18.1.04 - Influenza & COVID-19 Vaccination Policy

Public Health & Safety: Public Health

Last Updated: 09/29/2021

Original policy date: 03/30/2016

Applies to: Faculty, Staff, Residents & Clinical Postdoctoral Fellows, Postdoctoral Fellows, Students

 

Policy Status, Date of Last Review
Current, as of  September 14, 2021 
Next Scheduled Review Date
September 30, 2021

 
I. Rationale
The purposes of this policy are to (1) reduce the risk of influenza and COVID-19 infection for Baylor College of Medicine (BCM) patients, faculty, staff, resident and fellow physicians, research postdoctoral scholars, clinical postdoctoral fellows, learners, and their family members; (2) voluntarily align with Texas state law requirements for influenza vaccination for health care facilities which includes development, implementation, and enforcement of a policy and procedure to protect patients from vaccine preventable diseases; (3) adhere to best practices for influenza and COVID-19 vaccination as stated by the Texas Medical Association (TMA) and Centers for Disease Control and Prevention (CDC); (4) significantly limit the spread of influenza and COVID-19 infection within the BCM community through annual influenza and as-directed COVID-19 immunization of all BCM Employees and Learners regardless of learning environment or practice setting; and (5) explain how to request an exemption from influenza or COVID-19 vaccination requirements.

 
II. Stakeholders Affected by this Policy
This policy applies to all BCM Learners and Employees based on potential exposure to infectious agents that can be transmitted to and from support staff, healthcare service providers, and patients. Therefore, compliance with this policy is mandatory for all BCM Learners and Employees on the BCM Campus, in facilities owned or operated by BCM, and at affiliated clinical sites in which BCM Learners and Employees work and/or learn. This policy does not apply to BCM Learners and Employees located outside of the United States of America, because Learners and Employees in other locations may experience different Flu seasons and COVID-19 infection risks based on their location.

 

III. Definitions
(a)   BCMBaylor College of Medicine.
(b)   CDC – Centers for Disease Control and Prevention
(c)   Employees – includes faculty and staff.  
(d)   Influenza (Flu) – as defined by the CDC, the Flu is a contagious respiratory illness caused by influenza viruses that infect the respiratory tract (e.g. nose, throat, lungs). Cases of the Flu may be mild or severe, and can lead to hospitalization or even death.
(e)   Flu Vaccination – a preparation of influenza antigens that stimulate production of specific antibodies when introduced to the body, and provide protection against influenza virus infection. 
(f)    Learners – includes resident and fellow physicians, research postdoctoral trainees, clinical postdoctoral fellows, all students currently enrolled in any BCM school and degree-granting program or certificate program, and other trainees who are invited to complete time-limited learning experiences that are administered by designated BCM departments and that do not require enrollment. 
(g)   OHP – Occupational Health Program.
(h)   COVID-19 – as defined by the CDC, COVID-19 is a highly contagious respiratory disease caused by the SARS-CoV-2 virus.  
(i)   COVID-19 Vaccinationa vaccine/vaccine series that is:

·   On the World Health Organization Emergency Use Listing (WHO EUL);

·   Approved for distribution in the U.S. by the Food and Drug Administration (FDA) or has FDA Emergency Use Authorization (EUA) approval; OR

·   Approved for BCM community use by BCM OHP and BCM Infectious Disease, in accordance with advice provided by the CDC Advisory Council on Immunizations Practices.    

IV. Policy
A.    Annual Vaccination Requirements.
1.    Deadline for Compliance

a.   All BCM Learners and Employees must complete Flu Vaccination by the annual deadline, as established by the Medical Director of the OHP. All new Employees must receive a Flu Vaccination within 60 days of hire.

b.   All BCM Employees must complete COVID-19 Vaccination by the announced deadline, as established by the Medical Director of the OHP. All new Employees must complete COVID-19 Vaccination within 60 days of hire.

c.   These deadlines may be changed based on market conditions (e.g., postponed due to delays in vaccine distribution) or other relevant considerations (e.g., outbreaks in the local community).

d.   Employee noncompliance with any of these Vaccination requirements, as evidenced by attestation (see Section IV.A.3, below) or exemption request submission (see Section IV.B, below) on or before the applicable deadline, will result in an employment action up to and including termination.

2.     Facilitating Access and Compliance at BCMTo facilitate full compliance with this policy, OHP will make available Flu and COVID-19 Vaccinations free of charge to Learners and Employees at designated sites in the Houston area. Learners and Employees may also access these vaccinations locally at health departments, pharmacies, physicians’ offices, or elsewhere.
3.     Attestation

a.   For Influenza, each Learner or Employee must self-attest to receipt of the Flu Vaccination or exemption request through an online portal. Learners and Employees who choose to receive a Flu Vaccination elsewhere (e.g., affiliate, local pharmacy, physician’s office, health department), must produce a record documenting any required vaccination upon request. Upon completion, each Learner or Employee who receives a required vaccine through a third-party must self-attest through the online portal.

b.   For COVID-19, Employees must self-attest to receipt of complete COVID-19 Vaccination or exemption request through an online portal. Employees who choose to receive COVID-19 Vaccination elsewhere (e.g., affiliate, local pharmacy, physician’s office, health department), must produce a record documenting any required vaccination upon request. Upon completion, each Employee who receives a required vaccination through a third-party must self-attest through the online portal. 

c.   BCM may periodically request verification of documentation from Learners and Employees who self-attested.  

 
B.    Influenza and COVID-19 Vaccination Exemptions.  

1.     Scope. BCM will recognize the following exemptions to the Influenza and COVID-19 Vaccination requirements, provided that the requestor submits an acceptable Exemption Request Form with required documentation (see Section IV.B.3, below).

a.   Medical exemptions are allowed if an individual is unable to receive a Flu or COVID-19 Vaccination due to their own disability or medical condition. Completed exemption request forms must be signed by a U.S.-licensed Independent Provider (i.e., M.D., D.O., N.P., P.A.). The exemption request must indicate if it is short term.  Individuals whose exemption is short term shall begin vaccination within 60 days of their exemption expiration date.

b.   Religious exemptions are allowed if an individual is unable to receive a COVID-19 Vaccination due to their sincerely held religious beliefs, practices or observances. Exemption requests must be documented on the Vaccination Exemption Request Form.

2.     Exemption Request Deadlines.

a.   Influenza – Exemption requests are due at least 30 days before any applicable vaccination deadline. For persons joining BCM after the annual deadline has passed, Flu exemption requests are due within 60 days of their start date.  

b.   COVID-19 – Exemption requests are due at least 14 days before any applicable vaccination deadline. For persons new to BCM, COVID-19 exemption requests are due within 60 days of their start date.  

3.     How to Request a Flu or COVID-19 Vaccination Exemption. Individuals who wish to request a vaccination exemption MUST complete a Vaccination Exemption Request Form and submit appropriate supporting documentation as provided below:  

a.   Individuals must submit the Exemption Request Form via Power Apps. Forms must be complete to be considered.  Incomplete submissions are not considered valid.

b.   Exemption requests will be reviewed by BCM Occupational Health. A determination will be provided to the individual via BCM email.

c.   If a request is not approved, an individual shall complete vaccination and provide proof of vaccination within 60 days to BCM Occupational Health.

4.     Duration of Approved Exemptions. Short-term vaccination exemptions are valid for at most one-year after which the individual may resubmit a Vaccination Exemption Request Form for consideration to extend the exemption. 

5.     Anti-Retaliation. In accordance with Baylor’s Policy Regarding Harassment, Discrimination, and Retaliation (02.2.25), retaliation, discrimination, and harassment against persons exempted from one or more vaccination requirements are prohibited.

  

1.     Individuals exempted from otherwise required vaccinations under this policy must take alternate steps to safeguard the health of themselves, BCM patients, Employees, Learners, and their families. If there is not a BCM wide general masking policy in place, those exempted from vaccination must wear masks at all times during scheduled shifts and/or while present in BCM facilities in BCM facilities in accordance with OHP requirements.  The Medical Director of the OHP determines when masks are required and announces masking directives based on the prevalence of viral disease in the community. Refer to BCM’s mask and face covering guidelines during a pandemic here. Employees or Learners who do not comply with these alternative requirements may be subject to progressive discipline up to and including termination.

2.     BCM affiliates may require an individual to be vaccinated prior to coming onsite at their locations and/or providing services under contracts they have with BCM regardless of whether an exemption applies. 

3.     When an individual’s inability to be vaccinated prevents them from performing essential functions of their job or course of study due to such an affiliate requirement, BCM cannot guarantee that alternate work assignments will be available and lack of vaccination may result in termination of employment or course of study.

4.     Trainees and Learners must be aware that inability to meet vaccination or other requirements of an affiliate where they are assigned for clinical, residency, or other training required by their programs may render them unable to complete their course of study or receive degrees or certifications demonstrating completion of training. 

5.     The process described in this policy is separate and distinct from the Americans with Disabilities (ADA) accommodation request procedure for workplace accommodations.  All continued and new requests for accommodations due to an employee’s own medical condition (whether or not Flu or COVID-19-related) must go through the ADA process.

 
V. Responsibilities
A.    Supervisors in all departments, functional units, and schools must allow their Employees and Learners reasonable time to receive required vaccinations and ensure that Employees are aware of this policy.
B.    The Office of Human Resources must provide new Employees with information about this policy during orientation.
C.    OHP will:
1.     Ensure vaccine accessibility:
a.   On an annual basis, make Flu  and COVID-19 Vaccines available to Employees and Learners (as applicable);
b.   Coordinate with the Office of Communications and Community Outreach to notify Learners and Employees when and where vaccinations will be available.
2.     Verify stakeholder compliance:
a.   Maintain records of Employees and Learners who have received the Flu and/or COVID-19 Vaccines from OHP,
b.   Maintain records of Employees and Learners who have requested exemptions to mandatory vaccination requirements. 
3.     Assess compliance rates:
a.   Review annual Flu and COVID-19 vaccination rates as evidenced by Learner and Employee self-attestations,
b.   Review requests for exemption,
c.   Compare exemption and compliance rates from year-to-year,
d.   Evaluate the online self-attestation process implemented by the College.  
 
VI. Procedures for Implementation and Review
BCM will make the influenza vaccination available annually to BCM Employees and Learners at no cost through OHP. OHP will determine the scheduled dates, times, and locations where Flu Vaccines will be provided. The Office of Communications and Community Outreach will ensure that Learners and Employees in clinical, research, and administrative settings are notified in advance of scheduled Flu Vaccination events in various locations on the BCM campus, in facilities owned or operated by BCM, and at select affiliate sites where BCM Learners and Employees are located. OHP will maintain records documenting vaccinations that OHP provides.
 
VII. Stakeholder Compliance
BCM expects all BCM Learners and Employees comply with this policy to emphasize the value the BCM community places on preventative healthcare. Supervisors/Managers must enforce the Alternative Requirements for their Employees and/or Learners as stated in Section IV.C.1 (above). Employees and Learners who do not comply with required vaccinations or complete the exemption process may be subject to progressive discipline.

 

VIII. Tools
·         Flu & COVID-19 Vaccination Attestations (via Power App);
·         COVID-19 Vaccination Exemption Request Form (submit via Power App); 
·         OHP Website : Flu Vaccine Information
·         Providing a Safer Environment for Health Care Personnel and Patients Through Influenza Vaccination: Strategies for Research and Practice. This Joint Commission document outlines successful strategies and initiatives.
 

IX. Related Policies
·         31.1.01 – Code of Conduct; 
 
X. Applicable Laws, Regulations & Standards
·        25 Tex. Admin. Code §1.702
·        Texas Medical Association (TMA) Recommendations (see 135.016 – Influenza Vaccine Recommendations for Health Care Workers; 245.019 – Physician Immunizations Against Communicable Diseases)