I will be kicking off today's panel, talking about COVID-19 and farm workers, occupational safety and health. Can you hear me? Yes. Okay, perfect. Okay. So, just a quick note about Farm Worker Justice. Farm Worker Justice was founded in 1981. We are a national nonprofit based in Washington, D.C. Our aim is to empower farm workers to improve their living and working conditions, immigration status, occupational safety and health, and access to justice. And we use a multi-faceted approach, including litigation, advocacy, training and technical assistance, coalition building, corporate social responsibility, and public education. And I want to start off with a quote. This is from Tom Jorge, who is a farm worker in California. And he says, there's a lack of empathy for farm workers because they say that each team has a job. So, to understand the occupational safety and health vulnerabilities of farm workers, it's important to know who are farm workers. So, a lot of this data comes from the Department of Labor. And farm worker data, for those of you who may be familiar here, is pretty hard to come by. There are an estimated 2.4 million farm workers in the U.S., around 4 million in their families. Seventy-two percent are foreign born. The majority speak Spanish. But there is a large number of workers from the Philippines and Mexico and Guatemala, that speak indigenous languages, such as Mixteco, or Zapotec, or Piche, that's the primary language. And there are also workers who come from Haiti and Jamaica and other parts of the world. About 37% are without work authorization. About one-fifth are below the federal poverty level. And only about 56% of workers have health insurance. Now, the H-2A program, and I'll talk a little bit about that in a second, has grown tremendously in the past decade. In the past five years, it's almost doubled, with 317,000 H-2A visas certified in fiscal year 2021. Now, the reason why I talk about H-2A workers is because they are a growing number of the population of farm workers in the United States. And H-2A workers have their own unique vulnerabilities. The majority are from Mexico. And when they come to the U.S., they come here through an employer. So their visa is tied to the employer, usually for up to 10 months. They live in an employer-provided housing. And importantly, they are provided workers' compensation regardless of the state-paid coverage for agricultural workers or workers' compensation. Now, farm worker health is not just about their own health in terms of how they themselves stay healthy. What really determines farm worker health are what we call the social determinants. So discrimination, immigration status, language, regulatory issues, policy issues. Many of the reasons why farm workers are vulnerable to various illnesses is because of these systemic issues that are really outside of their control. Now, I want to talk a little bit about COVID-19. And I'm talking about COVID-19 not because we're still in COVID-19. But COVID-19, of course, had a devastating impact on the farm worker communities. And it really highlighted the vulnerabilities of farm workers in terms of their lack of control over their living and working conditions. So why were farm workers vulnerable to COVID-19? Well, primarily, it was their working conditions. So farm workers, as I mentioned, lack control over their working conditions. Many farm workers lack access to personal protective equipment like masks. They weren't really able to socially distance in the fields. And certainly not in transportation. Many shared transportation to and from the fields. They also have a lack of access to hand washing stations. And we'll talk about some of the policies in a moment. Farm workers don't have sick leave. So it's not as though farm workers get sick that they can just go to the doctor. Getting sick means losing wages and perhaps losing their jobs. And employee retaliation is a real fear. So it's a real concern that if you get sick from COVID-19, then you may be fired. Of course, their living conditions tend to be overcrowded and substandard. Primarily due to their low wages and the lack of affordable housing. And then, you know, there are other issues outside of those working and living conditions. Such as lack of health insurance. Lack of access to testing and vaccination. Fear of stigma related to COVID-19. And of course, misinformation. Now, there's not a lot of data on the impact of COVID-19 on farm worker communities. Purdue University put together an index. And according to their index, at least 1 million farm workers have tested positive for COVID since the start of the pandemic. And at least 19,000 have died. Now, I think we can all agree, but let's look at the estimates. According to a study by UCSF, food and agricultural workers experienced the highest excess mortality during the pandemic of all sectors. And that's a 39% increase compared to past years. And for Latinos and agricultural workers, again, as we saw, the majority of farm workers are Latinx, Hispanic. It was a 59% increase in mortality compared to previous years. So, what is the role of occupational safety and health policy? So, farm workers, we all know, have always been essential workers. But, on March 14, 2020, the federal government said, okay, food and agriculture are one of the critical structures within the sectors. And farm workers are essential workers. And in response, some agricultural employers provided what they call essential worker letters to their work workers, so that if they were pulled over during the shelter-in-place restrictions, they could show whomever that they were a designated essential worker. Now, even though they were designated as essential workers and continued to work throughout the pandemic, they really lacked workplace protection. So, at the beginning of the pandemic, the CDC and the Department of Labor provided guidance for agricultural employers. The guidance included recommendations to speed up employment for workers, for workplace protocols to reduce COVID-19 transmission, and other ways to reduce exposure in your housing and transportation, as well as ways to provide information to workers. However, as you know, that is just guidance, and guidance is not enforceable. OSHA, at the federal level, has not implemented any type of workplace protection or emergency measures to protect agricultural workplaces, despite the fact that, as I showed, and as I'm sure many of you know, the workplace is really where farm workers are most vulnerable, and where they lack a great deal of control. Now, in the absence of federal regulations, a handful of states, including Washington, Oregon, Michigan, and Wisconsin, issued emergency regulations specific to agricultural workplaces. So, they control product protections for agricultural workplaces. And in states like California and Virginia, also in place protections for all workers, including farm workers in California, that included shared housing and transportation. Now, there are policies in place, outside of COVID, to protect workers and protect the workplace of agricultural workers. There aren't many, but there are a few. So, the Real Dedication Standard was implemented by OSHA, and it is a standard that basically says that there has to be a toilet and hand-washing facility for every 20 workers in Real. So, there needs to be potable water, there needs to be soap, and single-use towels. And these toilets and hand-washing facilities must be within a quarter mile of each worker. So, for COVID, they certainly had the Real Dedication Standard that said you had to have hand-washing stations. However, because they have to be located within a quarter mile, that's quite a distance. And so, for workers to have to go a quarter mile to a hand-washing station, and then there might be a line, and then taking time to actually wash their hands, and then return to work for CDC recommendations, that can take quite a while. And that's time that's taken away from their work, and that's lost wages. So, it's a bit of a challenge in terms of COVID, but generally there is a scale down rating standard. There's also the OSHA General Duty Laws, and that's a pretty broad clause. And it can cover a range of issues, including COVID, including paint, including wildfires. But it is hard to enforce. And then, of course, there are state workers' compensation laws. But there is variability in terms of workers' compensation coverage for agricultural workers. This is a map that Farmers for Justice created as part of a labor map that shows labor laws by states. And as you can see, for workers' compensation, only a handful of states have full coverage for agricultural workers under workers' compensation. Other states have limited coverage where there are limited requirements. And then, in a number of states, there's optional coverage for workers' compensation. So, workers' compensation really varies from state to state for agricultural workers. Now, another issue, of course, is their immigration status. You know, according to the National Agricultural Workers Survey, about 37% of workers are unauthorized, undocumented. But in some areas, the estimates are much higher. And immigration status plays a huge role because undocumented workers and H-2A workers are much more isolated. And there's a real fear of employer retaliation. For undocumented workers, it's a fear because of immigration enforcement. For H-2A workers, it's a fear of losing their job, which is really what their visa is tied to. So, once they lose their job, they lose their immigration status in the United States. Of course, public charge continues to be a real fear. Despite the fact that the Biden administration rolled back the Trump public charge rule and rolled back the 1999 field guidance, there is still a lot of fear and misinformation around public charge. And, of course, due to immigration status in most states except California, there's limited eligibility for health insurance, for the Affordable Care Act, for Medicaid. And then there's always this fear of information sharing, regardless of your immigration status, because of just fear of providing information to the federal government. And that includes for COVID-19 testing and vaccines. So, I want to talk quickly about supporting farmworkers during the COVID-19 pandemic. There have been a lot of efforts to promote COVID-19 testing and vaccine access in farmworker communities. USCIS did announce at the beginning of the pandemic that the COVID-19 testing and treatment would not be considered a public charge. And then ICE said that they would not conduct enforcement operations at or near vaccine distribution sites. And then CDC shared that they would not be sharing any data with ICE. And so all of this was to reassure immigrant communities, including farmworker communities, that they were able to access testing and vaccines for COVID. And also, of course, we all know that vaccines are available to all, regardless of immigration status. Now, when the vaccines were first rolled out, the CDC identified food and agricultural workers as frontline essential workers, and they recommended them under the first phase of vaccination. And several states did follow suit. And so in many states, farmworkers did have priority access to the COVID-19 vaccine. Health centers and community-based organizations played a huge role in the COVID-19 vaccine and testing rollout. The community health center program had a vaccine program that they provided vaccines to underserved communities, including farmworker communities. Many health centers went on site to the fields, to farmworker housing, to provide testing and COVID-19 vaccines, because farmworkers cannot necessarily get to the health center, nor were the mass vaccination sites really a doable option for farmworker communities. And then, of course, most importantly, community-based organizations played a really important role in terms of being the trusted messengers to provide information about COVID-19, to connect workers to resources, and to ensure that farmworkers were comfortable accessing COVID-19 vaccines and testing. And there were many partnerships between health centers and community-based organizations and employers, actually. So promising practices. There were a lot of promising practices, a lot of cross-sector collaborations. There was a huge community assessment. There was a huge push for linguistically and culturally appropriate messaging. And community-based organizations, promotores de salud, community health workers, played a huge role, as I said, being those trusted messengers. And what it really did was, it was really about addressing those factors that limit farmworker accessibility. So really kind of thinking about those social determinants of health. And I think looking ahead, you know, when we think about COVID-19 and the response, I think what COVID-19 really did was it just highlighted farmworkers' existing vulnerabilities. So farmworkers always had these challenges. They were always vulnerable to these health issues. But COVID-19 really highlighted that. So now that it's out there, and now that people know that farmworkers are vulnerable, now is the time to really look at that and think beyond COVID, what are the other issues that farmworkers face? Right now, the biggest issue is heat stress and wildfire smoke. And there are efforts at the national level. OSHA put forth an advance notice of proposed rulemaking to put forth a federal heat stress standard. Only 50 years after NIOSH put forth the recommendation for our heat stress standard, it only took 50 years. And many states have implemented heat standards in lieu of federal standards. And a few states on the West Coast are now implementing wildfire smoke regulations and protections. So action is happening. There also is a need to strengthen other workplace protections, like the field sanitation standard and access to sick leave. Because as we've seen, the field sanitation standard can be strengthened, and workers need access to sick leave. They need to feel comfortable accessing health care when they need it, without fear of losing wages or their jobs. And really, it's about raising the profile of farmworkers and their roles as essential workers. And in both the economy and in our communities, farmworkers are important members of our communities. And it's important that that's acknowledged. And I think the pandemic really kind of highlighted that. And of course, there's always a push for immigration reform, as well as overtime protection and higher wages, to ensure that farmworkers are able to live in housing and live healthy lives, and feel comfortable asserting their rights and empowered to assert their rights. We have a lot of resources. We have a lot of COVID-19 resources. I encourage you. We created this documentary called Voices from the Field. It really highlighted the farmworker voice, as well as organizations that serve farmworkers and their response to the pandemic. It's on our YouTube channel. Of course, we have occupational safety and health resources, clinician guides, issue briefs, the interactive farmworker rights map, which was that workers' compensation map that I shared earlier. So I encourage you to go to our website. And I will just close with this quote. This is from Suget Lopez. She is the executive director of Líderes Campesinas, which is a farmworker organization in California. She said, we are also and want to be part of the solution. We are capable, very brave, very intelligent, and ready to collaborate with respect and great results. Thank you. Can we stop sharing? Thank you, Alexis. We're going to ask that you save questions to the end. And you're able to hang on, Alexis, right? Hang out for a bit? Yes, I am. Okay. Thank you. What I'll do now is just introduce our next speaker. So we have four speakers today. And you met Alexis already from Farmworker Justice. The first two will be Zoom. The other two are recorded. But I think very special speakers that hopefully you'll find some really good information from. Oh, okay. Thank you. Back in grade school. Everybody grab a partner and head to the center of the room, please. So our second speaker is Maricel Pagan-Santana, who serves as Migrant Clinician Network Senior Program Manager in Puerto Rico, where she leads and coordinates MCN's current climate-related projects. In this role, Dr. Pagan-Santana provides technical assistance, training, and tool development for community health centers and community residents to address disaster-related issues and target health-related outcomes. In addition, she is the principal investigator in various small projects exploring natural disasters in agricultural communities in Puerto Rico. She also fosters MCN's network of organizations working on climate and health initiatives in Puerto Rico. She has extensive experience in providing training to high-risk and vulnerable worker populations and conducting community-based projects. She also has more than six years in the field as an industrial hygienist. Previous areas of work include the development and implementation of occupational and environmental health training, emergency preparedness, and business continuity planning programs. Maricel has a master's degree in industrial hygiene and a doctorate in public health with an emphasis in environmental health from the University of Puerto Rico Medical Sciences Campus. She was the 2021 recipient of the Lauren Kerr Award, an American Public Health Association honor, for her dedication to worker health and safety. Maricel. Thank you. As it was presented, I'm Maricel Pagan-Santana. I'm the senior program manager in Puerto Rico. Today, I'm going to try to follow up Alexis' presentation, and talk a little bit more about the challenges and opportunities of frontline clinicians caring for immigrant and migrant workers in health. First of all, Migrant Clinicians Network is a nonprofit. Our mission is to create practical solutions at the intersections of vulnerability, migration, and health. We work with clinicians all over the states and also in San Juan, Puerto Rico, and now in Virgin Islands. That's where we're located. We have several offices and staff, key persons who work with communities and health departments and community health centers in several states. Our constituents of the people that we work with are mostly underserved migrants and immigrants, clinicians, migrant community health centers, states, and local health departments. MCN serves immigrants that are vulnerable, and clinicians for us are those service providers from a physician to a community advocate and health educator, health centers, and states. We see clinicians as the whole health provider group, rather than just physicians. That's going to be important following along the way that we do partnerships and target and address workers and migrant self. And I want to go a little bit over the headlines regarding COVID-19 farm workers and migrant populations. So this is a bit of a non-audio video of several headlines that have been going on around the last few years. There were several headlines regarding outbreaks, farm workers getting sick, essential workers getting sick, employers not agreeing to do testing and other sorts of responsive actions to what the COVID-19 emergency was impacting, how it was impacting the different areas, especially what we were talking about, meatpacking and farm workers in different states in the United States. And these are not all, but a lot of the highlights and a lot of the cases that were featured in the different news and newspapers. So, we saw a lot of the topic and title of essential worker, and we were talking about essential worker other than the first responders, we were talking to you about farm workers, meat, chicken, and seafood processors, and dairy workers, those workers that were responsible for continued food change across the U States. And as Alexis was presenting, a lot of the farm workers were, are Hispanic, are not native English speakers, and those were the populations that we saw were disproportionately impacted by COVID-19. We saw the CDC presenting a lot of the risk rate regarding Hispanic or Latinx in comparison to white non-Hispanic cases. We saw a hospitalization rate two times higher, and the death rate, as we were mentioning, it was mentioned before me, higher than some of the other populations. So, we were having the same groups that were working as essential workers being the hardest hit from the COVID pandemic. And this number was the same that we were referring in the first presentation, it was more than 1 million farm workers infected with COVID, and we saw the rate regarding that. So, when we talk about the social determinants of health, why we saw this case rate, why we're seeing this hospitalization rate, and what were the vulnerabilities that make farm workers and migrant populations such a risk population for COVID-19 mortality? We saw in different studies about non-English speaker households being significantly higher levels of mortality, and we saw that these characteristics about being more at risk and having a higher chance of dying were repeating themselves. So, we saw that about the language, we saw about their other social characteristics that were putting those individuals at risk. There was also the Chamacos COVID-19 study regarding seeing the farm workers in California, seeing like they were four times higher in testing positive than other farm workers and other populations. And we saw that both household and workers' exposures were associated with the infection. So, there was a difference between the populations that were presenting as having a higher prevalence in infections, and we saw again that a lot of the relationship that we saw with these higher risk has to do with a lot of the systems and social vulnerabilities that were carried out before the COVID pandemic for this population. And we didn't get a first and in some instance, we haven't get the response that we wanted. We saw the response from employers and some of the higher agency officials was to blame workers. We saw different reasons to blame workers. We saw home and social conditions as the responsible to cause meatpacking outbreaks. We saw the living circumstances in center cultures being responsible for higher case rate. And we saw the way that transportation to work was also responsible for these case rates. And again, we were seeing headlines and we were seeing responses that were not aligned to having a response and recovery time and addressing public policy and resources need to support this population and to actually manage this situation as they were essential workers. And that reflects in how the farm workers see themselves. They hear about being essential. They hear about the importance that they have in maintaining food security for a lot of people and for the industry, but they feel like they're too dispensable. So they feel what we're seeing. They feel and they suffer the lack of policy and the lack of response for some of the states and regulations that we're lacking or are not being implemented as we need to. I'm not going to stop much more in this because I know Alexis was over this topic, but we know that they don't have basically, there's limited personal protective equipment for farm workers. And this is an issue that is not exactly COVID related. The limitation in personal protection equipment is related to the lack of enforcement of regulations and to deal with exposures that were pre-COVID-19. So that's something that I want to talk about. And we saw that housing and transportation was something that was causing or were systems that were putting them at risk is something that comes with the territory of farm working, but not having adequate housing and transportation methods and protocols in place, what was putting them too at risk. And with the personal protective equipment, I want to just stop by that farm workers before COVID-19 and after COVID-19 are being exposed to chemical hazards. So having personal protective equipment is not just a COVID-19 thing. It's something that we have to take in consideration for farm working purposes when we are exposed to pesticides, fertilizers, fumigants, equipment operation, and animal confinement. When we saw the PPE inventory affected, we saw some farms in areas trying to replace respirators with face masks or not having the adequate personal protective equipment. And seeing a lot of the response for essential workers going towards only first respondents with what's needed at that point for management, the medical situation that we were having and we are having, we saw that there was a lack of indication that we have to address to the inventory of the personal protective equipment of these essential workers. So there's a relationship of how the lacking of equipment in this process could have also caused other types of non-COVID illness for workers who were now exposed and there was no PPE inventory for them to be protected. Other risks for illness are associated to the living conditions that farm workers are living in. According to workers' housing range from labor camps, apartment trailers, some farm workers may even resource to live in tents, vans, or cars if no other affordable housing is available. It is common for rental units to be poorly maintained or overcrowded because of rents, prices, farm workers are frequently squeezed in as many as they can in a single unit and can create serious health risks. And we see that there were issues for infectious diseases including COVID-19, intestinal parasites, conjuvitis, deep poisoning, pesticide poisoning, and carbon monoxide poisoning created to living in housing situations that were not adequate. Most of the housings and some of the housings lack modern conveniences such as indoor plumbing or heating and they will add a more healthy space for this population. We also have the issues of health care access, language, transportation, insurance, fear, loss of income, digital divide, and racism and discrimination are issues and a stressor and we're going to talk a little bit later regarding stressors that you may have or that can add to you not being able to be taken care of during this process of the COVID-19 and other environmental stressors that we may have. Moving on and not moving on entirely from the COVID-19 piece, we got to the climate crisis affecting not only farm workers but the migrant population as well. We know that we're going to be seeing and the prediction for migrants being displaced due to climate is going to be continuing increases and understanding the challenges of health care and how to support as clinicians these populations needs to be front and center of some of the policies and programs that we're developing because this is a situation that is not going to disappear. It's something that is going to increase and we need to include that in our day-to-day discussion and programs development. We know that there's going to be food security and job security issues regarding drought and farm working if we don't got crops developing that they might be migrant populations that reach a sea zone with the work that they were prospect to do is not viable anymore because of some issues regarding climate crisis. We know that wildfires and exposure to the fumes of wildfires is going to be something that we have to address. We saw that during California wildfires and how the migrant population and farm workers kept working while they were being exposed to these environmental hazards and a severe lacking of air quality while they were working without any type of protection. And there's also heat. So we know that extreme heat kills more people than hurricanes, floods, and tornadoes. And we know that climate crisis is going to be predicted to be increasing and we're going to see hotter days as we move forward. We know that extreme heat is the leading cause of weather-related illness but there's no national standard requiring training or programs centered around heat street prevention. So there's a lot of complications regarding how we are addressing and preventing farm workers and migrant farm workers to be ill due to exposure to heat and having heat strokes. There are a few states that have standards like California, Minnesota, but there's no national standard and we're advocating for that to become to be present and to become a reality. We also know that farm workers are 20 times more likely to die from heat-related illness than other workers. So not only a heat standard is needed but also addressing that in the specific occupations that are more vulnerable is important. So we know that we have to address that as the climate change and the projections become a reality for us and we see the days being hotter in different states. There's also the natural disaster implications for climate change. This is kind of affect not only for the exposure of vectors and other areas that you can, like unsafe water for example, and the tuberculosis. Farm workers are, if we take the case of Puerto Rico for example, a lot of the rural communities and farm workers were exposed and the case rate for tuberculosis was higher than other communities due to exposure to unsafe waters. And we know that these situations and extreme events are likely to happen again. We also know that there are some other consequences to extreme events like heat, hurricanes, and flooding. We know that there's going to be a food crisis or there can be food crisis or economic impacts that can contribute to migration. So there's a relationship not only to having the standards but to understand that the climate crisis is going to continue to push the stream of migration and displacement that can lead to more of this population in different states. And we know that we may have different characteristics and populations that we have to address our resources and our programs and systems to be able to support those individuals that arrive into the area that we are working. We also know that there's economic impact regarding how schools, child care, businesses were shut down due to the pandemic and how farm workers that were parents had few options regarding children. So these have not only an economic impact but also an increase of exposure to children that now were needed to be with the parents while they were working. So that's something that we have to understand too, that there are different needs in terms of economic impact and job security and child care that are accompanied by the process of just taking care of the health of farm workers. There's also food insecurity. Prior to the pandemic, researchers noticed higher rates of food insecurity among farm worker children compared to children in other poverty-striken households. Rural locations, ineligibility for supplemental food programs, or fear for exposing immigration status by enrolling in supplemental food programs may have further food insecurity levels among farm workers' families during the pandemic. In many cases, communities group and migrant health programs have been offering meals and groceries to farm workers during the pandemic, but the demand for such services remains significant. So we know that there's some issues that now are worsened or deepened by the pandemic, but they were already, as the previous presenters say, they were already there, and these situations of emergencies and public health issues are just being more visible now with the emergency that we're having. There's also the concern regarding mental health, and this is not only for farm workers and migrants. We know that the COVID-19 pandemic, there's a general increase in the population and the mental health crisis that we're having in general pediatric population, but we also now know that some of the services that were available at first were not targeting some of the populations that were at least hardest hit in this process. So we are working and we want to advocate towards having mental health response programs for farm workers and farm worker families. We also talked about this in the previous presentation, so I'm just going to refresh on that. We have, I'm sorry, we have some other vulnerabilities that make this come true, like the risk that we're seeing in COVID-19, the risk that we are going to see or are seeing regarding disasters, heat, and natural events are deepened by cultural and language difference, low wage, inherent dangers, and health risks of the occupation, immigration status, migration lifestyle, lack access to health care, and lack of regulations position. But we also know that there are communities and organizations working and that we have some best practices and ways to address this. We rely a lot in the community trust to be able to deliver some of the programs that we're looking to support farm workers during the COVID-19 pandemic and other related issues. Health centers have a critical role in preventing forest spread among those who grow, harvest, and process food. The COVID-19 pandemic has exposed these workers health protection disparities, particularly among meatpacking plants where close workers proximity and poor ventilation and rapid line work and the cool environments have accelerated the infection rate. And we saw, this is one of the board members of MCN who also works at the Virginia Garcia Health Center, we're seeing the impact but we don't have sufficient regulations and the workplace are unprepared. So we are pushing to adopt emergency regulations and to protect agricultural workers during the pandemic. We continue to see this as a front and center policy that we need to address for later on emergencies and the one that we're currently having. Across the country, we have seen some of the organizations and some of the health centers who have pivoted their efforts to keep patients safe. This is an example, the Wisconsin Farm Workers Coalition led by the Familia Health La Clinica, the only migrant health center in the state has developed a comprehensive risk mitigation strategy to protect state farm workers and to help clinicians determine a protocol for on-farm testing and education. This strategy also provides farms with best practice to ensure implementation of a statewide emergency order that aligns specific measures that must be met by farms. So this is, they have a document about how to strategize risk mitigation specifically for COVID-19 and it's something that you can be, it can be replicated not only for COVID-19 but for other emergencies that are, that can be impacting the farm worker population. It is important that we work with partnerships. I think what we are seeing with the COVID-19 response and we're seeing other states that have suffered emergencies due to climate related issues, that the way that we can do a sustainable and efficient approach is to do partnerships within workers, community health centers, state local health department, other community-based organizations, and employers. If we don't have that it's really unlikely that the policy regulations and programs are going to be sustainable and are going to be a success. We saw the new coalitions and partnerships quickly develop early in the pandemic and this is one of the papers that we published on these community-based partnerships to address health and safety. We're seeing a successful bridge being formed between workers, clinicians, and other organizations to address health related needs, ones that started with the pandemic and now are developing and sustaining into other issues as we understood that there was this was not a COVID-19 exclusive issue but also health and systems and society and policy issue. We know too that we have ways to do this and I'm closing down now, we have ways to address these issues in terms of our clinicians and clinics. We have to work in cultural adaptations, we have to work with mobility adaptations, and we have to have appropriate service-delivered models. One of the things that we have to address is that our information that we resources and tools that we develop are appropriate in language and literacy levels among other things. We have to understand that a lot of the workers that we're seeing are going to be mobile so having a bridge case management and a way to transmit electronic health records is going to be really really essential and we know that we have to have appropriate service-delivered model like mobile units or ways to have outreach that can actually get to the work sites rather than just aspiring for farm workers and this population to reach the clinics. Lastly, we still have vaccines for COVID-19 and we have some critical efforts that need to continue to make this fully accessible with culturally appropriate education and conversation available in the language that the patient understands and can answer and do these questions regarding vaccination. We have seen challenges like access to vaccines, the mobility and the second dose, time to recover from side effects. We have no no pace at Glyph so we know that farm workers are likely to want to miss days because of the side effects. Identification and some of the challenges at the beginning of vaccination procedures requiring ID so we know that some of the fear regarding the that their status as a migrant worker and then the misinformation and disinformation and how we address those issues in their language and culture. We have seen some reference in the news and documentaries regarding how social networks has an impact and how it was easy to detect misinformation and disinformation in English and how it was not addressed in Spanish. So a lot of the issues regarding this the vaccine and how their willingness to get vaccinated had to do with a lot of the energy being put into identifying only English speaking misinformation and disinformation and the challenge for organizations like Farm Worker Justice and Migrant Relations Network and other organizations community-based organizations into address what was going on in social media but in Spanish and other languages. We know that we have a long history of exceptionalism and it was we saw that being afforded down during COVID and this and seeing the disparities and injustice. So we need core regulations and policies focusing in farm worker health and safety. We need to strengthen those that we already have but we also need to do natural regulations that address the disparities and work as a system rather than just that just the policy piece. We need to address this as a system and partnership in terms of how we're going to address this population, because it's not going to work if you just have a one-way type of regulation. We need to figure out how to be more standard across states so we can address this mobile population throughout the states. We have resources at MCM web page. We also have our social media. So for those who are interested in accessing our latest resources regarding farm workers, health, COVID, and other stuff, you can subscribe to our blog or see our web page or social networks, and you can definitely reach out to us. Thank you. Thank you, Maricel. Will you be able to stick around, too, for any questions? Yeah, thank you. Appreciate that. Actually, Alexis alluded or mentioned in her talk about the Occupational Safety and Health Act of 1970. And so as you can see, I mean, we still have a long ways to go to protecting our workforce and everybody in it. Our next speaker is actually the Secretary-Treasurer for our section. That's Samah Noor. And she's coming to us from Abu Dhabi. She's the Chair of Occupational Medicine at Cleveland Clinic, Abu Dhabi. She's Clinical Assistant Professor of Medicine at Cleveland Clinic Lerner College of Medicine and Case Western Reserve University. Prior to joining Cleveland Clinic Abu Dhabi, Dr. Noor was a lead physician at Mercy Medical Center. And she received her medical degree from the Royal College of Surgeons in Ireland in 2001. She also completed her preventive medicine residency at Johns Hopkins and has dual board certification from the American Board of Preventive Medicine in occupational medicine, as well as public health and general preventive medicine. She has held various leadership positions, including medical director at Concentra Medical Centers, wellness medical expert panel at Concentra, and lead physician at General Motors in Baltimore. She currently serves as our Secretary-Treasurer and has done so very well for several years now. Welcome, Samah. So she has a recorded, Samah and Dr. Kelly Huffman have both prerecorded their presentations and had attended to be here, but the prices rose so extraordinarily for plane travel that, yeah, it was just prohibitive. Thank you. That's Samah Noor, N-O-U-R. Hi, greetings and welcome to AOHC 2022. I'm really excited to join you today. My name is Samah Noor. I'm the Chair of Caregiver Well-Being, Occupational Medicine here at Cleveland Clinic Abu Dhabi. Today, we'll be talking about prevalence and clinical correlations of COVID-19 serology assays in our institution. I have no conflict of interest, and I would like to thank Dr. Lisette Cardona and Dr. Mayadel Kalilia for their support during this study. So just to give you a little bit of background about Cleveland Clinic Abu Dhabi, we're located in the capital city. We are part of Cleveland Clinic Foundation. We serve 10 million UAE residents and nationals, out of which 80% of our population are expatriates and 20% of us are Emiratis. It's a 364-bed hospital. It's a center of excellence for heart and vascular neurology, digestive disease, respiratory, transplant, and critical care. So we are the primary referral center for all these services. Within our hospital itself, our employees are called caregivers. There is approximately 5,600 employees, out of which 1,600 are contractor population and 3,570 or so are permanent caregivers. Now, the contractor population is usually our security officers, our EVS. A lot of the blue-collar workers within the hospital fall within that contractor population. We experience COVID like everyone else. It started in February 2020. At the beginning, we had multiple strains. And as the year progressed in 2020, we were hit with the beta wave. And followed by that, we had Delta, predominantly in 2021. However, in 2022, we were hit with Omicron. But as you can see, the peaks with Omicron were not as high as in other neighboring countries or in South Africa. And I think that was largely a function of the mass surveillance and also the vaccination efforts that was done within the country. As you can see, we're a highly vaccinated population, if not the highest vaccination rates within the world. Within the United Arab Emirates, there's approximately 99.7 doses per population. Within our caregiver population, 84% of the employees and contractors have had at least three to four doses of COVID-19 vaccination. A lot of these may include combinations of Sinopharm, the Chinese vaccination, along with Pfizer. And we have multiple other permutations of these vaccinations. But within the majority of our caregiver population is vaccinated at this point. As you can see, our positivity rate within United Arab Emirates is much lower than the U.S. The highest positivity rate we had at any point was approximately 5% or so. It has been around the 2.5% or so throughout the COVID-19 pandemic. Within the Emirate of Abu Dhabi, we have very strict guidelines for entering, number one, the Emirate, but also for us working healthcare. For example, we need to get weekly swabs just to have an app stay in the green. We also need to get either vaccinated and recent PCR testing to show entry to any mall, supermarket, or cinema. In general, our positivity rate is a little bit higher than the general population, as we do expect. So our positivity rate is probably three to four times at any point in time. So we started our study early in July of 2020. And one of the things we wanted to understand was the correlations between seropositivity and PCR positivity, and whether or not that positivity remains over time. What are some of the things that affects your positivity over time? As you can see, we started weekly PCR vaccination back in 2020. At the same time, we started testing using the IgG antinucleic capsid serology testing. That was the only test that was available for us at the time. So it's a qualitative test. It tests for prior infections with COVID-19. Initially in the July, August period, we had tested approximately 400 to 500 of our caregivers. As you can imagine, a lot of them were exposed in the first phase of the epidemic. And we wanted to see within three to four months, what is the proportion of them that tested positive? We continued testing. As the assays got better, we started incorporating anti-spike, which is quite sensitive to vaccination. And more recently, Imprimeric was introduced into the market. Now, bearing in mind that in Abu Dhabi, the only vaccination that was available to all of us here was Sinopharm Beijing in August, 2020, followed by Pfizer, which we started giving in about April, 2021. So there was about an eight months period in which people were vaccinated solely with Sinopharm while we were collecting their samples. So these are the different serology assays that were available to us. So as I mentioned, we do have the nucleic acid antibody, which is more detects natural immunity. It does not, it cannot be used to distinguish post-vaccination immunity. And we also have the quantitative and anti-spike protein, which is more useful in detecting vaccination, post-vaccination immunity. For the anti-nucleic acid, we used the Roche, which has a sensitivity of 100% and specificity of 99.8%. So interestingly, when we looked at our PCR positivity rates amongst our caregivers, the highest positivity rates we did find was amongst our contractors. That surprised us a little bit because, you know, our clinical caregivers are the ones taking care of patients. So they're the ones that are dealing with COVID-19 positive patients. We went back and looked at the exposures and we found out that 85% of the exposures that we had within our caregiver community and contractor community was actually community exposures, i.e. exposure outside the hospital. So as you can imagine, in contractors where they have compact housing, where you have multiple people living in a room, that poses a risk for exposure to COVID. Now, as you can see, the risk for contractor positivity is three and a half times more than non-clinical caregivers who had the lowest, and that was significantly higher. And it didn't matter if they were vaccinated or not. In addition, also the risk for, their odds ratio of being quarantined was also significantly higher than our non-clinical counterparts. Similarly, the clinical were higher than non-clinical as expected. So they had about twice, they were twice as likely to test positive, even if they were vaccinated and to be quarantined. We did have a high proportion of the non-clinical caregivers work from home at that point, but their housing situation is a little bit different than the contractors. So working from home for them may mean exposure to one or two people. The other thing I'd like to point out is in 2022, early on, we were hit with Omicron, which is why you can see the rates were significantly higher than 2021. So in early 2021, we were highly vaccinated, and protected against the Delta virus. But as it came to 2022, the Omicron, it was more than six months after our last vaccination with Pfizer. And so those rates did pick up. So over here, we have the anti-nucleocapsid positivity by occupation. So when you look at our contractor population, you can see that early on in the pandemic, so in 2021, we had a much higher proportion of them test positive. The anti-nucleocapsid depicts the natural immunity. So you can see that these contractors were more likely than clinical and non-clinical caregivers to test positive. And again, these were people that were initially vaccinated with Sinopharm vaccine. And when it came to 2022, the serology wasn't significantly different between the all three groups. I think at that point, it was Omicron, and the time from vaccination was similar. And as you can see, the serology was similar. So we did have high levels of protection amongst all three. Now, amongst the caregivers that were testing positive using anti-nucleocapsid, what were some of the things we noticed? So the median age group was 38, very similar to our caregiver population. In general, healthcare workers here are similar, are much younger of age than the U.S., where the median age there is in the 50s. In general, the UAE population is much, much younger. We tend to be more female than male. There was no significant difference between those that tested positive using serology than those that did not. People who tested positive were more likely to be married than single. Again, when you think about exposure, so when you have more than one person living at home, you're more likely to test positive than not. In general, our COVID-19 severity wasn't a lot. We had only one mortality during the whole course of the epidemic, and it wasn't an immunosuppressed individual. We've only had a couple of people that were hospitalized. There was no difference, essentially, between those that had COVID-19 serology based on severity. Also, the symptoms were very similar in those that tested positive using serology and those that tested positive on PCR. So it was fever, cough, dyspnea, pharyngitis, very similar symptoms that we saw within those that tested positive using serology and those that did not. Now, interesting, so we went back and looked at the clinical markers to see if there was a difference. Why were some caregivers testing positive at this point, one and a half years after their initial infections and others were not? We're trying to discern what is it about either the infection that they got initially or individual factors that determined how long they remained positive with antinucleic acid serology. So the only factor that we did see that influenced potentially those that tested positive and those who were not was CRP. And interestingly, CRP is related to severity of infection. But that was the only factor that we did find. So the median CRP for those that were positive was slightly higher than the normal value. As expected, there is a significant correlation between testing positive on a serology and on nasopharyngeal swab. You can see that majority of people that tested positive on serology were also had previous known COVID-19 infection. There was only 2.2% of our total population that tested positive on serology that had no known COVID. Mind you, we're testing every week and we're checking for symptoms before the beginning of shifts. So 2.2% out of the total. So in conclusion, we said it's very highly unlikely for you to test positive in serology if you have tested negative on PCR testing. Now, what happens to those that test positive on serology? So unfortunately for people who don't want to take vaccines, that antinucleic acid antibody response declines quite rapidly, as has been shown in other studies as well. So about 50% of them will decline in about 75 days or so. Only a quarter of them actually did maintain this very, very long period of immunity. As pointed out earlier, these were people who usually had higher CRP values. So in conclusion, COVID-19 infections are much higher in healthcare workers than in normal population. Although we all work in the same hospital, we have different exposures. And in our case, 85% of these exposures were actually related to the home situation. So you have to think about compact living situations when you're dealing with special populations. Antibody response due to COVID-19 infection decreases significantly after only two months. Although for some people it remains for 200 days or so. And vaccination may affect the antibody response, but efficacy changes as we have different strains. So one of the limitations of the study is the changing serology testing that are coming and in the market. So we would have loved to use a TSA response to really understand how long the immune responses lasted within our different caregiver population. We also would have liked to have had uniform vaccination, but because this is a population-based study and different vaccinations were introduced at different times, it's hard to be able to measure the different effects that the different vaccines had on our study population. Thank you so much for listening. I welcome your questions at the end of the session. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you, Samah. I'm gonna speed into Dr. Kelly Hoffman's presentation. She's a psychologist in the Neurological Institute at the same institution, Cleveland Clinic Abu Dhabi. She's passionate about well-being and resiliency of healthcare workers and has worked with the Cleveland Clinic Abu Dhabi Occupational Health Department to develop interventions at the individual and organizational levels designed to foster resilience, prevent burnout and promote general well-being. Dr. Hoffman is a licensed psychologist both in the UAE and the USA and clinically specializes in helping patients cope with chronic health problems as well as general mental health concerns such as depression, anxiety, stress and stress. Prior to joining Cleveland Clinic Abu Dhabi, she was a clinical health psychologist in the Neurological Institute at Cleveland Clinic in the USA and she is also an educator and has held various academic appointments including as assistant professor in the Case Western Reserve University Learner College of Medicine and as adjunct faculty at Cleveland State University. Dr. Hoffman earned her PhD in counseling psychology from the University of Wisconsin-Madison and postdoctoral specialty training at Cleveland Clinic USA. Thank you. Are we gonna have time to ask our live presenters some questions or? Well. This is recorded, we could maybe see that later. Yeah, that's a good idea. We thought we would have enough time after everything but Kelly, are you able to, are you there? Yes, I'm here. Okay. Can we take a few questions? Does that work for you guys, this remote panel? Yeah. Yeah, sure, that's fine. All right, let's do that and then we'll play your presentation. Thank you. I do have a question. Okay, good. So, if we have a microphone. I don't know if there is a microphone. Well, maybe. This goes to the two presenters who talked about our migrant workers and farm workers and I was wondering if you could discuss a little bit maybe some work that you may have done with maybe some of the larger farming employers. So, obviously in the United States at least and also in Canada, there's a whole variety of size of farmers. Some of the larger companies, whether it's Corteva, Dow, Bayer slash Monsanto, have very dedicated internal environmental health and safety programs and I'm wondering, and obviously those don't cover maybe smaller farmers. Some of the smaller farmers really don't have a lot of resources but I'm wondering if just as farm worker and the other non-profit, if you have experience of working and partnering with the larger farming corporations in the United States at least. Thank you. Thank you. Alexis or Maricel, do either of you wanna respond to that question? Oh, good, there's Alexis. I can start off with that question. So Farmworker Justice is part of what's called the Equitable Food Initiative. So this is a multi-stakeholder corporate social responsibility project. Some of the employers include Andrew Williamson, Agsocio, and a number of others, Nature's Sweet Tomatoes. And then there are also, you know, Pacoon is part of it, and others are part of this Equitable Food Initiative from Worker Justice. So this is multi-stakeholder, it includes employers, and it's really about kind of, you know, providing standards for employers and ensuring the involvement of workers in the assurance of protections for the workers on these farms. They get certified, and then they are sold at stores, including at Costco. Beyond that, I know that many health centers have partnered with employers, and Maricel spoke about this a little bit. Maricel, you may wanna go into more detail, but many health centers have, and community-based organizations, have partnered with agricultural employers during the COVID-19 pandemic to provide vaccinations and testing. And I think the hope is that those partnerships will continue beyond the pandemic to ensure that farm workers have access to healthcare at all times. But Maricel, please share more. Sure. So personally, because of my location in Puerto Rico, I haven't been the one as Migrant Clinician Network doing the work, but we do have staff members in Maryland and California who have been working with multiple stakeholders. In terms of Maryland, there was a Vulnerable Population Task Force that Tyson was part of it, Tyson Foods. So that's one of the biggest ones. Sadly, it wasn't kind of like this one-to-one relationship of success story, but we do have connections with them in the process of trying to target stakeholders and multiple organizations to work together towards a goal, which is protecting the farm worker population. We also mostly work with health centers and community-based organizations that then work with those employers. So that's the way that we usually work as kind of like a network, basically, is our word or work or name, is try to foster those networks. So what we did was for our biggest program was community health worker program that was in alliance with some of the employers. So we got some of the workers trained to then do training or get some mobilization towards vaccination, testing and process, and then trying to do the connection between the community health center providing the service and then the worker having training and then the employer receiving that service and or acknowledging that service. So we do work in that way. We haven't worked in a formal collaboration, at least in my part. It might be different for other staff members, but we do foster the networking piece and the stakeholder as assistant, understanding that there are a lot of key players in the process. Thank you. You have another? Yes, she should be. Yeah. And then we'll go to the last presentation so she gets a chance to. Yeah. Hi, Dr. Andrew. I worked in Qatar for two years. We had the same experience with our contractors, our subcontractors. We actually went and looked at different groups. Doctors actually only were about 5% serology positive and nurses were 8% serology positive. Then admin were 15% serology positive. And then we had a lot of people who were in the community health center and we had a lot of people who were in the community health center and we had a lot of people who were in the community health center and we had a lot of people who were in the community health center and we had a lot of people who were in the community health center and we had a lot of people who were in the community health center and we had a lot of people who were in the community health center and we had a lot of people who were in the community health center and we had a lot of people who were in the community health center and we had a lot of people who were in the community health center and we had a lot of people who were in the community health center and we had a lot of people who were in the community health center and we had a lot of people who were in the community health center and we had a lot of people who were in the community health center and we had a lot of people who were in the community health center and we had a lot of people who were in the community health center and we had a lot of people who were in the community health center and we had a lot of people who were in the community health center and we had a lot of people who were in the community health center and we had a lot of people who were in the community health center and we had a lot of people who were in the community health center and we had a lot of people who were in the community health center and we had a lot of people who were in the community health center and we had a lot of people who were in the community health center and we had a lot of people who were in the community health center and we had a lot of people who were in the community health center and we had a lot of people who were in the community health center and we had a lot of people who were in the community health center and we had a lot of people who were in the community health center And that's how I felt in Qatar. And that's how I felt in Qatar. And that's how I felt in Qatar. And I was just wondering whether you had the same experience. whether you had the same experience. whether you had the same experience. Thank you for sharing that. Thank you for sharing that. As we mentioned on the presentation, As we mentioned on the presentation, so we did have similar findings so we did have similar findings in terms of contractors in terms of contractors versus admin workers versus admin workers but it also did change but it also did change during the course of the pandemic during the course of the pandemic because initially because initially it was mainly the contractors it was mainly the contractors that were getting infected that were getting infected as you alluded to as you alluded to a lot of it has to do a lot of it has to do with the compact housing with the compact housing and you know and you know their home situation their home situation but as the pandemic changed but as the pandemic changed and we moved from Delta and we moved from Delta to Omicron to Omicron it seemed like everybody it seemed like everybody was getting infected equally was getting infected equally just because just because it was all community based, right? it was all community based, right? So the admin staff So the admin staff had come back to work had come back to work and as they came back to work and as they came back to work they were getting exposed they were getting exposed within you know within you know whether they attended whether they attended dinners together dinners together even though even though we have limitations we have limitations in the number of people that can attend for example dinner together dinner together and things like that and things like that so my thoughts are so my thoughts are the contractors the contractors were definitely were definitely affected more affected more at every point at every point in the pandemic we were highly vaccinated we were highly vaccinated everybody had access to PPE everybody had access to PPE it's hard to tease out the socioeconomic status the socioeconomic status because we do have nationality details because we do have nationality details but we don't have income details on everyone income details on everyone and it's not and it's not easy to easy to you know divide divide we can only do it we can only do it by observation by observation essentially essentially and as I said and as I said we were highly vaccinated we were highly vaccinated and Europeans and the Americans and Europeans and the Americans were affected were affected at a very high rate as well at a very high rate as well thank you though very thoughtful questions very thoughtful questions thank you Saman thank you Alexis thank you Saman thank you Alexis and Maricel and Maricel now let's hear now let's hear from Dr. Kelly Huffman from Dr. Kelly Huffman thank you thank you thank you thank you Dr. Kelly Huffman thank you Dr. Kelly Huffman thank you it's a pleasure it's a pleasure to be here again this year to be here again this year for AOHC for AOHC my name is Dr. Kelly Huffman my name is Dr. Kelly Huffman and I'm a psychologist and I'm here today and I'm here today to talk to you about updates to talk to you about updates on a study which we previously presented about last year with preliminary data with preliminary data so for those of you who were here before I'm excited to give the updates I'm excited to give the updates the topic of this talk today is healthcare worker is healthcare worker well-being well-being during COVID-19 during COVID-19 and I would also like and I would also like to acknowledge to acknowledge all of the co-authors all of the co-authors on this study so Dr. Cardona so Dr. Cardona Dr. Knorr Dr. Knorr Salama Al-Qubaisi Salama Al-Qubaisi our research assistant our research assistant Dr. Al-Khalili Dr. Al-Khalili Dr. Lambert Dr. Lambert and Terence St. John and Terence St. John our biostatistician our biostatistician so many people so many people have contributed have contributed a great amount of effort over the past year and we're so grateful and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here and we're so grateful to have you here

COVID-19

antibodies

prevalence

Cleveland Clinic Abu Dhabi

serology assays

infection rate

disease severity

serology testing

pandemic

potential immunity

healthcare workers

UAE hospital

vaccination efforts