Migrant Clinicians Network continues to receive questions from our clinical network on COVID-19 and vaccines for migrant, immigrant, and farmworker communities. Here, we offer our newest questions followed by an archive of previous questions.
This FAQ was last revised May 5, 2023. 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 regular updates. Please refer to the CDC for the most up-to-date recommendations.
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The Latest Questions What do we know about the newest Omicron variant, XBB.1.16?
In March almost 90% of COVID cases in the US were from the variant XBB.1.5, but now, in May 2023, that number has dropped to around 69%, with the newer strain XBB.1.16 accounting for almost 12% of cases, according to the CDC . XBB.1.16 has been circulating in India and slowly gaining prominence in the US, but appears very similar to XBB.1.5 in terms of transmissibility and severity. Some things we know:
Both XBB.1.16 and XBB.1.5 are highly transmissible -- the most transmissible of any COVID variants to date. XBB.1.5 has been estimated at 20% more transmissible than the already-highly-transmissible BQ.1, and XBB.1.16 is likely more transmissible than XBB.1.5.
Symptoms are the same as earlier variants, including shortness of breath, fever, sore throat, muscle aches, and cough. The loss of smell is, however, less prevalent.
XBB.1.16 has been reported to be linked to conjunctivitis in children, but the condition, known colloquially as “pink eye,” has been reported with other strains as well.
The bivalent booster is expected to be protective against XBB.1.5 and XBB.1.16 -- more so than previous boosters -- and patients should be highly encouraged to get their bivalent booster.
Early data suggest that XBB.1.5 and XBB.1.16 infections are similar in severity compared to recent variants.
More data are needed, but with less funding and less testing of genotypes, our information of its spread is likely to be less robust.
An older patient wondered whether she should get the second bivalent vaccine now that it’s available. She had her last booster in October. When should she get it?
In April 2023, the CDC approved a “spring booster,” a second dose of the bivalent vaccine. It is available for people over 65 years old, four months after their first dose, or for anyone who is immunocompromised, two months after their first dose. For those who are eligible for the second bivalent vaccine, they should consider their risk factors, and determine their best timing, according to Dr. Katelyn Jetelina. For risk factors, those at highest risk – over 75 years old, over 65 with a comorbidity, or immunocompromised – should consider the spring booster immediately. For timing, if it’s been longer than six months, they should schedule a spring booster right away. Dr. Jetelina breaks down these two factors here .
Few of our patients will have this concern, however, because under 20% of the US population has received the first bivalent vaccine. And, 90% of those in the hospital (whether in the hospital “for” or “with” COVID) have not received the first bivalent vaccine. It is critical that anyone who is eligible receive their first bivalent vaccine gets that shot – it is an important line of defense against severe COVID, long COVID, hospitalization, and death. See MCN’s new colorful and easy-to-understand guide to help patients understand what shots they are eligible for and when, available in English and Spanish: Updates to Bivalent COVID-19 Vaccine Eligibility
I want to talk to a patient about getting their initial COVID vaccines. If they start now, what series would they take?
In April 2023, the CDC simplified its primary series. For an unvaccinated child or adult, one dose of the bivalent vaccine is used instead of the multi-dose vaccine series. See MCN’s new colorful and easy-to-understand guide to help patients understand what shots they are eligible for and when, available in English and Spanish: Updates to Bivalent COVID-19 Vaccine Eligibility
A patient’s workplace requires him to be “up to date” on COVID vaccines. Does that include a bivalent booster?
Yes. The CDC has updated its definition of “up to date” to include one dose of a bivalent vaccine. With under 20% of the US population with a bivalent vaccine, this means most people are no longer considered “up to date” on their vaccines. See this CDC page: When Are You Up to Date?
What should I warn my patients about, considering the end of the COVID emergency declarations?
MCN has several resources geared specifically for migrant and immigrant patients.
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. There is a concerning increase in new-onset cardiovascular events and diabetes after COVID infection that some are categorizing as a form of long COVID. (See “Post-COVID Health Risks.”)
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.” The CDC guidance also emphasizes the higher burden of COVID among people of color in part due to structural racism and social determinants of health, and calls for greater deployment of resources to communities of color who lack sufficient access to services as well as culturally and linguistically appropriate materials. Other guidelines include:
The American Academy of Physical Medicine and Rehabilitation’s initial guidance statements on cardiovascular complications, 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.)
Post-COVID Health Risks A growing body of research shows a strong association between COVID infection and new-onset cardiovascular disease, diabetes, and mental health disorders . As COVID can damage multiple organs, from the lungs to the brain, the long-term impact of acute COVID may vary greatly. See questions below for details on cardiovascular events and diabetes. All clinicians should be aware of these elevated risks. Clinicians must account for diagnosed and undiagnosed COVID infections when taking patients’ recent medical histories.
CHWs are encouraged to share this information along with the signs and symptoms with their communities. The CDC offers information and resources on the signs and symptoms of stroke and diabetes . For those newly diagnosed, MCN’s diabetes comic book in English and Spanish is a useful primer.
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. New research emphasizes that the increased risk wanes; after one year , one study found no increase in diabetes diagnosis compared to the control group.
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. A newer study found that the risk of cardiovascular events declines over time, as is the case with diabetes risk.
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.
Paxlovid & Other COVID Treatment My immunocompromised patient cannot take Paxlovid because of prescription interactions. Now, Evusheld is no longer recommended. Her treatment options feel highly limited. What can she do?
Immunocompromised patients have limited treatment options. All immunocompromised patients should discuss with their provider their best treatment options – before they contract COVID – and regularly check in with their provider as treatment options change. For example, Paxlovid is contraindicated by many classes of drugs, but some patients may be recommended to temporarily pause or reduce concomitant medications rather than avoid Paxlovid entirely. Remdesivir and molnupiravir are two other antiviral therapies that have retained their effectivity against Omicron variants. Other treatments, including monoclonal antibody treatments and combinations including Evusheld, are no longer recommended for treatment because of poor effectivity against Omicron variants. In 2022, the CDC also noted that the recommendation of Evusheld for pre-exposure prophylaxis (PrEP) may change due Omicron variants’ “rapidly increasing” resistance to the drug combination. Consequently, for immunocompromised individuals, prevention is of the highest priority. A high-quality respirator like an N95, physical distance, and ventilation should continue to be emphasized for infection prevention, with recommendations for meeting people out of doors instead of inside, for example. Clinicians are also encouraged to consider the patient’s mental health needs through this long pandemic, where many of the patients have remained isolated and fearful throughout, while friends, family, and neighbors returned more or less to “normal.”
Should I prescribe Paxlovid? Paxlovid, the highly effective treatment against COVID infection, is under prescribed in the US, particularly for the underserved. For example, Hispanic populations were 30% less likely to be prescribed Paxlovid , compared with white populations.
After a careful review of the patient’s prescriptions to avoid negative drug interactions , clinicians should prescribe Paxlovid for those within the first five days of their COVID-19 infection. But many are choosing not to. This is a mistake, particularly for the most at-risk populations.
Migrant and immigrant patients who have poor access to care and vaccines need access to Paxlovid. The CDC notes that “some people from racial and ethnic minority groups are at risk of being disproportionately affected by COVID-19 from many factors, including limited access to vaccines and healthcare. Health care providers can consider these factors when evaluating the risk for severe COVID-19 and use of outpatient therapeutics.”
It is concerning how many patients are reporting that their primary care providers are refusing to prescribe Paxlovid, when its safety and effectivity are well understood. We strongly encourage clinicians to use this lifesaving tool in the outpatient setting, to prevent hospitalizations, severe disease, and long COVID. Please refer to the following questions for patient and provider concerns on Paxlovid.
Paxlovid Concern: “It’s only for high-risk people.”
Paxlovid is not only for high-risk people.
Any outpatient infected with COVID-19 may get Paxlovid if they are:
50 years old or older (a change from previous CDC recommendations), OR
Is not up to date on their vaccinations, OR
With any condition that may complicate an infection – like asthma, cirrhosis of the liver, diabetes, obesity, physical inactivity, smoking, and many others .
For example, anyone over 50, regardless of risk, is eligible. People of any age with a risk factor may not feel they are “high risk” but are still eligible for Paxlovid, if they do not regularly exercise or if they have asthma, for example.
Paxlovid Concern: “I’m not eligible.”
California made headlines when its Public Health Officer recommended that anyone who is symptomatic and wants Paxlovid should seek treatment . That’s because many people have risk factors that they don’t realize – including being physically inactive or overweight; being a current or former smoker; having a mood disorder including depression; and having hypertension or a substance use disorder. These and a list of other risk factors like diabetes, heart disease, and hypertension are listed by the CDC .
Paxlovid Concern: “COVID rebound makes it not worth it.”
A percentage of people who take Paxlovid find that their symptoms improve, but days or even weeks later, symptoms and/or detectable virus return. This percentage may be around 10%, but in one small study , 24% of Paxlovid-takers had symptoms rebound after initial improvement. However – and most critically -- those who rebound do not generally go to the hospital. For anyone whose COVID may progress to life-threatening, Paxlovid is a lifesaver, even with rebound. There is also a small percentage of patients with COVID, who do not take Paxlovid, who experience rebound.
Paxlovid Concern: “The side effects on the kidneys aren’t worth it.”
Many people are reporting that they are unable to get a prescription unless the patient undergoes a kidney screening while positive with COVID and feeling very ill. For patients with known kidney concerns – like kidney disease or who are on dialysis – Paxlovid is not recommended. “Since Paxlovid is cleared by the kidneys, dose adjustments may be required for patients with mild-to-moderate kidney disease,” says a Yale Medicine article . Across the world , farmworkers and other outdoor workers who work in extremely high temperatures have experienced chronic kidney disease and/or acute kidney injury that may lead to chronic kidney disease if persistent. Clinicians serving farmworkers should take an occupational history to uncover any unknown kidney injury. However, for generally healthy patients with no known kidney health concerns or risk factors, a kidney screening is not warranted.
Paxlovid Concern: “I’m vaccinated so I don’t need it.”
A vaccinated individual should consider Paxlovid if the person has any other risk factors. People who were vaccinated several months ago should strongly consider Paxlovid as the antibodies associated with the vaccine may be waning.
Paxlovid Concern: “It’s toxic.”
There is widespread misinformation about the toxicity of Paxlovid. It does not cause any major side effects or death. Minor side effects like changes in taste and the poor or metallic taste of the pills themselves may have propelled these rumors. “But, says Michael Ganio , director of pharmacy practice and quality at the American Society of Health System Pharmacists, ‘a bad taste for five days is a small price to pay for a drug that can save your life.’”
How sick is “sick enough” to take Paxlovid?
It is recommended to take Paxlovid regardless of severity of COVID symptoms. Remember, Paxlovid must be started within the first five days of COVID symptoms, but hospitalization typically occurs a week or more from the onset of symptoms, so Paxlovid treatment should begin before a patient typically feels ill enough to go to the hospital.
If a high-risk patient is pregnant or breastfeeding, the FDA recommends discussing the patient’s specific situation as there are little data on Paxlovid among these populations.
If a high-risk patient is vaccinated, the patient already has a lower chance of becoming hospitalized or dying from COVID. Paxlovid could still reduce the severity of infection and further lower the risk of hospitalization or death.
If a high-risk patient is unvaccinated, it is very important that they pursue Paxlovid treatment when available, as they are the most likely to develop severe COVID or die.
Please note that more than two dozen medications are contraindicated for Paxlovid, and many more must be temporarily withheld to treat with Paxlovid. These medications are for diverse health concerns, and the list includes neuropsychiatric agents, antiarrhythmic agents, lipid-modifying agents, migraine medications, anticonvulsants, and more. Other medications, like pain medications, diabetes medications, and others, may require adjusted dosage. Sometimes blood tests are required to establish that there would be no contraindication related to kidney and liver function. See NIH guidelines for complete lists and recommendations .
What accessibility considerations do we have to make for refugee, immigrant, and migrant communities for Paxlovid? A June 2022 CDC report found that dispensing rates of oral antiviral prescriptions like Paxlovid “were lowest in high vulnerability zip codes, despite these zip codes having the largest number of dispensing sites.” This means that despite efforts to prioritize low-income and harder-to-reach communities to reduce inequities in access, fewer members of those communities are filling the prescriptions, and are consequently at higher risk of hospitalization or death than those who access Paxlovid.
Refugee, immigrant, migrant, and farmworker communities are frequently left out. Increased access to pharmacies where Paxlovid is available is just the beginning, because significant barriers remain -- like lack of health insurance, transportation issues, concerns over loss of work to test, language barriers, and more.
Free and accessible testing – and information on that testing in the community’s languages and available in locations they frequent – are important first steps. Trusted messengers help community members know what to do if they test positive; not just how to isolate, but also how to access Paxlovid and what to expect.
What should I know about Paxlovid rebound? About two to 10% of people taking Paxlovid tested positive for COVID after having testing negative – but the real number may be higher. The CDC noted that, in the case of rebound, symptoms return between two to eight days after the end of Paxlovid treatment. It is presumed that a patient with symptoms and a positive test is contagious, and people experiencing rebound should restart isolation. Clinicians are encouraged to alert people with COVID who take Paxlovid about the possibility of rebound and the steps to take should it occur. Read the CDC’s clinical considerations for Paxlovid rebound here . It is also worth noting that about 30% of those who test positive for COVID and have symptoms also experience returns of symptoms – not just those who received Paxlovid.
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.
Paxlovid remains the most effective treatment option currently available. Paxlovid is now widely available, but some low-income high-priority communities are still not getting prescriptions. See the Paxlovid questions under “COVID Care” above.
Evusheld, a monoclonal antibody treatment that was used effectively against Delta variant infections is no longer authorized for emergency use for treatment of COVID because of its ineffectiveness against Omicron subvariants like XB.1.5.
Convalescent plasma, a promising treatment earlier in the pandemic, is not recommended because of inconsistency in the efficacy.
Ivermectin has been conclusively proven as ineffective in reducing hospitalizations and is not advised for use against COVID.
This “living infographic ” is regularly updated with the WHO guidelines on drugs for COVID-19 and includes recommendations by severity of disease.
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 has circulated 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:
Exposure, Quarantine, and Isolation
The CDC has changed COVID guidelines to focus largely on individuals to manage their own risk. How do I help my community, particularly essential workers, stay safe when many aspects of staying safe are beyond their control?
As the pandemic wore on, the CDC shifted its approach on COVID management and prevention, giving individuals the responsibility to determine their personal level of risk and risk tolerance. COVID transmission and hospitalization rates differ from state to state and even county to county, and fewer data are available. 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 the microCOVID Project , which is available in English, Spanish, and several other languages, and the COVID-19 Risk Calculator from Harvard T.H. Chan School of Public Health .
Additionally, outreach teams can play a role. CHWs can lean on the partnerships they have developed with local businesses over the course of COVID to keep essential workers safe. Businesses can encourage mask wearing on the job by providing signage recommendations and free high-quality respirators like N95s. CHWs can offer resources and guidance on the importance of ventilation, so that employers can provide workplaces that are as safe as possible. See “Improved ventilation is an important way to lessen…” question.
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? In August 2022, the CDC changed its recommendations regarding COVID exposure. The CDC no longer recommends quarantining after exposure to COVID, regardless of vaccination status. Instead, after exposure, the CDC says to wear a high-quality mask for 10 days, and get tested five days after exposure. You can use MCN’s updated flowcharts in English and Spanish to help clinicians communicate what to do after exposure.
Guidelines that do not require quarantining after exposure come as a relief 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. However, with fewer guidelines encouraging quarantine, the risk of exposure grows – particularly in work situations with poor ventilation and few workplace protections. Talk with patients working in high-risk settings about ventilation, high-quality respirators, and keeping up to date on community spread. (See “The CDC has changed COVID guidelines…,” above.)
A community member is on day five of her COVID symptoms and is starting to feel better, but isn’t yet well. What should I recommend? If a patient is no longer symptomatic (or was always asymptomatic) five days after a positive test or after symptoms started, OR, if the patient is getting better and hasn’t had a fever for 24 hours, then that patient can leave isolation with the caveat that they continue to mask for five days, according to the CDC.
Many clinicians and infectious disease researchers are concerned that people who do not test after five days after the start of symptoms may still be shedding the virus, even if they are starting to feel better. Many people are testing positive five, seven, even 14 days after symptoms began.
CDC guidance from August 2022 clarified that those with moderate or severe illness need to isolate through day 10. Those with very severe illness or a weakened immune system are encouraged to consult a health care provider before ending isolation. Also important to note, in the age of Paxlovid rebound: if symptoms return, patients must begin isolation over again, starting with Day 0 being the day the patient tested positive again.
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 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. 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. If they test positive after five days, they should continue isolation and test regularly until they test negative. If they are fully vaccinated, afebrile, and otherwise symptom free, they could return to work while fully masked after those five days.
Should vaccinated patients who have been exposed to COVID-19 get a COVID-19 test if they are not experiencing symptoms? Yes.
If a patient has a known exposure, regardless of vaccination status, the patient does not have to quarantine, but should get tested five days after exposure, even if they do not have symptoms. They should also wear a high-quality respirator (like an N95) for 10 days following exposure if they do not test positive. Read more on the CDC’s Ending Isolation page. This recommendation may not apply to health care providers who are routinely exposed to COVID, unless the patient's exposure is deemed “higher risk” which includes prolonged exposure or lack of proper preventative equipment like respirators. Read more on the CDC’s page on higher-risk COVID exposures for health care providers.
Prevention & Ventilation How many COVID infections and COVID-associated hospitalizations and deaths have been prevented among vaccinated persons by the US COVID-19 vaccination program? Vaccination has saved millions of lives in the US and worldwide. In a modeling study published in The Lancet Infectious Diseases , one team estimated that 19.8 million lives were saved in the first year of vaccines alone. In the US, a Commonwealth Fund modeling study determined that 3.2 million lives were saved in the US, along with 18.5 million hospitalizations prevented, from the arrival of vaccines through November 2022.
Improved ventilation is an important way to lessen the risk of exposure to COVID. How do I help my patients address this component of risk mitigation?
Patient education is an important first step, and clinicians can provide information so patients can protect their health at work. The infographics and FAQ from WHO focus on what individuals can do to improve ventilation in their workplace or other indoor setting and is available in several languages. They also have an engaging multilingual online quiz to test knowledge on ventilation. Improved ventilation can be as simple as opening windows.
This Ventilation Checklist , created by MCN with NRC-RIM and also available in Spanish , covers important concepts like air exchanges per hour, purifier selection, and mitigation strategies outside of purifiers. The CDC has a complete ventilation FAQ on their COVID-19: Ventilation in Buildings page. Outreach workers who have developed relationships with local employers can provide resources and guidance on ventilation, or they can help prepare workers to talk with their employers. Ventilation can prevent illness spread in their work environments, which is a benefit to both employer and employee.
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 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, including XBB.1.5 . 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. Anyone with any of those symptoms should test for COVID-19 and isolate 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 “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?” under Exposure, Quarantine, and Isolation.)
Bivalent Vaccines and Vaccine Timing Very few of my patients are getting the bivalent booster. What can I do?
Here are MCN’s top seven reasons to get boosted right now, to share with patients:
It’s highly effective. The booster is proven to be effective in two ways:
Against severe disease: In contrast to early reports, the bivalent booster is proving highly effective at preventing severe illness from COVID-19. Depending on the timing of previous vaccinations, the effectiveness of the bivalent booster against hospitalization was between 31 and 73% .
Broader protection: The bivalent booster is shown to provide broad coverage against dominant variants like XBB.1.5. and XBB.1.16 .
Your initial vaccination and booster antibodies have dropped. Over time, protection from vaccines wanes. Those who were vaccinated in the summer of 2022 or earlier likely have minimal protection from COVID.
Infection does not guarantee high antibodies. Many people erroneously believe that an infection protects them from future illness – but the amount of antibodies a person produces after an infection is highly variable, whereas vaccination provides a more predictable antibody response. To be protected, vaccination is a must.
Avoid long COVID. While COVID strains in circulation are presently less severe than earlier in the pandemic, and treatments like Paxlovid are highly effective, patients who contract COVID are still at risk of severe illness and long COVID. At least one in five adults who have had COVID have symptoms of long COVID .
Repeat COVID infections increase the risk of death, as well as pulmonary, cardiovascular, hematological, diabetes, gastrointestinal, kidney, mental health, musculoskeletal and neurological disorders – and regardless of vaccination status. Protect those who can’t protect themselves. Immunocompromised people may have fewer COVID treatment options and a higher risk of severe disease. Protect our loved ones, friends, and neighbors through vaccination.
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. 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 a COVID-19 vaccine. 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.
Who should get a bivalent booster dose of a vaccine?
The CDC advises people ages 5 and up who have already completed their primary series to get a COVID-19 bivalent vaccination. See the CDC page for specifics on timing. Those who have received the bivalent vaccine will have the strongest protection against severe disease, hospitalization, and death , across all age groups, and across all COVID variants thus far.
The bivalent vaccine is now used as the primary series, for those who are still unvaccinated. 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 limited access to vaccines, 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 remains highly inequitable, with 29.8% of people vaccinated in low-income countries as of May 2023. In these countries, 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 some in the US are already receiving their fourth dose.
When’s the best timing to get the bivalent vaccine, if the patient was just infected with COVID?
The patient should wait three months after they last tested positive, and then get the bivalent vaccine.
How long will the bivalent vaccine provide protection?
It is unclear how long the bivalent vaccine will provide robust protection against COVID. However, the more people get vaccinated and follow public health behaviors to protect themselves from infection, the fewer opportunities that the virus has to mutate. With fewer mutations – that is, with fewer new resistant variants – the bivalent vaccine could remain effective for longer.
Does the bivalent vaccine protect against long Covid?
Yes, indirectly. While the bivalent vaccine does not specifically protect against long COVID, long COVID occurs more often in people who had severe COVID. This vaccine reduces a person’s risk of severe COVID, which therefore reduces their risk of long COVID. The best way to not get long COVID, of course, is to never get infected with COVID in the first place. The bivalent vaccine reduces a person’s chance of contracting COVID.
Should a migrant patient get the COVID bivalent vaccine and the influenza vaccination at the same time?
Yes. It is safe to get the COVID bivalent vaccine and the flu shot at the same time . Migrant patients who have limited access to health services may have very few opportunities to get vaccinated and it is recommended that they get both as soon as they can. If their work schedules are more flexible and access to services is good, they may wish to split the vaccines up. Some people prefer to get the vaccines on different days, as both shots on the same day may increase side effects like headache, fatigue, fever, and pain at the injection site. Others may wish to time the COVID vaccine to maximize effectiveness over certain events or the holidays. However, clinicians should be careful to ensure that delaying the vaccine will not result in barriers that lead to no vaccine.
Should a migrant patient get the COVID bivalent vaccine and the mpox vaccination at the same time?
No. The CDC recommends delaying any COVID vaccine four weeks after either mpox vaccine. However, the CDC does not presently give a recommendation about timing of an mpox vaccine after a COVID vaccine. One mpox vaccine, ACAM2000, has been linked with myocarditis in young males. There is insufficient data to report on myocarditis with the mpox vaccine, JYNNEOS.
Clinicians should talk with the patient to determine which vaccine would be a priority, based on the patient’s risk of exposure to each infection, and plan accordingly. COVID continues to be deadly for unvaccinated people or those with weakened immune systems. Mpox cases has fallen dramatically since its peak in 2022. If the patient is moving to an area of higher mpox transmission, consider signing the patient up with Health Network to ensure the patient can access vaccination at the next destination.
COVID-19 Testing and Diagnosis A community member was exposed to COVID. She does not feel sick. She took an at-home test. It was negative. Should she test again at home?
Yes. As of August 2022, the FDA recommends a person who was exposed to COVID but does not have symptoms take three tests in total . The first test, per the CDC guidelines, should be taken five full days after exposure – and she should wear a high-quality respirator (like an N95) for 10 days following exposure . The second test, per FDA guidelines, is taken 48 hours after the first negative test. If the second test is also negative, a third test should be taken 48 hours after the second negative test. The recommendation is based on newer research that shows that serial testing improves the accuracy of the result. People with symptoms, however, are not instructed to take three tests – just two, 48 hours apart, should suffice. Of course, if any test has a positive result, the person likely has COVID-19 and should begin isolation immediately in accordance with the CDC guidelines.
An at-home COVID test that a patient recently received has an expiration date of just a few weeks later. Can she still use the test, after its expiration date?
The FDA does not recommend using at-home COVID-19 diagnostic tests beyond their authorized expiration dates because it may provide inaccurate results – but those expiration dates may have changed. As more data have been gathered on the longevity of at-home tests, the FDA has extended some of its expiration dates, meaning that your patient’s test may not be expired after all. The FDA maintains a website where expiration date extensions are listed by manufacturer. Be sure to consult the page before disposing of a test past its expiration date.
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 on COVID-19 Vaccine Requirement for Farmworkers in English and Spanish.
What does an H2-A worker or other immigrant need to enter the US? As of June 2022, all air passengers, regardless of citizenship or vaccination status, are no longer required to show a negative COVID test to enter the US.
As of May 2023, all non-US citizen, non-US immigrant visitors to the US, including H2-A workers, are no longer required to show proof of COVID vaccination to enter the US. 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. Both are not FDA approved, but they are recognized by the CDC. If a patient is partially vaccinated with a non-FDA-approved but CDC-recognized vaccine, then the patient does not have to start the primary series over again. In this case, the CDC recommends one dose of the bivalent vaccine to complete the primary series. Read more on the CDC page .
The Moderna, Pfizer-BioNTech, and Novavax vaccines require two shots. What if a patient is moving? As of April 2023, patients only need one bivalent vaccine to be considered “up to date” including to complete their primary series. Two-dose primary series are no longer recommended. See MCN’s new colorful and easy-to-understand guide to help patients understand what shots they are eligible for and when, available in English and Spanish: Updates to Bivalent COVID-19 Vaccine Eligibility
Pregnant People 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.
Is it safe for a person to get vaccinated during pregnancy, while breastfeeding, or when planning to get pregnant? Hundreds of thousands of women have received the vaccination during pregnancy or while breastfeeding, and repeated studies of these women show no increased risk of pregnancy loss, growth problems, or birth defects. In fact, COVID vaccination during pregnancy was associated with a lower risk of NICU admission and intrauterine fetal death. As a reminder, the COVID-19 vaccines are not live vaccines, and pregnant women and their babies cannot get COVID-19 from the vaccine.
More striking are the data on pregnant people who choose not to get vaccinated. COVID can kill pregnant women or cause a miscarriage, preterm birth, or stillbirths, even in an asymptomatic case. Early in the pandemic, a CDC Morbidity and Mortality Weekly Report showed that 31.5% of women who contracted COVID during pregnancy were hospitalized, compared to just 5.8% of nonpregnant women with COVID.
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 more likely to get very sick from COVID-19 compared those who are not pregnant. Are more likely to need ICU care. Are more likely to need a breathing tube. Are at an increased risk of dying. Are at an increased risk of having a stillbirth or preterm birth. Are at an increased risk of having a baby infected with COVID-19.
It is worth pointing out that COVID can cause 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.” “Over 200,000 pregnant women have been vaccinated against COVID.” 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 A community member’s four-year-old son recovered from COVID two weeks ago. Should he get vaccinated now, or wait?
In August 2022, the CDC updated its recommendations for vaccination after COVID infection. People who have recently recovered from a COVID vaccine “may consider delaying a primary series dose or their first or second COVID-19 vaccine booster dose by three months from symptom onset or positive test.” Newer studies indicate an improved immune response with the three-month delay. However, certain factors like severe COVID and community spread must be considered as well. (See the CDC for more on those factors.) For migrant and immigrant patients, it must also be determined whether a person, like this four-year-old, will have easy access to the vaccine in the preferred timeframe. In this case, the CHW or health care provider who is working with the parents can make a concrete plan including an appointment for the child to get vaccinated. If the family is migrating before the ideal vaccination window, the clinician can sign the family up with Health Network, or adjust the vaccination date to meet the needs of the family.
Make sure, however, that the family understands how important vaccination is, even if it is delayed. 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, to ensure he has the highest level of protection from re-infection.
Which is better, the Moderna or Pfizer vaccine for children under five?
Since June 2022, both the Moderna and Pfizer vaccines have been 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 two years, and now have an excellent record of safety for young children who have received the vaccine since its summer 2022 release.
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.
Research is beginning to indicate that real-world efficacy of these vaccines for this age group is on par with other age groups. Data indicate that during the Omicron wave of 2022, estimated Moderna vaccine efficacy was 36.8% among those aged two to five, and 50.6% for those aged six to 23 months, a response which was deemed “noninferior to that observed in young adults.”
Children six months through four years old who received Pfizer’s three-dose primary series are not eligible for a booster; the third dose is Pfizer’s bivalent vaccine. For children six months to five years old, Moderna’s two-dose primary series can be followed by Moderna’s bivalent vaccine as a booster. (Older children who received either vaccine for the primary series are eligible for the bivalent vaccine.)
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 may occur.
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.
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 very low risk of myocarditis.
As new variants develop, the risk for children may grow. For example, although XBB.1.5 is less severe than previous variants, it is highly contagious, and the number of children infected may become 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:
Greater Than's excellent videos feature pediatricians and doctors answering FAQs on children and COVID-19. Available in English and Spanish .
MCN's colorful trifold on Children & COVID-19 is customizable and available in English and Spanish .
Many of the parents in my community seem hesitant about the under-five 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
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
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 is something that may have benefit, but for which they have lingering questions or concerns, which encourages them to put off the decision to vaccinate. 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 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.
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 changed 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 .
Basic COVID Questions With so many getting sick regardless of whether they’re vaccinated, how do we encourage people to get vaccinated anyway? XBB.1.5, which continues to be the dominant variant in the US, continues to infect people across the nation. Approximately 1,100 people die each week of COVID in the US alone. It is worth noting that most people who are hospitalized or die from COVID are not up to date on their vaccines. While vaccinated individuals who are exposed may get sick from COVID, most avoid death and hospitalization. According to the New York Times , unvaccinated people are currently three times more likely to contract COVID-19 and four times more likely to die from COVID, as of May 2023.
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.
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.
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 80% of the US population – over 265,600,000 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.htm l
