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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
 

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 September 26, 2022. Information is evolving 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.

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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

 

The Latest Questions

How do I explain what the bivalent vaccine is to my migrant patients?

The latest booster, the bivalent vaccine, was released without the promotion and outreach that previous COVID vaccines had. As a result, a lot of people are not actively considering the bivalent vaccine, or do not know enough to make a decision. For migrant patients who may struggle to find time to get a vaccine, you can emphasize:

  • The bivalent vaccine will greatly reduce your chances of severe COVID, death, and long COVID through the fall and winter holidays, when there’s a greater chance of COVID cases rising again, as people gather for in-person events inside.
  • This vaccine is a booster that patients can take two months after the primary series or your last booster, or three months after COVID infection.
  • It is safe, effective, and uses the same technology as the initial series of mRNA vaccines.
  • It is conserved “bivalent” because it was designed to work against the original strain of COVID-19 as well as more recent Omicron strains, BA.4 and BA.5.
  • It will likely be the last one provided for free from the federal government (although some states may still provide it for free to those who do not have health insurance).
  • The side effects are very similar to the initial series.
  • There are two available bivalent vaccines. Pfizer is for 12 and up. Moderna is for 18 and up.

Discuss with your patients when you got the bivalent vaccine, and why. Keep in mind that migrants may have very limited access to vaccines; if you are actively working with a patient, help them make an appointment, or provide a warm hand-off to the vaccine clinic.


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 monkeypox vaccination at the same time?

No. The CDC recommends delaying any COVID vaccine four weeks after either monkeypox vaccine. However, the CDC does not presently give a recommendation about timing of a monkeypox vaccine after a COVID vaccine.  One monkeypox vaccine, ACAM2000, has been linked with myocarditis in young males. There is insufficient data to report on myocarditis with the monkeypox 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. If the patient is moving, consider signing the patient up with Health Network to ensure the patient can access vaccination at the next destination.


When’s the best timing to get the bivalent vaccine…

…If you just had the 4th booster?

Wait two months after your last dose, whether that was a booster or the primary series, and then get the bivalent vaccine.

…If you were just infected?

Wait three months after you last tested positive, and then get the bivalent vaccine. If you have never been vaccinated, then you will need to start with the primary series first, and then the bivalent vaccine as a booster.  


Which bivalent vaccine should I get, Pfizer or Moderna?

Both are highly effective and recommended. Moderna is only available to ages 18 and up, so those aged 12 – 17 must take Pfizer.

If you are a male between 18 and 30, and the Pfizer is available, it would be preferred, for the slightly lower risk of myocarditis compared to the Moderna. Of course, contracting COVID-19 increases your risk of myocarditis much more than either vaccine – so don’t delay getting vaccinated.


Will this vaccine cover new variants that are likely to arise?

The bivalent vaccine targets both the ancestral strain of SARS-CoV-2 and the Omicron variants BA.4 and BA.5. This two-pronged approach is why it is called a bi-valent booster. We do not have definitive answers on how well the bivalent vaccine prevents infection from Omicron variants, until human trial data is completed, or we gather information from those who received the vaccine. While it does not specifically target any other Omicron variants, it is expected to give broad protection against future Omicron or SARS-CoV-2 strains that emerge.


How long will this 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 this 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 booster 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.

 

 

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 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. COVID transmission and hospitalization rates differ from state to state and even county to county. 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.
MCN is currently updating its flow-charts in English and Spanish to help clinicians communicate the new process.   
The newest CDC recommendations that remove quarantine requirements may be easier 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 and isolation, the risk of exposure – particularly in work situations with poor ventilation and few workplace protections – may grow. Talk with patients working in high-risk settings about ventilation, masking, and keeping up to date on community spread. (See “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? ”)


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. 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. 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 mask or respirator (like an N95) for 10 days following exposure if they do not test positive. Read more on the CDC’s Isolation and Precautions page. 


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 they can protect their health at work. The infographics and FAQ from WHO focuses 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.

 

 

Prevention

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. In a CDC-led modeling study, COVID vaccination in the US was estimated to prevent 27 million COVID infections, 1.6 million COVID-associated hospitalizations, and 235,000 COVID-associated deaths among vaccinated persons 18 years or older, from December 1, 2020, to September 30, 2021. By September 30, 2021, vaccination prevented an estimated 52% of expected infections, 56% of expected hospitalizations, and 58% of expected deaths.

 

 

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 BA.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 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 “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.)


What do we know about the Omicron subvariants?

As of summer 2022, BA.5 is the primary subvariant of Omicron that is circulating in the US. 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.5 is more contagious than the initial strain of Omicron which surged in January, or its subvariants BA.2 and BA.2.12.1, which caused late spring bumps in infection. Our official case counts are deceptively low. Because of the prevalence of at-home testing, the infection-detection rate – what percentage of COVID cases are reported – is estimated to be just 14% as of June 2022. Many people who became infected with Omicron or its variants earlier in the spring have experienced infection with BA.5. 


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 these strains are 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 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. (At-home testing has led to a gross undercount of cases. It is estimated that just 14% of cases are reported as of June 2022.)

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 COVID. 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.

Third, some assisted living and senior living facilities are not equipped for COVID-positive patients. In some areas, any resident of these facilities who tests positive – even if asymptomatic – is sent to the hospital until that person consistently tests negative, which places a large burden on community hospitals. Further, these facilities are also experiencing staffing shortages as staff test positive for COVID, and consequently are unable to receive hospitalized patients who are ready for discharge. 

 

 

Boosters & Vaccine Options

A community member just got sick with COVID. When should she get her second booster shot?

Getting a second booster is a reliable and effective way to reduce risk of severe disease or death – even if the person has just had COVID. If your community member is eligible for a second booster (ie, 50 years old or older and/or moderately or severely immunocompromised), it is safe for her to get her second booster as soon as she has ended her isolation following CDC guidelines.

It is important to note that COVID infections do not provide a reliable boost in immunity to prevent another infection. Boosters reliably increase a patient’s level of antibodies. As more contagious strains continue to spread, it is important as ever to stay up to date with vaccinations even after an infection. 


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.


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 2022, a second booster (also called the “fourth dose”) is available for patients aged 50+ or those who are immunocompromised. Initial data demonstrate that a second booster rebuilds a person’s immunity against COVID-19 after the first booster's effectivity wanes. In a CDC study, vaccine effectiveness for COVID-associated emergency room encounters during the BA.2 and BA.2.12.1 wave was at just 32% for people who had received the first booster four months before. A fourth booster received in that time frame, however, brought the vaccine effectiveness back to 66% for emergency room encounters. Vaccine effectiveness against hospitalization jumped from 55% four months after the first booster, to 80%, a week after the second booster. 

Farmworker, migrant, and immigrant patients may have trouble accessing vaccines, from finding time to get the vaccine, to traveling to a vaccine site, to taking time off for recovery. Clinicians are encouraged to discuss an individual's risk, the community spread, and 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 immigrant, migrant, and food and farmworker communities to get the booster shot is the highest priority. As of August 2022, only 20.7% of people in low-income nations have received any COVID vaccine. MCN continues to advocate for equal access to the initial series and boosters across the world to begin to ensure pandemic health equity and to effectively slow the pandemic.

 


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 hospitalization and death from COVID-19. 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.5.

Across the 12 states reporting data on boosters, fewer Hispanics overall are opting for the additional shot compared to other ethnicities. As of July 2022, just 15% of booster recipients were Hispanic, according to the CDC – but, critically, Black and Hispanic people made up the larger share of people receiving booster doses, meaning that messages of its importance are getting across.

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 boosted.


 

Who should get a booster dose of a vaccine?

The CDC advises any people ages 5 and up who have already completed their primary series to get a COVID-19 booster shot. The CDC advises a second booster for those ages 50 and up, at minimum four months after the first booster. See the CDC page for specifics on timing for each type of vaccine. Although many people who are up to date on their vaccines and boosters may still contract COVID-19, those who have the booster have the strongest protection against severe disease, hospitalization, and death, across all age groups, and across all COVID variants thus far.

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. Boosters keep that protection high over time.

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 some in the US are already receiving their fourth dose.


How does the booster shot affect vaccine mandates?

Presently, most company 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 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 Care

How sick is “sick enough” to take Paxlovid?   

Anyone who has a positive COVID test and is at high risk for developing severe COVID is eligible to receive a Paxlovid prescription. That means people with underlying conditions like cancer, diabetes, or obesity, or any people over the age of 65. People with more than one underlying condition are at even greater risk of severe COVID. Because all of the groups mentioned are at higher risk, 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 must 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 some of the hardest to reach. 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?

Only one to 2% of people taking Paxlovid in clinical trials tested positive for COVID after having testing negative – but the real number may be higher. There is insufficient data to determine how many people have experienced this COVID “rebound” since Paxlovid’s release, but, anecdotally, many people are reporting a return of symptoms and positive testing after a recovery. 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. 


 

 

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 5 full days after exposure – and she should wear a high-quality mask or 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.


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. 


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.

The World Health Organization regularly updates its guidelines on COVID treatments; see the British Medical Journal for its living document.

Paxlovid (a combination of nirmatrelvir and ritonavir) 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 question above.

The same monoclonal antibody treatments that were used effectively against Delta variant infections are proving less effective against Omicron infection. Various other monoclonal antibody treatments effective against Omicron are being tested presently.

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.


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. 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. 

  • 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 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.)


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 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. 

All non-US citizen, non-US immigrant visitors to the US, including H2-A workers, who received vaccination outside of the US must have completed the primary series of a vaccine approved by either the FDA or the WHO. Visit this CDC website to learn more about air travel. See this CDC page for the updated list of FDA- and WHO-approved vaccines that the CDC accepts.

“Fully vaccinated” presently means more than 14 days after the last dose of a primary series. As of August 2022, 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. 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 an mRNA vaccine to complete the primary series. The CDC also recommends receiving all recommended boosters when eligible. Read more on the CDC page


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

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?

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 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 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.” “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 infection “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?

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 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. See the question, “Do teenage boys who get vaccinated have a higher risk of myocarditis?” for more. 

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:

  • 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.

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


Why is it recommended that adolescent boys have different spacing between mRNA vaccine doses than the general child population?

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.


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

Am I at higher risk of having long-term health problems like stroke or diabetes, if I have had COVID? How do I know?

A growing body of research shows a strong association between COVID infection and new-onset cardiovascular disease and diabetes, but there is much we still don’t know. 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.


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 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.

 

 

Basic COVID Questions

With so many getting sick regardless of whether they’re vaccinated, how do we encourage people to get vaccinated anyway? 

BA.5, the most transmissible variant to date, is now the dominant variant in the US, pushing case numbers ever higher. The August 2022 case average of 100,000 per day is considered a significant undercount as at-home testing has become the norm. Nearly 500 people are dying in the US of COVID every day. It is worth noting that most people who are hospitalized or die from COVID have not been vaccinated. While vaccinated individuals who are exposed may get sick from COVID, most avoid death and hospitalization. According to the New York Times, and based on the most recently available data from the CDC, unvaccinated people are three times more likely to contract COVID-19 and six times more likely to die from COVID. While vaccines are not preventing infections, they are very effective in preventing severe disease, hospitalization, and death.

Average Daily COVID Cases - The New York Times


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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