ACEP COVID-19 Field Guide

Table of Contents


Special Populations

Authors: Caroline Schulman, MD; and Aisha T. Terry, MD, MPH, FACEP

Despite worldwide efforts to contain the COVID-19 pandemic, the virus continues to spread. Particularly vulnerable populations that are often overlooked include immigrants living in the US. Immigrant populations overlap with all special populations, including pediatric patients, immunosuppressed persons, racial and ethnic minorities, pregnant women, the elderly, and many more. Additional challenges to be addressed are accessibility to health care and the ability to adhere to precautions. The following information is based on current evidence and evolving information and legislation. 


Immigrant populations include all noncitizens, those both lawfully present and undocumented, which constitute over 22 million people. Both groups are less likely to have access to health care than citizens.1 This section primarily focuses on undocumented immigrants because they are less likely to have access to public services for housing, food, education, and health care. Many have overcrowded households without the ability to self-isolate if they become symptomatic or are concerned about having been exposed and possibly infected with COVID-19. In Washington, DC, during the COVID-19 pandemic, it is common to have households of four or more people living in studio apartments. Many do not have primary care physicians and rely heavily on emergency departments.1 An especially vulnerable subset of this population is immigrants in US Immigration and Customs Enforcement (ICE) detention facilities. These facilities often have inadequate social services, including services related to health care. Pleas to release detained immigrants who do not pose a threat to public safety have yet to be answered.2


Person-to-person spread via respiratory droplets is thought to be the predominant means of transmission of COVID-19, although some emerging evidence suggests a potentially increasing role of spread via aerosols. It is presumed that transmission can also occur via contaminated fomites. At least one study has demonstrated that SARS-CoV-2 (the virus that causes COVID-19) may remain viable in aerosols for up to 3 hours, on cardboard for up to 24 hours, and on plastic and stainless steel for as long as 3 days. It is unclear whether infection can be spread via other bodily fluids (eg, blood, stool), although SARS-CoV-2 RNA has been detected in stool specimens, and in pediatric patients, it has been demonstrated to persist longer in stool than in the nasopharynx. For more information, refer to the CDC’s “Clinical Questions About COVID-19: Questions and Answers.”

Clinical presentation

In the absence of clinical research, clinical presentation of the immigrant population is expected to be similar to the general population. One could postulate that due to limited health care, patients may present to the emergency department more frequently than primary care, and patients may present later in the disease course with more severe symptoms. More research is needed on this topic. 

Testing recommendations

Testing recommendations for immigrant populations are not clearly defined but can be inferred to be similar to adult and pediatric patients in similar demographics. Additional consideration may be warranted for more rapid testing in immigrant populations in institutions that offer expeditious testing. Rapid results can mitigate challenging follow-up and allow positive patients to be provided with resources. Negative tests can minimize lost work days, which can be devastating. More information regarding general testing guidelines can be found via the CDC at “Evaluating and Testing Persons for Coronavirus Disease 2019 (COVID-19).”


Definitive treatment for COVID-19 is ever evolving and generally focuses on suppression of symptoms and complications. Addressing the social needs of the immigrant population is essential to minimizing spread. Primarily, thresholds to use interpreters should be low, and interpreters should be offered to all patients who are non-native English speakers. Clear communication around strict precautions and concerns is imperative. Furthermore, follow-up care may be difficult, and emergency physicians may be the only clinicians undocumented immigrants seek for care, making clear communication key. Some areas offer follow-up telemedicine visits or make citywide hotlines available in other languages. Connecting patients to these resources can save lives. Registration staff can help patients set up health insurance enrollment. Several cities have set up food resources and housing options for patients who are self-isolating. Social workers can also help to connect these populations with available local resources.


Recent legislation regarding “public charge” has led to increased undocumented immigrant disenrollment from Medicare.3 A month after the legislation was passed, the US Citizenship and Immigration Services (USCIS) posted an announcement that undocumented immigrants with symptoms of COVID-19 should seek treatment and would not be “negatively affected” as part of public charge analysis.4 Recent data from New York City has demonstrated that these communities are less likely to be tested for COVID-19 and are more likely to be positive, if tested.5 This lack of testing suggests that these populations are still hesitant to seek care. 


  1. Health coverage of immigrants. Kaiser Family Foundation website. 2020 Mar 18. 
  2. Keller AS, Wagner BD. COVID-19 and immigration detention in the USA: time to act [published online ahead of print, 2020 Mar 31]. Lancet Public Health. 2020;S2468-2667(20)30081-5. doi:10.1016/S2468-2667(20)30081-5
  3. Page KR, Venkataramani M, Beyrer C, Polk S. Undocumented U.S. immigrants and COVID-19 published online ahead of print, 2020 Mar 27]. N Engl J Med. 2020;10.1056/NEJMp2005953. doi:10.1056/NEJMp2005953
  4. Inadmissibility on public charge grounds final rule. U.S. Citizenship and Immigration Services website. 2020 Feb 24. 
  5. Borjas GJ. Demographic determinants of testing incidence and COVID-19 infections in New York City neighborhoods. HKS Working Paper No. RWP20-008. 2020 Apr 10.

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