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EDMUND G. BROWN JR.
Governor

State of California—Health and Human Services Agency
California Department of Public Health


AFL 21-34.4
October 5, 2022


TO:
All Facilities

SUBJECT:
Coronavirus Disease 2019 (COVID-19) Vaccine Requirement for Healthcare Personnel (HCP)
(This AFL supersedes AFL 21-34.3)


All Facilities Letter (AFL) Summary

This AFL revision notifies all facilities of the Public Health Order – Health Care Worker Vaccine Requirement and State Public Health Order – Adult Care Facilities and Direct Care Worker Vaccine Requirement issued September 13, 2022. The routine diagnostic screening COVID-19 testing requirements for all unvaccinated exempt HCP and booster-eligible HCP who have not yet received their booster are rescinded.

Background

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 – Health Care Worker Vaccine Requirement 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.

On September 13, 2022, CDPH amended the Public Health Order – Health Care Worker Vaccine Requirement and State Public Health Order – Adult Care Facilities and Direct Care Worker Vaccine Requirement to no longer requiring routine diagnostic screening COVID-19 testing for unvaccinated HCP. These amendments were made to reflect recent CDC recommendations, the current science of the Omicron subvariants, the increases in community immunity from vaccination and infection, and increases in vaccine coverage of our healthcare workforce.

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 receive 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 VaccinePrimary vaccination seriesVaccine booster dose
Moderna or Pfizer-BionTech or any other two-dose vaccine authorized or approved by US Food and Drug Administration or World Health Organization1st and 2nd doses Booster dose at least 6 months after 2nd dose
Johnson and Johnson [J&J]/Janssen1st dose Booster dose at least 2 months after 1st dose
World Health Organization (WHO) emergency use listing COVID-19 vaccineAll 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 vaccinesAll recommended dosesSingle 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 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.

Pursuant to the Public Health Order – Health Care Worker Vaccine Requirement and State Public Health Order – Adult Care Facilities and Direct Care Worker Vaccine Requirement issued September 13, 2022, HCP are no longer required to undergo the routine SARS CoV-2 diagnostic screening testing; however, facilities should have the ability to ramp up testing at their worksite in the event it is required again at a future date. HCP may consider routine diagnostic screening testing if they have underlying immunocompromising conditions due to the greater risks such individuals face if they contract COVID-19.

For HCP who test positive, hospitals should follow AFL 21-08.8, "Guidance on Quarantine for Health Care Personnel (HCP) Exposed to SARS-CoV-2."

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. 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.

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, the agreement shall also require the contractor to maintain records 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 – Health Care Worker Vaccine Requirement and Adult Care Facilities and Direct Care Worker Vaccine Requirement, facilities and providers must maintain records demonstrating compliance with the vaccine 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

Deputy Director


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