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FAQ: COVID-19 and Migrant, Immigrant, and Food & Farm Worker Patients

FAQ: COVID-19 and Migrant, Immigrant, and Food & Farm Worker Patients

Table of Contents

The Latest Questions
Exposure Quarantine and Isolation
Prevention
Variants
Boosters
COVID-19 Diagnosis and Care
Long COVID
Migration, Immigration, and International Travel/Vaccination
Pregnant People
Children
Vaccine Cards
COVID and Other Health Issues
Basic COVID Questions

Migrant Clinicians Network continues to receive questions from our clinical network on COVID-19 and vaccines for migrant, immigrant, and farmworker communities. While vaccines are available for all in the US, in reality, COVID-19 vaccines remain less accessible for many people, for a variety of reasons, including fear over immigration status, misinformation, lack of information in a preferred language, and lack of vaccination infrastructure. The dynamic situation does not belie the underlying mantra: everybody deserves a chance to get vaccinated against COVID-19. Vaccination is critical and efforts need to continue to make it fully accessible, with culturally appropriate education and conversation available in the language of the patient to answer their questions and build trust.

Until everyone is vaccinated, we will continue to see new variants emerge. Worldwide equitable vaccination is essential to end the pandemic.
 

This FAQ was last revised June 29, 2022. Information is changing rapidly. Remember that our understanding of COVID, its variants, and the effectiveness of the vaccines over time continues to develop as we receive more data, and, consequently, recommendations may change. Please continue to check back here for updates and from other trusted sources like the CDC. Please refer to the CDC for the most up-to-date recommendations.

 

The Latest Questions

COVID vaccine for children under 5

Which is better, the Moderna or Pfizer vaccine for children under five?

In June 2022, both the Moderna and Pfizer vaccines will be available in lower dosages for children ages six months to five years old. Both vaccines are safe, effective, and highly recommended. Both had minimal and expected side effects like irritability and tenderness at the injection sight, and some side effects like fevers with frequency similar to other childhood vaccines. Both clinical trials did not produce any cases of myocarditis, a rare side effect that has been seen particularly in adolescent males.

Throughout the pandemic, marginalized communities have struggled to access vaccines, even when in some cases their communities are at higher risk due to lack of workplace protections and other determinants. It is critical that clinicians emphasize that the safety and efficacy of these two vaccines have been proven again and again in older children and adults for over a year and a half. 

There are differences between the vaccines, however. The vaccine formulas, clinical trials, and even the number of doses studied are different. Children who received the Moderna vaccine had more side effects than the Pfizer, which may be expected since the Moderna vaccine has a higher dosage. Moderna’s clinical trial data, as epidemiologist Katelyn Jetelina has pointed out, are more robust, meaning their projected efficacy is more likely to reflect real-world protection. Both need more data to determine long-term efficacy.

While Moderna has been authorized for a two-dose series, the company plans to apply for a third booster shot for this age group to be administered later in the year. Pfizer has been authorized as a three-dose series.

The bottom line is that, while there are differences between the two options, anyone who is six months or older and has an opportunity to get vaccinated should be encouraged to get vaccinated because vaccination continues to show itself as the best way to prevent severe disease and death from COVID. 

 

A community member said her child doesn’t need a vaccine because the death rate for children is so low. What should I say?

Here are a few facts to consider:

  • Death is a concern.
    • Annual pediatric deaths from COVID-19 have been higher than deaths typically seen from the seasonal flu.
    • Since March 2020, COVID-19 has been the fifth-leading cause of death in children aged one to four.
    • Even though the total number of child deaths from COVID is much lower than that of adults, each death of a child is tragic and, with COVID vaccines, parents can take steps to prevent deaths from COVID.
  • Long COVID is a concern.
    • Children who contract COVID-19 are at risk of long COVID complications, although it is rarer than among adults.
    • Children who contract COVID-19 have a higher risk of myocarditis than children who avoid COVID-19 because they are vaccinated.
  • Community spread and the overtaxing of the health care system remain concerns.
    • As has been repeated throughout the pandemic, taking steps to protect yourself against infection helps stop the spread of COVID, which in turn reduces the risk of infection for people who cannot be well protected, including the elderly and the immunocompromised.
    • As we’ve seen throughout the pandemic, health systems can get overwhelmed when a new variant causes an increase in hospitalization, which increases the risk of mortality and morbidity from non-COVID health concerns.
    • Continued community spread increases the likelihood of mutations and new variants. Vaccination reduces the spread of COVID.
  • Natural immunity wanes over time.
    • Although many children have been infected with Omicron in the last six months, natural immunity wanes and many of these children are again vulnerable to infection.

 

A community member’s four-year-old son recovered from COVID two weeks ago. Should he get vaccinated now, or wait?

Yes, he should get vaccinated now. Many factors determine a child’s level of antibodies after a COVID-19 infection. Children infected with one variant may not produce antibodies that protect them from other variants. A mild infection may cause a smaller immune response, with fewer or no antibodies generated. With no clear measurement of how protected the child is, it is prudent to get the child vaccinated now, to ensure he has the highest level of protection from infection. 

 

Most of the parents in my community seem hesitant about the under-5 vaccine for children. What can I do?

Many parents are nervous about giving the vaccine to their youngest children, even if older children or they themselves are vaccinated. As Aisha Jha noted in the New Yorker, only a third of adults were eager to get vaccinated in December 2020, and yet now, 80% of adults have received at least one dose of the COVID vaccine. What encouraged vaccination? Over time, more data proved the vaccine’s safety and efficacy, and people saw their neighbors get vaccinated, normalizing the shot – but just as critically, trusted clinicians, including outreach teams and community health workers, shared new data, corrected misinformation, expressed their concerns around the virus, and voiced strong confidence in the vaccine.

Hyper-local campaigns on the safety and efficacy of the vaccines have helped thousands of people make the choice to get vaccinated. These approaches once again become critical to help build confidence in the vaccines for our youngest community members. 

Make sure the vaccine is easily accessible, in locations that make sense for the community, and at hours that busy parents can make. Ensure you have community materials that address the community’s concerns, and are culturally and linguistically appropriate. Design materials that feature local community leaders that parents trust, like pediatricians and faith leaders.  MCN’s customizable materials are available in English, Spanish, and Haitian Creole on our COVID-19 Vaccine Awareness Campaign page.

Dr. Katelyn Jenner lists numerous high-quality resources for clinicians to support parents as they make their vaccine decision. She also created helpful Q&A fact sheets in English and Spanish. While not low-literacy, community health workers and others may refer to them to answer common questions: COVID-19 vaccine info for trusted messengers: Kids <5 years

 

Pregnancy & Vaccines

A woman got vaccinated while pregnant. Now, her child is six months old. Should she vaccinate her baby?

Yes, her baby should get vaccinated now. Vaccination while pregnant does pass antibodies through the placenta which is protective for the newborn. However, it is unclear how long this protection lasts. It is best to get the baby vaccinated to ensure he has the highest level of protection from infection. 

 

A breastfeeding woman who is vaccinated wondered if her antibodies, which are transferred through breastmilk, are enough to delay her eight-month-old girl’s vaccination.

Her baby should get vaccinated now. Yes, it is true that antibodies are transferred through breastmilk. However, the level of protection will be less than if the baby is vaccinated. It is best to get the baby vaccinated to ensure she has the highest level of protection from infection. 

 

Other

What is a bivalent vaccine and is it more effective than our current vaccines?

In June 2022, Moderna released data on a new bivalent vaccine – meaning, a vaccine that stimulates an immune response to two different antigens in one vaccination. The bivalent vaccine in this case aimed to create antibodies against the Alpha and Omicron variants. The data on the bivalent vaccine shows that the vaccine increased the levels of antibodies against all variants of concern, and not just against the variants that the bivalent vaccine targeted, compared to the original vaccine. The data are not able to show long term efficacy or side effects due to the short duration of the trials although Moderna executives believe the data will show efficacy for more than six months, and maybe even a year. More data are needed, but many epidemiologists and public health experts believe a bivalent vaccine is the next step forward in the strategy against COVID-19. Moderna executives and others are voicing that the bivalent vaccine is a good candidate to be an annual booster against COVID-19 because it may produce high levels of antibodies for much longer than our current vaccines.

 

What are the connections between diabetes and COVID?

New research is beginning to show the complex and bidirectional relationship between diabetes and COVID.  While more studies need to be conducted to better understand the mechanisms driving these connections, data confirm that those with diabetes have a greater risk of severe acute COVID. Additionally, individuals with diabetes have a four-fold higher risk of developing long COVID. Finally, those who had acute COVID have a 40% higher likelihood of a new type 2 diabetes diagnosis in the months following infection.

 


 

Exposure, Quarantine, and Isolation

The CDC guidelines on what a patient should do when she has had close contact with someone who tested positive are confusing. What do you recommend?

MCN has created these flow-chart resources, in English and Spanish, to help you communicate the process. One resource describes what to do if a patient is exposed. A second resource explains what to do if a patient tests positive.

Resources in Spanish: He dado positivo a COVID-19. ¿Y ahora qué?

Resources in English: Testing Positive for COVID-19. Now what?

Resources in Haitian Creole: Mwen te teste pozitiv pou COVID-19. Kounya Kisa?

Remember that the CDC recommendations may once again change as conditions and our understanding of COVID shift, so please check back often for updates.

These CDC recommendations can be especially difficult to complete for migrant and immigrant patients, who may have housing situations that make quarantine difficult, or may have informal work situations that make time off to quarantine or to get tested very difficult. Voice these concerns with patients and help them develop a plan to quarantine or isolate, and keep themselves and the community safe. Earlier in the pandemic, many community health clinics partnered with hotels and other locations to ensure migrants have safe places to isolate or quarantine, with food and other essentials delivered to the location. As new variants emerge, these partnerships and processes become critically important once again.


The CDC doesn’t require a test to end isolation after a COVID infection. What do I tell my patients?

The CDC’s guidance as of January 2022 is that, if a patient is no longer symptomatic (or was always asymptomatic) five days after a positive test, then that patient can leave isolation with the caveat that they continue to mask for five days.  Many clinicians and infectious disease researchers are concerned that people who do not test after five days may still be shedding the virus.

The best way to ensure that a patient is not infectious is to get tested after five days. This is not required by the CDC, nor is it feasible in many areas where tests are still in very short supply and/or are expensive. Migrant, immigrant, and refugee patients, along with food and farmworkers, often lack easy access to at-home and PCR tests. The federal program to provide tests, along with a mandate to require health insurance companies to provide tests, are two important steps to improve test access. However, access remains difficult. Outreach teams are encouraged to provide testing opportunities in after-hours and weekend pop-ups at churches, flea markets, farmers’ markets and grocery stores, farmworker camps, and local events.

In short, patients should be encouraged to test after five days, although it should be clarified that it is not required – and health care advocates should do their part to make sure that such testing is quick, convenient, and free.


Should vaccinated patients who have been exposed to COVID-19 get a COVID-19 test if they are not experiencing symptoms?

Yes.

If a vaccinated patient has a known exposure, the patient does not have to quarantine, but should get tested five to seven days after exposure, even if they do not have symptoms. They should also wear a mask for 14 days following exposure. Read more on the CDC’s Quarantine page. 

 

Prevention

The mask mandates have ended in my community, but transmission of Omicron BA.2 is rising. Should I encourage my patients to wear a mask?

As the CDC has shifted its approach on COVID management and prevention, individuals have gained the responsibility to determine their personal level of risk and risk tolerance.  Mask mandates differ from state to state and even county to county, as do COVID transmission and hospitalization rates. Clinicians are encouraged to share with patients how to determine their own risk:

  • What are your community's current hospitalization rates, and are they going up or down?
  • What is your personal health status? Do you have conditions that may increase your risk of COVID? Are you up to date on your COVID vaccinations?
  • What is the risk level of the event you would like to attend? Is it indoors or outdoors? How many people will attend? What kind of ventilation and distancing will there be?

In addition to local dashboards to help people understand local transmission, there are many risk calculators out there. Two calculators to try are: https://www.microcovid.org/  and https://covid-19.forhealth.org/covid-19-transmission-calculator/ 

 

Variants

A patient was surprised when she tested positive for COVID-19, when her symptoms seemed more like the stomach flu. What does the data say about Omicron symptoms?

Early data suggest that loss of taste and smell – the markers of COVID-19 infection for many – is less common with the Omicron variant. Additionally, because Omicron doesn’t infect the lungs as easily as previous variants, some people are being hospitalized without severe breathing problems, a change from earlier waves in the pandemic. However, this does not mean that Omicron is not sending people to the hospital. Many people are very ill with Omicron and most have symptoms similar to the flu and to earlier variants including but not limited to: fever, chills, cough, shortness of breath, fatigue, muscle aches, nausea, and vomiting. Anyone with any of those symptoms should test for COVID-19 and quarantine until results are conclusive. If a patient tests positive for COVID-19 or has symptoms, isolate for at least five days, according to the CDC. (See “What are the current recommendations relating to isolation if a patient contracts COVID?” under Isolation and Quarantine.)


What do we know about the Omicron sub-variants?

At the end of 2021, Omicron slightly mutated into a sub-variant called BA.2.  By early April, BA.2 had mutated again into BA.2.12.1, which is now spreading rapidly in the US. Other Omicron variants, BA.4 and BA.5, are currently spreading in South Africa and elsewhere. A person with a subvariant of Omicron will still test positive with a PCR test; the clinician will not be able to tell which subvariant it is  without further genetic sequencing. BA.2 is more transmissible than the initial strain of Omicron. BA.2.12.1 even more contagious than BA.2. Like BA.2, BA.2.12.1 does not cause more severe COVID infection.


I have read that Omicron and its subvariants are less severe than previous variants. Why are the hospitals so full?

There are two primary reasons that Omicron and its variants continue to strain hospitals. First, because Omicron is highly contagious, more people overall are getting infected. Even though they may be milder than earlier variants, because there’s such a large number of people infected, there’s still a high number of people who need to be admitted to the hospital and take up beds that are needed for patients with other life-threatening illness. 

Second, hospitals are overwhelmed because of staffing issues. Because Omicron and its variants are so contagious, many health care workers who are up to date on their vaccines still have contracted Omicron, BA.2, or BA.2.12.1. Even with a mild case, these infected health care workers can’t go to work, so hospitals are not only overfilled, they are also severely short staffed.

 

Boosters

 

A farmworker patient who is 52, in very good health, who has never had COVID, but has already received his initial series and booster shot, asked if he should get the second booster. Should he?

As of March 30, 2022, a second booster is available for patients aged 50+. More data are needed, but initial data demonstrate that a second booster rebuilds a person’s immunity against COVID-19 after the first booster's effectivity wanes. In one CDC study, the first booster of an mRNA vaccine’s effectiveness against emergency room visits dropped from 87% in the first two months after vaccination to 66% in the fourth month after vaccination. A second booster lifts the vaccine effectiveness again to reduce the risk of hospitalization. 

Farmworker patients may have trouble accessing vaccines, from finding time to get the vaccine, to traveling to a vaccine site, to time off for recovery. Clinicians are encouraged to discuss an individual's risk, the community spread, and, particularly for food and farmworkers, access to care over time to determine when a patient should receive a second booster.

It's important to note that receipt of the first booster is critical to reduce the risk of hospitalization and death. People of color, including Latinxs, are lagging far behind in getting their initial booster. At this time, encouraging food and farmworker communities to get the booster shot is the highest priority. As of mid-May 2022, only 15.9% of people in low-income nations have received any COVID vaccine. MCN continues to advocate for equal access to the initial series and booster across the world to begin to ensure pandemic health equity and to effectively slow the pandemic.


What are the changes to Pfizer booster recommendations?

The CDC updated their Pfizer booster recommendations in early January 2022: For all patients, the Pfizer booster is recommended five months after the second dose, instead of the previous recommendation of six.

In May 2022, the FDA approved a booster for children ages 5 to 11. As of May 17, 2022, the CDC has not yet updated its booster guidelines to reflect that change, but it is forthcoming.


A patient decided to wait to get a booster (because of concern that it might not work for Omicron, because of confusion over future boosters, or because of misinformation on its effectiveness). What should I say?

Encourage the patient to get the booster – it’s the strongest defense we have against contraction of disease, hospitalization, or death from COVID-19. Early studies indicate that the COVID-19 vaccine booster increases immunity for patients and protects them against severe disease and death from all currently circulating COVID variants including BA.2.12.1.

Across the 12 states reporting data on boosters, fewer Hispanics overall are opting for the additional shot compared to other ethnicities. As of April 2022, in California, just 47% of fully vaccinated Hispanic people have received the booster, compared to 64% of vaccinated white people, 56% of vaccinated Black people, and 71% of vaccinated Asian people.

This booster disparity is particularly concerning, given the April 5, 2022 drop-off in funding for vaccination of uninsured people. Without funding for boosters for the uninsured, the disparities may continue to grow, and many will be left at greater risk of infection. The concurrent drop-off in mandates for masking increases the risk of exposure. 

Vaccination remains our strongest tool against severe cases of or death from COVID-19. Please continue to stress that it is important for all eligible people – from ages 5 and up – to get vaccinated, and those age 12 and up who are eligible should get a booster.


Who should get a booster dose of a vaccine?

The CDC actively advises all vaccinated adults ages 18 and up to get a COVID-19 booster shot. Children ages 12 to 17 and immunocompromised children ages 5 to 11 are also eligible for a booster. See the CDC page for specifics on timing for each type of vaccine. Those who have received booster shots have reduced odds of contracting COVID-19, which indicates that the boosters are working to increase immunity after a period of waning immunity after initial vaccination.

In April 2022, the CDC began to allow a second booster for those age 50 and up, at least four months after the first booster.

It is critical to continue to voice that initial vaccinations with two doses of mRNA remain very highly effective against severe disease, hospitalizations, and death. Most deaths from COVID-19 continue to be among those who are unvaccinated. Getting initially vaccinated remains critically important to prevent severe disease, hospitalizations, and deaths.

Some vulnerable populations like migrants, immigrants, and refugees continue to have poor vaccine and booster access, because of fear of exposing documentation status, lack of transportation, lack of educational materials in the language of their choice, lack of childcare, concern after hearing misinformation, etc. It is critical that clinics, health departments, and other vaccine provision locations continue to connect with the historically marginalized and isolated members of their communities to facilitate vaccine access, with health fairs, mobile clinics, and partnerships with churches, farmers’ markets, and other local community groups.

Worldwide vaccine access is highly inequitable. Outside of the US, many frontline providers still lack access to a first dose, leaving them at high risk for infection. Additionally, oxygen supplies are hard to secure and/or transport throughout the Global South, leaving those with severe disease without access to a lifesaving intervention. Efforts like www.peoplesvaccine.org are working to address this ongoing health injustice by pushing for better worldwide access to first doses while we in the US begin the path to third doses.


How does the booster shot affect vaccine mandates?

Presently, most vaccine mandates do not include language around booster shots, meaning to be "fully vaccinated" means completion of the initial vaccination series (either one dose for J&J or two doses for Pfizer or Moderna). Individual companies and government entities with vaccine mandates may choose to require a booster shot if they desire. MCN strongly encourages everyone to stay up to date with their COVID vaccinations, regardless of vaccine mandates. 

 

COVID-19 Diagnosis and Care

I'm a Community Health Worker. A community member asked, “I am feeling ill, and I suspect I have COVID, but my at-home test is negative. What should I do?”  

Community members should be encouraged to get a PCR test if their at-home test was negative but they are still concerned that they may have COVID. The PCR test remains the most accurate diagnostic tool available. Regarding accuracy of at-home tests: a positive test in a rapid at-home test is very accurate. A negative test, however, may indicate that there is insufficient viral material at the time of testing for the rapid test to pick up. A second test two days later, with careful masking in the interim (preferably with an N95 or KN95), is warranted. 


A patient was surprised when she tested positive for COVID-19, when her symptoms seemed more like the stomach flu. What does the data say about the symptoms of Omicron and its variants?  

Data suggest that loss of taste and smell – the markers of COVID-19 infection for many – is less common with Omicron and its variants, BA.2 and BA.2.12.1. Additionally, because Omicron and its variants don’t infect the lungs as easily as previous variants like Alpha and Delta, some people are being hospitalized without severe breathing problems, a change from earlier waves in the pandemic. However, many people have become very ill with Omicron or its variants and most have symptoms similar to the flu and to earlier variants including but not limited to: fever, chills, cough, shortness of breath, fatigue, muscle aches, nausea, and vomiting. Omicron BA.2 appears similar in severity to Omicron (although it is more infectious). Omicron BA.2.12.1 is even more infectious than BA.2 – but similar in severity to BA.2 and Omicron. Anyone with any of those symptoms should test for COVID-19 and quarantine until results are conclusive. If a patient tests positive for COVID-19 or has symptoms, isolate for at least five days, according to the CDC. (See “What are the current recommendations relating to isolation if a patient contracts COVID?” under Exposure, Quarantine, and Isolation.)


What options are currently recommended for treating COVID?

Clinicians are encouraged to emphasize to patients that staying up to date on vaccination and consistently practicing preventative techniques are our best methods to prevent severe disease and death.

In late 2021, the FDA approved two antiviral pills to be delivered at the onset of COVID symptoms. These pills are rolling out in limited quantities. In May 2022, the Biden Administration announced efforts to expand availability of Paxlovid, a highly effective drug against severe COVID infection. 

Some monoclonal antibody treatments that were used effectively against Delta variant infections are proving less effective against Omicron infection. Testing of various monoclonal antibody treatments effective against Omicron are being tested presently.

Convalescent plasma, a promising treatment earlier in the pandemic, is presently not recommended because of inconsistency in the efficacy. Efforts to reintroduce convalescent plasma are ongoing.

Ivermectin has been conclusively proven as ineffective in reducing hospitalizations and is not advised for use against COVID. 

  


A community member asked me about Ivermectin to treat COVID-19. What should I say in response?

Unfortunately, a lot of misinformation/disinformation about Ivermectin is circulating on the internet, claiming that it is an effective cure for COVID-19. Here are some basic facts to share:

  • A robust study in March 2022 from the New England Journal of Medicine concluded that Ivermectin does not reduce the risk of hospitalization from COVID-19.  
  • Ivermectin is primarily a deworming medicine for animals. It has limited use for humans, against a number of health concerns like worms, lice, and onchocerciasis. It is not approved for use in humans against COVID-19.
  • The reason it isn’t approved for use in humans against COVID-19 is because there is insufficient evidence that it works against COVID-19.
  • One of the largest clinical trials to assess whether Ivermectin is effective against COVID-19 was halted because it was showing no benefit over placebo, according to the New York Times.
  • One of the journal articles that purportedly demonstrated benefit was retracted.
  • The NIH reported on each of the completed studies, their findings, and their limitations, on their COVID-19 Treatment Guidelines page. The panel reviewing the findings determined that “There is insufficient evidence for the COVID-19 Treatment Guidelines Panel (the Panel) to recommend either for or against the use of ivermectin for the treatment of COVID-19. Results from adequately powered, well-designed, and well-conducted clinical trials are needed to provide more specific, evidence-based guidance on the role of ivermectin in the treatment of COVID-19.”
  • Some people are getting sick from using Ivermectin. Calls to Poison Control for Ivermectin have increased significantly. Side effects include dizziness, pruritis, nausea, and diarrhea.

More Resources:

 

Long COVID

What should clinicians know about documenting work-related COVID and/or long COVID?

Documenting the work-relatedness of a COVID-19 infection may support your patient’s efforts to receive financial and health care compensation.  The COVID benefits available to workers who are infected at work or at home have varied throughout the pandemic. Because so many farm and food workers have been infected on the job, documenting the work-relatedness of these cases remains important, particularly should that patient have longer-term health consequences related to COVID-19, like long COVID or cardiovascular issues.  In some cases, the worker may be eligible for workers' compensation and disability benefits.  Initial documentation of the work-relatedness, even in mild cases, will be important. To document occupational illnesses and exposures, clinicians need to be "more certain than not" that the exposure happened at work.  In other words, the provider must be at least 51 percent that the case was a result of exposure in the workplace.

Workers’ compensation rules vary by state. In several states, workers’ compensation has been extended in certain industries to include COVID. As long COVID affects more people, there is a possibility that it, too, could be covered. At present, state rules do not include long COVID in their workers’ compensation rules. This article from the National Conference of State Legislatures tracks COVID-related workers’ compensation rules.

In addition to provider documentation in the medical record, Community Health Workers should alert COVID-positive community members to the possible utility of officially documenting their COVID infection with their health care provider, particularly if the patient has co-morbidities that may increase their risk of long COVID.

 


Should I be concerned about long COVID for my farmworker patients? What is the amount of time that farmworkers should stay home and recover if they are no longer testing positive, but don’t feel well?

Millions of people have had symptoms after acute COVID, called long COVID. Some people have symptoms during COVID that don’t resolve over time; others may begin to experience new symptoms weeks or even months after COVID infection. Some people who were asymptomatic with COVID may still develop long COVID. Migrants and low-income workers like food and farmworkers may be at higher risk of long COVID: 

  • People of color have experienced higher rates of hospitalization from COVID, and those who have been hospitalized have a greater risk of developing long COVID.
  • Those with certain comorbidities like diabetes may have a greater risk, and diabetes rates are higher among farmworkers than the general population.

Additionally, these same workers may struggle to implement guidance practices. For example, low-income workers may not be able to take sufficient time to rest and recover after a COVID infection. Many long COVID sufferers report experiencing post-exertional malaise, in which physical or mental activity triggers exhaustion. Many of these patients have found relief in the practice of “pacing” – reducing and spreading out activities that result in post-exertional malaise. Workers without sick pay, who are living in poverty, and who do not have reliable work or supportive workplaces, cannot practice pacing but must continue to work, which may exacerbate patients’ symptoms and prolong recovery.


What do you recommend to treat long COVID?

Because COVID can affect organs throughout the body, long COVID symptoms vary widely, and consequently treatments must as well. Fatigue, brain fog, and blood clots in legs (DVT), brain (CVA or stroke), and lungs (PE) are possible symptoms.

  • The CDC provides guidance on building a comprehensive rehabilitation plan tailored for each patient. Under that guidance, follow-up visits might be considered every two to three months, with “frequency adjusted up or down depending on the patient’s condition and illness progression.”
  • Other guildlines include:
    • The American Academy of Physical Medicine and Rehabilitation’s three initial guidance statements on fatigue, breathing discomfort, and cognitive symptoms, as well as a long COVID dashboard to keep track of cases nationwide. They have also gathered resources from other organizations.
    • The CAMFiC Long COVID-19 Study Group’s proposed primary care clinical guidelines, which suggest three primary care visits over the course of 14 weeks. Their guidance includes diagnostic approaches to each of the most common symptoms of long COVID.
  • Any rehabilitation plan needs to take into account the social determinants of health and occupational limitations of low-income workers.
  • Primary care teams can address concerns about blood clots by prescribing blood thinners following infection, and ensuring that patients know the symptoms of blood clots.
  • Health providers are encouraged to provide more information on heart risks after COVID. (See question on the heart and COVID for more.)


A worker who recently had COVID symptoms was tested at their workplace’s medic for COVID. It was a blood test, and it came back negative. The employer told him to go back to work, even though he had symptoms. That person then went to the doctor, who advised him to get a PCR test, which came back positive. He took the results to the workplace to get permission from work. The employer questioned the results, citing the original negative blood test. Which is more effective as a test?

A blood test is not a typical method to test for active COVID infection, but a blood test may be able to determine if there has been an antibody response to having had COVID in the recent past. This blood test may be a false negative if tested too soon (before antibodies have had time enough to develop) or too late (the antibody levels rose earlier but faded over time, especially in someone who has a weakened immune system). In neither case does it tell anything about active COVID disease. The PCR test (nasal swab) is a test that can confirm active disease, especially in someone who is also feeling COVID symptoms concomitantly. 

 

 

 

Migration, Immigration, and International Travel/Vaccination

I am coming to work in the US and I am vaccinated, but my vaccine is not on the list of approved vaccines in the US. What are the health impacts of getting vaccinated with a US approved vaccine in addition to the vaccine I already have?

It is unknown, as studies with overlapping COVID vaccinations are limited, but based on studies of other vaccines, the health risks are likely very low. Immigrants who have been vaccinated with a vaccine that is not on the list of approved foreign vaccines are encouraged to get vaccinated again with an approved vaccine. It is important to wait at least 28 days after vaccination to start a new series. Side effects may be stronger as antibodies may have already built up in one’s system. Read NCFH's resource for more, in English and Spanish.


What does an H2-A worker or other immigrant need to enter the US?

As of December 6, 2021, all air passengers, including those who are vaccinated, must show a negative COVID-19 test taken no more than one day before travel to the United States.

All non-US citizen, non-US immigrant visitors to the US, including H2-A workers, must be vaccinated with a US-approved vaccine. The current list of US-approved vaccines for entry into the US are: Johnson & Johnson, Pfizer-BioNTech, Moderna, AstraZeneca, Covaxin, Covishield, BIBP/Sinopharm, and Sinovac.  Visit this CDC website to learn more.

“Fully vaccinated” presently means more than 2 weeks after the last dose. As of December 6, 2021, a booster shot is not required to be considered “fully vaccinated” but that may change over time. Refer to the CDC website for any updates.


What do I do if a patient is partially vaccinated with a non-FDA approved vaccine, like AstraZeneca or Synovax?

Some migrant patients are arriving in the US with partial vaccination. AstraZeneca and Synovax are two vaccines that are not available in the US, but are widely used in other countries. Both require two shots.

If a patient arrives with documentation indicating only one shot of the two has been administered, MCN recommends the following.

For migrant women between the ages of 18 and 60, and if Pfizer or Moderna are available, MCN recommends that the patient begin the Pfizer or Moderna two-shot series. (Learn more about why MCN recommends this here.)

Read the CDC’s recommendations here.


The Moderna and Pfizer-BioNTech vaccines require two shots. What if a patient is moving?

We recommend that farmworkers get vaccinated when they have the opportunity to do so.  Encourage the patient to take a photo of the vaccination card and to send that photo to a family member or trusted person, so that if the card is lost (or even the phone), there is evidence of the first dose of vaccination.

If a patient isn’t sure if they can make a second appointment, sign them up with Health Network.  Migrant Clinicians Network operates Health Network, a virtual case management system that assists migrants with ongoing health needs in finding health care at their next destination. Clinicians are strongly encouraged to enroll patients who may need to migrate before they can receive the second vaccination. After enrollment, a Health Network Associate will follow up with the patient and assist in finding a health facility in the migrant’s next location so the patient can access the correct second dose. Health Network’s services are without cost to the health facilities or patients.

Learn more about Health Network here: www.migrantclinician.org/services/network

Learn more about Health Network enrollment here: www.migrantclinician.org/services/network/enrollment-in-health-network

Contact Theressa Lyons-Clampitt for more information: tylons@migrantclinician.org.

 

 

Pregnant People

Is it safe for a person to get vaccinated during pregnancy, while breastfeeding, or when planning to get pregnant?

As of late August, more than 139,000 pregnant people have been vaccinated against COVID-19. Of that cohort, no unexpected pregnancy or fetal problems have occurred. There have been no reports of any increased risk of pregnancy loss, growth problems, or birth defects. As a reminder, the COVID-19 vaccines are not live vaccines, and pregnant women and their babies cannot get COVID-19 from the vaccine. It is also believed that some immunity is conferred by the vaccinated mother to the newborn.

With this data, the CDC has strongly recommended vaccination for pregnant women.

Resources:


How do I talk to people who are pregnant or breastfeeding about getting vaccinated?  

People who are pregnant or breastfeeding will have many questions and hesitancies because of their concern over the health of their babies. It is very important to share with pregnant people why it is so critical for them to get vaccinated.

People who get COVID-19 during pregnancy:

  • Are three times more likely to need ICU care;
  • Are two to three times more likely to need advanced life support and a breathing tube;
  • Have a small increased risk of dying from COVID-19;
  • May be at an increased risk of stillbirth and preterm birth;
  • May pass antibodies to their babies.

It is worth pointing out that COVID causes hypoxia (lack of sufficient oxygen) and severe hypoxia requires ICU care or advanced life support for a pregnant mother that is dangerous for a developing fetus. The COVID-19 vaccine is the best way to protect the fetus and the mother from serious disease, hospitalization, and death.

When encountering resistance from pregnant people:

  • Build trust with patients over time.
  • Listen with respect. Show empathy and support: “I understand your concerns and it’s good that you’re being careful regarding the health of your baby. It is important to protect your baby.”
  • Then provide the facts: “These studies provide evidence that this vaccine is a way to protect your baby.”
  • Tell stories, about other patients, about your own COVID-19 vaccination, or about colleagues or friends, that may be relevant. 
  • If the patient remains concerned, ask them to talk with another trusted source like a doctor or midwife.
  • It may take more than one conversation to help a mother through hesitancy.

 

 

Children

Many of my patients with boosters are enjoying loosening restrictions – but parents of children under five who cannot be vaccinated are still very distressed. They ask what they should be doing in daycare and how to minimize their risk. What can I share with them?

First, acknowledging their fears and stress can provide some comfort. These parents in many ways feel left behind. A clinician’s validation of their feelings can increase trust and reduce some anxiety. With the FDA’s announcement of another delay for the under-five vaccine in February 2022, these concerns are only increasing. 

Second, encourage families to take all the steps they can at home to continue to create a bubble around those who can’t be vaccinated. Make sure all members of the family are up to date on their vaccinations. Have older children and adults follow as many COVID-19 precautions as possible, including distancing and mask-wearing, when outside of the household.

Finally, make sure families are having open conversations with their child care or preschool to understand what is being done to control infection in those settings. Most guidance for mitigating COVID-19 has centered on school-age children. This has left a gap for those operating child care centers or preschools for children under five. The CDC has a page for Early Childhood Education & Child Care Programs. The Children’s Hospital of Philadelphia has an in-depth guide as well.


What is the new CDC guidance on primary vaccine series spacing and who does it affect?

In February 2022, the CDC updated its interim clinical considerations to change the recommended interval between the first and second dose of mRNA vaccines for people 12 years and older.  Under the new guidance, the recommended interval between Pfizer doses is three to eight weeks. For Moderna, the recommended interval is four to eight weeks.

The CDC notes that “an eight-week interval may be optimal for some people ages 12 years and older, especially for males ages 12 to 39 years.  A shorter interval (three weeks for Pfizer-BioNTech; four weeks for Moderna) between the first and second doses remains the recommended interval for: people who are moderately to severely immunocompromised; adults ages 65 years and older; and others who need rapid protection due to increased concern about community transmission or risk of severe disease.”  This change was based on new data indicating that the longer interval reduced the risk of the very rare side effect of myocarditis found primarily among young males.


A patient expressed concerns about getting her child vaccinated. How do I approach this conversation?

Hesitancy around vaccination for children must be approached in a similar way to hesitation for the self:

  • Spend time listening to the parent’s concerns; 
  • Reflect back and validate those concerns without judgment; 
  • Ask questions to get specific about their concerns; 
  • Provide the information we have and be up front about the information we don’t have;
  • Provide an open and safe space for discussion.

For many parents – including many who have been vaccinated themselves – the vaccine still seems too new. Some have heard misinformation about the vaccines potentially affecting fertility (of which there is no evidence); others are concerned that the vaccine may result in myocarditis in adolescent boys. (See question about myocarditis, below, and new CDC recommendations about primary vaccine spacing, above.) Hearing out their specific concerns, affirming their concerns, and providing the evidence we have that point to the safety of available vaccines is a start. Then, reaffirming why vaccination is important in the family and community – to protect the abuelos from hospitalization, to prevent more deaths in the community, to avoid future dangerous mutations, and to ensure that school, prom, and hangouts with friends aren’t interrupted again – can help reframe the conversation in a positive light.


What do I say to parents who refuse the vaccine on the grounds that children rarely get very sick from COVID-19?

In addition to building trust and confidence using the strategies outlined above, clinicians can provide some basic facts and figures to parents:

  • Vaccines reduce community spread: Asymptomatic and symptomatic children with COVID-19 carry high quantities of the disease, independent of disease severity, according to a recent study. Children who are up to date with their COVID vaccines have a lower risk of becoming infected. The best way to reduce community spread – to protect those among us who likely will get very ill with COVID, if they get infected – is to vaccinate our children.
  • Some children do get very ill: It is accurate to say that the risk of serious disease among children is very low. However, in 2021, COVID-19 was estimated to be the sixth-largest killer of children in the US.  The risk is low, but many children are still going to the hospital and dying.
    • As of May 2022, at least 1,151 have died from COVID-19. As of August 2021, at least 39,000 children were hospitalized.
    • Studies show many disparities. Children of color have higher rates of hospitalization from COVID and were more likely to have myltisystem inflammatory syndrome (MIS-C) as a result of infection. Black children were more likely to be admitted to intensive care units due to MIS-C.  Overall, Black, Hispanic, Native American, and Alaska Native children had higher rates of death than white children. 
    • In one CDC review, hospitalization rates were 10 times higher among unvaccinated than among fully vaccinated adolescents. 
  • The benefits greatly outweigh the very low risks of vaccination: Millions of children ages 12 – 17 have received the COVID-19 vaccine across the world.  Many children experience side effects – pain at injection site, fever, headache. There is a low risk of myocarditis. (See next question.)
  • As new variants develop, the risk for children may grow. For example, although Omicron is less severe than previous variants, it is highly contagious, and the number of children infected was very high. Consequently, more children ended up in the hospital. A future variant may be more effective at infecting children. The best way to prevent illness and to stop future variants from forming is to maximize the number of people who are vaccinated, including children.

Resources:


Do teenage boys who get vaccinated have a higher risk of myocarditis?  

It’s important to first note that there is a greater risk of myocarditis from a COVID-19 infection than from the COVID-19 vaccine.

Vaccine-related occurrence: There has been an increase of cases of myocarditis (inflammation of the heart muscle) and pericarditis (inflammation of the lining of the heart) after vaccination with an mRNA COVID-19 vaccine (Pfizer and Moderna), particularly among male adolescents. Myocarditis is commonly triggered by viral infections, and the inflammation after vaccination may be similarly triggered. As of February 2022, VAERS has received 2,239 preliminary reports of myocarditis or pericarditis among people ages 30 years and younger after they received COVID-19 vaccine. Parents should know that male adolescents are at higher risk than other groups, and more often after the second dose. Symptoms include chest pain, shortness of breath, and a feeling of a fluttering heart. Read more on this CDC webpage. To reduce this already very small risk, the CDC stated in February 2022 that “an eight-week interval [between primary vaccine doses] may be optimal for some people ages 12 years and older, especially for males ages 12 to 39 years.”  See question above on primary spacing for more.

Infection-related occurrence: What is very critical to express to parents is that a child's risk of myocarditis as a result of COVID-19 infection is much higher than the risk of myocarditis from the vaccine.  From March 2020 to January 2021, the CDC found that patients infected with COVID-19 had nearly 16 times the risk for myocarditis compared to those who were not infected. The same study found that the myocarditis risk is 37 times higher for infected children under the age of 16, compared to that of children without COVID-19 infection. The best way to avoid infection is through vaccination.

Comparing vaccine- or infection-related risks: Those cases of vaccine-associated myocarditis have resulted in rapid recovery (weeks) as opposed to COVID infection-associated myocarditis which can remain long term and adversely affect the efficiency of the heart’s pumping ability (left ventricular ejection fraction). It does not appear that any cases of myocarditis reported after COVID-19 vaccine (whether linked to the vaccine or not) have resulted in death.

Misinformation: A pre-print study was retracted when the risk of myocarditis after vaccination was grossly overstated. Unfortunately, this pre-print study was shared widely on social media before it was retracted, which is affecting parents’ understanding of the risk of myocarditis after vaccination.


Many places are requiring parents to be present when children receive their vaccinations. This is posing a barrier to many of my immigrant and migrant patients who need to work. What suggestions do you have to address this?

Rules vary greatly according to state, and some states are changing their laws because of the COVID-19 vaccines. Presently, medical consent laws in 40 states require parental approval for children under 18 to receive a vaccine. Some states are moving to reduce barriers for teens to receive COVID-19 shots; others are pushing for greater stringency to block teens from acting without parental consent. Additionally, some counties have their own consent laws that override state laws. The website vaxteen.org provides guidance on minor consent laws by state and by county if applicable. The website also offers materials to help teens discuss vaccination with their parents.  We recommend that clinicians check their states’ laws to determine whether parent presence is required.

In areas where parents are required to be present, some parents encounter a barrier to vaccination. Many health centers and health departments are offering after-hours and weekend clinics to increase access to COVID-19 vaccines. If your patient is unable to attend available vaccination clinics, it is likely that that patient is not the only one in the community with limited access. It is highly recommended to coordinate vaccination clinics that cater to the needs of the migrant and immigrant community, taking into account work schedules, mobility, language and cultural barriers, and fear of immigration status. Mobile vaccination clinics that go to farmworker housing, and pop-up clinics in popular locations like grocery stores, flea markets, and churches, are critical avenues to increase access. Culturally relevant vaccination materials are also important. (See “Practical Resources from MCN” under Basic COVID Questions for materials.)

 

Vaccine Cards

What considerations should I make for migrant and immigrant workers getting the COVID-19 vaccine, considering workplace mandates?

Because of vaccine mandates, the vaccine card is no longer just a health document, but is a required employment document. Many migrants and immigrants work under an alias. It is critical that clinicians discuss with the patient whether the patient will need the card in the patient’s real name or in their alias name. The patient may need two cards, and the clinician may explore putting the worker’s name and alias (“AKA”) name in the state’s vaccine database.


A worker got vaccinated under his own name. He uses an alias at work. Now, there’s a vaccine mandate at his work, but his vaccine card doesn’t match his work name. What should he do?

Because of vaccine mandates, the vaccine card is no longer just a health document, but is now a required employment document. We recommend that the clinician issue a second card with the alias name. If possible, the clinician is encouraged to include the alias (“AKA”) in the state’s vaccine database if possible, so that both cards hold information that is verifiable in the database that is accessible only to health care providers.


A worker got vaccinated under his name, but uses an alias at work. Because of the new workplace mandate, his workplace had a mandatory vaccine clinic for those who couldn’t show proof of vaccination, so he got vaccinated a second time. What are the health implications of double vaccination?

There are limited data on patients who have received more vaccinations than is recommended.

Initial data from the CDC about people who have received a third dose showed similar or more mild side effects to those of the two-shot series. These side effects include short-term fever, chills, and other flu-like symptoms.


What do I do if a patient has lost the vaccination card?

Patients who say they have already received a vaccine but do not have evidence may need assistance in contacting the location of their vaccination to verify their vaccination status – social workers and outreach workers may be helpful here. If the patient has migrated since they got vaccinated, determine any details the patient remembers – location, time and date, type of vaccination – and contact the vaccination site. Each location has a different process in terms of recording and providing vaccine records to the local health department. Each state has a vaccination registry that contains records of all vaccinations provided in the state. Depending on the location, the patient’s information may already be registered with the state. The CDC’s Immunization Information Systems gives contact information for each state here.

 

 

COVID and Other Health Issues

What does COVID do to the heart? How does that affect patients who have recovered from COVID?

The risk of cardiovascular events after even a mild case of COVID is substantial. After a COVID infection, people have a higher risk of stroke, heart attack, myocarditis, and more. The risk is dependent on the severity of the acute infection; for example, the risk for stroke among non-hospitalized patients after COVID infection was 23% higher, compared to 425% higher among hospitalized patients.

Clinicians are encouraged to share with patients who typically are not at risk of cardiovascular events (like young and otherwise fit patients) the signs and symptoms of common cardiovascular diseases.


Should a patient get a mammogram after getting the COVID-19 vaccine?

It is recommended to wait at least two weeks after the provision of a COVID-19 vaccine before receiving a mammogram or other diagnostic imaging exam. This is because the COVID-19 vaccines may cause swollen lymph nodes, which may be interpreted as cancer in such imaging exams. Read more here. As a precaution, if the patient is not migrating and can delay the imaging exam, clinicians may recommend that the patient wait six to ten weeks after the second COVID-19 dose. If a patient needs to move before that six-to-ten-week period is over, clinicians can enroll the patient in Health Network, and we can assist in guiding the patient in the new health system in their next location to schedule a mammogram or other diagnostic imaging exam.


What special concerns should I be looking for among migrants, immigrants, and refugees?

Frontline clinicians are reporting that some patients, particularly otherwise young and healthy patients, who are very or severely ill with COVID-19 have been found to have uncontrolled and undiagnosed diabetes. Initial studies indicate diabetes is one of the most common comorbidities in people with severe COVID disease. Additionally, those with diabetes are also at higher risk of long COVID.

Diabetes remains a serious health concern among migrant, immigrant, and refugee communities, who lack access to health care and oftentimes struggle to implement and maintain strategies for healthy living. Clinicians who serve these populations are encouraged to increase outreach to these communities and screen patients for diabetes.

Read more about diabetes and access resources on MCN’s Diabetes page. 

 

Basic COVID Questions

A patient who is hesitant about the vaccine asked if there’s a difference in immunity between someone who gained immunity after COVID-19 infection, versus someone who gained immunity from COVID-19 vaccines.

Immunity after vaccination has been well studied and is predictably very high. Immunity after infection varies greatly. The CDC notes that “the level of protection people get from having COVID-19 may vary depending on how mild or severe their illness was, the time since their infection, and their age.” In general, immunity from the vaccine lasts longer than immunity from the illness as far as we have seen so far, but more studies are needed when talking about COVID variants.

If a patient has recovered from COVID-19, that person should not rely on immunity after infection. One CDC study showed that people who had been infected with COVID-19 but did not get immunized after recovery were twice as likely to contract COVID-19 compared to those who were immunized after recovery. This study further points to vaccination as a better way to ensure robust immunity after infection.

The important thing to keep in mind is that those who are unvaccinated remain vulnerable. The newer variants are not necessarily less severe for the unvaccinated. And unfortunately, our vaccination rates are lower in the US than other industrialized countries. Additionally, among those vaccinated, we have a lower percentage of boosted individuals, making some of the vaccinated vulnerable to hospitalizations and death.

While we cannot say conclusively that vaccination is better than natural immunity because of the highly variable and unpredictable level of immunity gained from infection, we can say that vaccination is a guaranteed, safe, and important way of achieving a high level of immunity from COVID-19.


What does “up-to-date" mean? How does it compare to “fully vaccinated”?

The language around COVID continues to shift. In January 2022, the CDC defined these terms:

  • “Up-to-date" means a person has received all recommended COVID-19 vaccines, including any booster dose(s) when eligible.
  • “Fully vaccinated” means a person has received their primary series of COVID-19 vaccines.


What is considered a breakthrough case?

A breakthrough case is a positive COVID-19 case that occurs two weeks or more after the last dose of the COVID-19 vaccine is administered. This case may be symptomatic or asymptomatic. It is important to note that as more people are fully vaccinated, it is natural to expect a rise in the number of fully vaccinated people who are hospitalized – especially those who were already immunocompromised. Breakthrough cases among people who are up to date on their COVID vaccines are more common with Omicron and its variants, due to its very high transmissibility.


How do I respond to my patients’ basic questions about the safety of vaccines?

This critical basic question is very important to answer fully, with respect and patience, and in a culturally competent manner.

It is important to remember that some vulnerable populations who would best benefit from the COVID-19 vaccine are also the populations that have been grossly mistreated historically during vaccine trials or forced into state-sponsored medical procedures without consent.  The racist underpinnings of our public health systems continue to traumatize our patients today.

Some basic points to consider:

  • Since its release, over 77% of the US population – over 256,000,000 people -- including millions of health care workers, leading scientists, politicians, and community leaders, have received the shot themselves. Many of your doctors, nurses, and health care staff, those who work tirelessly to care for you, have taken the shots to protect themselves and in turn their communities, showing another vote of confidence in the safety of the vaccines.
  • Side effects remain very low, while the risk of developing severe disease and death without the protection of the vaccine continues to be high.

Practical Resources from MCN

Other Resources


What do I do if my patient or my patient’s community is encountering misinformation about the vaccine?

Patients are concerned about the safety of the vaccine and much misinformation is circulating around. Help the patient understand the safety of the vaccine and how to deconstruct conflicting or confusing health messages that may be misinformation through our interactive guide, “Deconstructing Health Misinformation”.

Interactive Prezi version: https://prezi.com/view/2zUKL4KGQWaysr1BertD/

Single-page handout version: https://www.migrantclinician.org/toolsource/resource/deconstructing-health-messages-five-key-questions.html


 

 

 

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