Manual
Corporate
Theme
Ensuring a Healthy
Workplace
Cluster
Human Resources
Number
00103
Influenza Vaccine Program
Preamble
BACKGROUND
Influenza is a serious contagious disease spread by droplet transmission through close
contact with an infected individual. According to the National Advisory Committee on
Immunization, there are approximately 3,500 deaths per year in Canada from influenza
and its complications. Infected individuals are highly contagious and can transmit influenza
prior to the onset of symptoms. Some individuals infected with influenza may develop few
or no respiratory symptoms but may be shedding virus, i.e., transmitting it and potentially
infecting others.
Among vaccine-preventable diseases, influenza causes more deaths than all others
combined.
Hospitalized patients are generally more vulnerable to influenza than members of the
general population. Influenza in vulnerable groups, especially the elderly, the very young
and the immune-suppressed, is associated with significant morbidity and mortality.
Influenza infection is a major contributor to hospitalizations during winter.
Healthcare workers are a source of influenza in healthcare settings. Vaccination of
healthcare workers will reduce their risk of getting influenza and spreading it to patients.
The most effective strategy for preventing influenza is annual vaccination. Influenza
vaccine is safe and effective.
In addition to vaccination, there are several important infection control measures that help
to prevent influenza transmission, including hand hygiene, cough etiquette, restrictions on
work and visiting, the use of anti-viral medications, and rapid identification and
management of ill patients.
The wearing of masks can serve as a method or source control of infected healthcare
workers who may not have symptoms. Masks may also protect unvaccinated healthcare
workers from as yet unrecognized infected patients or visitors with influenza.
While all these infection control measures are essential components of a comprehensive
prevention program, vaccination remains the cornerstone of efforts to control influenza
transmission.
PURPOSE
The purpose of this policy is to protect patients, employees, physicians, students and
volunteers from influenza infections. It is one component of a broader influenza prevention
and control strategy.
Policy Statement
Holland Bloorview Kids Rehabilitation Hospital, as a participating member of the Toronto
Academic Health Sciences Network (TAHSN), is committed to workplace and patient safety
Page 1 of 12
Manual
Corporate
Theme
Ensuring a Healthy
Workplace
Cluster
Human Resources
Number
00103
Influenza Vaccine Program
and supports the prevention and control of communicable diseases. The hospital will make
every reasonable effort to identify potential risks and minimize them through our
Occupational Health and Safety and Infection Prevention and Control programs.
All individuals covered by this Policy must be vaccinated annually against influenza, or
wear a mask during the Vaccination Required Period in areas where patients are present
and patient care is delivered, in accordance with this Policy.
Page 2 of 12
RESERVED AREA
Preamble
Manual
Corporate
Theme
Ensuring a Healthy
Workplace
Cluster
Human Resources
Number
00103
Influenza Vaccine Program
Procedure:
SCOPE – AFFECTED INDIVIDUALS
This policy applies to all persons who carry out activities at Holland Bloorview, including
employees, physicians and other credentialed professionals, volunteers, students/trainees, and
contract workers (e.g. agency providers). For the purpose of this policy, these individuals will be
referred to as “Affected Individuals.”
ROLES AND RESPONSIBILITIES
Employer:
• Commit to support the influenza program, including appropriate operational and financial
support to administer vaccine and monitor program implementation
• Communicate expectations to all Affected Individuals and internal and external
stakeholders
• Determine the annual Vaccination Required Date and Vaccination Required Period (see
Definitions below) in consultation with TAHSN partners and Toronto Public Health
(TPH)
• Incorporate policy requirements into external contracts and affiliation agreements
• Honour collective agreements that contain influenza vaccine clauses by incorporating this
healthcare worker influenza policy in a manner that is consistent with any and all existing
collective agreement language regarding influenza and vaccination.
Hospital Management (Supervisors, Managers, Directors, Senior Leaders):
• Monitor to ensure all Affected Individuals adhere to this policy
• Ensure all direct reports comply with this policy
• Ensuring adherence to influenza vaccine clauses in collective agreements
Occupational Health and Safety:
• Administer influenza vaccine and optimize vaccine accessibility
• Maintain influenza immunization records and track immunization rates
• Report healthcare worker influenza immunization rates to TPH as required
• Provide a list of individuals required to wear a mask
• Audit departments on masking compliance
• Ensure adequate supply of masks throughout the hospital
Page 3 of 12
Manual
Corporate
Theme
Ensuring a Healthy
Workplace
Cluster
Human Resources
Number
00103
Influenza Vaccine Program
TAHSN/Toronto Public Health Task Force:
This Task Force is a collaboration of the following partners:
• Participating TAHSN hospital leadership
• Participating Infection Prevention Control and other medical experts
• Toronto Public Health
Together this Task Force will monitor policy efficacy and determine when influenza activity
and the associated risk to patient/staff is high.
AFFECTED INDIVIDUALS
All Affected Individuals are to be vaccinated against influenza by the Vaccination Required
Date, or wear a mask during the Vaccination Required Period in all areas where patients are
present and patient care is delivered (See Attachment A - Patient Care Zones). In addition,
the following protocols will be practiced:
• All Affected Individuals who are vaccinated against influenza are required to have an
identifier indicating their influenza immunization status provided by the hospital for the
duration of the Vaccination Required Period. For example, an influenza sticker may be
attached to the front of the name tag or a laminated card carried on their person.
•
All Affected Individuals who receive influenza vaccination by a provider other than the
hospital’s Occupational Health and Safety unit will advise the hospital of their influenza
immunization status in a manner acceptable to the hospital before the annual Vaccination
Required Date.
•
All Affected Individuals who are not able to demonstrate that they have received
influenza immunization in the current season, regardless of vaccination status, are
required to wear a mask in accordance with this Policy. Exceptions may be made for
healthcare workers whose duties require exclusion, and these will be evaluated on a case
by case basis.
•
Based on best medical and research evidence, individuals are considered immune from
influenza fourteen (14) days after receiving the influenza vaccination. Once the vaccine
required date is set, Affected Individuals will be required to wear a mask if they have not
been vaccinated or if it has been less than fourteen days since their vaccination occurred.
Masks will be required until the fourteen days have expired.
•
Individuals required to wear a mask will be responsible for maintaining their mask in
good condition and replacing it as necessary in accordance with the hospital’s protocols.
Page 4 of 12
Manual
Corporate
Theme
Ensuring a Healthy
Workplace
Cluster
Human Resources
Number
00103
Influenza Vaccine Program
• Masks will be provided by the hospital.
•
•
All Affected Individuals are to continue applying the hospital’s infection control practices,
including adherence to routine practices and additional precautions, to prevent the
transmission of communicable diseases, including influenza.
All Affected Individuals are needed to participate in training as required.
Vaccine Mismatch
How well the flu vaccine works can vary from season to season. Significant protection
against transmission is provided even in partial mismatch seasons. In the very rare situation
where influenza vaccinations felt to provide unacceptably low protection, the Task Force will
recommend appropriate reasonable modifications to this policy, up to a potential requirement
that all Affected Individuals, regardless of their influenza vaccination status, may be required
to wear a mask during the Vaccination or Mask Required Period. It is important to take all
reasonable precautions for the protection of both patients and health care workers. This
determination will be undertaken by the Task Force.
PROCEDURE
All individuals covered by this Policy must be vaccinated annually against influenza or
wear a mask during the Vaccination Required Period in areas identified in Attachment A
- Patient Care Zones.
The influenza vaccine will be offered and available to all staff members/ volunteers and
students, every year at no cost. The Occupational Health and Safety Department is
responsible for this program. Affected individuals who receive the vaccine elsewhere
must provide medical documentation of having received the vaccine from the provider,
documentation to include date of administration. This documentation is to be forwarded to
the Occupational Health and Safety Department on an annual basis.
Staff will be asked to sign the Influenza Vaccination Declaration form to identify they
have received the immunization as per policy, or to confirm they will be wearing a mask
for the entire influenza season.
Page 5 of 12
RESERVED AREA
Manual
Corporate
Theme
Ensuring a Healthy
Workplace
Cluster
Human Resources
Number
00103
Influenza Vaccine Program
Institutional Influenza Outbreak
During an institutional influenza outbreak, this mask-wearing requirement is suspended and
standard policies regarding influenza outbreak management and the use of anti-viral medications
will apply (Outbreak Management Policy #00316).
Consequence of non-compliance
Any Affected Individual found in violation of this policy may be subject to remedial and/or
disciplinary action, up to and including termination of employment, cancellation of contract
and/or revocation of privileges (Progressive Discipline Policy #00267)
DEFINITIONS
Vaccination Required Date
The date established annually by the employer, in consultation with TAHSN partners and TPH,
after which all persons covered under this policy are required to be vaccinated against influenza
or wear a mask in accordance with this Policy. The Vaccination Required Date will usually be no
later than the first week of December.
Vaccination or Mask Required Period
A period of time determined by the Task Force. The Vaccination Required Period will begin on
the Vaccination Required Date and will extend through the period of influenza activity, until
normally the end of March. This period may vary somewhat with seasonal epidemiology and
occasional novel strains of influenza. During the Vaccination Required Period, Affected
Individuals will be required to be vaccinated against influenza or wear a mask in accordance
with this Policy. Every effort will be made to limit the duration of the Vaccination or Mask required
period to the shortest period required to protect patients from circulating influenza.
Page 6 of 12
RESERVED AREA
Manual
Corporate
Theme
Ensuring a Healthy
Workplace
Cluster
Human Resources
Number
00103
Influenza Vaccine Program
Mask
Includes a surgical or procedure mask supplied by the hospital. An N95 respirator is not
required for the purpose of this policy.
Patient Care Location
Patient care location is where patients (clients) are present and patient care is delivered,
in accordance with this Policy, and including:
• Any building, property, or site owned, leased, rented or operated by the hospital where
there are patients, residents or clients who are receiving care;
• Any patient/client/resident home or other location where Affected Individuals interact
with the patient/client/resident in the course of his/her work for the hospital.
• The above does not include any location designated by the hospital to be excluded from
the definition of Patient Care Location.
Page 7 of 12
Manual
Corporate
Theme
Ensuring a Healthy
Workplace
Cluster
Human Resources
Number
00103
Influenza Vaccine Program
Influenza Vaccination Policy - Attachment A
Patient Care Areas
Guiding Principle:
All Affected Individuals are required to wear a mask if they have not been vaccinated against influenza,
anywhere that a patient/client is present.
Definitions:
Mask areas:
Masks are mandatory in these areas for Affected Individuals
Conditional areas:
Masks are mandatory for Affected Individuals only when a patient/client is
present in these areas
Exclusion Areas:
Masks are not required in these areas for Affected Individuals as no
patient/client interaction occurs in these areas
Page 8 of 12
Manual
Corporate
Theme
Ensuring a Healthy
Workplace
Cluster
Human Resources
Number
00103
Influenza Vaccine Program
Floor
Location
0
1
Mask areas
Conditional areas
Exclusions
•
•
•
•
•
0W290
0W220
0W225
•
•
•
•
Conference Centre
•
2 West Individual offices
2 East Individual Offices
2W625
•
•
•
2 West Employee Cubicles
TR&L/P&I workstations
BRI (ARC) offices
Clinician, Physician and
Manager offices
•
Nursing Administration
Offices
•
•
•
•
•
•
•
•
Pharmacy reception desk
Activities of Daily Living
Lounge
Corridors
1W110 - Day Program Room
Family Resource Centre
Ronald McDonald Playroom
Centre for the Arts
Reception
Registration
Corridors
2
•
•
•
•
•
•
•
•
3
•
All Areas Except for Exclusion •
and Conditional Areas
Page 9 of 12
Therapy Gyms/Rooms
Clinic area
2nd floor registration
Dental
2 East Treatment and
Interview Rooms
• Corridors
• Kindercircle
Building Services
Stores/Loading dock
Pool Deck
Organizational
Development and
Learning
• Volunteer Resources
• Cafeteria
• Tim Horton’s Line
RESERVED AREA
Manual
Corporate
Theme
Ensuring a Healthy
Workplace
Cluster
Human Resources
Number
00103
Influenza Vaccine Program
•
Page 10 of 12
Discharge Planning Office
•
•
•
3 East Report Room
3 East Staff Room
3 West Report Rooms
RESERVED AREA
Manual
Corporate
Theme
Ensuring a Healthy
Workplace
Cluster
Human Resources
Number
00103
Influenza Vaccine Program
4
•
•
•
•
5
•
•
•
•
•
Elevators
School &
School
Gymnasium
Kindercircle
Nursery
School Sites
Satellite
Clinics
Community/
Home Visits
Page 11 of 12
•
•
•
•
•
•
•
•
•
4 West - Communication and
Writing Aids Assessment
Rooms
CWAS reception area
Clinical Technologies Clinic
Rooms
Clinical Technologies
Reception
Corridors
Accommodations
Health Data Records
Reception
Finance Reception
Corridors
All Elevators
Classrooms when clients
present
Corridors
Kindercircle Rooms
Classrooms
Corridors
Reception Areas
Clinic Rooms
When in client’s home or
interacting with clients in the
community.
•
•
•
•
•
•
4E100
4E105
Clinical Technology
Offices
Bloorview Research
Institute
•
5E100
5E105
•
Management and Staff
Offices
•
Offices and Cubicles
•
Management and staff
Offices
Management and Staff
Offices
•
Manual
Corporate
Theme
Ensuring a Healthy
Workplace
Cluster
Human Resources
Number
00103
Influenza Vaccine Program
Policy Lead
Tracey Millar
Issued Date
Nov 26, 2015
Committee Chair
Review Date
-
Committee Member(s)
Review Date
-
Authorizer
Judy Hunter
Authorizer's Signature
Page 12 of 12
Review Date
Nov 26, 2015