Approaches


  • Organized by decision points: definitions; deadlines; information systems requirements; leave policies; exemptions and deferrals; metrics; administration; combining vaccination requirements; incentives.
  • Disclaimer:
    • Suggestions and examples. These do not reflect endorsement by SHEA, endorsing societies, or the authors, nor do they necessarily reflect approaches being taken by the authors’ institutions.
    • They are neither legal nor clinical advice.
    • Employers should consult their own attorneys and other qualified professionals when making decisions regarding implementing a policy of COVID-19 vaccination as a condition of employment.
    • These examples may not be able to be used by certain facilities or may be mutually exclusive.

At boosters have not yet been recommended by ACIP as of Sept. 2021, the below information applies to primary doses. 

  • Definitions:
    • Healthcare personnel:
      • Multisociety Statement: “…healthcare personnel and others in the service of healthcare who work or operate in US healthcare settings…The consensus statement also supports COVID-19 vaccination of nonemployees functioning at a healthcare facility (eg, students, contract workers, volunteers, etc).”
      • CDC: “…all paid and unpaid persons serving in healthcare settings who have the potential for direct or indirect exposure to patients or infectious materials, including body substances (e.g., blood, tissue, and specific body fluids); contaminated medical supplies, devices, and equipment; contaminated environmental surfaces; or contaminated air.”
    • Fully vaccinated:
  •  Timing:
    • How long do HCP have to become vaccinated and/or show that they are compliant with the CoE policy?
      • Example approaches:
        1. 7 weeks
        2. 12 weeks
        3. First dose or accepted exemption: 5 weeks for managers/leaders who qualify for incentive program, 8 weeks for all other HCP. Receipt of both doses: 12 weeks from announcement
        4. 8 weeks
    • How long do HCP have to submit exemption requests?
      • Example approaches:
        1. Requests due 2 weeks after institution posts forms; decision from institution 3 weeks after request deadline; HCP whose requests are declined have 4 weeks to become compliant
        2. Requests due 4 weeks after announcement; decision from institution 2 weeks after submission deadline; HCP whose exemption requests are declined must adhere to original compliance deadline, which is 8 weeks after exemption decisions are made. Late exemption requests allowed for changes to a person’s medical condition (e.g. severe reaction to first dose, new diagnosis of COVID-19 with monoclonal antibody treatment).
        3. Requests due 5 weeks after announcement; decision from institution processed on rolling basis with minimum 1 week of notice before HCP’s respective deadline; HCP whose exemption requests are declined must adhere to deadline for both doses.
        4. Requests due 4 weeks after announcement. No decisions were issued prior to this deadline. First dose for HCP with declined exemptions due 4 weeks after decisions were issued.
      • Files:
    • Factors and potential considerations:
      • Ongoing access to vaccines for new hires
      • Approach for contractors
      • Reasonable accommodation for HCP to receive shots (21-28 day interval for mRNA vaccines)
      • Internal turnaround for posting information, approval/denial of exemption requests (“not penalizing employees for internal delays”)
      • Not issuing decisions prior to date of submission for exemption requests
      • The time at which an approved exemption request is reevaluated, and whether the HCP is required to reapply or resubmit documentation.
      • Duration that COVID-19 vaccination requirement stays in place
      • Alignment with influenza vaccination requirement dates
  • Legal Considerations
  • Ethical Frameworks:
  • Administration:
    • Who is administering vaccines to HCP?
      • In-house, e.g. by Occupational Medical Service
      • Community health department (submitted by non-US facility; US facilities would need to determine feasibility)
      • Outsourced to commercial pharmacy
    • Where are you administering vaccines?
      • Onsite, by appropriating one of the facility’s cafeterias to use as a vaccination clinic
      • At regional hospitals in system
      • Commercial pharmacy provides onsite clinic, plus option for HCP to go to local pharmacy with voucher that facilitates reporting to HCP’s employer
    • Factors and potential considerations:
      • Administering through facility, while still accepting documentation of vaccination elsewhere:
        • Pros: convenient, on-site, can develop a system where employees who receive the vaccine through their employer are tracked so they do not have to upload
        • Cons: resources (staffing, space, logistics)
      • Outsourcing:
        • Pros: convenient, employees may not realize it is a vendor
        • Cons: cost, space; facility/institution still needs to develop a database for info
  • Metrics:
  • Leave policies:
  • Exemptions and temporary exemptions/deferrals:
    • Multisociety statement: “Exemptions from this policy apply to those with medical contraindications to all COVID-19 vaccines available in the United States and other exemptions as specified by federal or state law.”
    • Example exemptions and forms
    • Legal considerations and example medical exemption flowchart
    • EEOC:
      • Title VII: 42 U.S.C. § 2000e-2 is the federal statute prohibiting discrimination on the basis of religion, and regulates the employer’s treatment of employees as “individuals.” (EEOC, K.12.)
      • ADA: COVID-19 and the ADA, the Rehabilitation Act, and other EEO laws (Section K) refers employers to the FDA’s EUA page for guidance as to how to assess the legal implications of EUA or the FDA approach to vaccines.
    • For those with approved exemptions:
      • Employer has a legal obligation to provide reasonable accommodations, and its attorneys should assess its policy.
      • Employer should identify the time at which approved exemption requests are reevaluated, and whether HCP are required to reapply and/or resubmit documentation.
      • Example approaches to mitigation measures:
        • Masks:
          • In settings with universal masking, implementing double-masking or masking plus face shield for exempted HCP; however, these approaches do not have consensus and can be challenging to enforce and burdensome for managers
          • No change (universal masking, regardless of vaccination status)
        • Screening by testing:
          • No testing of asymptomatic persons, due to required staffing and resource burden
          • Weekly saliva or mid-turbinate for asymptomatic persons
          • NP swab for symptomatic
          • No testing for a person who has had a positive test in the past 90 days
        • Physical distancing while eating/drinking, or no indoor, common area eating/drinking
        • All employees (exempted or not) required to self-screen for symptoms and follow illness protocols (reporting via hotline, testing, isolating), with consequences for lack of adherence.
  • Combining with other policies or facility requirements:
    • Combine with flu requirement: mostly germane to healthcare employers who mandate flu vaccine, although an employer who does not have a flu mandate could consider offering voluntary flu shots at time of COVID-19 vaccination.
      • Pros: Saves staffing, space. More convenient for employees.
      • Cons: If administering both vaccines on the same day, more likelihood of post-vaccine illness which, per OSHA, must be compensated so the employer may be paying for time off for flu shot side effects since it’ll be impossible to know which vaccine is the culprit. Likewise, if a reaction occurs, it’ll be impossible to know which vaccine to blame.
    • Separate from flu requirement
  • Communications:
  •  Incentives:
    • ICHE, Table 5 (pdf): types of incentives and their effect on vaccination rates
    • National Governors Association: specific incentives being used by states to encourage COVID-19 vaccination for residents and for state employees.
Last updated September 10, 2021