AFL 21-27 From the California Department of Public Health
August 3, 2021
TO: General Acute Care Hospitals
SUBJECT: Coronavirus Disease 2019 (COVID-19) Testing, Vaccination Verification and Personal Protective Equipment (PPE) for Health Care Personnel (HCP) at General Acute Care Hospitals (GACHs)
All Facilities Letter (AFL) Summary
This AFL requires SARS-CoV-2 diagnostic screening testing for healthcare personnel (HCP) in hospitals.
- The Public Health Order issued July 26, 2021 related to unvaccinated workers in high risk setting becomes effective August 9, 2021.
- This AFL requires hospitals to develop and implement processes for verifying the vaccination status of all HCP and for obtaining and tracking documentation of results of SARS-CoV-2 diagnostic screening testing from HCP who are unvaccinated or incompletely vaccinated and includes additional PPE requirements. These requirements are effective August 9th and should begin as soon as reasonably possible, with full compliance no later than August 23, 2021.
HCP1 working in hospitals remain at potential risk for SARS-CoV-2 exposures both in the community and in their workplace. Infected HCP can transmit to other HCP (through close contact in break rooms and other common areas) as well as to their patients. In December 2020, the California Department of Public Health (CDPH) recommended routine SARS-CoV-2 diagnostic screening testing of hospital HCP to aid in early identification and work exclusion of infected HCP, reduce transmission risk to other HCP and patients, and prevent hospital outbreaks.
On June 15, 2021, following a period of sustained low case rates and hospitalizations, California moved Beyond the Blueprint for a Safer Economy and phased out many pandemic-related non-pharmaceutical interventions and restrictions. However, coinciding with increasing circulation of more transmissible variants of the SARS-CoV-2 virus, COVID-19 incidence is rising rapidly in California and the vast majority of cases are occurring in unvaccinated individuals. Despite the availability of safe and highly effective COVID-19 vaccination, many HCP remain unvaccinated and are at high risk of acquiring COVID-19 and exposing other HCP and patients. In an ongoing effort to ensure patient safety and to minimize the spread of COVID-19 among vulnerable individuals, CDPH is requiring GACHs to develop and implement processes for verifying the vaccination status of all HCP, and for obtaining and tracking documentation of SARS-CoV-2 diagnostic screening testing of all HCP who are unvaccinated or incompletely vaccinated and to provide PPE to unvaccinated HCP.
GACHs must make their best efforts to comply with this AFL, as soon as reasonably possible, but no later than August 23, 2021. GACHs can also implement additional infection control policies beyond these requirements, as some already have.
Verifying Vaccination Status and Options for Providing Proof of Vaccination:
Per the CDPH Guidance for Vaccine Records Guidelines & Standards, only the following modes may be used as proof of vaccination:
- COVID-19 Vaccination Record Card (issued by the Department of Health and Human Services Centers for Disease Control & Prevention or WHO Yellow Card1) which includes name of person vaccinated, type of vaccine provided, and date last dose administered); OR
- a photo of a Vaccination Record Card as a separate document; OR
- a photo of the client’s Vaccination Record Card stored on a phone or electronic device; OR
- documentation of COVID-19 vaccination from a healthcare provider; OR
- digital record that includes a QR code that when scanned by a SMART Health Card reader displays to the reader client name, date of birth, vaccine dates and vaccine type; OR
- documentation of vaccination from other contracted employers who follow these vaccination guidelines and standards.
HCP may access their digital vaccination record by using the Digital COVID-19 Vaccine Record website.
In the absence of knowledge to the contrary, an employer may accept the documentation presented as valid. Facilities must have a plan in place for tracking verified worker vaccination status. Documentation of the verification must be kept on file at the facility and made available upon request by CDPH or the local public health department.
Diagnostic Screening Testing of Asymptomatic Unvaccinated or Incompletely Vaccinated HCP
- HCP who are unvaccinated or incompletely vaccinated must undergo twice-weekly SARS-CoV-2 diagnostic screening testing
- HCP who are unvaccinated or incompletely vaccinated and work no more than one shift per week must undergo weekly SARS-CoV-2 diagnostic screening testing, and the testing should occur within 48 hours before their shift
- HCP who are unvaccinated or incompletely vaccinated and work less often than weekly must undergo SARS-CoV-2 diagnostic screening testing, and the testing should occur within 48 hours before each shift
- HCP who are unvaccinated or incompletely vaccinated and do not work in areas where care is provided to patients, or to which patients do not have access for any purpose, must undergo weekly SARS-CoV-2 diagnostic screening testing
GACHs can provide antigen testing or polymerase chain reaction (PCR) testing to HCP. HCP may choose to use antigen or PCR tests provided by the GACH to satisfy this requirement. HCP that are unvaccinated or incompletely vaccinated shall be tested at the cadence specified above with either PCR testing or antigen testing. PCR testing is recommended if testing is conducted only once weekly as it is more sensitive, and more frequent testing improves outbreak prevention and control. Any PCR (molecular) or antigen test used must either have Emergency Use Authorization by the U.S. Food and Drug Administration or be operating per the Laboratory Developed Test requirements by the U.S. Centers for Medicare and Medicaid Services.
HCP that are unvaccinated or incompletely vaccinated must observe all other infection control requirements, including masking, and are not exempted from the testing requirement, even if they have a medical contraindication to vaccination, since they are still potentially able to spread the illness. Previous history of COVID-19 from which the individual recovered more than 90 days earlier or a previous positive antibody test for COVID-19 does not waive this requirement. HCP with COVID-19 should be excluded from work for the duration of their isolation period. GACHs should follow AFL 21-08.3, CDC Guidance on Mitigating Staffing Shortages, and CDC Return to Work guidance to determine when positive HCP may return to work.
Diagnostic screening testing of asymptomatic fully vaccinated HCP is not currently required. See AFL 20-88.2 for recommendations on testing for asymptomatic fully vaccinated HCP. Additionally, facilities may consider continuing routine screening testing for fully vaccinated HCP with underlying immunocompromising conditions (e.g., organ transplantation, cancer treatment), which might impact the level of protection provided by COVID-19 vaccine. However, data on which immunocompromising conditions might affect response to the COVID-19 vaccine and the magnitude of risk are not presently available.
For additional information about response testing, diagnostic testing of symptomatic HCP, diagnostic screening testing of asymptomatic fully vaccinated HCP, testing for patients, plans for use of test results, and procedures for work exclusion please refer to AFL 20-88.2.
Hospitals who conduct workplace diagnostic screening testing should have a plan in place for tracking test results, conducting workplace contact tracing and response testing, and reporting results to public health departments. There are IT platforms available that can facilitate these processes for employers. Testing is not a substitute for other COVID-19 prevention measures, such as vaccination, mask wearing, physical distancing, improved ventilation, hand hygiene, and cleaning and disinfection.
Hospitals should continue to implement strategies to increase and maintain vaccination coverage among HCP as high as possible, including verifying vaccination status of new hires, and offering education, listening sessions, counseling, and vaccination at every opportunity, even to those HCP who have previously refused.
Additional Personal Protective Equipment and Masking for Unvaccinated HCP The Aerosol Transmissible Disease (ATD) Standard (Title 8 of the California Code of Regulations section 5199) requires employees working in an area or residence where a suspected or confirmed COVID-19 case is present to use National Institute for Occupational Safety and Health (NIOSH) approved respirators. An N95 is the minimum protection permitted for these employees. A higher level of respiratory protection is required for certain medical procedures. Hospitals are covered by the ATD Standard.
The COVID-19 Emergency Temporary Standard (ETS) (Title 8, sections 3205 – 3205.4) requires employers to provide NIOSH approved respirators, such as N95s, upon request to employees who are unvaccinated or incompletely vaccinated and who are working indoors or in vehicles with more than one person.
Pursuant to the July 26, 2021 Public Health Order, all facilities identified in the Order must strictly adhere to current CDPH Masking Guidance. To the extent they are already applicable, facilities must also continue to adhere to Cal/OSHA’s standards for Aerosol Transmissible Diseases (ATD) and Emergency Temporary Standards (ETS).
In addition to respirators required under Title 8 of the California Code of Regulations, facilities must provide respirators to all unvaccinated workers who work in indoor settings where (1) care is provided to patients or residents, or (2) to which patients or residents have access for any purpose. Workers are strongly encouraged to wear respirators in all such settings. The facility must provide the respirators at no cost, and workers must be instructed how to properly wear the respirator and how to perform a seal check according to the manufacturer’s instructions, if this has not already occurred.
GACHs may submit any questions about this AFL or about infection prevention and control of COVID-19 to the CDPH Healthcare-Associated Infections Program via email at HAIProgram@cdph.ca.gov or email@example.com.
If you have any questions about state testing prioritization plans, please contact the Testing Taskforce at firstname.lastname@example.org.
Original Signed by Cassie Dunham
Acting Deputy Director
1Healthcare Personnel (HCP) refers to all paid and unpaid persons serving in healthcare settings who have the potential for direct or indirect exposure to patients or infectious materials, including body substances (e.g., blood, tissue, and specific body fluids); contaminated medical supplies, devices, and equipment; contaminated environmental surfaces; or contaminated air. HCP include, but are not limited to, nurses, nursing assistants, physicians, technicians, therapists, phlebotomists, pharmacists, students and trainees, contractual staff not employed by the healthcare facility, and persons not directly involved in patient care, but who could be exposed to infectious agents that can be transmitted in the healthcare setting (e.g., clerical, dietary, environmental services, laundry, security, engineering and facilities management, administrative, billing, and volunteer personnel). For purposes of this guidance, this does not include HCP in other buildings in a site containing a High-Risk Setting, such as a campus or other similar grouping of related buildings, unless such personnel do any of the following: (i) access the acute care or patient areas of the High-Risk Setting; or (ii) work in-person with patients who visit those areas.
2People are considered fully vaccinated for COVID-19: two weeks or more after they have received the second dose in a 2-dose series (Pfizer-BioNTech or Moderna or vaccine authorized by the World Health Organization), or two weeks or more after they have received a single-dose vaccine (Johnson and Johnson [J&J]/Janssen).