DHMH POLICY

DEPARTMENT OF HEALTH & MENTAL HYGIENE

Office of Regulation and Policy Coordination

201 W. Preston Street – Suite 512 – Baltimore, Maryland 21201-2301

Phone 410 767-6499 FAX 410-767-6483

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DHMH POLICY

http;//www.dhmh.state.md.us/policies/inpolm.htm

OFFICE OF INFECTIOUS DISEASE EPIDEMIOLOGY AND OUTBREAK RESPONSE

DHMH POLICY 03.02.04

(OIDEOR) / Prevention and Health Promotion Administration (PHPA) / DSPHS and DSO

Effective Date: November 12, 2015

POLICY ON

INFLUENZA VACCINATION FOR DHMH EMPLOYEES

WORKING IN STATE FACILITIES, LOCAL HEALTH

DEPARTMENT CLINICAL BUILDINGS, FORENSIC

RESIDENTIAL CENTERS, STATE RESIDENTIAL

CENTERS, AND CHRONIC DISEASE CENTERS

I. EXECUTIVE SUMMARY

This policy requires DHMH employees and local health department employees working in

certain clinical settings, including all State facilities, as defined under Health-General Article

§10-101 and §10-406, forensic residential centers (SETTs), DHMH-operated state residential

centers (Holly Center and Potomac Center) and chronic disease centers (Deer’s Head and

Western Maryland) to be vaccinated annually for influenza and to provide documentation to their

DHMH employer of the vaccination. This policy sets forth the background for the policy; the

definitions related to the policy; the authority for the policy; and certain exceptions to the

requirement it otherwise imposes.

II. BACKGROUND

Influenza (“Flu”) seasons are unpredictable and can be severe. Over a period of 30

years, between 1976 and 2006, estimates of flu-associated deaths in the United States range

from a low of about 3,000 to a high of about 49,000 people. In Maryland, each year about 4,000

Maryland residents are hospitalized and around a thousand die from flu.

Flu season severity can vary widely from one season to the next depending on many

things, including:

DHMH POLICY 03.02.04 INFLUENZA

VACCINATION POLICY

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This version DHMH Policy 03.02.04 effective November 12, 2015 combines and supersedes DHMH Policy

03.02.02 and DHMH Policy 03.02.03 both dated October 10, 2014.

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1. What flu viruses are spreading;

2. How much flu vaccine is available;

3. When vaccine is available;

4. How many people get vaccinated; and

5. How well the flu vaccine is matched to flu viruses that are causing illness.

Since 1981, the federal Centers for Disease Control and Prevention (“CDC”) have

recommended that healthcare workers receive annual influenza vaccinations to protect staff and

patients. Numerous studies in the medical literature reveal the risk of person-to-person

transmission of influenza illness in the healthcare setting (References: 1-7), and that annual

influenza vaccination of healthcare facility staff is a tool to reduce illnesses that occur in patients

in both acute and long term care (References: 8-13) settings. Other data show that up to 75%

of healthcare workers continue to work with influenza (References: 14-17), increasing the risk of

influenza transmission, and that influenza illness is associated with an excess of absenteeism

among healthcare workers (References: 18-22). Research has shown that hospitalized patients

exposed to healthcare workers with influenza like illness (ILI) were at a greater than 5 times risk

of developing healthcare-associated ILI than if not exposed, and that a 2-fold greater risk of ILI

exists in the hospital compared to within the community (Reference: 8).

The Infectious Diseases Society of America, the Society for Healthcare Epidemiology of

America, and the Pediatric Infectious Diseases Society support universal immunization of

healthcare workers by healthcare employers, without an opt-out for discretionary refusal.

Although some voluntary programs, when combined with strong institutional leadership and

robust educational campaigns, have been effective in encouraging healthcare workers to

become vaccinated, mandatory programs are the most effective way to increase vaccination

rates. The infectious disease and epidemiological societies have recommended that, when less

than 90% of an institution’s work force has not been vaccinated, the facility should mandate

vaccination as a condition of employment, unpaid service, or receipt of professional privileges.

In Maryland’s private hospitals, voluntary and opt-out vaccination strategies have not been

effective in markedly increasing vaccination rates. Therefore, in 2010, the Maryland Hospital

Association released a policy statement recommending mandatory vaccination policies. Today,

almost all hospitals in Maryland, including the Johns Hopkins Health System and the University

of Maryland Medical System, have mandated that their healthcare workers become vaccinated

for influenza, allowing workers to refuse only for documented medical and religious reasons.

Under this policy, DHMH employees at Local Health Departments, state facilities,

chronic disease centers and state residential centers may decline to be vaccinated for

documented medical or religious reasons only. Many of the patients at these facilities have

chronic conditions that increase their risk for influenza-associated morbidity and mortality. For

example, individuals at Holly Center and Potomac Center can have impaired lung function as a

result of developmental delays, difficulties with immobility, and orthopedic conditions. This would

make them more vulnerable to death from influenza. The DHMH influenza policy reinforces the

importance of patient safety standards and employee wellness protections.

The flu vaccination is covered for all State employees enrolled in the State employee

health plan with no co-payment if the vaccination is provided by the in-network provider during

a routine office visit and is also covered at many pharmacies with which a carrier in the State

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VACCINATION POLICY

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This version DHMH Policy 03.02.04 effective November 12, 2015 combines and supersedes DHMH Policy

03.02.02 and DHMH Policy 03.02.03 both dated October 10, 2014.

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health plan has made a special arrangement. Local Health Departments and State Facilities

are encouraged to provide on-site vaccination clinics for all covered employees as part of this

policy, subject to financial appropriations.

III. LEGAL AUTHORITY

Under Health-General Article §2-102(b) (2), the Secretary is responsible for the

operation of the Department, including the forensic residential centers operated under the

Developmental Disabilities Administration. Health-General Article §10-401 places all State

psychiatric facilities under the general supervision of the Director of the Behavioral Health

Administration, Health-General Article §19-502 charges the Secretary with operating chronic

disease centers in the State, and Health-General Article §7-501 establishes State residential

centers for individuals with an intellectual disability in the Department’s Developmental

Disabilities Administration, each of which is operated under the direction of an administrative

head appointed by the Director of DDA. In addition, Health-General Article §§18-102 and 18-

103 authorize the Secretary to adopt rules and regulations necessary to prevent the spread of

infectious diseases and to devise means to control those diseases. The regulations adopted by

the Secretary pursuant to that authority require the Secretary to take actions to prevent the

spread of communicable diseases and authorize the Secretary to issue special instructions for

control of a disease.

IV. POLICY STATEMENTS

A. Definitions

1. "Clinical building" means any building in which persons receive

healthcare.

2. "Covered employees" means full-time, part-time, permanent, temporary,

and contractual workers, and independent licensed consultants of DHMH

and local health departments who regularly work in clinical buildings

operated by a local health department, at a State facility, as that term is

defined under Health-General Article §10-101 and §10-406, at a forensic

residential center operated by the Department, at State residential

centers (Holly Center and Potomac Center), or at a chronic disease

center (Deer’s Head Hospital Center and Western Maryland Hospital

Center).

3. “Covered facility” means clinical buildings operated by a local health

department, State facilities, as that term is defined under Health-General

Article §10-101 and §10-406, forensic residential centers, Holly Center,

Potomac Center, Deer’s Head Hospital Center and Western Maryland

Hospital Center.

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VACCINATION POLICY

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This version DHMH Policy 03.02.04 effective November 12, 2015 combines and supersedes DHMH Policy

03.02.02 and DHMH Policy 03.02.03 both dated October 10, 2014.

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4. "Declination form" means a form developed by the Department to

document an employee or licensed independent consultant declination of

influenza vaccine.

5. "Documentation of required vaccinations" means a printed receipt, card or

statement from the vaccinator clearly indicating that an influenza

vaccination was provided to the individual, by whom, and on what date.

6. "Independent licensed consultants" means persons licensed by a health

occupations licensing board who provide patient care in DHMH facilities

and local health departments.

7. "Influenza season" is defined by the Centers for Disease Control and

Prevention each season.

a. CDC or DHMH may modify the dates of the season if

epidemiological information indicates the necessity for a modification.

b. Covered employees, employed or hired during the influenza

season, shall be subject to this policy.

B. Policy

1. To protect patients, all covered employees shall be vaccinated against

influenza by December 15 of each year.

2. Each covered facility’s governing unit shall designate an influenza control

coordinator by November 1 of each year to ensure procedures are followed,

proper documentation collected, and required reporting is completed and

submitted in the manner and time required.

3. Each covered facility shall have an influenza infection control plan in

place by November 1 of each year. It shall be approved by the Prevention and

Health Promotion Administration prior to that date. By regulation, all facilities

operated by the Department are required to have infection control programs.

See COMAR 10.07.01.34; 10.07.02.21; 10.07.13.04D; 10.07.20.05C.

4. Each covered employee shall by December 15 of each year:

a. Receive a vaccination;

b. Provide documentation of required vaccination if the vaccination

was received elsewhere; or

c. Sign a declination form.

DHMH POLICY 03.02.04 INFLUENZA

VACCINATION POLICY

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This version DHMH Policy 03.02.04 effective November 12, 2015 combines and supersedes DHMH Policy

03.02.02 and DHMH Policy 03.02.03 both dated October 10, 2014.

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5. The declination form shall provide for two exemptions:

a. The vaccine (intranasal, intramuscular or intradermal) is medically

contraindicated (including a severe egg allergy, severe allergy to any

vaccine component, severe reaction after a previous dose of influenza

vaccine, a history of Guillain-Barre Syndrome, or other vaccine-

specific medical contraindication) for the employee; or

b. Vaccination (intranasal, intramuscular or intradermal) is against

the employee’s bona fide religious beliefs.

6. After being fully informed of the health risks to patients/clients and other

staff associated with transmission from an unvaccinated person and the

educational requirements, if the employee refuses the vaccine and does not

meet at least one of the two exemptions (medical contraindication or bona fide

religious beliefs) the employee shall be subject to disciplinary action, pursuant to

Annotated Code of Maryland, State Personnel and Pensions, Title 11-104 and

11-106. See Disciplinary Measures, section V, of this policy.

7. All employees who are not vaccinated by December 1 of each year shall

receive educational information by December 15 of that year. The education

information will include information about: vaccine and vaccine

recommendations; vaccine safety; patient/client safety including the

consequences/complications of flu among highest risk individuals; employee’s

safety and protection of family and friends; decreased absenteeism resulting

from influenza vaccination coverage. CDC responses to common excuses for

declining flu vaccine can be found at:

http://www.cdc.gov/flu/pdf/freeresources/general/no-excuses-flu-vaccine.pdf

V. DISCIPLINARY MEASURES

1. Appointing authority shall consider disciplinary action for the following related to this

policy:

a. Employee refuses to sign the declination form;

b. Employee who was vaccinated elsewhere does not comply with

documentation

Requirements; and

c. Employee declines the vaccination outside of the acceptable declination

reasons.

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This version DHMH Policy 03.02.04 effective November 12, 2015 combines and supersedes DHMH Policy

03.02.02 and DHMH Policy 03.02.03 both dated October 10, 2014.

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2. In accordance with §11-106 of the State Personnel and Pensions Article of the

Annotated Code of Maryland and prior to taking any disciplinary action related to any

violation of this policy, the appointing authority shall:

a. Investigate the alleged vaccination policy violation;

b. Meet with the employee;

c. Consider any mitigating circumstances;

d. Determine the appropriate disciplinary action, if any, to be

imposed; and,

e. Give the employee a written notice of the disciplinary action to be

taken and the employee's appeal rights.

3. Any disciplinary action must be imposed within the time limits prescribed by law and

regulation.

VI. OTHER PROCEDURES

1. Influenza Coordinators for each covered facility shall report to the Deputy Secretary

for Public Health Services on employee vaccination rates. Standard declination forms

and reporting survey forms shall be provided by DHMH.

2. Annual immunization rates for all covered facilities shall be gathered on a schedule

established by the Deputy Secretary for Public Health Services.

VII. REFERENCES

1. LaForce FM, Nichol KL, Cox NJ. Influenza: virology, epidemiology, disease, and

prevention. Am J Prev Med 1994; 10:31–44

2. Aschan J, Ringde´n O, Ljungman P, Andersson J, Lewensohn-Fuchs I, Forsgren

M. Influenza B in transplant patients. Scand J Infect Dis. 1989; 21(3):349-350

3. Weinstock DM, Eagan J, Malak SA, et al. Control of influenza A on a bone

marrow transplant unit. Infect Control Hosp Epidemiol. 2000;21(11):730-732.

4. Centers for Disease Control and Prevention (CDC). Novel influenza A (H1N1)

virus infections among health-care personnel—United States, April-May 2009. MMWR

Morb Mortal Wkly Rep. 2009; 58(23):641-645.

5. ECDC Technical Emergency Team. Initial epidemiological findings in the

European Union following the declaration of pandemic alert level 5 due to influenza A

(H1N1). Euro Surveill. 2009; 14(18):pii-19204.

6. Voirin N, Barret B, Metzger MH, Vanhems P. Hospital-acquired influenza: a

synthesis using the Outbreak Reports and Intervention Studies of Nosocomial Infection

(ORION) statement. J Hosp Infect. 2009; 71(1):1-14.

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VACCINATION POLICY

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This version DHMH Policy 03.02.04 effective November 12, 2015 combines and supersedes DHMH Policy

03.02.02 and DHMH Policy 03.02.03 both dated October 10, 2014.

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7. Cunney RJ, Bialachowski A, Thornley D, Smaill FM, Pennie RA. An outbreak of

influenza A in a neonatal intensive care unit. Infect Control Hosp Epidemiol 2000;

21:449–54

8. Vanhems P, et al, Arch Intern Med, vol 171, No 2, Jan 24, 2011, pp. 151-157.

Risk of Influenza-Like Illness in an Acute Health Care Setting During Community

Influenza Epidemics in 2001-2005, 2005-2006, and 2006-2007.

9. Kapila R, Lintz DI, Tecson FT, Ziskin L, Louria DB. A nosocomial outbreak of

influenza A. Chest. 1977; 71(5):576-579.

10. Andrieu AG, Paute J, Glomot L, Jarlier V, Belmin J. Nosocomial influenza

outbreak in a geriatrics department: effectiveness of preventive measures [in French].

Presse Med. 2006;35(10, pt 1):1419-1426.

11. Barlow G, Nathwani D. Nosocomial influenza infection. Lancet. 2000;

355(9210):1187.

12. Carman WF, Elder AG, Wallace LA, McAulay K, Walker A, Murray GD, et al.

Effects of influenza vaccination of health-care workers on mortality of elderly people in

long-term care: a randomized controlled trial. Lancet 2000; 355:93–7.

13. G A. Poland, P Tosha, RM. Jacobson, Mayo Vaccine Research Group, Requiring

influenza vaccination for health care workers: seven truths we must accept, Vaccine 23

(2005) 2251–2255

14 Salgado CD, Farr BM, Hall KK, Hayden FG. Influenza in the acute hospital

setting. Lancet Infect Dis. 2002; 2(3):145-155

15. Wilde JA, McMillan JA, Serwint J, Butta J, O’Riordan MA, Steinhoff MC.

Effectiveness of influenza vaccine in health

16. Lester RT, McGeer A, Tomlinson G, DetskyAS. Use of, effectiveness of, and

attitudes regarding influenza vaccine among house staff. Infect Control Hosp Epidemiol

2003; 24:839–44.

17. Weingarten S, Riedinger M, Bolton LB, Miles P, Ault M. Barriers to influenza

vaccine acceptance. A survey of physicians and nurses.

18. Fralick RA. Absenteeism among hospital staff during influenza epidemic. CMAJ.

1985; 133(7):641-642.

19. Hammond GW, Cheang M. Absenteeism among hospital staff during an

influenza epidemic: implications for immunoprophylaxis. Can Med Assoc J. 1984;

131(5):449-452.

20. Sartor C, Zandotti C, Romain F, et al. Disruption of services in an internal

medicine unit due to a nosocomial influenza outbreak. Infect Control Hosp Epidemiol.

2002; 23(10):615-619.

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This version DHMH Policy 03.02.04 effective November 12, 2015 combines and supersedes DHMH Policy

03.02.02 and DHMH Policy 03.02.03 both dated October 10, 2014.

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21. Wilde JA, McMillan JA, Serwint J, Butta J, O’Riordan MA, Steinhoff MC.

Effectiveness of influenza vaccine in health care professionals: a randomized trial.

JAMA. 1999; 281(10):908-913.

22. Salgado CD, Farr BM, Hall KK, Hayden FG. Influenza in the acute hospital

setting. Lancet Infect Dis. 2002; 2(3):145-155.

VII. APPENDIX.

1. Influenza Vaccination Policy Declination of Influenza Vaccination

2. DHMH Policy and Influenza Vaccination Frequently Asked Questions

APPROVED:

November 12, 2015

____________________________________________

Van Mitchell, Secretary, DHMH Effective Date

Revised November 12, 2015 with permission from the Immunization Action Coalition – St. Paul, MN

DHMH Policy 03.02.04 - Appendix 1

Maryland Department of Health and Mental Hygiene

Influenza Vaccination Policy for DHMH Employees Working in

State Facilities, Local Health Department Clinical Buildings,

Forensic Residential Centers, State Residential Centers and Chronic

Disease

Declination of Influenza Vaccination

My employer, ____________________________________________, requires that I receive influenza

vaccination to protect patients and staff in my work location.

I have read the DHMH Policy on Influenza Vaccination for DHMH Employees Working in State Facilities,

Local Health Department Clinical Buildings, Forensic Residential Centers, State Residential Centers, and

Chronic Disease Centers.

I acknowledge that I have been advised of the following facts:

 Influenza is a serious respiratory disease that kills an average of 36,000 persons and hospitalizes more

than 200,000 persons in the United States each year.

 Influenza vaccination is required to protect patients and staff from influenza disease, its complications,

and death.

 If I contract influenza, I will shed the virus for 24–48 hours before influenza symptoms appear. My

shedding the virus can spread influenza disease to patients in this facility.

 If I become infected with influenza, even when my symptoms are mild or non-existent, I can spread

severe illness to others.

 The strains of virus that cause influenza infection change almost every year, which is why a different

influenza vaccine is recommended each year.

 I cannot get influenza from the influenza vaccine.

 My refusal to be vaccinated could have life-threatening consequences to my health and the health of

those with whom I have contact, including patients, coworkers, family and community.

Despite these facts, I am choosing to decline influenza vaccination right now for the following reasons:

 Medical contraindication

 Religious objection

I understand that:



Refusing influenza vaccination for other reasons besides those above shall lead to disciplinary action.



I have read and fully understand the information on this declination form.

Signature: Date:

Name (print):

Department:

Reference: CDC Prevention and Control of Influenza with Vaccines Recommendation of ACIP at

http://www.cdc.gov/flu/professionals/acip/index.htm

DHMHPolicy03.02.04–Appendix2

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DHMH Policy and Influenza Vaccination

Frequently Asked Questions

Q. What is influenza (the flu)?

A. The flu is a contagious respiratory illness caused by viruses that infect the nose, throat,

and lungs.

Q. How is the flu spread?

A. Flu viruses are spread mainly by droplets made when people who have the flu cough,

sneeze, or talk. These droplets can land in the mouths or noses of people who are nearby.

Q. What symptoms are associated with the flu?

A. Symptoms of influenza can include fever, cough, sore throat, runny or stuffy nose, body

aches, head ache, chills and fatigue. Some people may also have vomiting and diarrhea.

People may be infected with the flu and have no symptoms at all, or only respiratory

symptoms without a fever.

Q. I never get sick. Why should I get a flu shot?

A. Anyone can catch the flu, even healthy individuals. If you catch the flu, you may be able

to pass the flu on to someone else before you know you are sick, even if you have no

symptoms. Most healthy adults may be able to infect others beginning one day before

symptoms develop and up to five to seven days after becoming sick.

Q. Will my annual flu shot be covered by insurance?

A. Effective July 1, 2011, flu vaccination is covered for all State employees enrolled in a

state health plan with no-copayment if the vaccination is provided by the in-patient

provider during a routine office visit. Many other insurance plans also cover influenza

vaccination. If you do not have insurance through a state health plan, check with your

plan for more information. You may also be able to get a free flu vaccination at work or

at your local health department.

Q. Why is influenza vaccination required, with just exemptions for medical and

religious reasons, for my facility this year?

A. Individuals who work in health care settings are frequently in contact with others, which

increases their chance of being exposed to someone with the flu, and therefore, getting

sick with the flu. It also increases the risk that they may expose others, including patients,

for whom illness can have serious consequences. Individuals who are at higher risk

include older people, young children, pregnant women, and people with certain health

conditions (such as asthma, diabetes, or heart disease), and persons who live in facilities

like nursing homes. Because health care workers are in regular contact with these

populations, the flu shot will protect both the workers themselves and the patients, from

the spread of flu. The role that you and other health care workers play in helping to

prevent influenza-related illness and death – especially in high-risk patients – is

invaluable. Research has shown that hospitalized patients who are exposed to health care

workers who have influenza or flu-like illnesses were five times more likely to get a

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healthcare-associated flu-like illness than if they were not exposed by the health care

worker. The patients at your facility are at risk for serious illness and death from

influenza this year.

Q. Are workers in other health care settings required to get vaccinated against flu?

A. The Maryland Hospital Association endorses patient safely policies that require

mandatory influenza vaccination for all health care workers. Many hospitals in Maryland

and other parts of the country require annual flu vaccination as a condition of

employment.

Q. What if I refuse the flu vaccine for medical reasons or religious belief?

A. A DHMH employee or licensed independent consultant may refuse to receive a vaccine if

they have a medical contraindication, including a severe egg allergy, severe allergy to

any vaccine component, severe reaction after a previous dose of influenza vaccine, or a

history of Guillain-Barre Syndrome. They may also refuse the vaccine if they have a

bona fide religious objection. The employee is not required to provide documentation

from their healthcare provider or religious affiliation to certify their exemption.

Q. When should I get a flu shot?

A. People can get sick with the flu as early as October. You should get a flu shot as soon as

vaccine becomes available in your community. It takes about two weeks after you have

received your flu shot before it will protect you against the flu.

Q. If I receive the flu vaccine from my primary care physician, can I use

documentation from that office as proof that I have been vaccinated?

A. Yes. A DHMH employee can present a printed receipt, card or statement from the

vaccinator clearly indicating that an influenza vaccination was provided to the individual,

by whom, and on what date.

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