Influenza Vaccination Laws for State Long-Term Care Facilities
Long-term care facilities can have requirements for vaccines for patients and healthcare workers that vary across the country. Find information about requirements and exemptions for influenza vaccines.
Purpose
This menu is one of a series of menus assessing vaccination requirements for patients and healthcare workers (HCW) in healthcare facilities. To reduce the risk of disease transmission and outbreaks, healthcare facilities across the country are increasingly requiring healthcare workers to be vaccinated for certain vaccine-preventable diseases. 1 In some instances, facilities are establishing these requirements under mandates set forth by state statutes or regulations. Depending on the vaccine, the legal requirements might apply to either patients, healthcare workers, or both, and can include the following types of provisions:
- Assessment requirements: The healthcare facility must assess a healthcare worker or patient's vaccination status. 2
- Administrative requirements for offering vaccination: The healthcare facility must offer a vaccination to a healthcare worker or patient. 3
- Administrative requirements for ensuring vaccination: The healthcare facility must require a healthcare worker or patient to demonstrate proof of vaccination or immunity against a specific vaccine preventable disease. 4
- Surgical mask requirements:The healthcare worker must wear a surgical mask during influenza (flu) season if he or she has been exempted from or declined flu vaccination.
Introduction
Flu can be a serious disease that can lead to hospitalization and sometimes even death; anyone can get very sick from flu, including people who are otherwise healthy. 5 Flu is primarily a community-based infection that is transmitted in households and community settings. 6 Each year, 5% to 20% of US residents get the flu. Deaths associated with flu are most frequent among older adults. 7 During the 1976–2007 flu seasons, an estimated yearly average of 21,098 flu-related deaths occurred among adults aged ≥65 years, corresponding to 90% of estimated annual average deaths across all age groups. 8
Healthcare-associated infections, which can include flu, 9 are "infections that occur during the course of healthcare delivery." 10 In healthcare settings, flu can be spread by healthcare workers passing germs from hands or clothes to other workers or to patients. 11 The Advisory Committee on Immunization Practices recommends annual flu vaccination for all healthcare personnel to reduce flu-related morbidity and mortality among both healthcare personnel and their patients. 12 Vaccination of healthcare providers has been associated with reduced work absenteeism and with fewer deaths among nursing home patients and elderly hospitalized patients. 13 Flu vaccine coverage rates for healthcare workers in long-term care settings are often lower than in other healthcare facilities, such as hospitals and ambulatory care facilities. 14 Yet in long-term care facilities, where residents are often aged 65 years or older, vaccination among healthcare workers is particularly important because flu vaccine effectiveness can be lower in elderly populations. 15
Twenty-four states establish flu vaccination requirements for long-term care facility healthcare workers, 16 and 32 states establish requirements for long-term care facility patients. 17 This menu assesses and gives examples of state laws that expressly establish flu vaccination requirements for long-term care facility healthcare workers and patients. 18 Specifically, it reviews these laws based on the facilities and individuals the requirements apply to, type of requirement, and the exemptions permitted under the law. Because of these range of categories, each law can be assessed from different angles. In many cases, a single law specifies the applicable healthcare facility and also identifies whether the law applies to all or particular patient populations or to all or particular employee populations.
CDC recommends that all adults receive the flu vaccine annually. To learn more, visit CDC's Vaccine Information for Adults web page for information about this and other recommended vaccines.
Flu vaccination laws for healthcare workers in long-term care facilities
Long-term care facilities "provide a variety of services, both medical and personal care, to people who are unable to manage independently in the community." 19 Examples of long-term care facilities include nursing homes and skilled nursing facilities, among others. 20 These laws establish requirements based on the long-term care facility type and the type of vaccination requirements. In addition, some state laws allow for vaccination exemptions.
Examples by long-term care facility type
Twenty-four states' flu vaccination provisions expressly reference long-term care facilities or apply to various healthcare facilities that are considered long-term care facilities. 21
- Kentucky law states that "[e]very long-term care facility shall require each employee to be immunized against . . . influenza virus." 22
- In Missouri, "all long-term care facilities . . . shall assist their health care workers, volunteers, and other employees who have direct contact with residents in obtaining the vaccination for the influenza virus by either offering the vaccination in the facility or providing information as to how they may independently obtain the vaccination." 23
- Under Georgia law, "[e]ach nursing home shall annually offer on site to its health care workers and other employees who have direct contact with patients, at no cost, vaccinations for the influenza virus." 24
- New Hampshire law requires that "each . . . residential care facility . . . licensed under this chapter shall provide to its consenting employees annual immunizations against influenza." 25
Examples by healthcare worker type
All healthcare workers
Eighteen states have flu vaccination requirements for all healthcare workers in long-term care facilities. 26
- Under Arkansas law, "[e]ach nursing home facility in this state shall . . . [d]ocument and report annually immunizations against . . . [i]nfluenza virus for . . . full-time and part-time employees . . . ." 27
Healthcare workers with occupational exposure
California is the only state that explicitly establishes flu vaccination requirements for long-term care facility healthcare workers with occupational exposure. 28
- California law states that "[t]he employer shall establish, implement, and maintain effective procedures for providing vaccinations against seasonal influenza to all employees with occupational exposure." 29
Healthcare workers with direct patient contact
Five states explicitly establish flu vaccination requirements for long-term care facility healthcare workers with direct patient contact. 30
- Per South Carolina law, "[d]irect care staff and residents shall have an annual influenza vaccination . . . ." 31
- Texas law states that "[t]he executive commissioner by rule shall require nursing homes to offer, in accordance with an immunization schedule adopted in department rules . . . influenza vaccine . . . to staff who are in contact with elderly residents." 32
Examples by requirement type
State vaccination laws for healthcare workers in long-term care facilities include assessment requirements, administrative offer requirements, administrative ensure requirements, and surgical mask requirements.
Assessment
Nineteen states have flu vaccination assessment requirements for healthcare workers in long-term care facilities. 33
- New York law requires that nursing homes "document the influenza vaccination status of all personnel for the current influenza season in each individual's personnel record or other appropriate record." 34
- Under Utah law, long-term care facilities must report "the total number of healthcare workers and the number of those workers who are documented to have received an influenza vaccine for the current influenza season." 35
Administrative offer
Twenty states require long-term care facilities to offer flu vaccination to healthcare workers. 36
- Oklahoma law requires that nursing facilities "shall document evidence of the offering of annual vaccination against influenza for each . . . employee." 37
- Per Maine law, "[a] nursing facility or licensed assisted living facility shall adopt a facility policy that recommends and offers annual immunizations against influenza to all personnel who provide direct care to residents of the facility." 38
Administrative ensure
Sixteen states require long-term care facilities to ensure that healthcare workers are vaccinated against flu. 39
- Under South Carolina law, nursing home "[d]irect care staff . . . shall have an annual influenza vaccination unless the vaccine is medically contraindicated or the person is offered the vaccination and declined." 40
- District of Columbia law requires nursing facility employees to "undergo immunization for influenza virus." 41
Surgical mask
Three states require long-term care facility healthcare workers to wear surgical masks during flu season if they have been exempted from or declined vaccination. 42
- Colorado law states that long-term care facilities shall ensure that "each healthcare worker who does not have proof of immunization wears a surgical or procedure mask during influenza season when in direct contact with patients and in common areas as specified by the licensee's policy." 43
- In Rhode Island, healthcare workers who are not immunized are "required during any declared period in which flu is widespread—as part of his or her professional licensing obligation—to wear a surgical face mask for the duration of each direct patient contact in the performance of his or her duties." 44
Examples by exemption type
States with flu vaccination requirements often explicitly permit exemptions from these requirements in certain circumstances, 45 such as when vaccination is medically contraindicated or when it violates a person's religious or philosophical beliefs. 46
Medical
Twenty-two states permit medical exemptions for vaccination requirements, 47 although even where not explicitly exempted by law, it is likely that employees with a medically contraindicated condition are not required to be vaccinated.
- Employees in long-term care facilities in Massachusetts are not required to be vaccinated for flu if "the vaccine is medically contraindicated, which means that administration of influenza vaccine to that individual would likely be detrimental to the individual's health." 48
- Per Texas law, nursing facilities "must offer influenza vaccinations to . . . employees in contact with residents, unless the vaccination is medically contraindicated by a physician . . . ." 49
Religious
Thirteen states permit religious exemptions for flu vaccination requirements for long-term care facility healthcare workers. 50
- Under Alabama law, long-term care facility employees are not required to receive the flu vaccine "if the vaccine is against the individual's religious beliefs." 51
- North Carolina states that nursing homes must "require . . . employees to be immunized against influenza virus," but "[n]o individual shall be required to receive vaccine under this section if the vaccine is . . . against the individual's religious beliefs. . . ." 52
Philosophical
Twenty-four states permit philosophical exemptions for flu vaccination requirements for long-term care facility healthcare workers. 53
- Under Pennsylvania law, long-term care facilities "shall request that . employees be immunized for influenza virus," but "[n]o . . . employee shall be required to receive either the influenza or pneumococcal vaccine if "the employee . . . refuses the vaccine after being fully informed of the health risks of such action." 54
- Oregon law requires long-term care facilities to report the "[n]umber of staff with a documented refusal of influenza vaccination during the previous influenza season." 55
Flu vaccination laws for patients in long-term care facilities
Examples by long-term care facility type
Thirty-two states have flu vaccination provisions that expressly reference long-term care facilities or that apply to various healthcare facilities that are considered long-term care facilities. 56 These laws establish requirements based on the long-term care facility and patient category and the type of vaccination requirements. In addition, some state laws allow for vaccination exemptions.
- Alabama law requires that "[a] long term care facility shall document the annual immunization against influenza virus and the immunization against pneumococcal disease for each resident." 57
- In New Jersey, long-term care facilities must "document evidence of annual vaccination against influenza for each resident." 58
- Illinois law requires "long-term care for under age 22 facilities" to "annually administer or arrange for a vaccination against influenza to each resident." 59
- Under North Carolina law, nursing homes "shall require residents and employees to be immunized against influenza virus and shall require residents to also be immunized against pneumococcal disease." 60
Examples by patient type
While many states have vaccination laws that apply to all patients, other states have vaccination laws for patients who are particularly vulnerable to flu.
All patients
Thirty-two states have flu vaccination laws for all patients. 61
- Arkansas requires nursing homes to "[d]ocument and report annually immunizations against . . . [i]nfluenza virus for residents." 62
- Delaware law requires nursing facilities to "have on file evidence of annual vaccination against influenza for all residents." 63
Patients aged 65 years or older
Two states have flu vaccination laws for patients aged 65 years or older. 64
- Under California law, healthcare facilities, including nursing facilities, "shall offer . . . immunizations for influenza and pneumococcal disease to residents, aged 65 years or older, receiving services at the facility." 65
- In Texas, nursing homes must "offer . . . influenza vaccine to elderly residents," 66 defined as those aged 65 years or older. 67
Examples by requirement type
State vaccination laws for long-term care facility patients include assessment requirements, administrative offer requirements, and administrative ensure requirements.
Assessment
Twenty-one states have flu vaccination assessment requirements for long-term care facility patients. 68
- Kentucky law requires that "[u]pon admission, the long-term care facility shall . . . [a]ssess the resident's immunization status for influenza virus." 69
- In North Carolina, nursing homes are required to "document the annual immunization against influenza virus . . . for each resident." 70
Administrative offer
Twenty-seven states require long-term care facilities to offer flu vaccination to long-term care facility patients. 71
- In Michigan, [a]nursing home shall "offer each resident . . . an annual vaccination against influenza." 72
- Nebraska requires its nursing facilities to "offer onsite vaccinations for influenza . . . to all residents and to all inpatients prior to discharge." 73
Administrative ensure
Twenty-three states require long-term care facilities to ensure patients are vaccinated against flu. 74
- South Carolina law states that "residents shall have an annual influenza vaccination." 75
- District of Columbia law requires that nursing facilities "ensure that each resident . . . has either received immunization against influenza virus or has refused such vaccination." 76
Examples by exemption type
States with patient flu vaccination requirements often explicitly permit exemptions from these requirements in certain circumstances. 77
Medical
Twenty-nine states explicitly permit long-term care facility patients to be exempted from receiving flu vaccination for medical reasons, 78 although even where not explicitly exempted by law, it is likely that individuals with a medically contraindicated condition are not required to be vaccinated.
- In Arizona, nursing care institutions must ensure that "vaccinations for influenza and pneumonia are available to each resident . . . unless . . . the vaccination is medically contraindicated." 79
- Texas law requires nursing facilities to law "offer influenza vaccinations to residents . . . unless the vaccination is medically contraindicated." 80
Religious
Thirteen states permit religious exemptions to their flu vaccination requirements for patients in long-term care facilities. 81
- North Carolina law requires nursing home residents to be vaccinated for influenza but states that "[n]o individual shall be required to receive vaccine under this section if . . . the vaccine is against the individual's religious beliefs." 82
- In Pennsylvania, a long-term care facility resident will not "be required to receive either the influenza or pneumococcal vaccine if it is against his religious beliefs." 83
Philosophical
Twenty-seven states permit philosophical exemptions to their flu vaccination requirements for patients in long-term care facilities. 84
- Hawaii law states that "[e]ach resident shall receive age-appropriate immunizations or vaccinations including but not limited to pneumococcal and annual influenza vaccines . . . unless . . . refused by the resident." 85
- In South Dakota, nursing facilities "shall arrange for influenza vaccination to be completed annually for all residents . . . [d]ocumentation of vaccination or refusal shall be recorded in the resident's medical record." 86
CDC recommends that healthcare workers receive the flu vaccine annually. To learn more, visit the CDC's Recommended Vaccines for Healthcare Workers web page for information about this and other recommended vaccines.
Acknowledgements and disclaimers
This document was developed by Hillary Li, JD candidate 2017 at the University of North Carolina School of Law and Fall 2016 extern; Aila Hoss, JD, former Carter Consulting, Inc.; Alexandra Bhatti, JD, MPH, Cherokee Nation Assurance, LLC; and Dawn Pepin, JD, MPH, Cherokee Nation Assurance, LLC, with the Public Health Law Program (PHLP). This document was produced in collaboration with CDC's National Center for Immunization and Respiratory Diseases. The authors thank Lindsay Culp, JD, MPH, Megan C. Lindley, MPH, and Matthew Penn, JD, MLIS, for their research and editorial assistance.
For further technical assistance with this inventory, please contact phlawprogram@cdc.gov. PHLP provides technical assistance and public health law resources to advance the use of law as a public health tool. PHLP cannot provide legal advice on any issue and cannot represent any individual or entity in any matter. PHLP recommends seeking the advice of an attorney or other qualified professional with questions regarding the application of law to a specific circumstance. The findings and conclusions in this summary are those of the authors and do not necessarily represent the official views of CDC.
This menu includes states laws collected from WestlawNext during September 9–November 8, 2016.
Appendices
- Long-Term Care (LTC) Facility Type
- HCW Type
- Requirement Type
- Exemptions
- Long-Term Care (LTC) Facility Type
- Patient Type
- Requirement Type
- Exemptions
