Farmworkers and COVID-19: FAQ

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Farmworkers harvesting blueberries

Migrant Clinicians Network has been hard at work fielding clinician requests for guidance as the COVID-19 pandemic, and the anxiety it produces, stretch into even very rural communities. To reduce obstacles to participation for those in the fields or at home, we headed to Facebook Live over our typical online platforms. Last week, MCN’s Laszlo Madaras, MD, MPH, Chief Medical Officer, and Amy K.Liebman, MPA, Director of Environmental and Occupational Health, used Facebook Live for an hour-long talk on farmworker health during the coronavirus pandemic. The talk was hosted by the Association of Farmworker Opportunity Programs [3] (AFOP) and Childrens in the Field Campaign. Watch the recorded conversation here [4]. This week, MCN’s Ed Zuroweste, MD, joined Liebman for another Facebook Live webinar sponsored by MCN, followed by a Spanish language one hosted by MCN’s Alma Galván, MHC, Senior Program Manager of Environmental & Occupational Health and Eva Galvez, MD, from MCN’s Board of Directors. View the archived webinars on our Facebook page [5], or on our Archived Webinars page [6]. Follow us on Facebook, subscribe to our mailing list [7], and subscribe to our blog [8] to hear about new resources and support.

Jump to a topic:
Concerns Around Farmworker Health and COVID-19
Clinical Questions: Sharing The Basics, Dispelling Rumors
Documentation and Services
Outreach Services: Recommendations and Best Practices for CHWs and Outreach Workers
Recommendations for Growers

Major Takeaways

There is much about this virus that we don’t yet know conclusively. As you read the answers to these FAQs, we ask you to keep in mind the following:

Recommendations are changing every day. As new data are gathered and research is carried out, our understanding of COVID-19, how it works, and how it spreads is refined. Necessarily, our recommendations must adjust. Please continue to review recommendations from the CDC and adjust strategies accordingly.
Always presume that the virus is present. Asymptomatic individuals may be unwittingly spreading the virus, and our understanding of its spread remains limited. In the absence of extensive testing and given our early understanding of the disease, take full precautions as if COVID-19 is present.

Concerns around Farmworkers and COVID-19

We know that even in times when we are not facing this unprecedented crisis, our farmworker community is vulnerable. Farmworkers are considered “essential workers” because of their key contribution to our food production systems. Consequently, many farmworkers continue to work despite shelter-in-place and other orders that are keeping people home. Others are losing their jobs or are on reduced hour schedules as economic pressures influence farm employment. We are concerned about:

Lack of health insurance/inability to become insured;
Lack of access to health care;
Lack of childcare;
Lack of adequate education and nutrition programs when schools close;
Lost work and lost wages and the serious consequences that can follow, including inability to pay for basics like food, rent, and utilities, and the results of that inability, including hunger, eviction, and/or lack of basic services;
Lack of unemployment compensation;
Lack of paid sick leave;
For those with paid sick leave, pressure from employers or from the reality of poverty to continue to work despite illness;
Unsanitary, crowded housing and the risk of losing housing due to job loss;
Impacts of the broken immigration system and lack of immigration status for a majority of farmworkers;
Threats of immigration enforcement, either real or perceived;
Uncertainty regarding the H-2A agricultural guestworker program and the closing of US consulates’ visa processing;
Lack of access to accurate, timely information in appropriate languages;
Stress and anxiety, and lack of mental health resources.

Given these (and many additional unlisted) overlapping concerns and pressures, it is very difficult for farmworkers to heed the recommendations to prevent the spread. Clinicians, including outreach workers and community health workers, are tasked to remove as many barriers as possible to support workers to be able to continue their work and stay healthy. Growers also have a responsibility to extend labor practices, health policies, and housing protocols. This FAQ is built to equip you with information and strategies to do just that, to the best of our abilities at this very difficult and unprecedented moment in time.

Clinical Questions: Sharing The Basics, Dispelling Rumors

Outreach workers and farmworker advocates are reporting that misperceptions on the spread of COVID-19 are present in farmworker communities. Here are some answers from Dr. Laszlo Madaras and Dr. Ed Zuroweste from MCN on the basics for outreach workers and community health workers, to have some background when talking with farmworkers and others in the community.

What is COVID-19?
COVID-19 is a virus in the family of corona viruses, as are SARS and MERS. It is spreading faster and affecting many more people than previous viruses. There are many types of viruses out there such as influenza (the flu) and the common cold. What makes this different is that it is a novel virus, that is a new as yet unknown virus and our immune system does not yet know how to counter this one. There is no vaccine and there is no cure at this time.

Why should we be concerned about COVID-19?
COVID-19 is much more deadly than the flu. Early estimates, that may change as they are continuously strengthened as more data arrive, point to COVID-19 being 10 to 40 times more deadly than the flu. The flu kills about one to two persons per 1,000 infected. COVID-19 now appears to have a mortality rate of a minimum of 1 per 100 and, in some countries, much higher. Presently, the mortality rate is roughly 4.5 percent worldwide. While the numbers are constantly shifting and gaining accuracy, we will not know for many weeks exactly how deadly COVID-19 is. Given the data that we have so far, it is clearly evident that COVID-19 is a dangerous and deadly virus.

While roughly 80 percent of infected people recover without any need for medical care, 15 to 20 percent of those infected need to be hospitalized. Of those, 10 to 25 percent end up in the ICU. It was reported earlier that 80 percent of the deaths were in individuals over the age of 65, most with pre-existing conditions such as diabetes, hypertension, COPD or an immunocompromised condition. More recent evidence indicates that younger adults are also being severely affected and many are winding up on ventilators in the intensive care unit.

How does COVID-19 spread?
It is spread person-to-person through contact such as common activities like shaking hands. It can get into your system if, after shaking hands, you touch your mouth or nose or rub your eyes. To the best of our knowledge, it does not travel through the air for more than six feet.

How can we reduce the spread of COVID-19?

Wash your hands with soap and water for at least 20 seconds.
Use hand sanitizer with at 60 percent alcohol, if soap and water are not available.
Social distance – Maintain at least six feet between people.
Use sneezing and coughing etiquette – sneeze/cough into the crick of your elbow or into a tissue that you immediately dispose of. (And then repeat step one -- wash your hands!)
Clean surfaces regularly - the CDC recommends bleach and water to disinfect surfaces.

What should we be concerned about in rural communities?
COVID-19 spreads the same way regardless of the type of community. Here are some concerns about rural areas.

The elderly (60 and over) and those with pre-existing conditions [9] -- diabetes, hypertension, COPD -- are more at risk. One of the issues in rural areas is that there are proportionately more elderly individuals (19 percent in rural areas, versus 15 percent in urban areas) and higher rates of diabetes, high blood pressure, and obesity.
There are also proportionately more smokers in rural areas and smoking is another risk factor with this virus.
Health care may be harder to access due to the geographic distance, absence of health insurance, and rural characteristics.
Many rural hospitals are smaller in terms of beds including ICU beds, which fill up quickly in an epidemic. They may be understaffed and rapidly exhaust and overwhelm even the best trained staff.

What should be done if a farmworker is sick?
If a worker starts having symptoms of COVID-19 such as fever, cough, or shortness of breath, follow the CDC’s guidelines [10]. These include:

Contact your local health officials for guidance.
Have the worker stop working immediately and isolate the person from other workers. People with these symptoms should not be working.
If they have these symptoms, house them in the area designated for sick people and arrange for them to see a medical provider. Call the medical provider in advance so health care workers can take appropriate precautionary measures.
Workers should take a private vehicle to get to the medical provider. If they do not have their own vehicle, please assist with transportation following CDC guidelines [11] to protect the worker in the vehicle and others, including the following:
- Notify the transporter and the receiving health care facility that the person has signs and symptoms suggestive of COVID-19 so that appropriate infection control precautions may be taken.
- Provide the sick person with a disposable facemask, if available, and keep them separated from others as much as possible.
- Use ventilation in the vehicle by opening car windows or using the ventilation system on non-recirculated mode.
- Do not use public transportation, ridesharing, or taxis to transport the ill person.

Make sure they have enough food and water as they will not be able to go to the store and may not have any funds to buy their own.
Monitor for worsening symptoms. About 20 percent of infected people will need hospitalization.

If a worker is diagnosed with COVID-19:

Notify your local health department for instructions about isolation.
Instruct workers who had close contact with the COVID-19 patient to self-monitor for symptoms of COVID-19 (fever and onset of respiratory symptoms such as cough or shortness of breath) for 14 days. These exposed workers should be separated from non-exposed workers for 14 days (e.g., sleep in a separate room, work in a separate area).
If they develop symptoms of COVID-19, contact your local health department.
No infected or exposed farmworker should be allowed or forced to return home prior to being cleared by a health care provider for travel.

Will migrant clinics have access to COVID-19 testing?
It depends. This is a rapidly changing scenario. Some of it will depend on how fast we can get test kits to our rural communities. Some community health centers are actively engaged in testing. However, each state and community is different and it is important for employers to fully understand what is available to them and their workers. Contact your local community health center for more information: https://www.findahealthcenter.hrsa.gov/ [12].

What other assistance/services are migrant clinics providing farmworkers during this time? Community health centers are built with farmworkers in mind. They can provide all primary care services to farmworkers and their families. They are more likely to have expertise in terms of being able to do outreach to the community and provide services in a linguistically and culturally appropriate way, which is highly needed during this pandemic.

Can the COVID-19 virus be spread to produce?
Currently there is no evidence of food or food packaging being associated with transmission of COVID-19. Like other viruses, it is possible that COVID-19 can survive on surfaces or objects for hours and possibly even days. For that reason, practice safe hygiene including regular hand washing and disinfection of surfaces. Peel produce that can be peeled, wash produce that cannot be peeled, at least until we have more data. Read more at the USDA site [13].

Documentation and Services

Many farmworkers without authorization to live and/or work in the US are ineligible for unemployment and other social services to help them when they lose their jobs. Many additional barriers, including those outlined in the opening paragraphs of this FAQ, further distance farmworkers from access to services.

Is care for COVID-19 considered under the new public charge rule?
The USCIS provided a statement [14] that says, “USCIS encourages all those, including aliens, with symptoms that resemble Coronavirus Disease 2019 (COVID-19) (fever, cough, shortness of breath) to seek necessary medical treatment or preventive services. Such treatment or preventive services will not negatively affect any alien as part of a future Public Charge analysis.”

Will seeking health services expose people without authorization to ICE?
Immigration and Customs Enforcement (ICE) has stated it will “not carry out enforcement operations at or near health care facilities, such as hospitals, doctors' offices, accredited health clinics, and emergent or urgent care facilities, except in the most extraordinary of circumstances.” The statement also says that “Individuals should not avoid seeking medical care because they fear civil immigration enforcement.”

What resources are available for agricultural workers and others with questions around health access and documentation?

Visit Protecting Immigrant Families' Immigrant Eligibility for Public Programs During COVID-19 [15].

The California Rural Legal Assistance Foundation has an excellent and regularly updated COVID-19 resource page [16] that is largely applicable to people outside of California as well, and covers questions about postponed court dates, access to health, and more.

Several law advocates are working to provide information on Medicaid, emergency scenarios, and COVID-19 in different states. Read the National Law Health Program’s overview [17] to learn more.

In Sonoma County, California, UndocuFund [18] is one model for communities to support their local farmworkers without authorization, in times of disaster.

Outreach Services: Recommendations and Best Practices for CHWs and Outreach Workers

How do we keep CHWs and outreach workers safe when visiting farmworker or other communities?
Even before this pandemic, agricultural worker communities were largely isolated, due to poverty, language and cultural differences, fear and anxiety over immigration status, and other barriers. Community health workers (CHWs), promotores de salud, and outreach workers are critical links to connect agricultural workers to the health education and services that they need. Now, more than ever, those services are needed. We encourage health centers to continue and even expand community outreach services, with safety precautions in place. Here are some suggestions to keep CHWs and outreach workers safe.

Conduct phone calls, instead of face-to-face visits, to keep contact with residents if possible.
Limit in-the-field work to COVID-19 education and preparation (and telehealth support if applicable). Suspend non-essential trainings or events.
When traveling to sites, follow the CDC’s recommendations for transportation: keep windows open when possible; increase ventilation; regularly disinfect surfaces.
Do not reduce protections or precautions after leaving the health center. When in the community, take all precautions provided by the CDC in their Interim Guidance for Businesses and Employers to Plan and Respond to Coronavirus Disease 2019 (COVID-19)
Provide services outside, not inside, the mobile unit, to allow for better ventilation.
When setting up tables, provide marks on the ground to indicate the six-foot separation necessary for people waiting in line. Remember to clean surfaces and wash hands frequently before and after any direct interactions with any of the clients.
If working with anyone who has been exposed to COVID-19, follow the CDC’s Interim Guidance for Public Health Personnel Evaluating Persons Under Investigation (PUIs) and Asymptomatic Close Contacts of Confirmed Cases at Their Home or Non-Home Residential Settings.

Can outreach workers assist in telehealth appointments?
Many rural communities lack the infrastructure or connection to be able to conduct telehealth appointments. Outreach workers can assist in telehealth. An example of an existing mobile outreach unit’s integration of telehealth can be found in this issue of Streamline (See “Navigating the Telehealth Waters” [19]).

Read the CMS’s guidance on telehealth, and this CMS fact sheet, which include information on a federal waiver to allow for more telehealth services to be covered under Medicaid. Find resources related to telehealth in your state by visiting the National Consortium of Telehealth Resource Center’s nationwide map.Read the CMS’s guidance on telehealth [20], and this CMS fact sheet [20], which include information on a federal waiver to allow for more telehealth services to be covered under Medicaid. Find resources related to telehealth in your state by visiting the National Consortium of Telehealth Resource Center’s nationwide map.
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What are some recommended patient-facing materials that CHWs and outreach workers can use with farmworkers?
We are monitoring resources as they are developed, and we are developing additional resources to fill holes. Here are some simple, low-literacy and Spanish-language resources that may be of use: br>
CDC’s Printed Materials [22]
PAHO/WHO Communication Materials [23]
COVID-19 Materiales de consulta [24] from the Mexican government

Migrant Clinicians Network will continue to post recommended resources for vulnerable populations like migrant farmworkers on our blog [8] and on our COVID-19 webpage [25].

Recommendations for Growers

It is in growers’ best interest to maintain the health of our farmworker population. If we can succeed at reducing viral transmission following recommendations, we will be helping not only farmworkers, but our greater community. The products that farmworkers bring from the fields are not optional. We need the food they produce.

There is substantial potential for agricultural commodity loss (including fresh produce, milk, and processed foods) if workers are not available to work as a result of COVID-19. Due to the suspension of services within US consulates in Mexico, there is also concern that the H2-A program will be suspended or continue to be limited. Therefore it is in the best interest of growers and producers to take all of the necessary steps to prevent the spread of illness.

What do growers need to do to support their workforce?
Growers and employers have a very important role in keeping farmworkers healthy and safe in fields, barns, and packing houses, as well as while in transit and in farmworker housing. Growers should follow the CDC’s interim guidance for employers [10].

Growers must be willing to advance their employment policies to include the following:

1) Paid sick leave. Workers must not feel pressure to work when they are sick. The CDC recommends [10] that all workplaces “implement flexible sick leave and supportive policies and practices.” Farms are no exception.

2) Access to health care. Workers must be provided transportation and resources to seek health care. Open communication and collaboration with the local health center and other local organizations can link growers to programs specifically designed to meet farmworkers’ health needs.

3) Promotion of these policies and wellness protocols with the workers, as is recommended by the CDC. It is not enough to have policies in place if the workers do know about them or do not understand them. Provide low-literacy materials and workplace trainings in the language of the workers.

In order for farms to stay in business, and to ensure that our communities have food for our meals, farmworker health must be rapidly prioritized so they can do their jobs. While these recommendations may appear extreme or unattainable given standard practice previous to this pandemic, they are presently public health priorities that are desperately needed to fight the spread of this virus and to protect our food systems.

What precautions can be made at work?
Basic training on hygiene measures must be provided in the language of the workers, preferably low-literacy.

Hand washing: See PAHO’s infographics on handwashing [23] and the CDC’s hand washing video in Spanish [26]. (Although released previous to the COVID-19 pandemic, the video provides correct handwashing guidance and information on why to wash hands in Spanish).
Social distancing: See the Mexican Government’s social distancing page [27]; and
Isolation of the sick. See the CDC’s What To Do When You Get Sick [28]. Also, see below, “What precautions can be made in farmworker housing?”

The CDC’s Cómo protegerse [29] site in Spanish provides overall guidance and resources.

Of course, measures need to be implemented to allow farmworkers to practice strict hygiene. Hand washing stations must be provided and regularly cleaned; farm work must be coordinated to allow for six-foot distances between farmworkers; protocol for sick workers must be put into place and followed. Again, the CDC’s interim guidelines for employers [10] delineate recommended protocols.

What precautions can be made in farmworker housing?
Housing is one of the more challenging concerns and, given the structure of our system, is very hard to address. However, it is not impossible. We can learn from the TB community that has been addressing an airborne illness that is dispersed by droplets for a long time. We can also lean on the CDC’s recommendations for homeless shelters.

Resources to carry out protective hygiene measures must be made immediately available.

Workers must be provided with soap and a place to wash their hands regularly.
Sleeping arrangements must be made so that workers are at least six feet apart.
Surfaces in farmworker housing need to be regularly disinfected.
Make plans, including partnerships in the community and with local health care establishments, as early as possible, before the virus reaches your community. See the CDC’s “Interim guidance for homeless service providers to plan and respond to coronavirus disease 2019 (COVID-19) [30]” for more on creating plans for communal housing residents in the case of illness.

What if a farmworker who lives in farmworker housing becomes sick?
If a farmworker becomes sick, growers who provide housing have a responsibility to provide a safe and isolated space for the farmworker to recover. Follow CDC recommendations, “Disinfecting Your Facility if Someone is Sick [31].” The CDC requests that overnight facilities like farmworker housing use the following resources:

Follow CDC’s guidance for colleges and universities [32]. Work with state and local health officials to determine the best way to isolate people who are sick and if temporary housing is needed.
For guidance on cleaning and disinfecting a sick person’s bedroom/bathroom, review CDC’s guidance on disinfecting your home if someone is sick [33].

What precautions can be made for farmworkers in transit?
Transportation, like housing, is another very challenging issue. Workers are often transported in crowded vans and buses. When traveling to sites, follow the CDC’s recommendations [34] for transportation: keep windows open when possible; increase ventilation; regularly disinfect surfaces.

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