HUMAN RESOURCES INFLUENZA VACCINATION PROGRAM

I. PURPOSE

Influenza is one of the most common and vaccine preventable diseases that can lead to hospitalization and death. According to the Centers for Disease Control and Prevention (CDC), the annual flu vaccine is the best way to protect patients and yourself from influenza, and from spreading it to others. DCH is committed to delivering the best care in the safest environment. To achieve our goal in patient safety and to protect our patients, DCH Health System requires influenza vaccine for all Healthcare Workers (HCW), including employees, volunteers, contract staff, vendors and students. This policy is based on recommendations by all major regulatory, health, national, scientific and accrediting agencies, including CDC, American Nurses Association and the American Medical Association.

II. POLICY

The annual Influenza Vaccine is mandatory each year unless a medical or religious belief exemption has been granted. DCH Employee Health will offer the vaccine annually free of charge to all employees, volunteers, medical staff members and hospital board members.

III. SCOPE

This policy applies to all DCH employees, volunteers, students, contract staff, physicians, Licensed Independent Practitioner’s (LIP’s), and vendors, affiliated with DCH Health System based facilities and properties.

IV. DEFINITIONS

DCH Healthcare Worker (HCW) includes, but not limited to clinical and non-clinical employees, Volunteers, students, contract staff and vendors.

V. PROCEDURE

Flu Vaccination Program Requirements – Where and When to Get the Vaccine

• Employees and volunteers will receive the influenza vaccine offered by Employee Health Services (EHS) or provide proof of receipt of influenza vaccine from another source.
• New employees hired between October– March will be required to present proof of influenza vaccination, or will be offered influenza vaccination at their health screening. New employees hired outside of the months when the influenza vaccine is available will be notified of the policy and will be expected to comply with the vaccination the next influenza season.
• Those vaccinated will be offered a current Vaccination Information Sheet and complete a consent form prior to vaccination. Vaccination records will be recorded per Employee Health.
• DCH staff will receive notification of availability of flu vaccine via DCH Intranet – The Loop, monthly staff meetings, and advertisement throughout each facility announcing the dates available for vaccination and providing dates/times for facility Influenza vaccination clinics.
• Students, vendors, and contract staff will comply with this policy in accordance with contract agreement and compliance guidelines for employees.

Medical/Religious Exemption

• Exemption to immunization may be granted for medical contraindications/precautions after Employee Health receives appropriate medical exemption request form and proof. Ex: letter from primary care physician including medical contraindication or precautions.
• Individuals with an approved medical exemption, prior to November 2022, will not be required to submit a medical exemption request form or physician letter, if the condition is consistent with CDC standards.
• If an exemption is granted for a permanent condition consistent with CDC standards and manufactures safety profiles, (ex: a history of Guillain-Barre after a previous influenza vaccination, a history of a severe reaction to a component of the flu vaccine), the exemption does NOT need to be requested each year unless vaccine technology changes to eliminate issues regarding such allergies.
• If an employee requests a religious belief exemption, they must provide this in writing annually to Employee Health using the religious exemption request form.
• Employees granted an exemption due to medical contraindications or religious exemption will be required to wear a mask during the flu season (November 16 – March 31).

Vaccination Administration Period

• Vaccination administration period will be a facility decision and is subject to change each year. The usual vaccination period will be most likely begin in October depending on availability of vaccine. Multiple clinic dates will be advertised at all facilities. All current employees are required to be vaccinated by November 15 of the current calendar year.
• Management of vaccine shortage will be determined by the facility. For example, administration dates will be adjusted to accommodate a vaccine shortage and employees providing direct patient care will be given priority should a shortage occur.

Proof of Flu Vaccination

• Flu Vaccination Identification Sticker
• Employees and volunteers who receive the influenza vaccine will be issued a designated ID badge flu sticker provided by EHS that clearly shows compliance with annual influenza vaccination.
• Falsification of records pertaining to receiving a flu vaccine or displaying a flu vaccine badge sticker not issued by EHS may result in immediate separation of employment.
• Vaccination Outside of DCH
• Employees and volunteers who receive a flu shot outside of DCH must provide DCH with approved documentation, with vaccine lot number and expiration date, such as a signed physician’s note on a prescription pad or letterhead; copy of consent form with name and date of vaccination; immunization record; etc.
• Documentation of vaccination will be recorded upon receipt of approved documentation by EHS or other designated staff.
• HCW who receive a flu vaccine outside of DCH (i.e. Primary Care Physician, drugstore), must provide EHS with approved documentation by November 15 or upon hire for new employees hired between November 15 and March 31 to receive their flu sticker.
• All other HCW (i.e. contract staff, vendors, and students) will be responsible for providing proof of vaccination in accordance with contract agreement and compliance guidelines for non-employees.
• Proof of vaccination will only be accepted by hand delivery, email to flu@dchsystem.com, or text to 205-210-8869. Managers should not accept proof.

Masking Requirements

• HCW who do not receive a flu vaccine due to a medical or religious exemption will be required to wear a surgical mask in all DCH facilities, including off-site locations from November 16 thru March 31. Extension of annual flu season and mask requirement dates may be revised at the discretion of EHS in consultation with Infection Prevention (IP) and Infectious Disease Physician.
• The designated surgical mask will be determined by EHS and IP annually and will be provided at no charge to the HCW. Only approved mask provided by DCH will be permitted.
• Masks will be available on all nursing units, EHS, and DCH off-site facilities. Non-Nursing departments can order masks through Supply Logistics.
• HCW required to wear a mask will adhere to the following guidelines:
• Disposable mask is a single-use item and must be changed frequently during entire shift.
• Disposable mask should be discarded immediately and replaced if it becomes soiled or moist.
• Mask cannot be worn around neck, in lab coats, scrub tops or pockets of any kind.
• Mask should be discarded upon exiting an isolation room.
• Disposable masks used in non-isolation rooms should be discarded if contaminated or soiled.
• Masks must be worn according to manufacturer recommendation and may not be defaced or changed in any way.
• Masks will be required to be worn at all times inside DCH facilities with the exception of:
• When HCW is eating or drinking in staff break rooms, Sidewalk Café, cafeteria, and restrooms.
• In a private office with a closed door that is not shared with other persons.
• When lecturing or giving a presentation on-site.
• HCW who are unable to wear a surgical mask (i.e. allergy/irritation) must come to EHS for an evaluation. An alternative mask will be provided if necessary.

Consequences for Non-Compliance

• Non-Compliance with Vaccination
• Failure to comply with annual influenza vaccine requirements will result in:
• Employee is removed from work schedule (unpaid)
• Employee is issued a Final Accountability
• If employee is still non-compliant after five (5) business days, the employee will be separated from employment. This involuntary separation of employment will be coded as a no re-hire for six (6) months as stated in Separation of Employment policy.
• Manager is responsible for ensuring compliance with this policy and will advise if the employee does not comply. It may result in separation of the employee’s employment.
• Non-Compliance with submitting documentation of vaccination outside of DCH (i.e., primary care physician, drug store) by November 15 of the current year.
• Failure to comply with annual influenza vaccine documentation requirements will result in:
• Employee is removed from work schedule (unpaid)
• Employee is issued a Final Accountability
• If employee is still non-compliant after five (5) business days, the employee will be separated from employment. This involuntary separation of employment will be coded as a no re-hire for six (6) months as stated in Separation of Employment policy.
• Non-Compliance with Masking
• If an employee who has been approved for medical or religious reasons fails to comply with masking requirements, the employee will be placed on the next step in the employee accountability process.

Vaccine Shortages

• In the event of an influenza vaccine shortage, the situation will be evaluated by EHS and IP. Priority will be based upon job function and risk of exposure to influenza and will be given to those who:
• Provide direct hands-on patient care with prolonged face-to-face contact with patients.
• Care of patients at high risk for complications from influenza and/or have highest risk of exposure to patients and influenza.
• HCW who are at high risk for complications from influenza.
• EHS and IP will communicate this to the department supervisors and HCWs as priority areas are determined and to whom the vaccine is available.
• Those who are prioritized to receive the vaccine will be held to the standard of this policy. Those who are not prioritized to receive the vaccine will not be held to the standard for the duration of the vaccine shortage period, and recommendations will be provided to those who do not receive the vaccine.
• This policy is subject to change without prior notice depending on changing risk factor and the best interests of our patients, staff and community.

Non-Seasonal Influenza Vaccines

• All provisions of this policy may be applied to immunizations for non-seasonal influenza for which protection is not provided by the annual influenza vaccine, where it is determined that vaccinating healthcare workers is necessary to protect others from infection.
• Application of this policy other than to annual influenza immunization will be determined by DCH administration in consultation with EHS and IP.

VI. REFERENCES

Grohskopf Lisa A., MD; Blanton, Lenee H. MPH; Ferdinands, Jill M., PhD; Reed, Carrie, DSc; Dugan, Vivien G., PhD; Daskalakis, Demetre C., MD. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices – United States, 2025-26 Influenza Season, MMWR Recomm Rep 2025; 74 (No. 32): 500-507.

VII. CONTACT:

Employee Relations

VIII. RELATED POLICIES

Employee Accountability Policy

System Requirements Policy

Compliance Guidelines for Non-Employees

IX. REVISION DATE

Revised: September 2025