Summary

The shielding approach is an ambitious undertaking, which may prove effective in preventing COVID-19 infection among high-risk populations if well managed. While the premise is based on mitigation strategies used in the United Kingdom there is no empirical evidence whether this approach will increase, decrease or have no effect on morbidity and mortality during the COVID-19 epidemic in various humanitarian settings.

This document highlights a) risks and challenges of implementing this approach, b) need for additional resources in areas with limited or reduced capacity, c) indefinite timeline, and d) possible short-term and long-term adverse consequences.

Public health not only focuses on the eradication of disease but addresses the entire spectrum of health and wellbeing. Populations displaced, due to natural disasters or war and, conflict are already fragile and have experienced increased mental, physical and/or emotional trauma.

While the shielding approach is not meant to be coercive, it may appear forced or be misunderstood in humanitarian settings. As with many community interventions meant to decrease COVID-19 morbidity and mortality, compliance and behavior change are the primary rate-limiting steps and may be driven by social and emotional factors. These changes are difficult in developed, stable settings; thus, they may be particularly challenging in humanitarian settings which bring their own set of multi-faceted challenges that need to be taken into account.

Household-level shielding seems to be the most feasible and dignified as it allows for the least disruption to family structure and lifestyle, critical components to maintaining compliance. However, it is most susceptible to the introduction of a virus due to necessary movement or interaction outside the green zone, less oversight, and often large household sizes.

It may be less feasible in settings where family shelters are small and do not have multiple compartments. In humanitarian settings, small village, sector/block, or camp-level shielding may allow for greater adherence to proposed protocol, but at the expense of longer-term social impacts triggered by separation from friends and family, feelings of isolation, and stigmatization.

Most importantly, accidental introduction of the virus into a green zone may result in rapid transmission and increased morbidity and mortality as observed in assisted care facilities in the US.26The shielding approach is intended to alleviate stress on the healthcare system and circumvent the negative economic consequences of long-term containment measures and lockdowns by protecting the most vulnerable.

Implementation of this approach will involve careful planning, additional resources, strict adherence and strong multi-sector coordination, requiring agencies to consider the potential repercussion among populations that have collectively experienced physical and psychological trauma which makes them more vulnerable to adverse psychosocial consequences.

In addition, thoughtful consideration of the potential benefit versus the social and financial cost of implementation will be needed in humanitarian settings.