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October 19, 2022 12:36 PM

Order of the Health Officer of the County of Sonoma No. FLU22-01

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Please read this Order carefully.  Violation of or failure to comply with this Order is a misdemeanor and may be punishable by fine, imprisonment, or both.  (California Health and Safety Code § 120275, et seq.)


  1. Summary. This Order of the Health Officer requires specified direct care workers, health care and congregate care facilities to establish an influenza vaccination program requiring personnel to receive an annual influenza vaccination, subject to medical exemptions and disability and religious accommodation.
  2. Effective Date and Duration of this Order: This Order takes effect at 12:01 a.m. on November 1, 2022 and shall remain in effect until May 31, 2023, unless extended by order of the Health Officer due to influenza surveillance showing unusually early and/or late peaks.
  3. Basis for Order. The annual impact of influenza is well-documented, including by the Centers for Disease Control and Prevention. 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/preliminary-in-season-estimates.htm.)  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 and congregate 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 direct care, health care, and congregate facilities are at risk for influenza illness and can transmit the virus to their clients, 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. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3514716/.)  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. (Ibid.)   And studies show that comprehensive mandatory vaccination programs are associated with health care worker vaccination rates above 95%. (Ibid.)

    As Sonoma County works to manage the transmission of SARS-CoV-2 (also referred to as “COVID-19), influenza season is approaching.  The influenza 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 2022–2023 flu season. (https://www.cdc.gov/flu/season/faq-flu-season-2022-2023.htm.)

    The co-occurrence of influenza season with a possibility of another late fall/winter surge of COVID-19 may increase the risk that our health systems being overwhelmed with patients with critical respiratory illness.  Influenza is preventable with a vaccine that is currently available. (https://www.cdc.gov/flu/prevent/prevention.htm.)  Influenza vaccination has long been accepted as a safe and effective way to prevent millions of illnesses and thousands of related doctor and hospital visits every year. (https://www.cdc.gov/flu/prevent/keyfacts.htm.)

    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/Ektron%20Documents/assets/Sonoma/Sample%20Dept/Sample%20Dept/Divisions%20and%20Sections/Public%20Health/Sections/A%20Service/Services/A%20Service/_Documents/vaccination-of-healthcare-workers-for-influenza-masking-order.pdf.)  The order applied to every influenza season thereafter.

    In 2020, 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/.)

    In 2021, Sonoma County Public Health expanded the order to include certain specified health care and congregate care facilities. (http://socotestpsa.org/order-of-the-health-officer-of-the-county-of-sonoma-mandatory-influenza-vaccination-of-workers-at-health-care-facilities/.)

  4. Influenza Vaccine Verification Requirements. No later than November 1, 2022, 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 Personnel Subject to the Order to verify that they have received the 2022-23 seasonal influenza vaccine. All Personnel Subject to the Order must be in compliance by November 30, 2022.
  5. Exceptions and Accommodations. Facilities Subject to this Order may allow for medical exemptions and accommodations based upon disability or religious belief as follows:
    1. 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.
    2. Accommodations based upon disability or religious belief should be consistent with the facility’s policies and procedures for reasonable accommodations. If a facility grants accommodation due to religious belief or disability, the facility shall provide aggregate data to Sonoma County Public Health at PHNurse@sonoma-county.org every month for the Duration of this Order indicating the number or percentage of accommodations granted.
    3. Any personnel granted an exemption or accommodation 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 the facility has determined that the personnel should be exempted from wearing a face covering. The following personnel may be exempt from wearing masks:
      • Persons with a medical condition, mental health condition, or disability that prevents wearing a mask. This includes persons with a medical condition for whom wearing a mask could obstruct breathing or who are unconscious, incapacitated, or otherwise unable to remove a mask without assistance.
      • Persons who are hearing impaired, or communicating with a person who is hearing impaired, where the ability to see the mouth is essential for communication.
      • Persons for whom wearing a mask would create a risk to the person related to their work, as determined by local, state, or federal regulators or workplace safety guidelines.
  1. Definitions. For purposes of this Order, the following terms have the meanings given below.
    1. “Personnel Subject to the Order” shall mean, except where otherwise specified below in Facilities Subject to the Order, all paid and unpaid persons who work in indoor settings where (1) care is provided to individuals, or (2) persons in care have access for any purpose. This includes workers in health care or other health care settings as well as workers in residential care or other direct care 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, cosmetology, personal training, 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.
    2. “Facilities Subject to the Order” refers to an organization that employs and directs the Persons Subject to the Order in providing services, and shall apply to the following facilities:
      • 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 & Doctor Offices (including behavioral health, surgical);
      • Congregate Living Health Facilities;
      • Dialysis Centers;
      • Hospice Facilities;
      • Pediatric Day Health and Respite Care Facilities;
      • Residential Substance Abuse Treatment and Mental Health Treatment Facilities;
      • Adult & Senior Care Facilities;
      • In-Home Direct Care Settings (all 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);
      • Waiver Personal Care Services Providers and In-Home Supportive Services Providers (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);
      • Hospice Workers (who are providing services in the home or in a licensed facility);
      • Regional Center (Nurses serving clients that reside within Sonoma County and employees of Adult Residential Facilities for Persons with Special Health Care Needs (ARFPSHN));
      • Crisis Stabilization Units;
      • Psychiatric Health Facilities;
      • Mental Health Rehabilitation Facilities;
      • Pharmacies;
      • Home Health Care Workers; and,
      • Dental Offices;
  1. Interpretation. This Order is intended to apply to the facilities and persons who were subject to California Department of Public Health 2021-2022 COVID-19 Vaccination Orders, see archived orders:

Facilities who are Subject to this Order may refer any interpretation questions to Sonoma County Public Health, Disease Control Unit, at PHNurse@sonoma-county.org or (707) 565-4567.

  1. More Restrictive Order. Where a conflict exists between this Order and any state or federal public health orders, then the most restrictive provision (i.e., the more protective of public health) controls.
  2. Public Distribution. Copies of this Order shall promptly be: (1) made available at the County Administration Center at 575 Administration Drive, Santa Rosa CA 95403; (2) posted on the County Public Health Department website (https://sonomacounty.ca.gov/Health/Public-Health/) and (http://socotestpsa.org/); and (3) provided to any member of the public requesting a copy of this
  3. Severability.  If any provision of this Order to the application thereof to any person or circumstance is held to be invalid, the reminder of the Order, including the application of such part or provision to other persons or circumstances, shall not be affected and shall continue in full force and effect.  To this end, the provisions of this Order are severable.


Sundari R. Mase, MD MPH, Health Officer of the County of Sonoma

October 19, 2022