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 five months after receiving the second dose, but the Table in the Order still reflects six 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 vaccine 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 is the definition of "family member" as it applies to this Order?

A "family member" is defined by the agency or program that provides licensing, enforcement, and/or oversight (e.g. IHSS, CDSS, CDDS etc.) for the particular facilities or services being provided.

Are Assisted Living Facilities covered by this Order?

Yes, Assisted Living Facilities are covered by this Order.

Are Long-Term Care Ombudsmen Who Provide Services in Adult and Senior Care facilities covered by this Order?

Yes. The Order requires all workers who provide services or work in Adult and Senior Care Facilities licensed by the California Department of Social Services to have the first dose of a one-dose regimen or the second dose of a two-dose regimen by November 30, 2021. This Health Order covers all paid or unpaid Long-Term Care Ombudsman representatives who provide services in those Adult and Senior Care Facilities.

Does the Order apply to California Children's Services (CCS) Medical Therapy Unit program staff or other public health staff who provide intermittent home visits?

Yes, the Public Health Order applies to all CCS Medical Therapy Unit staff, including those who conduct home visits.

Does the Order apply to outside vendors that may need to enter a facility or home (for example, those providing durable medical equipment into the home)?

Outside vendors who do not work in the facility or home for extended periods or on a regular basis are not covered by this Order. It is recommended that facilities set up daily symptom screening and antigen testing sites for vendors not covered by the Order and provide surgical masks and hand hygiene stations. Unvaccinated vendors must wear face coverings and vendors should minimize their time spent in the facility or home, if possible. Within the context of home health or similar services, the client has the right to request proof of vaccination from the vendor prior to entry.

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 Health Care Worker Protections in High-Risk Settings 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.

Who will be responsible for enforcement of the requirements under this Order?

The employer or employer-recipient is responsible for enforcement of the requirements within this Order. As defined in the Order, an "employer" refers to an organization that employs and directs the worker in providing services. An "Employer-Recipient" refers to the person receiving services from IHSS workers, WPCS workers, and independent registered home care aides. In the case of workers in a facility, the facility is the employer. In the case of certified home health aides and affiliated home care aides, the home health agencies and home care organizations are the employer. Local health jurisdictions may also enforce the requirements in the Order. 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.

How will you verify workers are vaccinated, boosted or tested?

Each facility, employer, or employer-recipient will be required to verify and keep record of vaccination status or test results. Pursuant to the CDPH Guidance for Vaccine Records Guidelines & Standards, facilities have multiple options to verify vaccine status.

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 (8) of the Order.

Who is responsible for collecting and tracking vaccine verification and declination forms?

The employer is responsible for collecting and tracking vaccine verification and declination forms. As defined in the Order, an "employer" refers to an organization that employs and directs the worker in providing services. In the case of workers in a facility, the facility is the employer. In the case of certified home health aides and affiliated home care aides, the home health agencies and home care organizations are the employer.

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 September 28, 2021.

Originally published on December 22, 2021