Legislature(1995 - 1996)
03/28/1995 02:09 PM HES
* first hearing in first committee of referral
= bill was previously heard/scheduled
= bill was previously heard/scheduled
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.