Legislature(1995 - 1996)

03/28/1995 02:09 PM HES

Audio Topic
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
txt
 HB 274:  TUBERCULOSIS CONTROL                                               
                                                                               
 Number 1279                                                                   
                                                                               
 CO-CHAIR TOOHEY indicated HB 274 was sponsored by the Rules                   
 Committee by request of the Governor's Office.                                
                                                                               
 DR. PETER NAKAMURA, Director, Division of Public Health, DHSS, said           
 he was very happy to present HB 274.  Tuberculosis (TB) is a                  
 recurring problem, and has been receiving increased attention.  In            
 addressing the most recent outbreak of TB in this state, the DHSS             
 encountered a number of issues that led it back to the original               
 statutes on TB.  Those statutes were found to be inadequate and in            
 need of revision.  One of the major issues that needed to be                  
 revised was to assure that as the isolation of recalcitrant                   
 patients is addressed, due process is not overlooked.  It is                  
 important patients' rights are adhered to and recognized in that              
 situation.                                                                    
                                                                               
 DR. NAKAMURA asked to run through HB 274 by sections, and highlight           
 the key issues within each section.  Section 1 is basically a                 
 definition of what is needed to protect the public health from                
 persons with TB who pose a threat.  These are individuals who are             
 recalcitrant, and are either unable or unwilling to conform to the            
 recommendations for treatment.  This section also addresses                   
 voluntary care and monitoring to assure a system is in place in the           
 state for identifying patients who are diagnosed as having TB, and            
 assuring that their treatment is monitored until the point of                 
 completion.                                                                   
                                                                               
 Number 1367                                                                   
                                                                               
 DR. NAKAMURA said if a patient goes from place to place, their                
 records should follow them so providers in the new communities will           
 be able to address their problems.                                            
                                                                               
 DR. NAKAMURA said the special concern of his division is that if              
 there are patients who are identified and begin treatment,                    
 subsequently stop treatment, start again, and stop again, there is            
 a very real danger of developing a drug-resistant strain of TB.               
 Once that happens, the cost of care and the management is                     
 significantly increased.                                                      
                                                                               
 Number 1396                                                                   
                                                                               
 DR. NAKAMURA continued with Section 2.  He said it is reminiscent             
 of a previous bill, but with some amendments.  The amendments are             
 just to some of the terms.  For instance, "sanitorium" is changed             
 to "facilities."  Section 3 also refers to some amendments in the             
 existing bill.  Again, there are wording changes.  One term used is           
 "tuberculars."  This is replaced with "persons with tuberculosis."            
                                                                               
 DR. NAKAMURA said Section 4 refers to the reporting of new cases              
 and the cessation of treatment.  This goes back to the issue of               
 patients who are first diagnosed and records are placed into a                
 system which documents the disease.  It relates to the existence of           
 a system which follows up and contacts the patient periodically.              
 This is to make sure that when a patient is on treatment, that                
 treatment is carried out to completion.                                       
                                                                               
 DR. NAKAMURA noted there is a requirement that there be written               
 documentation in adherence to records that the State Medical                  
 Officer will have access to the patients records for                          
 epidemiological purposes.  It is also required that there is                  
 contact follow up, and there is reporting of the disease to the               
 State Medical Officer.  Examinations of suspected cases is also               
 mandated.                                                                     
                                                                               
 Number 1468                                                                   
                                                                               
 DR. NAKAMURA said Section 5 has an amendment changing the                     
 examination and reporting of those with TB from licensed physicians           
 in the state to those "who may lawfully practice" in the state.               
 The key in that issue is there are physicians who are with the                
 federal health care system who lawfully can practice in the state,            
 but who are not necessarily licensed in the state.                            
                                                                               
 DR. NAKAMURA continued that Section 6 repeals a section and re-               
 enacts portions of it.  This section refers to the ability to                 
 isolate or quarantine individuals who are less than willing to                
 follow the recommended therapy.  Recently, there was a situation in           
 an Alaskan community where a patient was infected and infectious,             
 and did not wish to or could not conform to therapy.  The                     
 requirement was that he be isolated in the quarantine state to                
 assure that treatment was administered.                                       
                                                                               
 Number 1523                                                                   
                                                                               
 DR. NAKAMURA said this section also gives assurance of due process.           
 If a patient is isolated or quarantined through the order of a                
 medical officer of the State Health Department, this patient has a            
 right to ask for a repeal of that isolation within five days.                 
 There has to be a review of the issue.  Within 60 days, there has             
 to be a type of court hearing on the case, and a determination must           
 be made whether the patient is to be retained in isolation or not.            
                                                                               
 DR. NAKAMURA explained that basically, this assures due process for           
 the patient.                                                                  
                                                                               
 Number 1550                                                                   
                                                                               
 CO-CHAIR BUNDE had a question about the isolation process.  He                
 asked if patients are isolated in a hospital, in their own homes,             
 or where.                                                                     
                                                                               
 DR. NAKAMURA said the language is written such that if it is                  
 feasible to isolate the individual at his or her home, that can be            
 done.  However, the isolation can also take place at a medical                
 facility or, in some situations where neither of the two are                  
 available, the patient could be quarantined in any other facility             
 that could provide the necessary isolation.                                   
                                                                               
 CO-CHAIR BUNDE asked if a correctional facility could be used.                
                                                                               
 DR. NAKAMURA said yes.                                                        
                                                                               
 Number 1584                                                                   
                                                                               
 DR. NAKAMURA said Section 7 allows the emergency detention of a               
 patient, and provides for due process rights.  Section 8 is an                
 extension of Section 6, which allows for the quarantine/isolation             
 of a patient, and the due process.  Section 9 allows for the                  
 treatment of patients who have strong religious convictions.                  
 Section 9 allows this to be taken under consideration, but with the           
 assurance that the public is protected from this individual in some           
 setting that would limit public exposure.                                     
                                                                               
 CO-CHAIR TOOHEY asked if that meant unless there is a miracle as TB           
 is not going to cure itself, people of a certain religious order              
 will have to be confined for the rest of their lives.                         
                                                                               
 DR. NAKAMURA said the wording is such that the special needs of               
 those people can be considered.  It does not say the state is                 
 mandated to excuse them from necessary treatment, if that is felt             
 to be necessary.                                                              
                                                                               
 Number 1659                                                                   
                                                                               
 CO-CHAIR TOOHEY said that in many Asian countries, people riding              
 bicycles wear surgical-style masks.  She asked if those masks have            
 any deterrent on TB at all.                                                   
                                                                               
 DR. NAKAMURA replied that the masks could have some degree of                 
 deterrent if the mask is of such a nature that it can catch most of           
 the droplets.  This is an airborne disease, and many of the                   
 organisms are transmitted through droplets.  This is not a foolish            
 precaution, it is definitely a measure of protection.                         
                                                                               
 DR. NAKAMURA continued with Section 10.  It is an amendment for the           
 protection of school children.  Basically, it says teachers should            
 be skin tested annually.  In the case the teacher already skin                
 tests positive, other examinations be administered.  These could              
 include either chest X-rays or sputum samples.                                
                                                                               
 Number 1701                                                                   
                                                                               
 CO-CHAIR BUNDE said that was the practice at one time in Alaska,              
 but those requirements were dropped.  Now they are going to be                
 reinstated.                                                                   
                                                                               
 DR. NAKAMURA said at least within the school setting, those are               
 going to be reinstated.  There is already a requirement that                  
 children in the rural areas be tested on an annual basis.                     
                                                                               
 CO-CHAIR BUNDE asked if Dr. Nakamura or the state has ever found a            
 teacher with active TB.                                                       
                                                                               
 DR. NAKAMURA did not have an answer to that question, but he                  
 offered to get it for Co-Chair Bunde.                                         
                                                                               
 CO-CHAIR BUNDE knows they have tested for TB for years, and he                
 didn't know if it was for the protection of teachers or children.             
                                                                               
 DR. NAKAMURA said it is a system of identifying cases of TB that              
 may be recurring in a community that previously was free of TB.               
 One of the sentinel events can be a child who turns positive.  This           
 allows the medical agencies to try and find the source of the                 
 infection.                                                                    
                                                                               
 Number 1742                                                                   
                                                                               
 DR. NAKAMURA summarized Section 11.  It is the last amendment, and            
 it is an inclusion of what was in the previous bill.  It allows for           
 penalties for violations of the aforementioned requirements.  Such            
 violations would be a misdemeanor.                                            
                                                                               
 CO-CHAIR TOOHEY asked what the penalties were for such a                      
 misdemeanor.                                                                  
                                                                               
 Number 1795                                                                   
                                                                               
 REPRESENTATIVE VEZEY asked what class the misdemeanor would fall              
 under, or if it was unclassified.                                             
                                                                               
 CO-CHAIR TOOHEY said it was a class A misdemeanor.                            
                                                                               
 REPRESENTATIVE VEZEY that would carry a six-month penalty.  A                 
 person could be confined for six months, whether in a jail or                 
 hospital.                                                                     
                                                                               
 Number 1795                                                                   
                                                                               
 REPRESENTATIVE VEZEY thought TB had been eradicated from Alaska a             
 few generations ago.  He wondered how he is going to explain to               
 people in Fairbanks and the North Pole area that people are being             
 incarcerated or confined because they are ill.  He asked Dr.                  
 Nakamura what he would tell them if he were Representative Vezey.             
                                                                               
 DR. NAKAMURA replied he would tell them that the patients are not             
 being incarcerated.  In fact, most patients with TB will not be               
 placed in such facilities.  It is only patients who are                       
 recalcitrant, and who refuse to conform to the necessary public               
 health practice to avoid infecting the rest of the public.  Those             
 patients who are more than willing to take their medications and              
 follow the recommended therapies would never be affected by this              
 requirement.                                                                  
                                                                               
 REPRESENTATIVE VEZEY said therefore, if a person is diagnosed with            
 infectious TB, as long as that person is following medical                    
 treatment, there is no reason to isolate that person from society.            
                                                                               
 DR. NAKAMURA said that was true.  There may be a need to initially            
 keep the patient from exposing the rest of the public to TB until             
 the medication has taken effect to the point that the patient is no           
 longer infectious.                                                            
                                                                               
 Number 1664                                                                   
                                                                               
 REPRESENTATIVE VEZEY asked how long that would take.                          
                                                                               
 DR. NAKAMURA said the time can vary from a period of one to two               
 weeks to a period of several months depending on the degree of the            
 infection.                                                                    
                                                                               
 REPRESENTATIVE VEZEY noted that any person under medical treatment            
 can possibly expose other members of society for about two weeks.             
 However, this bill is not targeted toward those people.                       
                                                                               
 DR. NAKAMURA said this bill is really targeted to those who refuse            
 to conform to therapy.  For example, his office encountered a                 
 person during the most recent outbreak of TB who refused to take              
 medication until he was quarantined and put under direct observed             
 therapy.  There are some individuals who are just unable to manage            
 their own destiny.  This may be because of substance abuse or for             
 other reasons.  These individuals either cannot or will not conform           
 to therapy.                                                                   
                                                                               
 Number 1908                                                                   
                                                                               
 REPRESENTATIVE VEZEY said therefore, it appears there are two                 
 classes of people that are involved here.  There are those who do             
 not have the faculties to conduct themselves in a responsible                 
 manner, and there are those who might, for some reasons of                    
 conviction, not want medical treatment.                                       
                                                                               
 DR. NAKAMURA agreed.  He said there is a need to make sure others             
 are not exposed to that individual without some sense of                      
 protection.                                                                   
                                                                               
 REPRESENTATIVE VEZEY asked about the TB cycle.  He asked how long             
 a person lives with disease.                                                  
                                                                               
 DR. NAKAMURA said that varies.  TB can manifest itself in many                
 different ways.  A person can be exposed to TB, get an infection,             
 and have nothing more than a converted skin test.  Those people               
 never actually get the disease to the point they are infectious.              
 There is always a possibility, about an 18 percent chance, that if            
 you are not treated at that point, you could break down and become            
 infectious with TB.                                                           
                                                                               
 DR. NAKAMURA explained there are others who, especially if they are           
 weakened by other diseases or illnesses, can have the TB infection            
 spread through their blood.  The TB can infect their brain, the               
 kidneys, the heart, the bones, etc.  There are many ways that TB              
 can present itself.  How it presents itself and what other                    
 underlying conditions the patient has can determine the length of             
 survival.                                                                     
                                                                               
 Number 1976                                                                   
                                                                               
 REPRESENTATIVE VEZEY resolved that there was no absolute mortality            
 table.  One cannot predict how long the disease will run.                     
                                                                               
 DR. NAKAMURA said no.  Some people will have the disease their                
 whole life, and have the continual potential to infect others, but            
 they will not progress to the point where they will die from the              
 disease.                                                                      
                                                                               
 REPRESENTATIVE VEZEY asked if anyone who tests positive for TB                
 could conceivably develop the symptoms of the disease at any time.            
                                                                               
 DR. NAKAMURA said TB is a funny disease.  When a person is                    
 initially infected, almost everyone has the ability to control and            
 confine that infection in a way that the disease does not become              
 active.  The disease can then progress or spread to others.  One              
 may find out he or she had the disease, and never knew it until a             
 chest X-ray showed calcification.  Or, perhaps a person was                   
 actually infected in the past but they never really got sick.  A              
 certain percentage of these people will then either break down or             
 progress to an active disease.  A person can either eventually die            
 from the disease or be severely impaired.                                     
                                                                               
 Number 2032                                                                   
                                                                               
 REPRESENTATIVE CAREN ROBINSON asked how long after a person begins            
 medication they are no longer infectious.                                     
                                                                               
 DR. NAKAMURA said that depends on a number of issues.  One is the             
 degree of the illness to which the person already has progressed              
 before treatment began.  If there is a cavity in a significantly              
 progressive disease, they may have to undergo treatment for weeks             
 or months before they are no longer infective.  There are others              
 who have a very minor infection and can be non-infectious in one to           
 two weeks.  It varies.  Plus, there are some organisms that are               
 resistant to medications used.  Until that is discovered through              
 lab tests, the patient may be on an ineffective drug.                         
                                                                               
 REPRESENTATIVE ROBINSON asked for clarification on the quarantine             
 provision.  They could be isolated at their house, a health                   
 facility or a correctional institution.  She asked why the state              
 would ever want to quarantine someone at a correctional                       
 institution.                                                                  
                                                                               
 DR. NAKAMURA said there are situations, for instance, of an                   
 individual in a rural community or village where the home setting             
 may not be ideal because of the many people in the home who may be            
 continually exposed to that person.  In addition, that would be an            
 option only if the patient were not willing to wear a mask and                
 cooperate in other protective measures.  There is no medical                  
 facility in which such an individual can be placed.                           
                                                                               
 Number 2091                                                                   
                                                                               
 DR. NAKAMURA noted that yet, the community members may be willing             
 to have that person stay within their community as long as they are           
 taking the medication and treatment.  The only place where that               
 isolation may take place may be in a correctional facility in that            
 community.                                                                    
                                                                               
 REPRESENTATIVE ROBINSON said there has been some concerns and                 
 arguments regarding contract jails.  Therefore, isolation in a                
 correctional facility would concern her.  She has not seen some of            
 those facilities, but some of the comments made on the floor of the           
 House leads her to believe that some of those facilities are not              
 fit for animals.  Therefore, she is concerned that someone would be           
 placed into an unfit facility.                                                
                                                                               
 DR. NAKAMURA said he cannot give her the assurance she desires                
 because he does not know each facility.  However, he would                    
 obviously try to avoid that type of situation.                                
                                                                               
 Number 2130                                                                   
                                                                               
 CO-CHAIR TOOHEY surmised that Representative Robinson was looking             
 at a very tiny percentage.  Perhaps one infected person every five            
 years would be in that situation.  The average person with TB is              
 very willing to undergo treatment.                                            
                                                                               
 REPRESENTATIVE ROBINSON realized that.  However, she was wondering            
 if it should be clear that facilities should be up to standards.              
 That may mean more work from the DHSS.  However, if this is a very            
 small number of cases, it may be worth it.  Representative Robinson           
 was curious whether there have been any such cases from the most              
 recent outbreak in which someone had to be isolated in the jails.             
                                                                               
 DR. NAKAMURA said there was one case in which there was a very                
 rapid turnaround.  This was because the state had the ability to              
 confine that individual.  Reality therapy comes into play when it             
 is known that the state will take action if the patient is not                
 responsible.  In that case, it may take no more than one day to               
 bring about that reality.                                                     
                                                                               
 Number 2180                                                                   
                                                                               
 REPRESENTATIVE ROBINSON was under the impression that a class A               
 misdemeanor can result up to one year in jail.  Since it can take             
 up to a few weeks for a patient to receive medication and be                  
 allowed back on the street, why would the state want to inflict a             
 penalty that could possibly lock up someone with TB for up to one             
 year.                                                                         
                                                                               
 CO-CHAIR BUNDE interjected that two different things were being               
 spoken of in this case.  One situation refers to isolating people             
 for their own protection and the public health.  The other                    
 situation refers to penalizing people who would knowingly infect              
 others.  The case that brought this up was the person who was aware           
 he was very infectious, and insisted on getting on an airplane and            
 infecting seven or eight other people in the two or three hour                
 flight to Anchorage.  That person could easily be incarcerated.               
 However, it would not be based on their own protection but on                 
 public health.                                                                
                                                                               
 DR. NAKAMURA corrected the last statement.  He said there was a               
 patient who did get on the plane and traveled against advice.                 
 Fortunately, no one was infected.  There was the potential for                
 infection, however.                                                           
                                                                               
 Number 2239                                                                   
                                                                               
 REPRESENTATIVE ROBINSON said on that issue, she understands there             
 are already adequate laws on the books which stipulate that if a              
 patient was to deny treatment, the Department of Law would be able            
 to charge them with other crimes such as reckless endangerment.               
 Therefore, perhaps more laws do not have to be added in this bill,            
 since such laws are already on the books.                                     
                                                                               
 CO-CHAIR BUNDE said it is his understanding that the state could              
 not prevent this person from getting on the airplane simply because           
 he was infectious.                                                            
                                                                               
 CO-CHAIR TOOHEY believes there is a law to stop a person from                 
 getting on an airplane.  Co-Chair Bunde said it did not stop the              
 patient in question at the time.                                              
                                                                               
 Number 2274                                                                   
                                                                               
 KRISTEN BOMENGEN, Assistant Attorney General, Criminal Division,              
 Department of Law (DOL), said she was present at the meeting to               
 address any of the legal concerns that may arise.  She asked to               
 briefly speak about what current law provides, and what went into             
 the process of recommending to the department that some change in             
 that law would help enable the department to more effectively carry           
 out its purpose in preventing the transmission of TB.                         
                                                                               
 MS. BOMENGEN explained that current statutory provisions provide              
 for the issuance of an examination order and the issuance of                  
 quarantine orders.  Those can be issued by the DHSS.  The law then            
 provides, if someone does not comply with those orders, that the              
 person be reported to a peace officer that a violation is                     
 occurring.  Criminal charges must also be filed in order to enforce           
 what is a public health order and what is an effort to assist a               
 person in obtaining medical care while protecting the public's                
 health.                                                                       
                                                                               
 MS. BOMENGEN said this law was put into place in 1984.  Things                
 subsequently went fairly well because the department worked with              
 people and found that they were agreeable and compliant.  Problems            
 did not occur.  In this last year, some circumstances arose in                
 which people objected to the orders the department issued.                    
 Therefore, the DOL Law had to file criminal charges in a case.                
                                                                               
 Number 2335                                                                   
                                                                               
 MS. BOMENGEN said it became apparent that the DOL may have been               
 missing some due process requirements by jumping immediately into             
 criminal sanctions when someone had a reason to object to the order           
 of a public health official.                                                  
                                                                               
 TAPE 95-28, SIDE B                                                            
 Number 000                                                                    
                                                                               
 MS. BOMENGEN said that is what is behind the orders from the DOL.             
 The orders are meant to fill in the gaps between the issuance of an           
 examination order/quarantine order, and the criminal sanction that            
 may be at the other end.  This bill, as Dr. Nakamura addressed,               
 sets out the other steps that may be necessary to all the                     
 department to be effective in this pursuit, and to allow for due              
 process protections.                                                          
                                                                               
 MS. BOMENGEN continued that this legislation will allow a                     
 medication order, for instance, so the department can issue a                 
 treatment order which the patient would be required to follow.  The           
 detention orders that are anticipated address circumstances in                
 which a person may be immediately infectious, and it is necessary             
 to take them out of the public.  This is because they may transmit            
 the disease through airborne droplets.  The detention order is also           
 designed to deal with someone who has demonstrated by previous                
 behavior that they will not comply with a medication order or a               
 treatment plan.                                                               
                                                                               
 Number 094                                                                    
                                                                               
 MS. BOMENGEN allowed that she is a lay person, and she does not               
 have thorough medical knowledge of TB.  However, during the course            
 of the case she was dealing with, there was a serious danger that             
 the person had not complied with the medication regimen.  As a                
 result, the medical dose they were receiving was possibly having              
 the effect of creating a drug-resistant strain in that person that            
 could then be transmitted.  Therefore, for public health reasons it           
 is necessary to perhaps detain a person who is not capable, for               
 their own reasons, of following the drug regimen in order to assure           
 that a more virulent, drug-resistant strain is not created.                   
                                                                               
 MS. BOMENGEN said the detention orders in this bill also anticipate           
 that someone may be detained in their own home.                               
                                                                               
 Number 161                                                                    
                                                                               
 CO-CHAIR TOOHEY said HESS Committee members are going to be hearing           
 a bill concerning HIV.  In that context, she asked Ms. Bomengen how           
 HB 274 addresses HIV.  She asked if testing was mandatory.  If                
 someone is walking around unbeknownst to him/her that they have TB,           
 can the department, on their own volition, say it is going to test            
 everybody in the village.  Co-Chair Toohey asked if that was legal.           
                                                                               
 MS. BOMENGEN replied that under this bill, it is anticipated that             
 if the department receives information that someone has been                  
 exposed to TB, the department may take appropriate action to                  
 determine whether TB has been transmitted to others in the area.              
 This bill, however, does not relate to HIV at all.                            
                                                                               
 CO-CHAIR TOOHEY said this bill gives the state the tools to mandate           
 a test.  Would not HIV testing also fall into that jurisdiction?              
                                                                               
 Number 249                                                                    
                                                                               
 MS. BOMENGEN was unaware of any reason that it would be comparable            
 to HIV.  TB is transmitted through airborne droplets, and there is            
 a known treatment and cure for TB.  Those factors distinguish TB              
 from HIV.  Again, Ms. Bomengen noted that she knows legal matters,            
 and she is not necessarily an expert on medical matters.  However,            
 because HIV and TB are so different, they would warrant different             
 treatment on that premise.                                                    
                                                                               
 CO-CHAIR BUNDE noted, regarding mandatory testing, that HB 274 says           
 mandatory testing exists for people in the school system.  How that           
 would be different from someone who is living in a small community            
 where there is a high possibility of widespread infection, Co-Chair           
 Bunde cannot imagine.  Testing is mandated in the school system               
 because there is a great number of people who are in close                    
 proximity where more contamination is possible.                               
                                                                               
 CO-CHAIR TOOHEY asked Ms. Bomengen if there is an "opt-out" for               
 testing in schools for a child and for other members of a                     
 community, if the tests are against religious convictions.                    
                                                                               
 Number 355                                                                    
                                                                               
 MS. BOMENGEN said this bill provides for consideration of religious           
 belief.  In order to assure that due process protections are                  
 recognized within the statute if a religious belief objection is              
 raised, the department, if it felt it was necessary to test                   
 someone, would issue an order and the objection may be raised under           
 this provision to allow for the practice of religion.  There would            
 then be an appropriate response to those concerns.  Ms. Bomengen              
 said she does not know what the outcome would be when it went                 
 before the court.  It would depend on the facts that were before              
 the court.                                                                    
                                                                               
 REPRESENTATIVE ROKEBERG said Section 10 requires the testing of               
 public and private school employees.  Representative Rokeberg asked           
 Dr. Nakamura if it was true that in the past, food service handlers           
 and other people with public contact also had mandatory testing for           
 TB.  If that is the case, Representative Rokeberg asked why those             
 tests were not being currently required.                                      
                                                                               
 DR. NAKAMURA said he is not quite sure of the answer to that                  
 question.  However, in this case, the purpose is to protect the               
 school children.  They comprise a large population of susceptible             
 children, exposed to a teacher.  The doctor is not aware of any               
 requirements for the TB testing of food handlers.                             
                                                                               
 Number 468                                                                    
                                                                               
 CO-CHAIR TOOHEY was not sure of the exact date, but she did know a            
 few years ago that became an obsolete requirement for food                    
 handlers.                                                                     
                                                                               
 REPRESENTATIVE ROKEBERG said given the situation, perhaps that                
 requirement should not be obsolete.                                           
                                                                               
 CO-CHAIR TOOHEY said TB cases occur mainly in very isolated                   
 villages, not in Anchorage.                                                   
                                                                               
 CO-CHAIR BUNDE said TB cases may be very isolated.  However, the              
 last briefing on TB stressed that foreigners may be bringing in               
 drug resistant strains of the disease.  Even one case of this would           
 be totally devastating because it is so difficult to treat.                   
 However, who is tested, why, and where leads Co-Chair Bunde to his            
 question.  There is a zero fiscal note, yet the state is going to             
 mandate testing and there may be people who must be quarantined               
 someplace other than their own house.  Co-Chair Bunde said it                 
 sounds like that would cost money.                                            
                                                                               
 Number 547                                                                    
                                                                               
 DR. NAKAMURA asked to respond to Representative Rokeberg's question           
 first, and then to answer Co-Chair Bunde's.  One of the reasons the           
 department is focusing on the testing of teachers is because part             
 of the transmission of the disease is based on the period of                  
 exposure.  In schools, there may be a teacher who is exposing a               
 group of children on a daily basis.  This is different than a food            
 handler exposing an individual who has a very quick, transient                
 exposure to the disease.  There must be a significant period of               
 exposure to catch TB.                                                         
                                                                               
 DR. NAKAMURA spoke of the people who were in the airplane with the            
 infectious individual.  Those people were in the airplane and were            
 exposed for a significant duration of time, however, there was no             
 transmission of the disease.  Part of this is related to the period           
 and degree of exposure.                                                       
                                                                               
 REPRESENTATIVE ROKEBERG said people are creatures of habit.  He               
 said there is a restaurant he frequently visits in Anchorage.                 
 Representative Rokeberg said he does not want to hold up the bill,            
 however, he thinks this should be looked at in the next committee             
 of referral.  Representative Rokeberg hopes there will be a good,             
 epidemiological answer for his question before the bill goes                  
 further.                                                                      
                                                                               
 CO-CHAIR TOOHEY said that is a valid point, and asked Dr. Nakamura            
 to find out why food handlers are no longer required to be tested             
 for TB.                                                                       
                                                                               
 DR. NAKAMURA said it very well may be due to the success in dealing           
 with disease.  The state has been successful to the point that it             
 brought the actual rate of infection in Alaska to about 9.5 per               
 100,000.  This is an amazing control of the disease.  The chance of           
 exposure has been significantly decreased.  Probably, the rates are           
 still very low.  That rate has decreased from 1993, when the rate             
 was about 12.5 per 100,000.  There is a very low probability of               
 exposure.                                                                     
                                                                               
 Number 680                                                                    
                                                                               
 CO-CHAIR BUNDE asked Dr. Nakamura to address the fiscal note                  
 dilemma.                                                                      
                                                                               
 DR. NAKAMURA explained the statutes allow the state to assume the             
 cost of treatment, but it does not mandate the state to assume the            
 cost of treatment.  The numbers of individuals that would actually            
 require isolation or quarantine are very low.  The state could very           
 well be responsible for an individual who has not insurance and has           
 a very low income.  However, overall the numbers of individuals the           
 state would encounter in this type of situation would be quite low.           
 The financial risk to the state would therefore also be quite low.            
                                                                               
 CO-CHAIR BUNDE understood that.  However, he was still concerned              
 about the zero fiscal note.  He said that even if the cost to the             
 state is $10, a fiscal note should still reflect that.  More                  
 importantly, will not testing in schools involve a lot of                     
 materials, qualified people, and travel?                                      
                                                                               
 CO-CHAIR BUNDE stressed that he was not speaking against the school           
 testing.  It is something that should be done.  However, Co-Chair             
 Bunde thinks there is a larger possibility that the teacher will be           
 infected by the child than vice versa.  There is some expense                 
 involved, and Co-Chair Bunde asked Dr. Nakamura to speak to that.             
                                                                               
 Number 777                                                                    
                                                                               
 DR. NAKAMURA believes most of the expense encountered would be                
 covered by an individual's medical insurance.  It would not                   
 necessarily be an expense to the department or to the state.                  
                                                                               
 CO-CHAIR BUNDE said to set up program testing at a school, someone            
 will have to do tine tests.  The school nurse may do those tests              
 are part of her regular duties.  But Co-Chair Bunde wanted to know            
 how much it costs, just for the materials if nothing else, for 50             
 or 100 people to perform a tine test.  If that cost is then                   
 magnified by the 50,000 students in Alaska, the cost can be                   
 considerable.                                                                 
                                                                               
 DR. NAKAMURA said he would have to go back and check with the                 
 department.  However, he anticipates that the state would not be              
 using state staff to administer the tests or to make the materials            
 available.   This would be part of the health care requirements of            
 any individual who is working as a teacher, etc.  The assumption is           
 that the tests would be covered by medical insurance and health               
 care.                                                                         
                                                                               
 Number 840                                                                    
                                                                               
 CO-CHAIR BUNDE asked if only teachers, and not the children, were             
 going to be tested.                                                           
                                                                               
 DR. NAKAMURA said only the testing of the teachers is required.               
                                                                               
 CO-CHAIR BUNDE thought all the children were going to be tested,              
 like was done previously.                                                     
                                                                               
 DR. NAKAMURA said the children are already being tested under the             
 present treatment protocols.                                                  
                                                                               
 CO-CHAIR TOOHEY said under Section 3, line 1, it reads, "The                  
 department, in establishing a comprehensive program for the control           
 of tuberculosis in the state, shall cooperate with state, federal             
 and local agencies...."  She said the bill goes on to read "a                 
 health care provider who treats a person with TB shall examine all            
 other persons in the household who have had contact with the                  
 patient...."  Co-Chair Toohey felt there is going to be a cost to             
 this bill.  It is not wise to pass the bill without the money it              
 will take to implement the program.                                           
                                                                               
 DR. NAKAMURA said there are not that many new impositions in this             
 bill that are not being currently done.  This bill is actually                
 revising the language and stating much of what is already taking              
 place.                                                                        
                                                                               
 Number 935                                                                    
                                                                               
 REPRESENTATIVE VEZEY asked Dr. Nakamura to further explain the                
 disease.  He said someone can be exposed to the disease, and still            
 not contract TB.                                                              
                                                                               
 DR. NAKAMURA said the person can either not get infected, become              
 infected but not ill, or they can become infected and become ill.             
 Many factors will determine which of those three situations will be           
 encountered.                                                                  
                                                                               
 REPRESENTATIVE VEZEY said therefore, a person can have contact with           
 the disease but not become infected.  Representative Vezey asked              
 what a positive skin test means.                                              
                                                                               
 DR. NAKAMURA replied that a positive skin test means a person is              
 infected with the TB organism.  However, it does not tell the                 
 person whether he or she is actually ill, or when he/she was                  
 infected.  The skin test only shows that somewhere in the course of           
 his/her life, the TB organism was picked up and it settled                    
 somewhere in the body.  He/she is infected, but not necessarily               
 ill.                                                                          
                                                                               
 Number 1000                                                                   
                                                                               
 REPRESENTATIVE VEZEY said therefore, once one tests positive for              
 TB, he/she will always test positive?                                         
                                                                               
 DR. NAKAMURA said yes.  It takes a few more steps to determine                
 whether one is actually ill from the disease.  One test is the                
 sputum test.   It shows whether there are TB organisms in a                   
 person's sputum.  If organisms are present, the person has gone               
 beyond the point of a simple infection.  A chest X-ray will also              
 show that the disease has advanced.                                           
                                                                               
 CO-CHAIR TOOHEY said unless a person is showing symptoms of the               
 disease, such a fever, coughing, etc., there is no need to get an             
 X-ray.  However, if one is feeling poorly, and one has tested                 
 positive, he or she should be thoroughly examined.  She noted that            
 once a person skin tests positive, he/she should always assume that           
 somewhere along the line there has been exposure to TB.                       
                                                                               
 Number 1056                                                                   
                                                                               
 REPRESENTATIVE ROBINSON asked why, in the drafting of the bill,               
 class A misdemeanor was chosen instead of class B or class C.  She            
 asked why it was felt the misdemeanor had to be class A.                      
                                                                               
 MS. BOMENGEN said the misdemeanor is not different from the current           
 provisions in the bill.  In putting the bill together, the steps              
 between actions were filled in.  The initial steps were decided,              
 and the final criminal penalty has always been there.  It has now             
 been placed in Section 11.  However, AS 18.15.138 is being repealed           
 by this bill.  That is actually an identical provision.  Nothing              
 has changed in that regard.                                                   
                                                                               
 MS. BOMENGEN said a number of intermediate steps have been put in             
 place, however.  These steps can achieve the purpose of                       
 enforcement.  These make the final eventuality highly unlikely                
 because there is even an emergency detention order that is provided           
 for earlier in the bill.   Again, there are intermediate steps to             
 be taken if someone is not complying with the department.  It is              
 not necessary to immediately resort to criminal sanctions in order            
 to enforce the statute.                                                       
                                                                               
 MS. BOMENGEN wanted to mention something in response to earlier               
 testimony about detainment in correctional facilities.  She does              
 not believe it is written anywhere that is the type of facility               
 that is intended.  In the emergency detention order section,                  
 Section 7, the bill reads of a "health care facility or another               
 location."  That is merely to leave the options available to the              
 department in circumstances where there may not be a health care              
 facility available, yet there is an immediate need to act to                  
 protect the public health.                                                    
                                                                               
 Number 1150                                                                   
                                                                               
 MS. BOMENGEN stressed it is not intended for a correctional                   
 facility to be used as a standard place for isolation.                        
                                                                               
 REPRESENTATIVE ROBINSON said there are two areas Ms. Bomengen                 
 should look at as the bill moves through the committees.                      
 Representative Robinson wanted to know if the penalty had to be so            
 stiff.  Representative Robinson knows that there have been very few           
 cases that would warrant such a penalty in the past, and the cases            
 have involved people who were not only were ill with TB, but also             
 had possible drug and alcohol addiction.  It seems to                         
 Representative Robinson, therefore, that the penalty is a little              
 stiff.                                                                        
                                                                               
 REPRESENTATIVE ROBINSON also believes strongly, in reference to               
 Section 7, that the first attempt for detainment should definitely            
 be in a health care facility.  Representative Robinson can see it             
 being more expedient to take someone to a correctional facility               
 instead of going through the problems of trying to find appropriate           
 health care.                                                                  
                                                                               
 Number 1222                                                                   
                                                                               
 CO-CHAIR TOOHEY closed the bill to public testimony and asked for             
 the wish of the committee.  Representative Vezey made a motion to             
 move HB 274 from the HESS Committee with individual recommendations           
 and attached fiscal notes.  There were no objections, and the bill            
 passed out of committee.                                                      
                                                                               

Document Name Date/Time Subjects