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

What should I know about Novovax?

• Not mRNA: Novovax is the only non-mRNA vaccine on the US market. This may be helpful for people who continue to be skeptical of mRNA vaccines due to misinformation or a perceived lack of data. 
• Two doses for unvaccinated people: Novovax is available for people aged 12 years and old and requires two doses, eight weeks apart (as opposed to the one-dose updated mRNA vaccines from Pfizer and Moderna) for those who haven’t had any other COVID-19 vaccine. Those who were previously vaccinated receive one dose.
• Still has a minor risk of myocarditis: The very small risk of myocarditis from mRNA vaccines has been mostly eliminated (see the question, “Do teenage boys who get vaccinated have a higher risk of myocarditis?” in the Children section, below) with the updated schedules. Novovax also carries a small risk of myocarditis.
• Other side effects in line with other vaccines: Pain and tenderness as the injection site, fatigue, fever, and other side effects were reported. 

Does Paxlovid reduce the risk of long COVID?

Studies are mixed on whether Paxlovid reduces the risk of long COVID. A March 2023 study of 282,000 people found that Paxlovid reduced the risk of long COVID by 26% in older adults and those with medical conditions, but a January 2024 study of a more diverse group of about 4700 people did not find any effect on long COVID. Long COVID is more common among people who are hospitalized with severe COVID. Paxlovid is effective at reducing the severity of COVID. Consequently, while the data are still mixed, it is recommended to prescribe Paxlovid to reduce the severity of COVID with the possibility of also reducing the risk of long COVID.  

What do we know about the latest subvariants that are spreading?

As of January 2024, the Omicron subvariant, JN.1 comprised over 61% of COVID cases tested in the US. HV.1 was responsible for another 15%; six other subvariants accounted for more than 1% of cases, according to the CDC.

A further mutation of the Omicron subvariant BA.2.86 (“Pirola”), JN.1 is highly transmissible and has many mutations that help it evade immunity.

Early data, however, show it’s similar in terms of transmission, symptoms and, severity to other recently circulating subvariants.

The new updated COVID vaccine is effective against severe disease from this variant as well as a lower risk of long COVID and we continue to recommend vaccination as a critical component to avoid severe illness and death. More data are needed, but with less funding and less testing of genotypes, our information of its spread will be less robust than earlier in the pandemic. 

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?

The first test, per the CDC guidelines, should be taken five full days after exposure – and she should wear a high-quality respirator (like an N95) when around others at home and indoors in public for 10 days following exposure. If she develops symptoms at any time during the 10 days, she should isolate and test again. If her results are still negative, she can end isolation but should continue masking until day 10. She can also consult CDC's COVID Calculator. Her health care provider may encourage her to test more, which is what the FDA recommends, in contrast to the CDC. Because of the expense of COVID at-home tests, many people in underserved communities may wish to reduce the number of tests they must take, in which case the CDC recommendations outlined above are recommended.

We recognize that the CDC’s approach – ten days of masking – is not in standard practice currently. Masking with a high-quality respirator like an N95 is a simple way to reduce exposing other people to this highly transmissible disease. Normalizing mask wearing to reduce the spread of respiratory illness may be difficult among people with “mask fatigue” after years of masking, but this effort supports public health, is inexpensive compared to testing, and minimally disruptive to the lives of our patients.

What does COVID do to the brain and nerves?

There is growing evidence that COVID causes neuroinflammation-induced injury, or brain inflammation that can cause symptoms of long COVID like brain fog and cognitive impairment. Several studies have found that the COVID proteins remain in the central nervous system long after the initial infection. You can learn more about the studies and the mechanisms and processes here. Read more about COVID’s link to diabetes, heart conditions, and mental health disorders in the Long COVID and Post-COVID Health Risks section, below.

How do I avoid long COVID?

The best way to protect yourself from long COVID is to get vaccinated. Growing evidence points to vaccination as the key method to protect one’s self from the post-exertional malaise, brain fog, and other debilitating symptoms of long COVID that affect roughly 7% of the entire population in the US.

Do we have an agreed-upon definition of long COVID?

Many definitions exist, but in May 2023 the Journal of the American Medical Association narrowed the definition to the 12 most common symptoms associated with long COVID, which they call by its clinical name, post-acute sequelae of SARS-CoV-2 infection:

• post-exertional malaise (or significant fatigue after a physical or mental activity)
• fatigue
• brain fog
• dizziness
• gastrointestinal symptoms
• heart palpitations
• issues with sexual desire or capacity
• loss of smell or taste
• thirst
• chronic cough
• chest pain
• abnormal movements

Is metformin a treatment for long COVID?

A study from June 2023 showed that metformin, a common diabetes medication, reduced incidence of long COVID by 41%. The study was randomized, quadruple-blind, and placebo-controlled. Over 1000 participants were followed for up to 300 days after acute infection. By day 300, 6.3% of participants who received metformin had at some point experienced long COVID compared to 10.4% who did not receive metformin, even after adjusting for factors like vaccination status, and the impact was seen regardless of which strain of COVID the participant contracted.

While the study is compelling, this off-label usage merits further research. Off-label medication use should always be discussed with a primary care physician.

There were a few limitations, including that the study excluded participants with healthy BMIs or who were under 30 years old, limiting the study to those who had a higher risk of developing long COVID. More research is needed to confirm that these findings would be replicated among healthy weight and younger adults. This study pertains only to incidence of long COVID related to metformin usage. There is insufficient data to demonstrate metformin’s utility as a treatment for COVID. It would be beneficial to repeat the study among a larger cohort as well. The Osterholm Update episode 133 reviews the study and covers the limitations in more depth.

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. US-wide rules on COVID and federal workers’ compensation was updated in January 2023. 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 although it can be categorized as a disability under the ADA which would require workplaces to provide reasonable work modifications.

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 and other post-COVID conditions?

Because COVID can affect organs throughout the body, long COVID symptoms vary widely, and consequently treatments must as well. Fatigue, brain fog, and post-exertional malaise are common long COVID symptoms, but other conditions increase in risk after COVID, beyond long COVID, for example: 1) increased risk of blood clots in legs (DVT), brain (CVA or stroke), and lungs (PE); 2) increased incidence of new-onset cardiovascular events; and 3) increased incidence of new-onset diabetes. (See additional questions below on specific post-COVID conditions.)

• The CDC provides guidance on building a comprehensive rehabilitation plan tailored for each patient. Under that guidance, follow-up visits might be considered every two to three months, with “frequency adjusted up or down depending on the patient’s condition and illness progression.” The CDC guidance also emphasizes the higher burden of COVID among people of color in part due to structural racism and social determinants of health and calls for greater deployment of resources to communities of color who lack sufficient access to services as well as culturally and linguistically appropriate materials.
• Other guidelines include:
  • The American Academy of Physical Medicine and Rehabilitation’s initial guidance statements on neurological symptoms, cognitive symptoms, autonomic dysfunction, cardiovascular complications, fatigue, breathing discomfort, , and a pediatrics guide.
     
  • 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 “What does COVID do to the heart?” for more.)

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, diabetes, and mental health disorders. As COVID can damage multiple organs, from the lungs to the brain, the long-term impact of acute COVID may vary greatly. See questions below for details on cardiovascular events and diabetes. All clinicians should be aware of these elevated risks. Clinicians must account for diagnosed and undiagnosed COVID infections when taking patients’ recent medical histories. 

CHWs are encouraged to share this information along with the signs and symptoms with their communities. The CDC offers information and resources on the signs and symptoms of stroke and diabetes. For those newly diagnosed, MCN’s diabetes comic book in English and Spanish is a useful primer. 

What are the connections between diabetes and COVID?

Research shows 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 who contract COVID 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. 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 2022 study found that the risk of cardiovascular events declines over time, as is the case with diabetes risk. Additionally, individuals with long COVID have a more than doubled likelihood of developing cardiovascular issues.

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.

My immunocompromised patient cannot take Paxlovid because of prescription interactions. Evusheld is no longer recommended. Her treatment options feel highly limited. What can she do?

Immunocompromised patients have limited treatment options. All immunocompromised patients should discuss with their provider their best treatment options – before they contract COVID – and regularly check in with their provider as treatment options change. For example, Paxlovid is contraindicated by many classes of drugs, but some patients may be recommended to temporarily pause or reduce concomitant medications rather than avoid Paxlovid entirely. Remdesivir and Molnupiravir are two other antiviral therapies that have retained their effectivity against Omicron variants. Prior to using molnupiravir, the possibility of pregnancy should be ruled out. Monoclonal antibody treatments and combinations including Evusheld, are no longer recommended for treatment because of poor effectivity against Omicron variants. In 2022, the CDC also noted that the recommendation of Evusheld for pre-exposure prophylaxis (PrEP) may change due to Omicron variants’ “rapidly increasing” resistance to the drug combination, and it is no longer a reliable pre-exposure choice due to the emerging Omicron variants. The CDC has not presently made changes to this recommendation.  

Consequently, for immunocompromised individuals, prevention is of the highest priority. A high-quality respirator like an N95, physical distance, and ventilation should continue to be emphasized for infection prevention, with recommendations for meeting people out of doors instead of inside, for example. Clinicians are also encouraged to consider the patient’s mental health needs through this long pandemic, where many of the patients have remained isolated and fearful throughout, while friends, family, and neighbors returned more or less to “normal.”

Should I prescribe Paxlovid?

Paxlovid, the highly effective treatment against COVID infection, is under-prescribed in the US, particularly for the underserved. For example, Hispanic populations were 30% less likely to be prescribed Paxlovid, compared with white populations. 

After a careful review of the patient’s prescriptions to avoid negative drug interactions, clinicians should prescribe Paxlovid for those within the first five days of their COVID-19 infection. But many are choosing not to. This is a mistake, particularly for the most at-risk populations.

Migrant and immigrant patients who have poor access to care and vaccines need access to Paxlovid. The CDC notes that “some people from racial and ethnic minority groups are at risk of being disproportionately affected by COVID-19 from many factors, including limited access to vaccines and healthcare. Health care providers can consider these factors when evaluating the risk for severe COVID-19 and use of outpatient therapeutics.”

It is concerning how many patients are reporting that their primary care providers are refusing to prescribe Paxlovid, when its safety and effectivity are well understood. We strongly encourage clinicians to use this lifesaving tool in the outpatient setting, to prevent hospitalizations, severe disease, and long COVID. Please refer to the following questions for patient and provider concerns on Paxlovid.
 

Paxlovid Concern: “It’s only for high-risk people.”

Paxlovid is not only for high-risk people.

Any outpatient infected with COVID-19 may get Paxlovid if they are:

• 50 years old or older (a change from previous CDC recommendations), OR
• Is not up to date on their vaccinations, OR
• With any condition that may complicate an infection – like asthma, cirrhosis of the liver, diabetes, obesity, physical inactivity, smoking, and many others.

For example, anyone over 50, regardless of risk, is eligible. People of any age with a risk factor may not feel they are “high risk” but are still eligible for Paxlovid, if they do not regularly exercise or if they have asthma, for example.
 

Paxlovid Concern: “I’m not eligible.”

California made headlines when its Public Health Officer recommended that anyone who is symptomatic and wants Paxlovid should seek treatment. That’s because many people have risk factors that they don’t realize – including being physically inactive or overweight; being a current or former smoker; having a mood disorder including depression; and having hypertension or a substance use disorder. These and a list of other risk factors like diabetes, heart disease, and hypertension are listed by the CDC.
 

Paxlovid Concern: “COVID rebound makes it not worth it.”

A percentage of people who take Paxlovid find that their symptoms improve, but days or even weeks later, symptoms and/or detectable virus return. A recent FDA analysis found that the percentage of people who took Paxlovid and experienced COVID rebound mirrored that of people with COVID infection who did not take Paxlovid, meaning that rebound is a common progression of the virus. Most critically, those who take Paxlovid and experience rebound do not generally go to the hospital. For anyone whose COVID may progress to life-threatening, Paxlovid is a lifesaver, even with rebound.
 

Paxlovid Concern: “The side effects on the kidneys aren’t worth it.”

Many people are reporting that they are unable to get a prescription unless the patient undergoes a kidney screening while positive with COVID and feeling very ill. For patients with known kidney concerns – like kidney disease or who are on dialysis – Paxlovid is not recommended. “Since Paxlovid is cleared by the kidneys, dose adjustments may be required for patients with mild-to-moderate kidney disease,” says a Yale Medicine article. Across the world, farmworkers and other outdoor workers who work in extremely high temperatures have experienced chronic kidney disease and/or acute kidney injury that may lead to chronic kidney disease if persistent. Clinicians serving farmworkers should take an occupational history to uncover any unknown kidney injury. However, for generally healthy patients with no known kidney health concerns or risk factors, a kidney screening is not warranted. 
 

Paxlovid Concern: “I’m vaccinated so I don’t need it.”

A vaccinated individual should consider Paxlovid if the person has any other risk factors. People who were vaccinated several months ago should strongly consider Paxlovid as the antibodies associated with the vaccine may be waning.
 

Paxlovid Concern: “It’s toxic.” 

There is widespread misinformation about the toxicity of Paxlovid. The FDA approved Paxlovid in May 2023 for full use, bringing it out of the Emergency Use Authorization, after studies showed “substantial evidence of effectiveness and a demonstration of safety for the drug’s intended use.” It does not cause any major side effects or death. Minor side effects like changes in taste and the poor or metallic taste of the pills themselves may have propelled these rumors. “But, says Michael Ganio, director of pharmacy practice and quality at the American Society of Health System Pharmacists, ‘a bad taste for five days is a small price to pay for a drug that can save your life.’”

How sick is “sick enough” to take Paxlovid?

For people with risk factors who are positive with COVID, it is recommended to take Paxlovid regardless of severity of COVID symptoms. Remember, Paxlovid must be started within the first five to seven days of COVID symptoms, but hospitalization typically occurs a week or more from the onset of symptoms, so Paxlovid treatment should begin before a patient typically feels ill enough to go to the hospital.

If a high-risk patient is pregnant or breastfeeding, the FDA recommends discussing the patient’s specific situation as there are little data on Paxlovid among these populations.

If a high-risk patient is vaccinated, the patient already has a lower chance of becoming hospitalized or dying from COVID. Paxlovid could still reduce the severity of infection and further lower the risk of hospitalization or death.

If a high-risk patient is unvaccinated, it is very important that they pursue Paxlovid treatment when available, as they are the most likely to develop severe COVID or die.

Please note that more than two dozen medications are contraindicated for Paxlovid, and many more must be temporarily withheld to treat with Paxlovid. These medications are for diverse health concerns, and the list includes neuropsychiatric agents, antiarrhythmic agents, lipid-modifying agents, migraine medications, anticonvulsants, and more. Other medications, like pain medications, diabetes medications, and others, may require adjusted dosage. Sometimes blood tests are required to establish that there would be no contraindication related to kidney and liver function. See NIH guidelines for complete lists and recommendations.

What accessibility considerations do we have to make for refugee, immigrant, and migrant communities for Paxlovid?

A June 2022 CDC report found that dispensing rates of oral antiviral prescriptions like Paxlovid “were lowest in high vulnerability zip codes, despite these zip codes having the largest number of dispensing sites.” This means that despite efforts to prioritize low-income and marginalized communities to reduce inequities in access, fewer members of those communities are taking Paxlovid, and are consequently at higher risk of hospitalization or death than those who access Paxlovid.

Refugee, immigrant, migrant, and farmworker communities are frequently left out. Increased access to pharmacies where Paxlovid is available is just the beginning, because significant barriers remain -- like lack of health insurance, transportation issues, concerns over loss of work to test, language barriers, and more.

Community Health Workers can be key in sharing information on Paxlovid. 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?

A percentage of people taking Paxlovid tested positive for COVID after having testing negative – but the real number may be higher. COVID rebound occurs among those who take Paxlovid and those who don’t – meaning, it’s a feature of the virus progression and may not be related to Paxlovid. The CDC noted that, in the case of rebound, symptoms return between three to seven days after the end of Paxlovid treatment. It is presumed that a patient with symptoms and a positive test is contagious, and people experiencing rebound should restart isolation. Clinicians are encouraged to alert people with COVID who take Paxlovid about the possibility of rebound and the steps to take should it occur. Read NIH’s treatment guidelines for Paxlovid here.

What options are currently recommended for treating COVID?

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

Paxlovid remains the most effective treatment option currently available. Paxlovid is now widely available, but some low-income high-priority communities are still not getting prescriptions. See the Paxlovid questions under “Paxlovid and Other COVID Treatments” above.

Evusheld, a monoclonal antibody treatment that was used effectively against Delta variant infections is no longer authorized for emergency use for treatment of COVID because of its ineffectiveness against Omicron subvariants.

Convalescent plasma, a promising treatment earlier in the pandemic, is not recommended because of inconsistency in the efficacy except in extreme cases. 

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

This “living infographic” is regularly updated with the WHO guidelines on drugs for COVID-19 and includes recommendations by severity of disease.

The Administration for Strategic Preparedness and Response (ASPR) regularly updates this page: COVID-19 Therapeutics: Resources for Health Care Professionals and Public Health Officials

NIH also includes information on other “miscellaneous drugs” that have been evaluated as treatments for COVID-19.

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

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

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

More Resources:

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

It’s four years into the pandemic, and people are still confused on what they should do if they feel sick and worry that it’s COVID. Can you reiterate what I should be sharing?

Clinicians, particularly CHWs working in communities, are encouraged to share the basics on COVID testing and isolation, as preventative education, before people get sick. Please note that these are updated recommendations and our resources have been updated to reflect the new recommendations.

• If a patient was exposed to COVID, use MCN’s print-out, in English, Spanish, and Haitian Creole: I Was Exposed to COVID-19. Now What?
  • Wear a respirator for 10 days when among people, even if the patient does not have symptoms.
     
  • Test with an at-home test, five days after exposure to make sure the patient is negative
     
  • Keep wearing that mask for a total of 10 days!
     
• If a patient has COVID symptoms, take two at-home tests, 48 hours apart.
   
• If a patient tests positive, isolate!
   
• The CDC’s COVID Calculator can help patients determine their next steps.

How are isolation and return-to-work different for health care workers versus the general population?  

There are some slight differences between return-to-work for health care workers versus the general population. For the general population, “return to work” criteria is in practice the same criteria for ending isolation. Once a person ends isolation, they may return to their work. States or counties may have additional recommendations.

Anyone testing positive for COVID should:

• Wear a high-quality mask until at least day 11, unless you have 2 negative tests 48 hours apart.
• Avoid immunocompromised people, elderly people, or those with chronic health conditions who may have higher risk of severe COVID, until at least day 11. 

The CDC has changed COVID guidelines to focus largely on individuals to manage their own risk. How do I help my community, particularly essential workers, stay safe when many aspects of staying safe are beyond their control?

As the pandemic wore on, the CDC shifted its approach on COVID management and prevention, giving individuals the responsibility to determine their personal level of risk and risk tolerance. COVID transmission and hospitalization rates differ from state to state and even county to county, and fewer data are available. Clinicians are encouraged to share with patients how to determine their own risk:

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

In addition to local dashboards to help people understand local transmission, there are many risk calculators out there. Two calculators to try are the microCOVID Project, which is available in English, Spanish, and several other languages, and the COVID-19 Risk Calculator from Harvard T.H. Chan School of Public Health.

Additionally, outreach teams can play a role. CHWs can lean on the partnerships they have developed with local businesses over the course of COVID to keep essential workers safe. During times of increased community spread, businesses can encourage mask wearing on the job by providing signage recommendations and free high-quality respirators like N95s. CHWs can offer resources and guidance on the importance of ventilation, so that employers can provide workplaces that are as safe as possible. See “Improved ventilation is an important way to lessen…” question.

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

In August 2022, the CDC changed its recommendations regarding COVID exposure. The CDC no longer recommends quarantining after exposure to COVID, regardless of vaccination status. Instead, after exposure, the CDC says to wear a high-quality mask for 10 days and get tested five days after exposure. You can use  MCN’s updated flowcharts in English and Spanish to help clinicians communicate what to do after exposure. 

Guidelines that do not require quarantining after exposure come as a relief for migrant and immigrant patients, who may have housing situations that make quarantine difficult, or may have informal work situations that make time off to quarantine or to get tested very difficult. However, with fewer guidelines encouraging quarantine, the risk of exposure grows – particularly in work situations with poor ventilation and few workplace protections. Talk with patients working in high-risk settings about ventilation, high-quality respirators, and keeping up to date on community spread. (See “The CDC has changed COVID guidelines…,” above.)

A community member is on day five of her COVID symptoms and is starting to feel better, but isn’t yet well. What should I recommend?

If a patient is no longer symptomatic (or was always asymptomatic) five days after a positive test or after symptoms started, OR, if the patient is getting better and hasn’t had a fever for 24 hours, then that patient can leave isolation with the caveat that they continue to mask for five days, according to the CDC. 

Many clinicians and infectious disease researchers are concerned that people who do not test after five days after the start of symptoms may still be shedding the virus, even if they are starting to feel better. Many people are testing positive five, seven, even 14 days after symptoms began.

CDC guidance from August 2022 clarified that those with moderate or severe illness need to isolate through day 10. Those with very severe illness or a weakened immune system are encouraged to consult a health care provider before ending isolation. Also important to note: if symptoms return, patients must begin isolation over again, starting with Day 0 being the day the patient tested positive again.

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

In short, patients should be encouraged to test after five days, although it should be clarified that it is not required – and health care advocates should do their part to make sure that such testing is quick, convenient, and free. If they test positive after five days, they should continue isolation and test regularly until they test negative. If they are fully vaccinated, afebrile, and otherwise symptom free, they could return to work while fully masked after those five days.

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

Yes.

If a patient has a known exposure, regardless of vaccination status, the patient does not have to quarantine, but should get tested five days after exposure, even if they do not have symptoms. They should also wear a high-quality respirator (like an N95) for 10 days following exposure even if they do not test positive. Read more on the CDC’s Ending Isolation page. This recommendation may not apply to health care providers who are routinely exposed to COVID, unless the patient's exposure is deemed “higher risk” which includes prolonged exposure or lack of proper preventative equipment like respirators. Read more on the CDC’s page on higher-risk COVID exposures for health care providers. 

Improved ventilation is an important way to lessen the risk of exposure to COVID. How do I help my patients address this component of risk mitigation?

Patient education is an important first step, and clinicians can provide information so patients can protect their health at work. The infographics and FAQ from WHO focus on what individuals can do to improve ventilation in their workplace or other indoor setting and is available in several languages. They also have an engaging multilingual online quiz to test knowledge on ventilation. Improved ventilation can be as simple as opening windows. 

This Ventilation Checklist, created by MCN with NRC-RIM and also available in Spanish, covers important concepts like air exchanges per hour, purifier selection, and mitigation strategies outside of purifiers. The CDC has a complete ventilation FAQ on their COVID-19: Ventilation in Buildings page. Outreach workers who have developed relationships with local employers can provide resources and guidance on ventilation, or they can help prepare workers to talk with their employers. Ventilation can prevent illness spread in their work environments, which is a benefit to both employer and employee.

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

Data suggest that loss of taste and smell – the markers of COVID-19 infection for many – ​​​​​​​is less common with Omicron and its variants,​​​​​​​ including XBB variants. Additionally, because Omicron and its variants don’t infect the lungs as easily as previous variants like Alpha and Delta, some people are being hospitalized without severe breathing problems, a change from earlier waves in the pandemic. However, many people have become very ill with Omicron or its variants and most have symptoms similar to the flu and to earlier variants including but not limited to: fever, chills, cough, shortness of breath, fatigue, muscle aches, nausea, and vomiting. Anyone with any of those symptoms should test for COVID-19 and isolate until results are conclusive. If a patient tests positive for COVID-19 or has symptoms, isolate for at least five days,​​​​​​​ according to the CDC. (See “The CDC guidelines on what a patient should do when she has had close contact with someone who tested positive are confusing. What do you recommend?” under Exposure, Quarantine, and Isolation.)

Who should get the updated COVID vaccine?

Anyone ages six months and older should get the updated COVID vaccine to increase their protection for the upcoming respiratory illness season. The health disparities that drove up COVID infections among migrant, immigrant, and farmworker communities are still bearing down on these communities, from poverty and food insecurity to work conditions that increase the risk of infection to higher rates of diabetes. Additionally, migrant, immigrant, and farmworker patients may encounter increased barriers to accessing the vaccine, including fear of exposing documentation status, lack of transportation, lack of educational materials or outreach in the language of their choice, lack of childcare, concern after hearing misinformation, etc. 

While the federal government has covered the cost of the vaccine for uninsured people through 2024, the funding for outreach has ceased. 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.

Why should a patient get the updated COVID vaccine?

Anyone ages six months and older should get the updated COVID vaccine to increase their protection for this respiratory illness season. Encourage your patients to get vaccinated, and remind them that it is safe and effective. Here are the top six reasons for a patient to get an updated COVID vaccine this fall:

1. Get prepared for increased exposures: COVID cases and hospitalizations have in recent weeks increased, and are expected to spike as we enter the fall and winter. The patient likely does not have much protection from previous vaccines. In the last year, only 17% of the population chose to get the (now unavailable) COVID bivalent booster that was first available last fall, meaning the vast majority of the US population – even those who received vaccines earlier in the pandemic – have not had a vaccine for a year or longer, and their antibodies have decreased. 
    
2. Avoid the emergency room: If you do contract COVID, you will likely have a shorter-duration illness, which reduces the window during which you are very sick and can spread the disease. That 17% of the population who got the vaccine saw 60% effectiveness against urgent care and emergency department visits and 65% effectiveness against hospitalization – a remarkable reduction in severe disease!
    
3. Get evidence-backed protection: The patient has unknown protection from previous infections. The only way to be certain to increase antibodies is to get vaccinated. To visualize the risk, a patient can use the COVID-19 Immunity Estimator. (For more, see the question: “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” under Basic COVID Questions.)
    
4. Reduce risk of long COVID: People with less severe illness are at a lower risk of long COVID. (See “Does the updated vaccine protect against long Covid?”)
    
5. Reduce the duration of transmission: Vaccination shortens illness, which in turn shortens the time during with the patient is infectious. This can be the difference between holidays with the abuelos, or staying home sick.
    
6. Get safe and effective coverage! Remind patients that, contrary to the misinformation that is prevalent in social media, this vaccine has very few side effects. Additionally, it is expected to be very effective at increasing antibodies against the COVID subvariants in circulation right now, including BA.2.86. (See questions “Do teenage boys who get vaccinated have a higher risk of myocarditis?” and “What do we know about the latest subvariants that are spreading?”)

Access the vaccine for free, for now: Private insurance is covering the vaccine. For most others without insurance, the vaccine is available for free with government funding, available at community health centers and health departments, at least through 2024.

Can a migrant patient get the COVID updated vaccine and the influenza vaccination at the same time?

Yes. Multiple studies, including a September 2023 study in JAMA Network Open, have found it is safe to get the COVID updated 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.

Can a patient get the flu vaccine, the updated COVID vaccine, and the new RSV vaccine at the same time?

The RSV vaccine, new for fall 2023, is now available for patients over 60 who consult with their doctor. As of mid-September 2023, the CDC has not yet offered guidance regarding the spacing of the RSV vaccine relating to COVID and flu shots. Anecdotally, clinicians have been giving patients all three vaccinations in one appointment. Clinicians can consider the patient’s individual situation, particularly for migrant patients or those who struggle to get to the clinic, those who may be higher risk, or may have recently recovered from COVID. Use your judgment and your knowledge of the patient to determine the ability of the patient to get to a return appointment.

What are the pros and cons of splitting the COVID and flu (and RSV) vaccines?

Many of our patients have poor access to vaccines, due to work inflexibility and schedules, transportation, childcare, and more. The primary benefit of giving the COVID and flu shot simultaneously is that the patient won’t have to figure out how to get back to the clinic for a second shot (or a third time, if they are eligible for the RSV vaccine). This is a very serious concern, because no vaccination means no protection.

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 have peak effectiveness over certain events or the holidays, or to time the vaccines to provide highest coverage during the historical peaks of the virus. (The historic peak of the flu, for example, is in February; RSV typically peaks in December but peaked in November last year; COVID has had multiple peaks throughout the year, but its deadliest months of each year have been January.) Additionally, studies show that coadministration of the COVID and flu shots very minimally decreases effectiveness. However, clinicians should be careful to ensure that delaying the vaccine will not result in barriers that lead to no vaccine.

What do we know about the fall 2023 vaccine?

Some key aspects of the revised COVID vaccine that is now available at health centers and health departments:

• Effective: This revised vaccine targets the XBB.1.5 subvariant of the Omicron strain of COVID. This vaccine is expected to be effective against all of the major subvariants in circulation, including JN.1.
   
• Cost and availability: The vaccine is now available. Patients can see exactly what locations have received the updated vaccines online on https://www.vaccines.gov/search/. Those without insurance are eligible for a free vaccine paid by the federal government. Those with private insurance will be covered by their insurance.
   
• Language change: This vaccine is not a bivalent vaccine, as it does not target two strains of COVID, but just one – the XBB subvariants of Omicron. It also now acts as the initial dose for those who have never been vaccinated for COVID, not just as a booster. This means, going forward, the language has changed – this vaccine is called “the updated COVID vaccine” or “the COVID vaccine” instead of a “booster” or a “bivalent vaccine.”
   
• Looking ahead, a simpler process: COVID vaccines are likely to shift to be more like the flu vaccine – one shot available in the fall, updated to best match the variants expected to dominate over the winter. Most people (the exceptions being children under six and immunocompromised people) will have just one shot to get, regardless of whether they have had an initial series or not, and the language and messaging can be simplified to reduce confusion.

Many patients are reporting that COVID vaccines cause death. What should I say?

Misinformation about COVID vaccines continues to spread. COVID vaccines are exceptionally safe and effective, yet the internet is abuzz with misinformed people blaming vaccines for a wide range of medical issues, with no or inconclusive data to support their claims. 

For example, a new KFF poll shows a third of adults believe the COVID vaccines “caused thousands of sudden deaths in otherwise healthy people.” There is no increased risk for mortality among COVID-19 vaccine recipients,​​​​​​​ according to the CDC and numerous other studies. However, there has been “excess mortality” in recent years, meaning there were more deaths over a given period than expected based on historical figures. We can confirm for patients:

1. Correlation does not equal causation – and there’s not even correlation. When looking globally at vaccine coverage with excess mortality for the fall of 2022, there was no correlation between vaccination coverage and excess mortality.
    
2. COVID infection affects the body in many ways. Many COVID-related deaths, like from a heart attack after a COVID infection, are not reported on the death certificate, thereby masking some COVID deaths which would be counted instead as excess mortality. 
    
3. Many other factors may have contributed, like avoidance of care during lockdowns which led to delayed diagnoses, overwhelmed health systems with staff shortages, extreme summer heat waves and other climate disasters, or a lack of health insurance – it’s complicated. 
    
4. Because it’s complicated, we need to be patient as researchers tease out the concrete reasons. This doesn’t mean we should avoid COVID vaccines in the meantime. On the contrary, avoiding an illness that has verifiably caused millions of deaths is a far safer strategy.

I want to talk to a patient about getting their initial COVID vaccines. If they start now, what series would they take?

The CDC has simplified its primary series. As of September 2023, for an unvaccinated child or adult, one dose of the updated vaccine is used instead of the multi-dose vaccine series. See MCN’s colorful and easy-to-understand guide to help patients understand what shots they are eligible for and when, available in English and Spanish: Who Can Get the Updated COVID-19 Vaccine

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 COVID-19 vaccine 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 the child has the highest level of protection from re-infection. 

The CDC’s updated infographic breaks down vaccination by age group and vaccine type (Pfizer, Moderna, or Novovax). 

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

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

When’s the best timing to get the updated vaccine, if the patient was just infected with COVID?

The patient is recommended to wait three months after they last tested positive, and then get the updated vaccine. Other considerations, like migration, may be taken into consideration.

Does the updated vaccine protect against long Covid?

Yes, indirectly. While the updated vaccine does not specifically protect against long COVID, long COVID occurs more often in people who had severe COVID. This vaccine reduces a person’s risk of severe COVID, which therefore reduces their risk of long COVID.  The best way to not get long COVID, of course, is to never get infected with COVID in the first place. The updated vaccine reduces a person’s chance of contracting COVID.

Should a migrant patient get the COVID updated vaccine and the mpox vaccination at the same time?

No. If a patient is recommended for an mpox vaccine, the CDC recommends delaying any COVID vaccine four weeks after either mpox vaccine. However, the CDC does not presently give a recommendation about timing of an mpox vaccine after a COVID vaccine.

A patient’s at-home COVID test has an expiration date of just a few weeks later. Can she still use the test, after its expiration date?

Expirations dates may have changed! 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.

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

As of June 2022, all air passengers, regardless of citizenship or vaccination status, are no longer required to show a negative COVID test to enter the US. 

As of May 2023, all non-US citizen, non-US immigrant visitors to the US, including H2-A workers, are no longer required to show proof of COVID vaccination to enter the US. Refer to the CDC website for any updates.

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

Some migrant patients are arriving in the US with partial vaccination. AstraZeneca and Synovax are two vaccines that are not available in the US, but are widely used in other countries. Regardless of their vaccination status, patients should be encouraged to receive one updated COVID vaccine for best protection. All adults who are unvaccinated, or previously partly or fully vaccinated with any COVID vaccines, are eligible for the updated COVID vaccine.

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

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

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

Hundreds of thousands of women have received the vaccination during pregnancy or while breastfeeding, and repeated studies of these women show no increased risk of pregnancy loss, growth problems, or birth defects. In fact, COVID vaccination during pregnancy was associated with a lower risk of NICU admission and intrauterine fetal death. As a reminder, the COVID-19 vaccines are not live vaccines, and pregnant women and their babies cannot get COVID-19 from the vaccine.

More striking are the data on pregnant people who choose not to get vaccinated. COVID can kill pregnant women or cause a miscarriage, preterm birth, or stillbirths, even in an asymptomatic case. Early in the pandemic, a CDC Morbidity and Mortality Weekly Report showed that 31.5% of women who contracted COVID during pregnancy were hospitalized, compared to just 5.8% of nonpregnant women with COVID.

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

Resources:

• Pregnancy and the COVID-19 Vaccine: MCN's customizable handout, available in English and Spanish.
• Pregnant? Get Vaccinated Immediately, Says the CDC with New Data in Hand, from the MCN blog, in English and Spanish.
• Characteristics and Outcomes of Women With COVID-19 Giving Birth, 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 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.

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.

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:

• 54% of children and teens who are hospitalized with COVID have no comorbidities – otherwise healthy children do end up in the hospital.
• 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 continuously been a leading cause of death in children and adolescents.
  • 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 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, the risk of which is outweighed by the benefits of vaccination. Incidences of myocarditis dropped with the 2022/2023 bivalent booster, with just 2 cases verified out of about 650,000 doses. The rate of myocarditis from COVID infection is much higher. This vaccine is very safe!

As new variants develop, the risk for children may grow. For example, although XBB subvariants are less severe than previous variants, it is highly contagious, and the number of children infected may become very high. Consequently, more children may end 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.

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

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

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

For many parents – including many who have been vaccinated themselves – the vaccine is something that may have benefit, but for which they have lingering questions or concerns, which encourages them to put off the decision to vaccinate. Some have heard misinformation about the vaccines potentially affecting fertility (of which there is no evidence); others are concerned that the vaccine may result in myocarditis in adolescent boys. (See question about myocarditis, below.) 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 was an increase of cases of myocarditis (inflammation of the heart muscle) and pericarditis (inflammation of the lining of the heart) after primary series vaccination with an mRNA COVID-19 vaccine (Pfizer and Moderna), particularly among male adolescents. This increase dropped with the bivalent booster; just 2 cases of myocarditis were verified from about 650,000 doses. Data are limited, but one theory is that the recommended spacing between doses dramatically reduced the risk of myocarditis. This very low incidence of myocarditis is expected to hold with the updated COVID vaccine. 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 the primary COVID-19 vaccine series. Symptoms include chest pain, shortness of breath, and a feeling of a fluttering heart. Read more on this CDC webpage. 

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. These figures were before the rate of myocarditis from vaccination dropped with the bivalent booster. 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. In fact, in one CDC report, most patients ages 12-29 with myocarditis following vaccination reported no impact on their quality of life, and most did not miss school or work.

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

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

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

In areas where parents are required to be present, some parents encounter a barrier to vaccination. Earlier in the pandemic, many health centers and health departments offered 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.)

A patient’s workplace requires him to be “up to date” on COVID vaccines. Does that include an updated vaccine?

Yes. The CDC has updated its definition of “up to date” for everyone 6 years and older to include one dose of the updated vaccine that was released in September 2023, regardless of previous vaccine history. See this CDC page: When Are You Up to Date?

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

Because of vaccine mandates, the vaccine card is no longer just a health document, but is for many 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.

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 where they received 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.

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

While COVID is not the killer it once was, it is still a massive problem in the US, causing severe illness and death across the nation, and localized spikes are causing overwhelm in hospital settings. For the week before January 2, 2024, an average of 19,567 people per day were hospitalized with COVID. Over 1,700 died of COVID in the first week of January 2024 alone. Vaccination reduces severity of the disease and prevents death.

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.”

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

The important thing to keep in mind is that those who are unvaccinated remain vulnerable. 

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

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 misinformation continues to circulate. 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