Coronavirus Disease 2019 (COVID-19) Vaccine Requirement for Healthcare Personnel (HCP)

AFL 21-34.3 From the California Department of Public Health

February 22, 2022

TO: All Facilities

SUBJECT: Coronavirus Disease 2019 (COVID-19) Vaccine Requirement for Healthcare Personnel (HCP)
(This AFL supersedes AFL 21-34.2)

AUTHORITY: State Public Health Order – Health Care Worker Vaccine Requirement
State Public Health Order – Adult Care Facilities and Direct Care Worker Vaccine Requirement

All Facilities Letter (AFL) Summary

This AFL notifies all facilities of the August 5, 2021 Public Health Order related to mandatory vaccination for healthcare workers in identified healthcare settings.
This AFL requires all HCP who provide services or work in healthcare facilities[i] to have received either the first dose of a one-dose regimen or their second dose of a two-dose regimen no later than September 30, 2021, unless exempt.
This AFL notifies all facilities of the September 28, 2021 Public Health Order that establishes COVID-19 vaccination requirements for settings in which direct care and services[ii] are provided, and were not included in the August 5, 2021 Public Health Order. Direct care workers must receive either the first dose of a one-dose regimen or their second dose of a two-dose regimen no later than November 30, 2021, unless exempt. This includes the following:
- All in-home direct services workers, including registered home care aides and certified home health aides, except for those workers who only provide services to a recipient with whom they live or who are a family member of the recipient for whom they provide services
- All hospice workers who are providing services in the home or in a licensed facility
Facilities and providers must document HCP COVID-19 vaccination or exemption status by the following dates to be in compliance with the public health orders:
- Healthcare facilities: September 30, 2021
- Home health agencies and hospice providers: November 30, 2021
This AFL revision notifies all facilities of the February 22, 2022 Public Health Order and requires HCP to be up to date with vaccinations and receive boosters by March 1, 2022, unless exempt. The revision also allows HCP who have completed their primary vaccination series and provide proof of subsequent COVID-19 infection may defer booster administration for up to 90 days from the date of clinical diagnosis or first positive test, which in some situations, may extend the booster dose requirement beyond March 1st. This revision also updates the testing requirements to require at least twice weekly COVID-19 testing for unvaccinated exempt HCP and booster-eligible HCP who have not yet received their booster in an acute care or long-term care setting and requires at least weekly COVID-19 testing such HCP other health care settings.

Background

Coinciding with increasing circulation of more transmissible variants of the SARS-CoV-2 virus, COVID-19 cases are rising rapidly with the majority of cases occurring in unvaccinated individuals. The recent emergence of the Omicron variant further emphasizes the importance of vaccination, boosters, and prevention efforts, including testing and masking, needed to continue protecting against COVID-19. Early data also suggest the increased transmissibility of the Omicron variant is two to four times as infectious as the Delta variant. Recent evidence also shows that among healthcare workers, vaccine effectiveness against COVID-19 infection is also decreasing over time.

In an ongoing effort to ensure patient safety and to minimize the spread of COVID-19 among vulnerable individuals, the California Department of Public Health (CDPH) is requiring COVID-19 vaccination for all HCP who provide services or work in healthcare facilities or direct care settings. Direct care workers include, but are not limited to, the following:

All in-home direct services workers, including registered home care aides and certified home health aides, except for those workers who only provide services to a recipient with whom they live or who are a family member of the recipient for whom they provide services
All hospice workers who are providing services in the home or in a licensed facility

HCP must have completed the vaccination series of either the first dose of a one-dose regimen or their second dose of a two-dose regimen by the following dates:

HCP in healthcare facilities: September 30, 2021
HCP in direct care settings: November 30, 2021

In accordance with the Public Health Order issued February 22, 2022, CDPH is requiring HCP to be up to date with vaccinations and receive boosters by March 1, 2022, unless exempt. HCP who have completed their primary vaccination series and provide proof of subsequent COVID-19 infection may defer booster administration for up to 90 days from the date of clinical diagnosis or first positive test, which in some situations, may extend the booster dose requirement beyond March 1st. HCP not yet eligible for boosters or who show proof of infection must be in compliance no later than 15 days after the recommended timeframe for receiving the booster dose. Additionally, COVID-19 testing must occur at least twice weekly for unvaccinated exempt HCP and booster-eligible HCP who have not yet received their booster in an acute care or long-term care setting and at least once weekly for such HCP in other health care settings. Facilities and providers can also implement additional infection control policies beyond these requirements, as some already have.

Vaccination Requirement

HCP subject to the vaccine requirement include all paid and unpaid individuals who work in indoor settings where care is provided to patients, or patients have access to for any purpose. This includes HCP serving in healthcare or other healthcare/direct care settings who have the potential for direct or indirect exposure to patients or SARS-CoV-2 airborne aerosols.

HCP include, but are not limited to, the following:

Direct supportive services staff
Hospice providers
Nurses
Nursing assistants
Physicians
Technicians
Therapists
Registered home care aides
Certified home health aides
Phlebotomists
Pharmacists
Students and trainees
Contractual staff not employed by the healthcare facility
Persons not directly involved in patient care, but who could be exposed to infectious agents that can be transmitted in the health care setting (e.g., clerical, dietary, environmental services, laundry, security, engineering and facilities management, administrative, billing, and volunteer personnel).

All HCP who provide services or work in health care facilities must be “up to date” on COVID-19 vaccination by receiving all recommended doses of the primary series of vaccines and a vaccine booster dose pursuant to the following table.

CALIFORNIA IMMUNIZATION REQUIREMENTS FOR COVERED HCP

COVID-19 Vaccine	Primary vaccination series	Vaccine booster dose
Moderna or Pfizer-BionTech	1^st and 2nd doses	Booster dose at least 6 months after 2^nd dose
Johnson and Johnson [J&J]/Janssen	1st dose	Booster dose at least 2 months after 1^st dose
World Health Organization (WHO) emergency use listing COVID-19 vaccine	All recommended doses	Single booster dose of Pfizer-BioNTech COVID-19 vaccine at least 6 months after getting all recommended doses
A mix and match series composed of any combination of FDA-approved, FDA-authorized, or WHO-EUL COVID-19 vaccines	All recommended doses	Single booster dose of Pfizer-BioNTech COVID-19 vaccine at least 6 months after getting all recommended doses

Those HCP currently eligible for booster doses per the Table above must receive their booster dose by no later than March 1, 2022. HCP who have completed their primary vaccination series and provide proof of COVID-19 infection may defer booster administration for up 90 days from date of clinical diagnosis or first positive test, which in some situations, may extend the booster dose requirement beyond March 1st. Workers not yet eligible for boosters or who show proof of infection must be in compliance no later than 15 days after the recommended timeframe above for receiving the booster dose.
Regardless of primary vaccine received, any of the COVID-19 vaccines authorized in the United States may be used for the booster dose, but either Moderna or Pfizer-BionTech are preferred.

Vaccination Exemptions

HCP may be exempt from the vaccination requirements only upon providing the facility operator or employer a written declination statement, signed by the HCP stating either:

The worker is declining vaccination based on religious beliefs; or
The worker is excused from receiving any COVID-19 vaccine due to Qualifying Medical Reasons.

To be eligible for a Qualified Medical Reasons exemption, the HCP must also provide their employer with a written statement signed by a physician, nurse practitioner, or other licensed medical professional practicing under the license of a physician stating that the individual qualifies for the exemption (but the statement should not describe the underlying medical condition or disability) and indicating the probable duration of the worker’s inability to receive the vaccine (or if the duration is unknown or permanent, so indicate). The employer may request documentation of a medical exemption or a religious exemption in accordance with federal and state antidiscrimination law.

If an operator of a facility or employer deems a worker to have met the requirements of an exemption, the unvaccinated exempt worker must meet the following requirements when entering or working in such facility or home:

Test for COVID-19 with either molecular (e.g. PCR) or antigen test that either has 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.
- Testing must occur twice weekly for unvaccinated exempt workers in acute health care and long-term care settings, and testing must occur once weekly for workers in direct care settings and other health care settings.
- HCP that provide care to patients in outpatient clinics that are not in the main hospital are not workers in the acute health care setting; for these unvaccinated exempt workers, testing must occur weekly.
- Unvaccinated exempt workers who work no more than one shift per week must undergo SARS-CoV-2 diagnostic screening testing within 48 hours of each shift. Unvaccinated exempt workers who work less frequently than weekly must undergo SARS-CoV-2 diagnostic screening testing within 48 hours of each shift.
Wear a surgical mask or higher-level respirator approved by the National Institute of Occupational Safety and Health (NIOSH), such as an N95 filtering facepiece respirator, at all times while in the facility or in the home providing care.

For HCP who test positive, hospitals should follow AFL 21-08.7, “Guidance on Quarantine for Health Care Personnel (HCP) Exposed to SARS-CoV-2.” Twice weekly or weekly testing is not necessary during quarantine.

Authorized Vaccine Options

The following vaccines are available:

Two-dose vaccines: Pfizer-BioNTech, Moderna, or vaccine authorized by the World Health Organization.
One-dose vaccine: Johnson and Johnson [J&J]/Janssen.

For more information regarding COVID-19 vaccines that are currently authorized for emergency use, please refer to the Food and Drug Administration COVID-19 Vaccines webpage and/or the World Health Organization COVID-19 Vaccines webpage.

To get vaccinated, HCP can check with their healthcare provider, the Centers for Disease Control’s Find Vaccines webpage, or California’s My Turn webpage.

HCP Vaccination Records

Consistent with applicable privacy laws and regulations, the operator of the facility or employer must maintain records of workers’ vaccination or exemption status. The facility operator or employer must maintain records of the workers’ testing results as described above. Facilities and providers must provide such records to CDPH, the local or state Public Health Officer, or their designee immediately upon request or by no later than the next business day after receiving the request.

Operators of healthcare facilities must maintain vaccination records per the July 26, 2021 Public Health Order. Additionally, facilities and providers must ensure the records are in compliance with CDPH Guidance for Vaccine Records Guidelines & Standards and contain the following information:

Full name
Date of birth
Vaccine manufacturer
Date of vaccine administration (for first dose and, if applicable, second dose).

If a contractor or vendor has entered into an agreement to verify and document HCP vaccination/exemption status or test results, the agreement shall also require the contractor to maintain records per the July 26, 2021, Public Health Order and provide such records to CDPH, the local or state Public Health Officer, or their designee immediately upon request or by no later than the next business day after receiving the request. The operator of the facility shall maintain a record of the agreement on-site.

Facility/Provider Policies and Procedures

Pursuant to the Public Health Order of August 5, 2021 and Public Health Order of September 30, 2021, facilities and providers must maintain records demonstrating compliance with the vaccine and testing requirements for HCP described in this AFL. Facilities and providers that do not present records demonstrating compliance with the Public Health Orders may be subject to enforcement actions by CDPH. CDPH recommends facilities and providers update their policies and procedures to address vaccination and documentation requirements.

If you have any questions about this AFL, please contact the CDPH Healthcare-Associated Infections Program via email at HAIProgram@cdph.ca.gov.

Sincerely,

Original signed by Cassie Dunham

Cassie Dunham
Acting Deputy Director

Resources:

[i]Healthcare facilities include: general acute care hospitals, skilled nursing facilities (including subacute facilities, intermediate care facilities, acute psychiatric hospitals, adult day health care centers, Program of All-Inclusive Care for the Elderly (PACE) and PACE centers, ambulatory surgery centers, chemical dependency recovery hospitals, clinics and doctor offices, congregate living health facilities, dialysis centers, hospice facilities, pediatric day health and respite care facilities, and residential substance use treatment and mental health treatment centers

[ii] Direct care settings include: home health agencies, hospice providers, adult and senior care facilities, waiver personal care services providers, and regional centers serving individuals with developmental and intellectual disabilities