Why are we allowing those that had an infection after completion of their primary series to defer their booster dose?
There has been a growing body of evidence suggesting that a combination of history of SarsCoV2 vaccination and infection can lead to a strong "hybrid" immunity after recovery from infection. Additionally, there is immunological data suggesting that allowing an adequate interval between an infection and a COVID-19 vaccination dose may be important to allow quality immune memory. Thus CDPH is updating its order requiring health care workers to be fully vaccinated and boosted by March 1, 2022 to allow delay of the March 1, 2022 deadline for receiving a booster for covered workers with proof of a recent infection for up to 90 days from date of infection. This update reflects the current science and understanding as it relates to hybrid immunity in those who are fully vaccinated and then become infected.
If a worker is not eligible for a booster dose by March 1st, can they still defer any future booster doses by 90 days if they become infected with COVID-19?
Yes, if a covered worker is not eligible for a booster dose by March 1st, but then becomes infected with COVID after March 1st, but before the recommended timeframe indicated in Table A in the order, they may still defer their booster dose by 90 days from the date of infection.
For example, if a worker is not eligible for a booster dose until June 1st, but is infected with COVID-19 on May 1st, they may defer their booster dose to August 1st. Workers with a deferral due to a proven COVID-19 infection must be in compliance with the booster requirement no later than 15 days after the expiration of their deferral.
How can a worker provide proof of prior infection?
Workers must provide documentation (including date of infection) of previous diagnosis from a healthcare provider or confirmed laboratory results to provide proof of COVID-19 infection.
When does this amended order go into effect?
Effective February 22, workers who provide documentation of previous infection (after having received their full primary series of COVID-19 vaccine) may defer their booster dose for up to 90 days from date of infection. Workers with a deferral due to a proven COVID-19 infection must be in compliance no later than 15 days after the expiration of their deferral.
Those who are booster eligible, and do not provide proof of recent infection, must receive their booster dose by March 1, 2022, or within 15 days of becoming eligible for a booster if they are not eligible as of March 1, 2022.
Is contracting COVID-19 the best way to gain immunity from subsequent infection?
No. Completing the COVID-19 vaccination series, including a booster, is the safest and more dependable way to build immunity to COVID-19 than getting sick with COVID-19. The level of protection people get from infection may vary widely depending on how mild or severe the illness was, the time since infection, the variant that caused the infection, and the individual's age. Vaccine-derived immunity is much more predictable and dependable. In addition, people who get COVID-19 are at risk for potentially severe outcomes.
If I had COVID-19, why do I need the vaccine at all?
California health officials strongly recommend getting vaccinated even after a COVID-19 infection. Research shows that the vaccine is effective and can further boost your immunity. For example, some people who have had a COVID-19 infection do not produce the same antibody levels as those who got the vaccine. However, not everyone infected will develop the ability to prevent getting infected again.
Are there health risks if someone receives their booster after completing their vaccine series and recovering from COVID-19 infection?
There are no known health risks with receiving a booster dose after testing positive or receiving a clinical diagnosis of COVID-19, and information is evolving regarding the development of optimal immune memory for evolving SarsCOV-2 virus variants.
Will there be more changes to healthcare workers' requirements to get booster doses?
California has always made decisions based on science. As we continue to learn more about post-Omicron infection immunity, waning immunity in general, and what new variants may evolve, we will continue to reassess and provide updates as appropriate.
Why are we requiring booster doses?
Current vaccine requirements of staff in health care settings did not prove sufficient to prevent transmission of the more transmissible Omicron variant. Although COVID-19 vaccination remains effective in preventing severe disease, data suggest vaccination becomes less effective over time at preventing infection or milder illness with symptoms, especially in people aged 65 years and older. Boosters have been available in California since September 2021.
Accordingly, making boosters mandatory and additional testing of workers eligible for boosters who are not yet boosted are necessary.
The CDC recently updated their timeframe for those that received the Pfizer-BioNTech or Moderna vaccine to 5 months after receiving the second dose, but the Table in the Order still reflects 6 months. Which timeframe should I follow?
The Order was written based on the most current information from the CDC at the time it was issued. Covered facilities should continue to use the timeframe provided in the order. However, CDPH encourages all persons to get boosted as soon as they become eligible.
Will all vaccinated workers who have not yet received their booster be required to test?
Not necessarily. Those who are currently eligible for a booster, according to Table A in the order, would be required to test on the cadence specified in the order, until such time as they become boosted. For those workers who are vaccinated, but not yet eligible for a booster, they are not required to test, but will be required to test once they become eligible for a booster but remain unboosted.
For example, if a worker received their full series of the Moderna within the last two months, they would not be considered booster-eligible and therefore would not be required to test, but will be required if they remain unboosted 6 months after they complete the second dose of the Moderna vaccine.
In addition, vaccinated workers that defer their booster dose based on documented previous infection in the last 90 days do not have to test during those 90 days, but must self-monitor for symptoms and continue to follow all other infection control requirements, including masking, as stated in the July 26 Order. Such workers must resume testing immediately after the 90 days if they are booster eligible, but have not yet received their booster dose.
Which tests qualify for workers who have a valid exemption or for booster-eligible workers who have not yet received their booster (e.g., point of care tests, rapid tests, community testing sites)?
Antigen, PCR, or any Nucleic acid amplification (NAAT) test would qualify.
Do tests need to be approved by the FDA?
Tests must be cleared, approved, or authorized, including in an Emergency Use Authorization (EUA), by the United States Food and Drug Administration (FDA) to detect current infection with the SARS-CoV-2 virus or be operating per the Laboratory Developed Test requirements by the U.S. Centers for Medicare and Medicaid Services.
Can a worker opt to regularly test instead of getting vaccinated or boosted?
No. Testing will be an alternate means for satisfying this Order only for those who are granted an exemption pursuant to the Order.
What facilities are impacted by the order?
The following health care facilities will be impacted by the Order:
- 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 Use Treatment and Mental Health Treatment Facilities
Is it everyone in these settings or just workers who interact with patients?
It applies to all individuals who are either paid or unpaid and are in indoor settings where (1) care is provided to patients, or (2) patients have access for any purpose.
Does this Order cover those who are not directly employed by the facility, but may be providing services or care in the facility? Is there a minimum frequency of time spent within a facility that falls under this Order that would make this Order apply to those who are not technically employed by the facility but provide service within the facility?
The Order applies to any individual who works in indoor settings where (1) care is provided to patients, or (2) patients have access for any purpose. This includes workers serving in health care or other health care settings who have the potential for direct or indirect exposure to patients or SARS-CoV-2 airborne aerosols. This would include workers, who may not be directly employed by the facility, but who are providing care on site at one of the covered facilities, as well as persons not directly involved in delivering health 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).
Are Long-Term Care Ombudsmen Who Provide Services In Residential Settings Required to be Vaccinated?
The Public Health Officer Order dated August 5, 2021, requires all workers who provide services or work in certain indoor long-term care settings (e.g., skilled nursing facilities, hospice facilities, PACE Centers, etc.) receive their first dose of a one-dose regimen or their second dose of a two-dose regime by September 30, 2021. This health order covers all paid or unpaid Long-Term Care Ombudsman representatives who provide services in those indoor long-term care settings
Are High Risk Congregate Settings covered under this Order?
No. Those settings—Adult and Senior Care Facilities, Homeless Shelters, and State and Local Correctional Facilities— remain covered by the July 26 Order. Additionally, State and Local Correctional Facilities with integrated health care settings are subject to the State Public Health Officer's Order of February 7 for Correctional and Detention Centers and Adults and Senior Care Facilities are subject to the State Public Health Officer's Order of February 7 for Adult Care Facilities and Direct Care Worker Vaccine Requirement.
Are dental offices included in this Order?
No. Dental offices are not included in this Order.
Are there any exemptions to the vaccination mandate?
The Order allows for two exemptions: (1) the worker is declining vaccination based on sincerely held religious beliefs or (2) the worker is excused from receiving any COVID-19 vaccine due to Qualifying Medical Reasons. To receive an exemption, a worker must participate in their employer's interactive process.
What are Qualifying Medical Reasons?
To determine qualifying medical reasons, the physician, nurse practitioner, or other licensed medical professional practicing under the license of a physician should refer to Interim Clinical Considerations for Use of COVID-19 Vaccines from the CDC, specifically, clinical considerations, as well as contraindications and precautions. The identified contraindications include:
- Documented history of severe allergic reaction to one or more components of all the COVID-19 vaccines available in the U.S.
- Documented history of severe or immediate-type hypersensitivity allergic reaction to a COVID-19 vaccine, along with a reason why you cannot be vaccinated with one of the other available formulations.
Additionally, the Interim Clinical Considerations for Use of COVID-19 Vaccines provides information on what are neither contraindications nor precautions to COVID-19 vaccination, which includes:
- Allergic reactions (including severe allergic reactions) not related to vaccines (COVID-19 or other vaccines) or injectable therapies, such as allergic reactions related to food, pet, venom, or environmental allergies, or allergies to oral medications.
Will the State be providing a template declination / exemption form for use?
No, the State will not be providing a template declination/exemption form for use. Facilities may use any existing form or process previously used for other mandated vaccines. If an entity does not have a previously used form, they should ensure that the requirements as stated in the Order are met, including written health care provider's statement where applicable, and testing records pursuant to section (3) of the Order.
Do people exempt from vaccination need to be tested if they have had COVID in the last 90 days?
Workers meeting qualified exemptions from the vaccination requirement, who have recovered from a diagnosis of COVID-19 in the last 90 days, and remained asymptomatic, do not need to submit to testing until after 90 days has expired but must self-monitor for symptoms and continue to follow all other infection control requirements, including masking, as stated in the July 26 Order. Workers must provide documentation of previous diagnosis from a healthcare provider or confirmed laboratory results to refrain from testing. Workers must immediately follow self-isolation guidelines and resume testing if new COVID-19 symptoms occur during the 90 days post-infection.
How will you verify workers are vaccinated, boosted or tested?
Each facility will be required to verify and keep record of vaccination status or test results. Pursuant the CDPH Guidance for Vaccine Records Guidelines & Standards, facilities have multiple options to verify vaccine status.
Who will be responsible for enforcement of the requirements under this Order?
Each covered facility will be required to enforce the vaccine mandate and testing requirements of their respective staff (including any staff that may come from a contracted staffing agency).
To the extent that the covered facilities are subject to state regulation, the state's regulating entities will ensure each facility is meeting the requirements for vaccine verification/exemptions. For example, the California Department of Public Health will enforce this requirement at hospitals, skilled nursing facilities, intermediate care facilities, and the other health care facilities it licenses; and the Department of Health Care Services will enforce this requirement at residential substance use treatment and mental health treatment facilities. Local health jurisdictions may also enforce the orders.
What should a facility do if they suspect a fraudulent vaccine card is being presented as proof?
Facilities should work with their counsel and may report suspected cases of healthcare fraud to the U.S. Health and Human Services through their tip line at 1-800-HHS-TIPS or by using other ways to contact the hotline.
When did the original Order take effect?
The original Order went into effect August 5, 2021.
Will the July 26 Public Health Order continue to apply?
Will this take staff away from already busy hospitals?
Keeping both workers and patients safe is our top priority and the purpose of this Order. We do not believe it will take staff away from already busy hospitals.
Is California the first to do this?
We are not aware of another state with such comprehensive requirements.
Originally published on December 22, 2021