Mobile Distribution of COVID-19 Vaccines to Migrant Farmworkers in Minnesota

Abstract

The COVID-19 pandemic has disproportionately impacted migrant farmworkers (MFWs). MFWs have experienced higher rates of infection and death than any other occupational group in the United States due to workplace exposure risks, overcrowded housing, and limited access to personal protective equipment. Barriers to accessing COVID-19 vaccines have also contributed to these disparities, especially in rural areas where the pandemic’s impact has been devastating. Mobile health clinics, in partnership with community-based organizations, are an effective method for vaccine distribution to rural communities where many MFWs live and work. Between June 2021 and October 2022, the University of Minnesota’s Mobile Health Initiative (MHI) organized health fairs in southern Minnesota to distribute vaccines to MFWs and their families. The success of these events can be attributed to partnering with trusted local organizations, bridging geographic barriers, ensuring language-concordant care, and offering multiple health services in one place. MHI’s health fairs serve as a model for future mobile vaccination events. As the COVID-19 pandemic has ended as of this time, future pandemics may occur, and equitable vaccine access must be a priority for MFWs. Mobile health clinics are an essential tool to achieving this goal.

In the United States (U.S.), the COVID-19 pandemic has had a disproportionately negative impact on migrant farmworkers (MFWs). [1,2]. Chen et al. found that working-age Latinos in California working in food and agriculture had a 39% relative excess mortality, the highest in the state in 2020 [1]. MFWs are defined by the U.S. Department of Labor as individuals absent from their permanent residence and principally employed in seasonal agriculture [3]. More than 70% of agricultural workers in the U.S. are immigrants or seasonal migrant workers, most of whom are from Latin America [4]. MFWs work and live under conditions that place them at increased risk for SARS-CoV-2 infection, including high-density housing, close-proximity work environments, shared transportation, and limited access to COVID-19 testing or personal protective equipment (PPE) [5,6]. Housing units (e.g., trailers, bunkhouses) can be poorly ventilated with numerous occupants, making quarantining or social distancing nearly impossible [7]. Until September 2021, no federal funding had been designated to help farm operators obtain PPE for their laborers as it had been for other essential workers such as nurses and police officers [8]. Furthermore, over 60% of MFWs lack health insurance [9], meaning that most workers do not have affordable access to healthcare services.

The social and economic vulnerability of MFWs compound the risk of COVID-19. Over half of farmworkers in the U.S. are undocumented [10] and therefore do not qualify for unemployment benefits or federal stimulus payments. Undocumented workers are usually ineligible for paid sick leave and often fear losing their jobs after taking time off to access health services. One day of missed work can result in significant loss of pay for families and taking time off may lead to termination. As a result, undocumented MFWs who are ill with COVID-19 or with ill family members at home may continue to work, increasing the risk of occupational exposure for other workers. Undocumented workers are also less likely to seek COVID-19 testing or present to healthcare facilities when ill [11]. As a result of these complex and interrelated factors, MFWs face a higher risk of infection, hospitalization, and death from COVID-19 than any other occupational group in the U.S. [1].

Since December 2020, highly effective COVID-19 vaccines have been available in the U.S. However, significant challenges have delayed widespread vaccination among MFWs. These challenges include lack of transportation to reach vaccination sites, inability to take time off work, lack of internet access to sign up for vaccine appointments, language barriers, misinformation about vaccine safety, and fears regarding immigration status [12]. Such barriers are exacerbated by the highly mobile nature of seasonal farm work, and distrust amongst MFWs towards government and healthcare organizations. For MFWs in Minnesota, the COVID-19 pandemic exacerbated health disparities, as it has throughout the U.S. The inability of MFWs to readily access COVID-19 vaccines due to geographic distance from vaccination sites like health clinics and pharmacies and the lack of Spanish-speaking staff has further magnified the pandemic’s impact on the MFW community. MFWs may also have concerns about the cost of the vaccine—despite the vaccine and its administration being free in the U.S.—and about missing work due to vaccine side effects [13]. Access to COVID-19 vaccination and other easily accessible health services can reduce the health and financial burdens on MFWs.

Rural farming communities in the U.S.—where most MFWs live—have been devastated by COVID-19, consistently reporting high COVID-19 cases per capita. There have been over 3 million estimated cases of COVID-19 among agricultural workers, with nearly 28,000 deaths [14]. In Minnesota, the counties with the highest number of COVID-19 cases and deaths per capita are all in rural areas [15]. Multiple outbreaks at farms and meat processing plants have compounded the negative impact of COVID-19 in rural counties [16]. Wabasha County is a representative example of rural areas in Minnesota. Located 80 miles southeast of Minneapolis, it has a population of 21,387 [17], though these data likely undercount large populations of seasonal workers. Manufacturing and agriculture are the second and fifth most common employment sectors, respectively [18]. Migrant workers travel to Wabasha County from Mexico and Texas in the spring to work on corn, soybean, and dairy farms through the fall.

Mobile health clinics are a promising method for addressing some of these challenges and bringing vaccines closer to where MFWs live and work [19]. The benefits of mobile health clinics for community health have been well-documented. Mobile health clinics overcome barriers to healthcare access including cost and distance and have demonstrated improvements in health outcomes [20]. Mobile health clinics can be equipped with the necessary personnel and supplies to provide a variety of healthcare services, including vaccinations, dental exams, and hemoglobin A1c testing to screen for diabetes mellitus. By going to medically underserved areas, mobile health clinics deliver care to individuals who lack the time and resources to travel to traditional medical clinics. The University of Minnesota’s Mobile Health Initiative (MHI) is one example of a mobile health clinic. Based in Minneapolis, Minnesota, MHI launched in June 2020 and began partnering with local organizations to deliver healthcare and screening services, including wellness exams, immunizations, vision and dental care and medication support to underserved communities in urban and rural settings. In May 2021, MHI began organizing vaccine distribution events in rural Minnesota.

During the summers of 2021 and 2022, MHI partnered with local community service organizations and public health departments to host health fairs that included COVID-19 vaccinations. The health fairs included a variety of screening health services, including annual physical examinations, sports physicals for school-aged children, blood pressure screening for hypertension, point-of-care hemoglobin A1c testing for diabetes screening, dental exams, vision screening with eyeglass provision, medication counseling with prescription refills, and health insurance applications. To reduce barriers to vaccination, MHI structured the events using guidelines from the National Resource Center for Refugees, Immigrants, and Migrants [21]. For example, vaccine education resources were always offered in Spanish, proof of residency was not requested from health fair attendees, and the health fairs were held as close to MFWs worksites as possible. The primary community partner for the health fairs was the Tri-Valley Opportunity Council (TVOC). TVOC is a non-profit agency that provides child and family services throughout Minnesota and North Dakota with a focus on migrant families working in agriculture. Over 95% of families served by TVOC are Spanish speaking.

In planning the health fairs, a childcare center operated by TVOC in Wabasha County was chosen as the event site, as many MFWs’ children attend programming there, making it a well-known, trusted organization. The center is located less than three miles from a nearby canning factory and apple orchard where many MFWs are employed. Community organizers promoted the events primarily by word of mouth and promotional vaccination campaign materials. Health fair staff were bilingual in English and Spanish, and many were bicultural and residents in Wabasha County. This meant that Spanish-speaking participants were able to interact with nurses, pharmacists and physicians and ask questions in Spanish as they moved around the event. Health fairs were held in the afternoon and evening, allowing workers to attend after completing daytime shifts or before starting nighttime shifts. The events were mostly held outdoors to allow for physical distancing and improved ventilation and reduce the risk of COVID-19 transmission. COVID-19 mRNA vaccines (Pfizer-BioNTech and Moderna) and vaccine education were provided by county public health workers with whom MHI partnered. In 2021, the focus of vaccination efforts was on the primary COVID-19 vaccination series, whereas in 2022, booster vaccines became the focus. Vaccines were available for adults as well as children. In accordance with CDC recommendations, the Pfizer-BioNTech vaccine was available for primary immunization of children ages 12 to 15 during the 2021 health fairs. During the 2022 health fairs, primary immunizations were available for children ages six months and older, with boosters available for children five years and older.

A total of five health fairs and two additional vaccination events were held between June 2021 and October 2022 in Wabasha County. Across all the health fairs, 506 individuals attended. Most participants were between the ages of 19 and 64, but 30% were under the age of 18 (Figure 1). Most (81%) of surveyed participants identified as Hispanic/Latino and Spanish was the primary language for most attendees.

Figure 1.

Age of Health Fair Participants in Steele and Wabasha County, 2021–2022

In 2021, 122 mRNA vaccine doses were administered to attendees ages 12 years and older in Wabasha County. In 2022, 73 vaccines were administered in Wabasha County. Similar health fair vaccination events were organized by MHI and TVOC in Steele County, Minnesota, another rural area heavily impacted by COVID-19. A total of 225 mRNA COVID-19 vaccines were administered in 2021, and 153 were administered in 2022. In addition, volunteer physicians and dentists performed medical and dental evaluations, acute care as needed, medication management and linkage to local clinics as needed. Pediatricians offered physical exams to children attending the health fairs—an important resource given that children of migrant workers are often uninsured and face gaps in routine medical care [22]. In 2021, 70 point-of-care hemoglobin A1c tests, 81 blood pressure checks, 61 medical exams, and 49 dental exams were provided. In 2022, 81 hemoglobin A1c tests, 82 blood pressure checks, 48 physical exams, and 66 dental exams were provided (Figure 2).

Figure 2.

Health Services Provided in Steele and Wabasha County, 2021 vs. 2022

Using a mobile health clinic model, the health fair events delivered COVID-19 vaccines to farmworkers and their families who may otherwise lack access to vaccination. The partnership between local public health departments, a community-based organization like TVOC, and a university-based mobile health project demonstrates successful collaboration across different sectors of the healthcare system to improve health equity. Health screenings like those provided at the health fairs are essential for diagnosing chronic medical conditions, especially given the barriers that MFWs face to accessing primary care. For example, hemoglobin A1c tests to detect diabetes mellitus are critical to offer since the Hispanic/Latino adult population is 70 percent more likely than non-Hispanic white adults to be diagnosed with diabetes and 1.3 times more likely than non-Hispanic whites to die from complications of diabetes [25]. New diagnoses of diabetes mellitus were made at the MHI health fairs and referred to our partner community health center.

This mobile health clinic model was used primarily to distribute COVID-19 vaccines to rural MFWs and their families due to the pandemic emergency, but this model could also be used for other routine vaccinations (e.g., influenza, Tdap, MMR). If MFWs have received vaccinations in Minnesota in the past, this information is documented in the Minnesota Immunization Information Connection (MIIC) – a confidential statewide system that stores electronic immunization records. At future health fair events, public health workers could offer multiple vaccines to attendees using MIIC to reference their immunization record. As evidence of this, 29 influenza vaccines were administered to MFWs in Steele County in the fall of 2022.

Despite the success of these events, constraints limited the number of attendees. 1) we were unable to compare pre and post-intervention among MFW. 2) There is little comparison in the literature for vaccination rates of MFWs. 3) With no public transportation options, MFWs needed access to a vehicle to attend. 4) Vaccine distribution was not offered on-site at farms, factories, or MFWs housing areas, which would have further facilitated access for workers without transportation. 5) We cannot compare primary series to boosters, but presume that the second year was mostly focused on boosters due to recommendations at that time. The child care center offered a large area for the events but lacked medical equipment like examination tables and blood pressure cuffs, which needed to be provided by the MHI team. For future vaccine distribution events, more collaboration is needed between employers, local government, and non-profit organizations to further increase vaccine convenience for MFWs. As the SARS-CoV-2 virus mutates and more infectious variants emerge, ongoing immunization efforts with COVID-19 primary series and booster vaccines in accordance with CDC recommendations are critically important. Finally, given the number of children in the MFW community, future events will benefit from more pediatric-focused services (e.g., lead testing, sports physicals) and healthcare navigators to help refer patients to primary care.

Even as the COVID-19 pandemic emergency declarations have ended, MFWs remain at an increased risk of infection, complications, and death compared to other groups. Equitable vaccine access must be a priority for this vulnerable population to mitigate the unequal burden of COVID-19, and mobile vaccine distribution is essential to achieving this goal. The success of MHI’s health fairs exemplifies how utilizing trusted local partners, bridging geographic barriers, and offering multiple essential health services at a single event can effectively provide COVID-19 vaccines to MFW communities.

Table 1.

Health Services Provided in Steele and Wabasha County in 2021 and 2022

Health Services	2021	2022
Hemoglobin A1c Tests	70	81
Blood Pressure Screening	76	82
Vision Exams	69	76
COVID-19 Vaccines	225	153
Dental Exams	49	66
Medical Exams	61	48