policy brief, Addressing the Unique Needs of Immigrant and Limited-English-Proficient Communities during the COVID-19 Pandemic, and we encourage public health departments to improve multilingual education and consider distribution of personal protective equipment to multigenerational households and home caregivers for COVID-19 patients. We also urge public health professionals, local governments and researchers to disaggregate their data related to racial/ethnic minorities. Considering the diversity of refugee and immigrant communities in the U.S., each population group has unique needs and risk factors that affect the pandemic’s impact.

And perhaps most importantly, we suggest that public health departments engage refugee and other immigrant stakeholders in planning processes to ensure that public health interventions are accessible to these communities. We encourage public health practitioners to work with researchers to conduct needs assessments within refugee and immigrant communities to hone in on their specific needs. As illustrated by the community voices highlighted in the policy brief, these stakeholders can provide valuable insights that can help guide vaccine distribution, post-pandemic recovery and future crisis response.

We are currently conducting a second wave of data collection, expanding to include refugees from other countries. With a larger sample from diverse refugee communities, we hope to better understand refugees’ experiences during the pandemic as well as help connect these families with needed resources during the pandemic and as they prepare for post-pandemic recovery.

Dr. Mengxi Zhang is an assistant professor of health science at Ball State University.

Ashok Gururg is a research assistant at PolicyLab.

Dr. Philip Anglewicz is an associate professor at Johns Hopkins Bloomberg School of Public Health.