Introduction: Dentistry Takes a Shot at COVID-19

EDITOR’S NOTE

It has been a year of challenge and change for dental professionals. CDA and the State Office of Oral Health have worked together to support dental practices and patients to deliver and receive dental care safely, to interpret guidance from authorities, to develop essential resources and to communicate using every tool at our disposal.

This month’s Journal brings you one of the resources designed as a toolkit: turn-key materials published in easyto-access formats, intended for dental professionals to use in their offices and clinics. Please use and share this, and look for additional toolkits in upcoming Journal issues. This is CDA and your State Office of Oral Health working for you! At the close of 2020, the U.S. Food and Drug Administration began issuing the first emergency use authorizations for COVID-19 vaccines. In January 2021, CDA began assembling resources to assist our member dentists with information for them, their dental team and their patients, as the swift rollout of the vaccines raised many questions for those who were considering the vaccine and eligible to receive them.

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At the close of 2020, the U.S. Food and Drug Administration began issuing the first emergency use authorizations for COVID-19 vaccines. In January 2021, CDA began assembling resources to assist our member dentists with information for them, their dental team and their patients, as the swift rollout of the vaccines raised many questions for those who were considering the vaccine and eligible to receive them.

CDA developed a COVID-19 vaccine toolkit to compile multiple COVID-19 vaccine resources on behalf of our members, including an overview of the vaccines and how they were developed and approved; information on vaccine distribution; employer resources; vaccine administration; registration and training; and, more recently, vaccine confidence materials to assist with addressing patient and staff hesitancy. CDA partnered with several outside sources including HealthNet to create a vaccine discussion guide and the California Department of Public Health to host a volunteer vaccinator webinar. The information provided in the toolkit in this month’s Journal is a “snapshot in time” of the resources provided over the past six months.

Due to production timeframes for this publication, the information shared in this issue does not reflect the most current evidence or recommendations, as the environment surrounding COVID-19 vaccines is comparable to the virus itself — incredibly fluid and everchanging.

We encourage readers to visit cda.org for the most current information and resources offered by CDA as well as the websites of the Centers for Disease Control and Prevention, the California Department of Public Health and the California Division of Occupational Safety and Health, better known as Cal/OSHA, for the most current standards and recommendations.

Vaccine Administration FAQ

Get answers to commonly asked questions regarding the emergency public health waiver issued by the Department of Consumer Affairs.

Below are answers to commonly asked questions regarding the emergency public health waiver issued by the Department of Consumer Affairs (DCA) on Jan. 4, 2021 (amended Jan. 21), allowing dentists to administer COVID-19 vaccines to people age 16 and over. This FAQ will be updated as new information develops.

What do I have to do before I can start administering the COVID-19 vaccine?

Dentists who wish to begin administering the COVID-19 vaccine must complete the required training, comply with all federal and state recordkeeping and reporting requirements and adhere to the administration requirements in accordance with the FDA emergency use authorization.

Please note, dentists are unable to administer vaccines in-office at this time and may only administer as a volunteer vaccinator at local community sites.

How do I receive proof of completion of the trainings?

Print or save certificates to keep in your records similarly to other C.E. course certificates. At this time, you will not need to submit the certificates to any state agency.

A few tips for completing the training:

• Registration is required to receive a certificate of completion.

• Take a screenshot of your completion as a backup record.

Many dentists may experience technical difficulties registering with the various systems the CDC is utilizing to host their trainings. Please use this troubleshooting guide that illustrates how to complete the trainings and print certificates of completion for the trainings that provide one.

Who can I administer the vaccine to?

Dentists may vaccinate individuals 16 years of age or older. In cases of severe allergic reaction, dentists are also permitted to administer epinephrine or diphenhydramine by injection. The waiver is limited to any FDA-approved or Emergency Use Authorized COVID-19 vaccine.

Why does the waiver allow for the administration of the vaccine to people age 16 and older?

While the DCA waiver allows for dentists to administer the vaccine to people as young as 16, dentists must also adhere to the limitations of each approved vaccine. The Moderna vaccine has only been approved for individuals aged 18 and over. However, the Pfizer vaccine has been approved for individuals aged 16 and over.

How do I sign up for the required state and federal vaccine registries?

An overview of immunization information systems (IISs), also known as “vaccine registries,” can be found here. However, until vaccine supply increases, registration for state vaccine registries for new providers, including dentists, is currently closed.

Where can I learn more about the storage and handling requirements?

While these topics will be covered in the mandated trainings, the following links provide brief but detailed overviews of the storage and handling requirements for the Pfizer and Moderna vaccines: n CDC Pfizer Storage and Handling Summary n

• CDC Moderna Storage and Handling Summary

• CDC Johnson & Johnson Storage and Handling Summary

Where can I learn more about the emergency use authorizations (EUAs) and administration requirements for the Pfizer, Moderna and Johnson & Johnson vaccines?

The CDC has developed the following in-depth resources on the FDA EUAs, vaccine administration, interim clinical considerations, Advisory Committee on Immunization Practices (ACIP) recommendations and FAQs for both vaccines:

• Pfizer Vaccine Resource

• Moderna Vaccine Resource

• Johnson & Johnson Vaccine Resource

What materials do I need to provide to individuals who I vaccinate?

Vaccine information sheets (VIS) have not been developed for the COVID-19 vaccines at this time. The appropriate FDA emergency use authorization fact sheets for recipients listed below should be provided to patients at the time of vaccination:

• Moderna Fact Sheet

• Moderna Fact Sheet Translations

• Pfizer Fact Sheet

• Pfizer Fact Sheet Translations

• Johnson & Johnson Fact Sheet

• Johnson & Johnson Fact Sheet Translations

How do I notify individuals’ physicians about vaccines that I have administered?

As more vaccination clinics are established throughout the state, we expect to be provided with additional guidance on what, if anything, dentists will need to do aside from inputting data into the state vaccine registry in order to inform individuals’ physicians about receiving a COVID-19 vaccine.

How do I bill for the vaccine?

CDA is engaged in active discussions with health plans, including dental benefit plans, to determine the most appropriate code to use when billing for the administration of the COVID-19 vaccine. CDA will keep members updated on these discussions in the CDA Newsroom.

Where can I administer the vaccine?

The DCA waiver does not specify in which settings a dentist can administer the vaccine. However, the dentist should ensure that all appropriate emergency response supplies are readily available and that the patient can be monitored for adverse reactions or side effects for 15 minutes after the injection.

It is unlikely that dentists will be able to administer vaccines from their dental offices at this time due to storage requirements, outstanding billing questions and lack of finalized vaccine administration plans in most counties. Dentists wishing to participate in vaccination efforts will likely be able to do so through efforts organized by government entities or local health systems and hospitals.

How can I participate if I haven’t yet received the vaccine?

CDA and local dental societies are working closely with health departments and emergency medical services authorities to learn how your county is deploying health professionals to administer the vaccine in your area. CDA is continuing to advocate at the state and local levels for dentists and their staff to be elevated in priority to access the vaccine and should receive at least their first dose prior to vaccinating community members.

When does the waiver expire?

The waiver does not have an expiration date but is expected to stand for the duration of the declared state of emergency due to the COVID-19 pandemic.

When can I start vaccinating my patients?

At this time, it is unlikely that dentists will be able to vaccinate individuals within their dental office due to vaccine storage requirements. It is likely for the indefinite future that dentists will be able to administer vaccines in hospital, clinic and mass vaccination sites. Additionally, because state and local vaccine rollout plans are still in flux, there is no estimated time for when vaccines will be available to the general public.

Please note that the information and any suggestions contained in this resource represent the experience and opinions of CDA. This communication does not constitute and should not be considered a substitute for legal, financial or other advice provided by licensed professionals. For that, you must consult your own attorney, accountant or other professional advisor.

Will the administration of vaccines be covered by TDIC?

For as long as the DCA waiver is in effect, the administration of the COVID-19 vaccine when provided in accordance with the waiver requirements will be considered within the scope of practice and therefore covered under a TDIC policy.

If you are covered by a different carrier, we recommend you inquire about temporary extended coverage and provide a copy of the DCA waiver. For dentists who have reactivated their inactive or retired license or are retired with an active license and no liability insurance, in order to help with state vaccination efforts, TDIC offers a volunteer policy where coverage can be purchased if volunteering for an organization without compensation, less any expenses.

The statutory immunities cannot prevent a claim or lawsuit from being filed against you, but can provide you with a legal defense against any such claims. In other words, the broad immunities are designed to protect you from being held liable for any claims based on administering the vaccine, so long as you are practicing within the standard of care. This includes taking the appropriate training and following all manufacturer guidance on storage and administration of the vaccine. The advantage of having a policy that specifically covers the administration of the COVID-19 vaccine is that should a claim be filed against you, the liability carrier would provide your legal defense as opposed to you finding an attorney on your own.

Employer Best Practices and Policies

Understand best practices regarding employee vaccination, including vaccine policies, employer mandates and employee vaccine reactions. Check for updates on cda.org.

For dentists who are also employers, there are considerations and best practices regarding employee vaccination, including vaccine policies, employer mandates and employee vaccine reactions. Find answers to common questions here.

If all of my employees are vaccinated, do I still have to implement the extra COVID-19 precautions (i.e., N95/ face shield/HEPA filters/staggered lunch breaks)?

Yes. Even with vaccinated employees, or patients, existing COVID-19 prevention precautions remain necessary until further notice. Cal/OSHA requirements remain in place regardless of the vaccine.

How can I encourage my staff to become vaccinated for COVID-19?

There are multiple resources available, but the CDC does offer a tipsheet to help bolster vaccine confidence — How to Build Healthcare Personnel Confidence in COVID-19 Vaccines.

Should I make the vaccine mandatory for my employees?

Employers in health care settings have the right to establish legitimate health and safety standards, policies and requirements so long as they are job-related and consistent with business necessity. However, CDA recommends as a best practice that employers encourage, but not require, employees to receive the COVID-19 vaccine.

Policies mandating vaccinations are more likely to be appropriate for employers in the health care industry. But legal risk and complications, including the potential for side effects from the COVID-19 vaccine and the need to consider medical and sincerely held religious objections can make encouraging and facilitating an employee vaccination a better option for businesses than requiring it.

Even if an employer’s vaccination policy is mandated to meet county requirements or qualifies as a legitimate health and safety requirement for the business, under certain circumstances, some employees may nonetheless be exempt from complying.

If employers feel strongly about requiring employees to be vaccinated, CDA Practice Support recommends speaking with an employment law attorney before implementing a mandatory policy.

What circumstances would allow for an employee exemption from vaccination?

Employees may be exempt from compliance with a mandatory vaccination policy if they have a sincerely held religious objection or a qualifying disability under the federal Americans with Disabilities Act (ADA) or California Fair Employment and Housing Act (FEHA) that prevents them from safely receiving the vaccine. Specific to the Pfizer and Moderna COVID-19 vaccines, this includes factors such as whether the employee is pregnant, nursing, or allergic to ingredients of the vaccine or has a compromised immune system.

Upon receiving a request to be excluded from a vaccination requirement as an accommodation, whether due to disability or religiousrelated reasons, an employer must engage in an interactive process with the objecting employee to determine if they can provide the employee with a reasonable accommodation that does not pose an undue hardship for the employer.

Do I need to pay my employees for their time and costs associated with receiving the COVID-19 vaccine?

As of April 1, employers of more than 25 employees must comply with the 2021 California Supplemental COVID-19 Paid Sick Leave law (SB 95), which mandates that employees who are unable to work or telework in order to obtain a COVID-19 vaccine or who are recovering from complications of the vaccine be paid up to a maximum of 80 hours (or equivalent to their normal two-week work schedule). Employers cannot require an employee to use other paid or unpaid leaves before using COVID-19 supplemental paid sick leave.

SB 95 took effect March 29 but applies retroactively to Jan. 1, 2021. This means employers are required to make retroactive payments for leave taken for any of the qualifying reasons between Jan. 1 and March 28 upon oral or written request of the employee. For more information visit dir.ca.gov.

Employers with fewer than 25 employees who have voluntary policies are not required to pay employee costs associated with the vaccine or time spent obtaining the vaccine. Most health insurers are covering the cost of the vaccine. However, employers who encourage employees to obtain the vaccine may consider reimbursement of costs (when applicable) and compensation of time to obtain it in order to remove any barriers for employees who may be reluctant to receive the vaccine. If you require employees to obtain the vaccine, then you are required to compensate your employees for their time and costs not covered by their health insurance associated with obtaining the vaccine.

What is an employer’s legal exposure if an employee refuses to be vaccinated?

Currently, there is no law that requires employers to vaccinate all employees with the COVID-19 vaccine. It is still too early to fully provide a legal liability response. Theoretically, it may be possible that, in the future, failure to provide or offer the vaccine to employees could be a workplace safety violation – but this is purely speculation. There is still much to be known. Some states are introducing bills to prohibit mandating vaccinations. If passed, that will change the liability exposure for employers.

It is possible that an employer may never have 100% of their employees vaccinated. Having a fully vaccinated staff does not completely reduce an employer’s liability or obligations to maintain workplace safety standards.

Can I have my employee, who refuses the vaccine, sign a waiver to release my liability if that employee transmits COVID-19 to a patient or another employee?

A waiver signed by an employee who refuses the vaccine may not provide an employer with liability protection from patients or other employees. Continue to follow standard COVID-19 prevention precautions regardless of employee vaccinations until further notice.

I’ve heard many people feel sick for several days after receiving the vaccine. Will my employees need sick time off following the vaccine? Do I pay them for the time off? Do they qualify for the COVID-19 FFCRA paid time off?

First, CDA recommends staggering the distribution of the vaccine among the dental team in the event that team members experience adverse reactions within the same window of time. Consider asking your front office team to stagger the days in which they receive the vaccine and the same for your back office team. This will help the practice maintain staff coverage. Employees who request time off due to the vaccine side effects may request to use any available employer- provided paid sick leave or vacation time, if approved by the employer.

Any reactions to the COVID-19 vaccine must be reported to the employee’s medical care provider or to local public health department if the individual does not have a medical care provider.

In the event that an employee experiences long-term health effects and requires a leave of absence, as of April 1, California employers have two supplemental COVID-19 paid sick leave laws to consider depending on the number of employees in the practice.

The American Rescue Plan Act (ARPA) does not require employers to provide paid and emergency family leave under the Families First Coronavirus Response Act (FFCRA); however, it does extend tax credits for employers who continue to voluntarily offer FFCRA leave. The ARPA resets the allotted amount of emergency paid sick leave an employee has, meaning employees who previously exhausted their leave prior to April 1 are now entitled to an additional 80 hours of EPSL. The act further expanded the qualifying reasons to include coverage for time an employee may use to obtain the vaccine a vaccine and time the employee may use to recover from complications due to receiving the vaccine.

If an employer chooses to voluntarily offer leave, it must be used for the same purposes and subject to the same conditions as originally outlined in the FFCRA and must be provided fairly to all employees.

As previously noted, under the expanded Supplemental COVID-19 Paid Sick Leave legislation (SB 95) California employers of 26 or more employees are required to provide COVID-19 supplemental paid sick leave. All employees working for covered employers are eligible to take paid sick leave if they are attending an appointment to receive a COVID-19 vaccine or are experiencing symptoms related to a COVID-19 vaccine that prevent the employee from being able to work or telework.

If an employer has already provided supplemental paid leave after Jan. 1 to an employee for any of the qualifying reasons and if the amount of leave is equal to or greater than the required amount, the employer is allowed to count those hours toward the new leave requirements.

Additionally, if an employee has exhausted their SPSL under SB 95 and requires additional covered leave for a qualifying reason after April 1, covered employers may choose to voluntarily provide leave under the new ARPA revisions as noted above and receive payroll tax credits.

Both the ARPA and California’s COVID-19 supplemental paid sick leave under SB 95 expire Sept. 30.

Vaccine Confidence FAQs

Find answers to frequently asked questions regarding vaccination.

Your patients are likely asking a lot of questions about the vaccine. Here are answers to some of those questions and resources to help you talk to your patients.

Why dentists should speak with their patients about COVID-19 vaccination

How can I talk to patients about the COVID-19 vaccine?

Prepare to answer questions about the vaccine from dental team members and patients. Most importantly, give your personal strong recommendation to get vaccinated. Learn more about engaging with patients on the COVID-19 vaccine from the CDC.

Benefits of Getting a COVID-19 Vaccine

Additional suggestions on how to discuss vaccination may be found in the following document:

Discussion guide: HealthNet and CDA offer a resource to assist with discussing COVID-19 vaccination with your patients.

• Discussion guide (color)

• Discussion guide (b&w)

How do I speak with patients who have religious concerns about vaccination?

In general, religions around the world support immunization. The Immunization Action Coalition offers several resources and suggestions for health care professionals who see patients with religious concerns about vaccination.

What is the best way for patients to manage their side effects post-vaccination? Where should those be reported?

Patients and staff can track any side effects from the COVID-19 vaccine by enrolling in V-safe, a smartphonebased tool that uses text messaging and web surveys to provide personalized health check-ins after someone receives a COVID-19 vaccine. Utilizing V-safe is a quick way to inform the CDC of any side effects and offers reminders for second vaccine doses.

My patient informed me he received the COVID-19 vaccine. Do I still need to implement the same precautions as I do for other patients without the vaccine?

Yes. Until further notice, it is important that you maintain the same COVID-19 prevention precautions in the practice consistently among all patients. According to the CDC, experts need to understand more about the protection that COVID-19 vaccines provide before deciding to change recommendations on steps everyone should take to slow the spread of the virus that causes COVID-19. Researchers are still conducting studies on how long the vaccine is efficacious for and whether booster vaccines are necessary. Other factors, including when the vaccine was received, whether the patient has received the second dose, how many people become vaccinated and how the virus is spreading in communities, will also affect this decision.

My patient asked if I’m requiring all employees of the practice to receive the vaccine. The patient doesn’t want treatment until all employees receive the vaccine. What should I tell this patient?

As the employer, it is important that you protect and keep your employees’ health and health status information confidential, therefore, disclosing whether your employees have or will receive the vaccine is not information you can, nor should share with patients.

A sample response to the patient who asks this question is, “Employee health and medical information is protected by the right to privacy, but please be assured that our dental practice is continuing to do all it can to ensure patient safety.” Further, explain to the patient the protections (such as PPE, staggering of patient appointments, patient and employee daily screenings, social distancing and additional patient barriers) your practice has put in place to mitigate COVID-19 exposure and keep patients safe.

Additional Resources

• Instilling Vaccine Confidence

• Vaccine Literacy — Helping Everyone Decide to Accept Vaccination