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

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Migrant Clinicians Network continues to receive questions from our clinical network on COVID-19 and vaccines for migrant, immigrant, and farmworker communities. While vaccines are available for all in the US, ages 5 and up, in reality, COVID-19 vaccines remain less accessible for many people, for a variety of reasons, including fear over immigration status, misinformation, lack of information in a preferred language, and lack of vaccination infrastructure. The dynamic situation does not belie the underlying mantra: everybody deserves a chance to get vaccinated against COVID-19. Vaccination is critical and efforts need to continue to make it fully accessible, with culturally appropriate education and conversation available in the language of the patient to answer their questions and build trust.

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

This FAQ was last revised April 6, 2022. Information is changing rapidly. Remember that our understanding of COVID, its variants, and the effectiveness of the vaccines over time continues to develop as we receive more data, and, consequently, recommendations may change. Please continue to check back here for updates and from other trusted sources like the CDC. Please refer to the CDC for the most up-to-date recommendations.

The Latest Questions

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

As of March 30, 2022, a second booster is available for patients aged 50+. More data are needed, but initial data demonstrate that a second booster rebuilds a person’s immunity against COVID-19 after the first booster's effectivity wanes. The first booster of an mRNA vaccine’s effectiveness [3] against emergency room visits drops from 87% in the first two months after vaccination to 66% in the fourth month after vaccination. A second booster lifts the vaccine effectiveness again to reduce the risk of hospitalization.

The US is not yet in the throes of an Omicron BA.2 wave as Europe has been for several weeks, and some patients wish to delay their second booster until hospitalizations rise again. However, farmworker patients may have trouble accessing vaccines, from finding time to get the vaccine, to traveling to a vaccine site, to time off for recovery. Clinicians are encouraged to discuss an individual's risk, the community spread, and, particularly for food and farmworkers, access to care over time to determine when a patient should receive a second booster.

It's important to note that receipt of the first booster is critical to reduce the risk of hospitalization and death. People of color, including Latinxs, are lagging far behind in getting their initial booster. At this time, encouraging food and farmworker communities to get the booster shot is the highest priority. As of April 1, 2022, only 14.5% of people in low-income nations have received any COVID vaccine [4]. MCN continues to advocate for equal access to the initial series and booster across the world to begin to ensure pandemic health equity and to effectively slow the pandemic.

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. 

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

It is unknown, as studies with overlapping COVID vaccinations are limited, but based on studies of other vaccines, the health risks are likely very low. Immigrants who have been vaccinated with a vaccine that is not on the list of approved foreign vaccines are encouraged to get vaccinated again with an approved vaccine. It is important to wait at least 28 days after vaccination to start a new series. Side effects may be stronger as antibodies may have already built up in one’s system. Read NCFH's resource for more, in English [5] and Spanish [6].

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

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

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

In addition to local dashboards to help people understand local transmission, there are many risk calculators out there. Two calculators to try are: https://www.microcovid.org/ [7]  and https://covid-19.forhealth.org/covid-19-transmission-calculator/ [8] .

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

The risk of cardiovascular events [9] after even a mild case of COVID is substantial. After a COVID infection, people have a higher risk of stroke, heart attack, myocarditis, and more. The risk is dependent on the severity of the acute infection; for example, the risk for stroke among non-hospitalized patients after COVID infection was 23% higher, compared to 425% higher among hospitalized patients.

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

Exposure, Quarantine, and Isolation

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

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

Resources in Spanish: He dado positivo a COVID-19. ¿Y ahora qué? [10]

Resources in English: Testing Positive for COVID-19. Now what? [11]

Resources in Haitian Creole: Mwen te teste pozitiv pou COVID-19. Kounya Kisa? [12]

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

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

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

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

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

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

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

Yes.

If a vaccinated patient has a known exposure, the patient does not have to quarantine, but should get tested five to seven days after exposure, even if they do not have symptoms. They should also wear a mask for 14 days following exposure. Read more on the CDC’s Quarantine [13] page. 

Variants

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

Early data suggest that loss of taste and smell – the markers of COVID-19 infection for many – is less common [14] with the Omicron variant. Additionally, because Omicron doesn’t infect the lungs as easily as previous variants, some people are being hospitalized without severe breathing problems, a change from earlier waves in the pandemic. However, this does not mean that Omicron is not sending people to the hospital. Many people are very ill with Omicron and most have symptoms similar to the flu and to earlier variants including but not limited to: fever, chills, cough, shortness of breath, fatigue, muscle aches, nausea, and vomiting. Anyone with any of those symptoms should test for COVID-19 and quarantine until results are conclusive. If a patient tests positive for COVID-19 or has symptoms, isolate for at least five days, according to the CDC [15]. (See “What are the current recommendations relating to isolation if a patient contracts COVID?” under Isolation and Quarantine.)

What do we know about the Omicron sub-variant, BA.2?

At the end of 2021, Omicron slightly mutated into a sub-variant called BA.2.  On January 26, 2022, the first Omicron BA.2 case was discovered in the US. A person with BA.2 will still test positive with a PCR test; the clinician will not be able to tell it’s BA.2 without further genetic sequencing.

BA.2 appears slightly more transmissible than the initial strain of Omicron (BA.1), which was already significantly more transmissible than earlier variants like Delta. BA.2 does not appear to be more severe than BA.1. As BA.2 spreads across Europe and Asia, and as it grabs a foothold in the US, we will have more data on this sub-variant.

I have read that Omicron is less severe than previous waves. Why are the hospitals so full?

There are two primary reasons that Omicron has severely strained hospitals. First, because Omicron is incredibly contagious, more people overall are getting infected. So, with Omicron, a smaller percentage of cases will advance to severe disease compared to other variants. However, there are so many people who have contracted Omicron that that small percentage ends up being a very large number of people. So, even though it may be a little milder than earlier variants, because there’s such a large number of people infected, there’s still a high number of people who need to be admitted to the hospital and take up beds that are needed for patients with other life-threatening illness. 

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

Boosters

What are the changes to Pfizer booster recommendations?

The CDC updated their Pfizer booster recommendations in early January 2022:

• For all patients, the Pfizer booster is recommended five months after the second dose, instead of the previous recommendation of six.
• Children ages 5 to 11 who are immunocompromised are advised to get the Pfizer booster shot 28 days after the second dose.

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

Encourage the patient to get the booster – it’s the strongest defense we have against contraction of disease, hospitalization, or death from COVID-19. Please stress that many hospitals around the country are strained or overwhelmed with COVID-19 cases from both Delta and Omicron. We have strong evidence that the COVID-19 vaccine booster increases immunity for patients and protects them against COVID variants.

Across the 12 states reporting data on boosters, fewer Hispanics overall are opting for the additional shot compared to other ethnicities. As of April 2022, in California, just 41% of fully vaccinated Hispanic people [16] have received the booster, compared to 60% of vaccinated white people, 50% of vaccinated Black people, and 65% of vaccinated Asian people.

This booster disparity is particularly concerning, given the April 5, 2022 drop-off in funding for vaccination of uninsured people. In Europe and Asia, where Omicron BA.2 has led to massive spikes in cases, data demonstrate the importance of the booster to reduce the risk of hospitalization and death from the Omicron subvariant BA.2. The concurrent drop-off in mandates for masking increases the risk of exposure. Without funding for boosters for the uninsured, the disparities may continue to grow, and many will be left at greater risk of infection.

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

Who should get a booster dose of a vaccine?

The CDC actively advises all vaccinated adults age 18 and up to get a COVID-19 booster shot. Children ages 12 to 17 and immunocompromised children ages 5 to 11 are also eligible for a booster. See the CDC page [7] for specifics on timing for each type of vaccine. Those who have received booster shots have reduced odds of contracting COVID-19 [17], which indicates that the boosters are working to increase immunity after a period of waning immunity after initial vaccination.

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

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

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

Worldwide vaccine access is highly inequitable. Outside of the US, many frontline providers still lack access to a first dose, leaving them at high risk for infection. Additionally, oxygen supplies are hard to secure and/or transport throughout the Global South, leaving those with severe disease without access to a lifesaving intervention. Efforts like www.peoplesvaccine.org [18] are working to address this ongoing health injustice by pushing for better worldwide access to first doses while we in the US begin the path to third doses.

How does the booster shot affect vaccine mandates?

Presently, most vaccine mandates do not include language around booster shots, meaning to be "fully vaccinated" means completion of the initial vaccination series (either one dose for J&J or two doses for Pfizer or Moderna). Individual companies and government entities with vaccine mandates may choose to require a booster shot if they desire. See OSHA’s website [19] for more including example signage for employers. MCN strongly encourages everyone to stay up to date with their COVID vaccinations, regardless of vaccine mandates. 

COVID Diagnosis and Care

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

Early data suggest that loss of taste and smell – the markers of COVID-19 infection for many – is less common [20] with the Omicron variant. Additionally, because Omicron doesn’t infect the lungs as easily as previous variants, some people are being hospitalized without severe breathing problems, a change from earlier waves in the pandemic. However, this does not mean that Omicron is not sending people to the hospital. Many people have become very ill with Omicron and most have symptoms similar to the flu and to earlier variants including but not limited to: fever, chills, cough, shortness of breath, fatigue, muscle aches, nausea, and vomiting. Omicron BA.2 appears similar in severity to Omicron [21] (although it is more infectious). 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 [22]. (See “What are the current recommendations relating to isolation if a patient contracts COVID?” under Exposure, Quarantine, and Isolation.)

What options are currently recommended for treating COVID?

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

In late 2021, the FDA approved two antiviral pills to be delivered at the onset of COVID symptoms. These pills are rolling out in limited quantities.

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

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

Ivermectin has been conclusively proven as ineffective [23] 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 [24].
• The NIH reported on each of the completed studies, their findings, and their limitations, on their COVID-19 Treatment Guidelines page [25]. 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.
• Remind patients how science works: that if well-conducted clinical trials show any indication that a drug works against COVID-19, that will be headline news. Such trials would be followed by additional studies to confirm its effectiveness and study side effects. In this way, scientists gather sufficient data to make sure a drug is both effective and safe for use. Unfortunately, at present, the clinical trials that have been completed [26] have significant limitations, and most do not show positive benefits of Ivermectin. Consequently, we continue to lack sufficient data to show that Ivermectin works against COVID-19 and cannot recommend it.

More Resources:

• FDA’s Why You Should Not Use Ivermectin to Treat or Prevent COVID-19 [27]
• AMA, APhA, ASHP Call for Immediate End to Prescribing, Dispensing, and Use of Ivermectin [28] to Prevent or Treat COVID-19 Outside Clinical Trials

Migration, Immigration, and International Travel/Vaccination

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

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

All non-US citizen, non-US immigrant visitors to the US, including H2-A workers, must be vaccinated with a US-approved vaccine. The current list of US-approved vaccines for entry into the US are: Johnson & Johnson, Pfizer-BioNTech, Moderna, AstraZeneca, Covaxin, Covishield, BIBP/Sinopharm, and Sinovac.  Visit this CDC website to learn more [29].

“Fully vaccinated” presently means more than 2 weeks after the last dose. As of December 6, 2021, a booster shot is not required to be considered “fully vaccinated” but that may change over time. Refer to the CDC website for any updates [29].

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

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

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

For migrant women between the ages of 18 and 60, and if Pfizer or Moderna are available, MCN recommends that the patient begin the Pfizer or Moderna two-shot series. (Learn more about why MCN recommends this here [30].)

For migrant women over the age of 60 and migrant men of any age, MCN recommends the administration of one dose of J&J if available.

Read the CDC’s recommendations here [31].

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 [32]

Learn more about Health Network enrollment here: www.migrantclinician.org/services/network/enrollment-in-health-network [33]

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

Considering that the flu didn’t circulate much last year, should I still recommend a flu shot?  

Yes. All patients aged six months and older are encouraged to get the flu vaccine. It is very important that community members are given culturally competent information on how and why to get it. 

As hospitals and intensive care units continue to be filled with COVID-19 patients, it becomes urgently important that community members are protected as much as possible from the flu to reduce the likelihood of overwhelmed hospital systems.

This lifesaving vaccine can protect those like young children and the elderly who die every year from influenza. It is worth noting that, with children back to school and many people back at work, our day-to-day situation is quite different than during last year’s flu season. The pandemic is not a good reason to skip the flu shot.

Pregnant People

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

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

With this data, the CDC has strongly recommended vaccination for pregnant women as of August 2021.

Resources:

• Pregnancy and the COVID-19 Vaccine [14]: MCN's customizable handout, available in English and Spanish.
• Pregnant? Get Vaccinated Immediately, Says the CDC with New Data in Hand [34], from the MCN blog, in English and Spanish.
• Characteristics and Outcomes of Women With COVID-19 Giving Birth [35], a study at US Academic Centers During the COVID-19 Pandemic.

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

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

People who get COVID-19 during pregnancy:

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

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

When encountering resistance from pregnant people:

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

Children

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

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

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

Finally, make sure families are having open conversations with their child care or preschool to understand what is being done to control infection in those settings. Most guidance for mitigating COVID-19 has centered on school-age children. This has left a gap for those operating child care centers or preschools for children under five. The CDC has a page for Early Childhood Education & Child Care Programs [36]. The Children’s Hospital of Philadelphia [37] has an in-depth guide as well.

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

In February 2022, the CDC updated its interim clinical considerations [38] to change the recommended interval between the first and second dose of mRNA vaccines for people 12 years and older.  Under the new guidance, the recommended interval between Pfizer doses is three to eight weeks. For Moderna, the recommended interval is four to eight weeks.

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

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

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

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

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

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

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

• Vaccines reduce community spread: Asymptomatic and symptomatic children with COVID-19 carry high quantities of the disease, independent of disease severity, according to a recent study [39]. Children who are up to date with their COVID vaccines have a lower risk of becoming infected. The best way to reduce community spread – to protect those among us who likely will get very ill with COVID, if they get infected – is to vaccinate our children.
• Some children do get very ill: It is accurate to say that the risk of serious disease among children is low. However, presently, COVID-19 is estimated to be the sixth-largest killer of children in the US [40].  The risk is low, but many children are still going to the hospital and dying, more so since the Delta variant has become dominant.
  • At least 8,300 children have been hospitalized and 791 have died from COVID-19.
  • At least 5,200 have been diagnosed with MIS-C [41] after COVID-19 infection.
  • Black, Native American, and Hispanic children were three times more likely to be hospitalized from COVID-19 [42] than their white peers.
• The benefits greatly outweigh the very low risks of vaccination: Millions of children ages 12 – 17 have received the COVID-19 vaccine across the world.  Many children experience side effects – pain at injection site, fever, headache. There is a low risk of myocarditis. (See next question.)
• As new variants develop, the risk for children may grow. For example, although Omicron is less severe than previous variants, it is highly contagious, and the number of children infected was very high. Consequently, more children ended up in the hospital. A future variant may be more effective at infecting children. The best way to prevent illness and to stop future variants from forming is to maximize the number of people who are vaccinated, including children.

Resources:

• Greater Than's excellent videos feature pediatricians and doctors answering FAQs on children and COVID-19. Available in English [43] and Spanish [44]. 
• MCN's colorful trifold on Children & COVID-19 is customizable and available in English [45] and Spanish [46]. 
• HRSA’s Action Checklist for COVID-19 Vaccinations for Children Ages 5-11 [47]

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 [48]. 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 [49] 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 [50]. 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 now 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 [51] 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 [52].

COVID and Other Health Issues

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

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

A patient came in and we weren’t sure if she had COVID or the flu, so we ordered a complete viral panel. She had both COVID and the flu. Is this common?

We have insufficient evidence to determine how widespread this problem is. However, Omicron appears to be presenting similarly to the flu; the loss of smell and taste are presenting less frequently than with Delta. Consequently, more clinicians are ordering viral panels and discovering co-infections. Influenza is circulating throughout the country, and clinics and hospitals may need to consider a third isolation area for patients with COVID and influenza, to ensure that patients with COVID aren’t exposed to the flu, and vice versa.

Considering that the flu didn’t circulate much last year, should I still recommend a flu shot?

Yes. All patients aged six months and older are encouraged to get the flu vaccine. It is very important that community members are given culturally competent information on how and why to get it.

As hospitals and intensive care units continue to be filled with COVID-19 patients, it becomes urgently important that community members are protected as much as possible from the flu to reduce the likelihood of overwhelmed hospital systems.

This lifesaving vaccine can protect those like young children and the elderly who die every year from influenza. It is worth noting that, with children back to school and many people back at work, our day-to-day situation is quite different than during last year’s flu season. The pandemic is not a good reason to skip the flu shot.

What is different about the flu vaccine this year? What about COVID and the flu?

The CDC’s new guidance for the flu shot highlights some changes. Clinicians are encouraged to review the CDC's guidance [4] in its entirety. All patients aged 6 months and older are encouraged to get the flu vaccine.

For those who have COVID-19: At present, there are no data to inform optimal timing of influenza vaccination for vaccine effectiveness in persons with COVID-19 or who are recovering from COVID-19, according to the CDC [53]. Patients without contraindications or allergies are encouraged to get both the COVID-19 and flu vaccines as soon as possible to protect themselves, their families, and their communities.

For those who wish to get the COVID-19 vaccine and the flu vaccine: It is safe to administer a COVID-19 vaccine and a flu shot on the same day. Migrant patients and others who have reduced access to health care and limited time to put toward recovery are particularly encouraged to receive the flu and COVID-19 vaccinations at the same time.

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

Frontline clinicians are reporting that some patients, particularly otherwise young and healthy patients, who are very or severely ill with COVID-19 have been found to have uncontrolled and undiagnosed diabetes. Initial studies indicate diabetes is one of the most common comorbidities [9] in people with severe COVID disease. Additionally, those with diabetes are also at higher risk of long COVID [54].

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

Read more about diabetes and access resources on MCN’s Diabetes [55] page. 

Basic COVID Questions

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

Immunity after vaccination has been well studied and is predictably very high. Immunity after infection varies greatly. The CDC notes [56] 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 [57] 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, 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 64% of the US population – over 214,000,000 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

• #YoMeLaPuse campaign to encourage vaccination with this short multigenerational video [58] and customizable and downloadable posters [59].
• “Vaccination is… [60]” campaign features numerous customizable materials for print-out and social media, in English, Spanish, and Haitian Creole. Created in partnership with the National Resource Center for Refugees, Immigrants, and Migrants (NRC-RIM) [61] with IDEO.org.
• What to Expect When Getting the COVID-19 Vaccine [62] is a colorful and customizable low-literacy flyer/poster, in English, Spanish, and Haitian Creole. An accompanying video guides users on how to customize it.
• Public service announcements in English and Spanish:
• • PSA in English: COVID-19 Vaccine: Dr. Eva Galvez, a physician serving migrant and immigrant communities [63]
  • PSA in Spanish: La Vacuna del COVID-19: Dra. Eva Galvez, una doctora sirviendo a las comunidades migrantes [64]
  • Interview in English: Interview: COVID-19 Vaccine: Dr. Eva Galvez, a physician serving migrant and immigrant communities [65]
  • Interview in Spanish: Entrevista: Vacuna del COVID-19: Dra. Eva Galvez, una doctora sirviendo a las comunidades migrantes [66]
• MCN's checklist helps outreach teams in safely planning in-person events, which may be helpful when planning vaccination events:
• • Checklist in Spanish: Safely Conducting “Touchless” Outreach Events During COVID-19 to Bring Services to Refugee, Immigrant, and Migrant Populations [67]
  • Checklist in English: Safely Conducting “Touchless” Outreach Events During COVID-19 to Bring Services to Refugee, Immigrant, and Migrant Populations [68]

Other Resources

• CDC’s Answering Patients’ Questions [69]
• FDA's fact sheets on the Pfizer and Moderna vaccines [70] have been translated into numerous languages. They include information on side effects.
• WHO's The Different Types of COVID-19 Vaccines [71], one of a multipart series on COVID-19 vaccines and all with accessible drawings, is available in English, Spanish, and other languages, for a more in-depth look at how the vaccines were developed.

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/ [72]

Single-page handout version: https://www.migrantclinician.org/toolsource/resource/deconstructing-health-messages-five-key-questions.html [73]

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