Infectious Diseases

DPH Flu Regulations

10.15.2010

Sidebar to "Flu 2010-2011:what nurses can expect"

From the Massachusetts Nurse Newsletter
October 2010 Edition

Regulatory Requirements for Vaccination of Healthcare Personnel in Massachusetts

The following language applies to hospitals (under 105 CMR 130.325), to clinics (under 105 CMR 140), and to Long-term care facilities (under 105 CMR 150)

130.325: Requirement that Personnel be Vaccinated Against Vaccine
(A) Definitions.
(1) For purposes of 105 CMR 130.325, personnel means an individual or individuals employed by or affiliated with the hospital, whether directly, by contract with another entity, or as an independent contractor, paid or unpaid, including but not limited to employees, members of the medical staff, contract employees or staff, students, and volunteers who either work at or come to the licensed hospital site, whether or not such individual(s) provide direct patient care.
(2) For purposes of 105 CMR 130.325, the requirement for influenza vaccine or vaccination means immunization by either influenza vaccine, inactivated or live; attenuated influenza vaccine including seasonal influenza vaccine pursuant to 105 CMR 130.325(B); and/or other influenza vaccine pursuant to 105 CMR 130.325(C).

(B) Each hospital shall ensure that all personnel are vaccinated with seasonal influenza vaccine unless an individual declines vaccination in accordance with 105 CMR 130.325(F). When feasible, and consistent with any guidelines of the Commissioner of Public Health or his/her designee, each hospital shall ensure that all personnel are vaccinated with seasonal influenza vaccine no later than December 15, 2009 and annually thereafter.

(C) Each hospital also shall ensure that all personnel are vaccinated against other pandemic or novel influenza virus(es) as specified in guidelines of the Commissioner or his/her designee, unless an individual declines vaccination in accordance with 105 CMR 130.325(F). Such guidelines may specify:
(1) the categories of personnel that shall be vaccinated and the order of priority of vaccination of personnel, with priority for personnel with responsibility for direct patient care;
(2) the influenza vaccine(s) to be administered;
(3) the dates by which personnel must be vaccinated; and
(4) any required reporting and data collection relating to the personnel vaccination requirement of 105 CMR 130.325(C).

(D) Each hospital shall provide all personnel with information about the risks and benefits of influenza vaccine.

(E) Each hospital shall notify all personnel of the influenza vaccination requirements of 105 CMR 130.325 and shall, at no cost to any personnel, provide or arrange for vaccination of all personnel who cannot provide proof of current immunization against influenza, as required pursuant to 105 CMR 130.325(B) and (C), unless an individual declines vaccination in accordance with 105 CMR 130.325(F).

(F) Exceptions.
(1) A hospital shall not require an individual to receive an influenza vaccine pursuant to 105 CMR 130.325(B) or (C) if:
(a) the vaccine is medically contraindicated, which means that administration of influenza vaccine to that individual would likely be detrimental to the individual’s health;
(b) vaccination is against the individual’s religious beliefs; or
(c) the individual declines the vaccine.
(2) An individual who declines vaccination for any reason shall sign a statement declining vaccination and certifying that he or she received information about the risks and benefits of influenza vaccine.

(G) Unavailability of Vaccine. A hospital shall not be required to provide or arrange for influenza vaccination during such times that the vaccine is unavailable for purchase, shipment, or administration by a third party, or when complying with an order of the Commissioner which restricts the use of the vaccine. A hospital shall obtain and administer influenza vaccine in accordance with 105 CMR 130.325 as soon as vaccine becomes available.

(H) Documentation.
(1) A hospital shall require and maintain for each individual proof of current vaccination against influenza virus pursuant to 105 CMR 130.325(B) and (C) or the individual’s declination statement pursuant to 105 CMR 130.325(F).
(2) Each hospital shall maintain a central system to track the vaccination status of all personnel.
(3) If a hospital is unable to provide or arrange for influenza vaccination for any individual, it shall document the reasons such vaccination could not be provided or arranged for.

(I) Reporting and Data Collection.
Each hospital shall report information to the Department documenting the hospital’s compliance with the personnel vaccination requirements of 105 CMR 130.325, in accordance with reporting and data collection guidelines of the Commissioner or his/her designee.

12/11/09

FPO