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     Indian Health Manual

Circular 16-04


DEPARTMENT OF HEALTH AND HUMAN SERVICES
Indian Health Service
Rockville, Maryland 20857

Refer to:  OPHS

INDIAN HEALTH SERVICE CIRCULAR NO. 2016-04


Effective Date:  July 28, 2016

MANDATORY SEASONAL INFLUENZA IMMUNIZATIONS FOR THE CIVILIAN HEALTH
CARE PERSONNEL

  1. Purpose.  This circular establishes the Indian Health Service (IHS) policy requiring mandatory seasonal influenza immunizations for civilian health care personnel working in IHS health care facilities.
  2. Background.  Influenza vaccination for health care facility staff and licensed independent practitioners is a major patient safety issue in the United States and is an important component of comprehensive infection control programs.  Individuals who become infected are contagious at least one day before any signs or symptoms of influenza appear, and therefore these individuals can infect others without knowing they are contagious.
  3. Policy.  All Civil Service employees, contract staff, temporary employees, students, and volunteers who work in an IHS health care facility, must receive a seasonal influenza vaccination by October 31 of each year or have on file a valid medical or religious exemption.  The vaccination deadline may be extended if seasonal influenza vaccine supply is inadequate or sufficiently protracted to preclude timely vaccination.  Commissioned Corps Officers of the United States Public Health Service (PHS) are already required to obtain their annual seasonal influenza immunization (per Manual Circular - Commissioned Corps Personnel - PHS No. 377, Subchapter CC26.1 Instruction 8, PHS Readiness Standards).
  4. Definitions.
    1. Health Care Personnel.  All Civil Service employees, contract staff, temporary employees, students, and volunteers whose duties and responsibilities require them to work permanently, temporarily or occasionally in an IHS health care facility are considered Health Care Personnel (HCP) for the purposes of this policy, regardless of their job category or level of patient contact.
    2. Health Care Facility.  Any Federal IHS hospital, clinic, or health station.
  5. Procedures.
    1. Documentation.  All HCP must provide acceptable documentation substantiating influenza vaccine receipt or request for exemption within 2 calendar weeks following issuance of this circular and by Oct. 31 annually in subsequent years.  Personnel routinely charged with infection control and/or employee health responsibilities at the facility are responsible for maintaining records of employee vaccination, medical exemption, or religious exemption as part of the employee health record.
      1. Receipt of Influenza Vaccine
        1. Influenza Vaccine Administered Within IHS Facilities.  Influenza vaccine will be offered free of charge to all HCP working in IHS health care facilities every influenza season.  At the time of vaccination, the following information should be recorded in the employee health record:  the date of administration, vaccine formulation (i.e., brand), vaccine manufacturer, dose volume, anatomic site of administration, vaccine lot and expiration date, and name of the provider administering the vaccine.  Upon request, employees may be provided written documentation of the influenza vaccination.
        2. Influenza Vaccine Administered Outside IHS Facilities.  Any HCP who receive influenza vaccine elsewhere must provide written proof of vaccination that documents the date of vaccination, vaccine formulation (i.e., brand), and name of provider administering the vaccine.  This information will be filed along with any additional documentary proof of vaccination as part of the employee health record.
      2. Request for Exemption
        1. Medical Exemption from Influenza Vaccination.  A request for medical exemption from influenza vaccination may be approved for any person contraindicated to receive influenza vaccine as outlined by Advisory Committee on Immunization Practices (ACIP) recommendations (see link below).  (http://www.cdc.gov/flu/professionals/vaccination/index.htm Exit Disclaimer: You Are Leaving www.ihs.gov )  Based on current recommendations, valid medical exemptions for influenza vaccines include a history of severe allergic reaction to any component of the influenza vaccine, including egg protein, or serious allergic reaction to a previous dose of influenza vaccine.  History of Guillain-BarrĂ© Syndrome (GBS) onset within 6 weeks following a prior influenza vaccine is a precaution for influenza vaccination, and may be considered a valid medical exemption if a medical provider determines the influenza vaccination poses a risk to the patient.
          1. Procedure for requesting a medical exemption.  All HCP requesting medical exemption from influenza vaccination must provide documentation, signed by a licensed, independent health care practitioner, affirming that a valid medical contraindication exists that precludes influenza vaccination.  Personnel routinely charged with infection control and/or employee health responsibilities at the facility will be designated to receive, review, approve/deny medical exemption requests in accordance with current ACIP recommendations, and maintain suitable records to document requests and outcomes.  Employees whose request for medical exemption is denied will receive written justification for the denial and must receive influenza vaccination within 2 calendar weeks of the denial notification.
          2. Renewal.  Employees with an approved medical exemption must provide a signed statement by October 31st annually reaffirming that the previously approved medical contraindication continues to preclude vaccination.  Such statements and other supporting documentation (e.g., statement from employee's medical provider) will be retained as part of the employee's health record.
        2. Religious Exemption from Influenza Vaccination.  Any HCP who feel their religious beliefs preclude influenza immunization may request an exemption from influenza vaccination.

          Procedure for requesting religious exemption.  Any HCP who feel their religious beliefs preclude influenza immunization must submit a signed, written statement justifying the request by October 31st annually for review.  Personnel routinely charged with infection control and/or employee health responsibilities at the facility will be designated to receive, review, approve/deny requests for religious exemption, and maintain suitable records to document requests and outcomes.  Supporting statements and approval of religious exemption requests from influenza vaccination will be maintained as part of the employee health record.

        3. Appeal of denials.
          1. Medical exemption requests.  Review and adjudication of appeals will be conducted by the facility Clinical Director or Service Unit Chief Medical officer.  Secondary appeals can be made to the Area Chief Medical Officer.  Third and final level of appeals can be made to the IHS Chief Medical Officer or their designee.
          2. Religious exemption requests.  Review and adjudication of appeals will be conducted by the facility's Chief Executive Officer.  Secondary appeals can be made to the Area Director.  Third and final level of appeals can be made to the IHS Chief Medical Officer or their designee.
      3. Approved Exemption.  Unvaccinated HCP with an approved medical or religious exemption must wear an IHS-provided surgical or similar mask when working in patient care areas or other areas frequented by patients in an IHS health care facility during the influenza season.  Influenza season is typically defined as November through March, though may include other periods of increased levels of influenza activity as determined by the Centers for Disease Control and Prevention and/or state public health authorities.  All HCP with an approved medical or religious exemption are required to receive annual instruction from appropriate infection control staff at the facility on the proper use of masks and other infection control measures relevant for preventing influenza infection.
  6. Compliance.  Health care personnel who refuse to comply with this policy and do not have an approved medical or religious exemption are subject to disciplinary action in accordance with Department of Health and Human Services and/or IHS policy and relevant sections of collective bargaining agreements as applicable.  Employee refusal to comply with this policy will be documented and filed as part of the employee health record.
  7. Supersedure.  This circular supersedes IHS SGM 2015-03, dated September 3, 2015.
  8. Effective Date.  This circular becomes effective on the date of signature.


/Mary Smith/
Mary Smith
Principal Deputy Director
Indian Health Service

Distributed:  IHS-wide
Date:  July 28, 2016
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