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All Facilities Letter 21-28
Since Thanksgiving, the statewide seven-day average case rate has increased by 34% and hospitalizations have increased by 17%. In addition, the recent emergence of the Omicron variant (it is estimated that approximately 70% of cases sequenced, nationally, are Omicron and rapid increases are occurring globally) further emphasizes the importance of vaccination, boosters, and prevention efforts, including testing, are 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, and there is evidence of immune evasion. Recent evidence also shows that among healthcare workers, vaccine effectiveness against COVID-19 infection is also decreasing over time without boosters. Consequently, current vaccine requirements of staff in health care settings are not proving sufficient to prevent transmission of the more transmissible Omicron variant. Boosters have been available in California since September 2021.
Although COVID-19 vaccination remains effective in preventing severe disease, recent data suggest vaccination becomes less effective over time at preventing infection or milder illness with symptoms, especially in people aged 65 years and older.
Based on the emergence of Omicron, additional statewide facility-directed measures are necessary to ensure we maintain adequate staffing levels within our healthcare delivery system. Additionally, given the current hospital census, even a moderate surge in cases and hospitalizations could materially impact California's health care delivery system within certain regions of the state. Accordingly, amendments to the original State Public Health Officer Order of August 5, 2021, to make boosters mandatory and to require additional testing of workers eligible for boosters who are not yet boosted, are necessary at this critical time.
The COVID-19 pandemic remains a significant challenge in California. COVID-19 vaccines are effective in reducing infection and serious disease. At present, 63% of Californians 12 years of age and older are fully vaccinated with an additional 10% partially vaccinated. California is currently experiencing the fastest increase in COVID-19 cases during the entire pandemic with 18.3 new cases per 100,000 people per day, with case rates increasing ninefold within two months. The Delta variant is highly transmissible and may cause more severe illness. In fact, recent data suggests that viral load is roughly 1,000 times higher in people infected with the Delta variant than those infected with the original coronavirus strain, according to a recent study. The Delta variant is currently the most common variant causing new infections in California.
Unvaccinated persons are more likely to get infected and spread the virus, which is transmitted through the air. Most current hospitalizations and deaths are among unvaccinated persons. Thanks to vaccinations and to measures taken since March 2020, California's health care system is currently able to address the increase in cases and hospitalizations. However, additional statewide facility-directed measures are necessary to protect particularly vulnerable populations, and ensure a sufficient, consistent supply of workers in high-risk health care settings.
Hospitals, skilled nursing facilities (SNFs), and the other health care facility types identified in this order are particularly high-risk settings where COVID-19 outbreaks can have severe consequences for vulnerable populations including hospitalization, severe illness, and death. Further, the settings in this order share several features. There is frequent exposure to staff and highly vulnerable patients, including elderly, chronically ill, critically ill, medically fragile, and disabled patients. In many of these settings, the patients are at high risk of severe COVID-19 disease due to underlying health conditions, advanced age, or both.
Vaccinations have been available in California from December 2020 to the present, and from January 1, 2021, to July 12, 2021, a total of 9,371 confirmed COVID-19 outbreaks and 113,196 outbreak-related cases were reported to CDPH. Increasing numbers of health care workers are among the new positive cases, despite vaccinations being prioritized for this group when vaccines initially became available. Recent outbreaks in health care settings have frequently been traced to unvaccinated staff members.
Vaccination against COVID-19 is the most effective means of preventing infection with the COVID-19 virus, and subsequent transmission and outbreaks. As we respond to the dramatic increase in cases, all health care workers must be vaccinated to reduce the chance of transmission to vulnerable populations.
For these reasons, COVID-19 remains a concern to public health and, in order to prevent its further spread in hospitals, SNFs, and other health care settings, new public health requirements are necessary at this time.
NOW, THEREFORE, I, as State Public Health Officer of the State of California, order:
1. All workers who provide services or work in facilities described in subdivision (a) have their first dose of a one-dose regimen or their second dose of a two-dose regimen by September 30, 2021:
a. Health Care Facilities:
i. General Acute Care Hospitalsii. Skilled Nursing Facilities (including Subacute Facilities)iii. Intermediate Care Facilitiesiv. Acute Psychiatric Hospitalsv. Adult Day Health Care Centersvi. Program of All-Inclusive Care for the Elderly (PACE) and PACE Centersvii. Ambulatory Surgery Centersviii. Chemical Dependency Recovery Hospitalsix. Clinics & Doctor Offices (including behavioral health, surgical)x. Congregate Living Health Facilitiesxi. Dialysis Centersxii. Hospice Facilitiesxiii. Pediatric Day Health and Respite Care Facilitiesxiv. Residential Substance Use Treatment and Mental Health Treatment Facilities
i. General Acute Care Hospitals
ii. Skilled Nursing Facilities (including Subacute Facilities)
iii. Intermediate Care Facilities
iv. Acute Psychiatric Hospitals
v. Adult Day Health Care Centers
vi. Program of All-Inclusive Care for the Elderly (PACE) and PACE Centers
vii. Ambulatory Surgery Centers
viii. Chemical Dependency Recovery Hospitals
ix. Clinics & Doctor Offices (including behavioral health, surgical)
x. Congregate Living Health Facilities
xi. Dialysis Centers
xii. Hospice Facilities
xiii. Pediatric Day Health and Respite Care Facilities
xiv. Residential Substance Use Treatment and Mental Health Treatment Facilities
b. Two-dose vaccines include: Pfizer-BioNTech or Moderna or vaccines authorized by the World Health Organization. The one-dose vaccine is: Johnson and Johnson [J&J]/Janssen. All COVID-19 vaccines that are currently authorized for emergency use can be found at the following links:
i. By the US Food and Drug Administration (FDA), are listed at the
FDA COVID-19 Vaccines webpage.ii. By the World Health Organization (WHO), are listed at the
WHO COVID-19 Vaccines webpage.
i. By the US Food and Drug Administration (FDA), are listed at the
FDA COVID-19 Vaccines webpage.
ii. By the World Health Organization (WHO), are listed at the
WHO COVID-19 Vaccines webpage.
c. "Worker" refers to all paid and unpaid individuals who work 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. Workers include, but are not limited to, nurses, nursing assistants, physicians, technicians, therapists, phlebotomists, pharmacists, students and trainees, contractual staff not employed by the health care facility, and 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).
2. All workers currently eligible for boosters, who provide services or work in facilities described in subdivision 1(a) must be "fully vaccinated and boosted" for COVID-19 receiving all recommended doses of the primary series of vaccines and a vaccine booster dose pursuant to Table A below.
California Immunization Requirements for Covered Workers
a. Those workers currently eligible for booster doses per the Table above must receive their booster dose by no later than February 1, 2022. Workers not yet eligible for boosters must be in compliance no later than 15 days after the recommended timeframe above for receiving the booster dose.
3. Workers may be exempt from the vaccination requirements under sections (1) and (2) only upon providing the operator of the facility a declination form, signed by the individual, stating either of the following: (1) the worker is declining vaccination based on Religious Beliefs, or (2) the worker is excused from receiving any COVID-19 vaccine due to Qualifying Medical Reasons.
a. To be eligible for a Qualified Medical Reasons exemption the worker must also provide to their employer 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).
4. If an operator of a facility listed above under section (1) deems a worker to have met the requirements of an exemption pursuant to section (3) OR deems a booster-eligible worker to have not yet received their booster dose pursuant to section (2), the worker must meet the following requirements when entering or working in such facility:
a. Test for COVID-19 with either 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 at least twice weekly for unvaccinated exempt workers and booster-eligible workers who have not yet received their booster in acute health care and long-term care settings, and at least once weekly for such workers in other health care settings. Facilities must begin testing of all booster-eligible workers who have not yet received their booster by December 27, 2021. CDPH strongly recommends that all workers in Skilled Nursing Facilities (including those that are fully vaccinated and boosted) undergo at least twice weekly screening testing.
b. 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.
5. Consistent with applicable privacy laws and regulations, the operator of the facility must maintain records of workers' vaccination or exemption status. If the worker is exempt pursuant to section (3), the operator of the facility then also must maintain records of the worker's testing results pursuant to section (4).
a. The facility must provide such records to the local or state Public Health Officer or their designee promptly upon request, and in any event no later than the next business day after receiving the request.b. Operators of the facilities subject to the requirement under section (1) must maintain records pursuant to the CDPH Guidance for Vaccine Records Guidelines & Standards with the following information: (1) full name and date of birth; (2) vaccine manufacturer; and (3) date of vaccine administration (for first dose and, if applicable, second dose).c. For unvaccinated workers: signed declination forms with written health care provider's statement where applicable, as described in section (2) above.d. Testing records pursuant to section (4) must be maintained.
d. Testing records pursuant to section (4) must be maintained.
6. Nothing in this Order limits otherwise applicable requirements related to Personal Protective Equipment, personnel training, and infection control policies and practices.
7. Facilities covered by this Order are encouraged to provide onsite vaccinations, easy access to nearby vaccinations, use of work time to get vaccinated, and education and outreach on vaccinations, including:
a. access to epidemiologists, physicians, and other counselors who can answer questions or concerns related to vaccinations and provide culturally sensitive advice; andb. access to online resources providing up to date information on COVID-19 science and research.
b. access to online resources providing up to date information on COVID-19 science and research.
8. The July 26 Public Health Order will continue to apply.
9. This Order shall take effect on December 22, 2021, and facilities must be in full compliance with the Order by February 1, 2022.
10. The terms of this Order supersede the August 5, 2021 State Health Officer Health Care Worker Vaccine Requirement Order.
11. This Order is issued pursuant to Health and Safety Code sections 120125, 120140, 120175,120195 and 131080 and other applicable law.
Tomás J. Aragón, MD, DrPH
Director and State Public Health Officer
California Department of Public Health