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TO: General Acute Care Hospitals, Skilled Nursing Facilities (including Subacute Facilities), Intermediate Care Facilities, Acute Psychiatric Hospitals, Adult Day Health Care Centers, Adult Day Programs licensed by California Department of Social Services, Program of All-Inclusive Care for the Elderly (PACE) and PACE Centers, Ambulatory Surgery Centers, Chemical Dependency Recovery Hospitals, Clinics & Doctor Offices (including behavioral health, surgical), Senior Care Facilities licensed by the Department of Social Services, Dialysis Centers, Hospice Facilities, Hospice Workers in Senior Care and Skilled Nursing Facilities, Pediatric Day Health and Respite Care Facilities, Residential Substance Abuse Treatment Facilities, Psychiatric Health Facilities, Mental Health Rehabilitation Facilities, Pharmacies, Home Health Care Workers, and Dental Offices.

RE: Mandatory Influenza Vaccination of Workers at Health Care and Specified Facilities

The annual impact of influenza is well-documented, including by the Centers for Disease Control and Prevention (“CDC”).  Influenza is a seasonal disease that infects tens of millions in the United States each year and can result in serious medical outcomes, including hospitalizations and death. (https://www.cdc.gov/flu/about/burden/2019-2020.html.)  It is a respiratory pathogen, and its impact can be greatly lessened through broad utilization of the annual influenza vaccine in combination with other effective public health measures, such as universal masking in high-risk settings, maintaining good hand hygiene, as well as maintaining good daily healthy personal habits, such as good nutrition and physical exercise. https://www.cdc.gov/flu/prevent/prevention.htm)

Patients and residents in our health care facilities, especially young children, pregnant women, the elderly, and those with chronic health conditions, are at greater risk for influenza-related hospitalizations and death. (https://www.cdc.gov/flu/highrisk/index.htm.)  Workers in health care and congregate facilities are at risk for influenza illness and can transmit the virus to their patients and coworkers.  Moreover, influenza-related illness in health care workers can cause absenteeism, placing further strain on our limited health care resources, and is preventable by means of annual vaccination. (Ibid.)  The United States Office of Disease Prevention and Health Promotion’s Healthy People 2020 objectives includes a target of 90% seasonal influenza vaccination rate for all health care personnel.  And studies show that comprehensive mandatory vaccination programs are associated with health care worker vaccination rates above 95%.

As Sonoma County works to reduce transmission of SARS-CoV-2 (also referred to as “COVID-19), influenza season is approaching.  The flu viruses and COVID-19 will likely be spreading at the same time, and relaxed COVID-19 mitigation measures (such as stay-at-home orders, or mask mandates) may result in an increase in flu activity during the upcoming 2021–2022 flu season. (https://www.cdc.gov/flu/season/faq-flu-season-2021-2022.htm.)  Furthermore, “[r]educed population immunity due to lack of flu virus activity since March 2020 could result in an early and possibly severe flu season.”(Ibid.)

Since at least 2017, Sonoma County required that all health care facilities establish an influenza vaccination program requiring that all health care workers providing direct patient care receive an annual influenza vaccine or wear a mask. (https://sonomacounty.ca.gov/Health/Public-Health/Disease-Control/Health-Advisory-Influenza-October-2-2017/.)  The order applied to every influenza season thereafter.

Last year, Sonoma County Public Health expanded the order to require that all health care and specified congregate care facilities establish an influenza vaccination program requiring all staff to receive an annual influenza vaccination, subject to medical exemptions and religious accommodation. (https://sonomacounty.ca.gov/Mandatory-Flu-Vaccines-for-Healthcare-Staff/.)

This year, Sonoma County Public Health will expand the order to require all persons working in certain specified health care and congregate care facilities to establish an influenza vaccination program requiring all workers to receive an annual influenza vaccination, subject to medical exemptions and religious accommodation.

Legal Authority:

The Health Officer has the authority to “take measures as may be necessary to prevent and control the spread of disease within the territory under their jurisdiction” (Health and Safety Code §120175).  State law requires that general acute care hospitals and certain other health care facilities offer influenza vaccination to employees and, for those employees who decline vaccination, maintain a record of the signed declination form (Health and Safety Code §1288.7; 8 Cal. Code Regs §5199: Aerosol Transmissible Diseases Standard of Cal OSHA, effective September 1, 2010).

Order:                                                                                                      

No later than November 1, 2021, all Facilities Subject to the Order in Sonoma County must implement an influenza vaccine verification program through the Duration of this order that requires all Persons Subject to the Order to verify that they have received the 2021-22 seasonal influenza vaccine.

All Persons Subject to the Order must be in compliance by November 15, 2021.

Duration:

Influenza season starts November 1st and ends May 1st.  If influenza surveillance shows unusually early and/or late peaks, the order may be extended.

Persons Subject to the Order:

This order applies to all paid and unpaid persons serving in health care or specified congregate settings who have the potential for direct or indirect exposure to patients/clients/residents or influenza airborne aerosols. Workers include, but are not limited to, nurses, nursing assistants, physicians, technicians, therapists, phlebotomists, pharmacists, students and trainees, contractual staff not employed by the covered facility, and persons not directly involved in patient care, but who could be exposed to infectious agents that can be transmitted in the covered setting (e.g., clerical, dietary, environmental services, laundry, security, engineering and facilities management, administrative, billing, and volunteer personnel).  To the extent that remote workers, or those not working within these facilities, do not meet this definition, then they would not be covered by this order.

Facilities Subject to the Order:

This order applies to the following covered facilities:

• General Acute Care Hospitals;
• Skilled Nursing Facilities (including Subacute Facilities);
• Intermediate Care Facilities;
• Acute Psychiatric Hospitals;
• Adult Day Health Care Centers;
• Adult Day Programs licensed by California Department of Social Services;
• Program of All-Inclusive Care for the Elderly (PACE) and PACE Centers;
• Ambulatory Surgery Centers;
• Chemical Dependency Recovery Hospitals;
• Clinics & Doctor Offices (including behavioral health, surgical);
• Dialysis Centers;
• Hospice Facilities;
• Hospice Workers in Senior Care Facilities and Skilled Nursing Facilities;
• Pediatric Day Health and Respite Care Facilities;
• Residential Substance Abuse Treatment;
• Crisis Stabilization Units;
• Psychiatric Health Facilities
• Mental Health Rehabilitation Facilities;
• Pharmacies;
• Home Health Care Workers; and,
• Dental Offices;

Exceptions and Accommodations:

Any person granted an exemption according to this section must 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 indoor work settings, unless exempted from wearing a face covering under Cal/OSHA COVID-19 Emergency Temporary Standards and/or the Cal/OSHA Aerosol Transmissible Diseases Standards.

Facility mandatory influenza vaccination programs may allow for a medical exemption.  Medical exemptions must be based upon a written recommendation from the primary health care provider that the person should be medically exempted from receiving an influenza vaccination.

Facility mandatory influenza vaccination programs may also allow requests for accommodation based on disability or religious belief consistent with the facility’s policies and procedures for reasonable accommodation.  If a facility grants accommodation due to religious belief or disability, the facility shall provide aggregate data to Sonoma County Public Health every month indicating the number or percentage of accommodations granted.

For any additional questions, please contact Sonoma County Public Health, Disease Control Unit, at PHNurse@sonoma-county.org or (707) 565-4567

Thank you for your role in flattening the curve and protecting our county’s most vulnerable residents.

Sincerely,

Dr. Sundari R. Mase, MD MPH

Health Officer of the County of Sonoma