Legislature(2015 - 2016)CAPITOL 106

04/14/2015 03:00 PM HEALTH & SOCIAL SERVICES

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Audio Topic
03:08:39 PM Start
03:09:05 PM Presentation: Alaska Section of Epidemiology
04:23:53 PM HB99
04:31:14 PM Adjourn
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ Presentation: TELECONFERENCED
"Section of Epidemiology" by Dr. Jay Butler &
Dr. Joe McLaughlin
+ Bills Previously Heard/Scheduled TELECONFERENCED
+= HB 99 VOLUNTARY TERMINATION OF LIFE TELECONFERENCED
Heard & Held
                    ALASKA STATE LEGISLATURE                                                                                  
      HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE                                                                     
                         April 14, 2015                                                                                         
                           3:08 p.m.                                                                                            
                                                                                                                                
MEMBERS PRESENT                                                                                                               
                                                                                                                                
Representative Paul Seaton, Chair                                                                                               
Representative Liz Vazquez, Vice Chair                                                                                          
Representative Louise Stutes                                                                                                    
Representative David Talerico                                                                                                   
Representative Geran Tarr                                                                                                       
Representative Adam Wool                                                                                                        
                                                                                                                                
MEMBERS ABSENT                                                                                                                
                                                                                                                                
Representative Neal Foster                                                                                                      
                                                                                                                                
COMMITTEE CALENDAR                                                                                                            
                                                                                                                                
PRESENTATION: ALASKA SECTION OF EPIDEMIOLOGY                                                                                    
                                                                                                                                
     - HEARD                                                                                                                    
                                                                                                                                
HOUSE BILL NO. 99                                                                                                               
"An Act relating to the voluntary termination of life by                                                                        
terminally ill individuals; and providing for an effective                                                                      
date."                                                                                                                          
                                                                                                                                
     - HEARD & HELD                                                                                                             
                                                                                                                                
PREVIOUS COMMITTEE ACTION                                                                                                     
                                                                                                                                
BILL: HB 99                                                                                                                   
SHORT TITLE: VOLUNTARY TERMINATION OF LIFE                                                                                      
SPONSOR(s): REPRESENTATIVE(s) DRUMMOND                                                                                          
                                                                                                                                
02/09/15       (H)       READ THE FIRST TIME - REFERRALS                                                                        
02/09/15       (H)       HSS, JUD                                                                                               
04/09/15       (H)       HSS AT 3:00 PM CAPITOL 106                                                                             
04/09/15       (H)       Heard & Held                                                                                           
04/09/15       (H)       MINUTE(HSS)                                                                                            
04/14/15       (H)       HSS AT 3:00 PM CAPITOL 106                                                                             
                                                                                                                                
WITNESS REGISTER                                                                                                              
                                                                                                                                
JAY BUTLER, MD, Chief Medical Officer/Director                                                                                  
Division of Public Health                                                                                                       
Central Office                                                                                                                  
Department of Health and Social Services (DHSS)                                                                                 
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:   Answered questions during  the presentation                                                             
by the Section of Epidemiology.                                                                                                 
                                                                                                                                
JOE McLAUGHLIN, M.D., MPH                                                                                                       
Chief and State Epidemiologist                                                                                                  
Section of Epidemiology                                                                                                         
Division of Public Health                                                                                                       
Department of Health and Social Services (DHSS)                                                                                 
Anchorage, Alaska                                                                                                               
POSITION   STATEMENT:     Presented  a   PowerPoint  during   the                                                             
presentation by the Section of Epidemiology.                                                                                    
                                                                                                                                
REPRESENTATIVE HARRIET DRUMMOND                                                                                                 
Alaska State Legislature                                                                                                        
Juneau, Alaska                                                                                                                  
POSITION  STATEMENT:   Answered  questions  about  HB 99  as  the                                                             
sponsor of the bill.                                                                                                            
                                                                                                                                
                                                                                                                                
ACTION NARRATIVE                                                                                                              
                                                                                                                                
3:08:39 PM                                                                                                                    
                                                                                                                                
CHAIR PAUL  SEATON called  the House  Health and  Social Services                                                             
Standing   Committee    meeting   to    order   at    3:08   p.m.                                                               
Representatives Seaton, Wool, Talerico,  Vazquez, and Stutes were                                                               
present at  the call  to order.   Representative Tarr  arrived as                                                               
the meeting was in progress.                                                                                                    
                                                                                                                                
^Presentation: Alaska Section of Epidemiology                                                                                 
          Presentation: Alaska Section of Epidemiology                                                                      
                                                                                                                              
3:09:05 PM                                                                                                                    
                                                                                                                                
CHAIR SEATON announced that the  first order of business would be                                                               
a  presentation by  the  Alaska Section  of  Epidemiology in  the                                                               
Division  of  Public  Health, Department  of  Health  and  Social                                                               
Services (DHSS).   He emphasized the  importance of understanding                                                               
the Section  of Epidemiology,  as it had  influence on  health in                                                               
Alaska.                                                                                                                         
                                                                                                                                
3:10:02 PM                                                                                                                    
                                                                                                                                
JAY  BUTLER,  MD,  Chief Medical  Officer/Director,  Division  of                                                               
Public Health,  Central Office, Department  of Health  and Social                                                               
Services (DHSS), explained that he  would be in a supporting role                                                               
in  the presentation,  noting that  Dr. McLaughlin  had been  the                                                               
section  chief since  2007, and  was the  president-elect of  the                                                               
Council of State and Territorial Epidemiologists.                                                                               
                                                                                                                                
3:12:10 PM                                                                                                                    
                                                                                                                                
JOE  McLAUGHLIN,  M.D.,  MPH,  Chief  and  State  Epidemiologist,                                                               
Section of  Epidemiology, Division  of Public  Health, Department                                                               
of  Health and  Social Services  (DHSS), introduced  a PowerPoint                                                               
titled  "Epidemiologists-The Disease  Detectives."   He  directed                                                               
attention to  slide 2, "Definitions,"  which he declared  was the                                                               
study of  how and why diseases  occur in populations.   He shared                                                               
that epi meant upon, demos meant  people, and ology was the study                                                               
of, hence the  definition being the study of people.   He defined                                                               
an  epidemic as  the  occurrence  of cases  of  an  illness in  a                                                               
community that  are in  excess of normal  expectancy.   He shared                                                               
that epidemics that were limited  to a more localized increase of                                                               
a disease  were called outbreaks; whereas  larger scale epidemics                                                               
that affected  many people on  multiple continents  were referred                                                               
to  as  pandemics.    He   moved  on  to  slide  3,  "Fundamental                                                               
Assumptions and Goal," and stated  that the primary assumption of                                                               
epidemiology  was that  diseases  did not  occur  at random,  and                                                               
could, therefore, be  studied and described.  Once  a disease was                                                               
understood, it could be mitigated  and prevented.  He stated that                                                               
the  main goal  of  the  epidemiologist was  to  learn about  the                                                               
distribution  and determinance  of  diseases  in populations,  by                                                               
finding the  characteristics of the  disease, who it  affected in                                                               
the  population, where  and when  it  specifically occurred,  and                                                               
what was the problem that actually occurred.                                                                                    
                                                                                                                                
3:15:06 PM                                                                                                                    
                                                                                                                                
DR. McLAUGHLIN directed attention to  slide 4, "Alaska Section of                                                               
Epidemiology,"  and reported  that  epidemiology was  one of  the                                                               
eleven  sections in  the Alaska  Division of  Public Health.   He                                                               
noted that this was not  the only section which did epidemiologic                                                               
work, as the Sections of  Chronic Disease and Women's, Children's                                                               
& Family Health, as well  as Public Health Nursing, all routinely                                                               
engaged  in epidemiologic  work.   He  addressed  slide 5,  "What                                                               
specifically does the Section of  Epidemiology do?"  He explained                                                               
that the  Section of Epidemiology  consists of six  major program                                                               
areas, with about  65 staff, fellows, and interns  working in the                                                               
section.    He  listed  the six  program  areas,  which  included                                                               
infectious diseases,  HIV/STD, and immunization.   He stated that                                                               
the day-to-day work addressed most  of the essential functions of                                                               
public health pictured  on the slide.  He offered  to focus in on                                                               
the work as a subset of the functions.                                                                                          
                                                                                                                                
DR. McLAUGHLIN directed attention  to slide 6, "Essential Service                                                               
#1: Monitor,"  and indicated that monitoring  health outcomes was                                                               
the first  piece of  the public  health essential  functions pie,                                                               
which  is  essentially the  role  of  epidemiologists and  public                                                               
health in  general.  The  epidemiologic term used  for monitoring                                                               
was  surveillance,  which   represents  the  ongoing  collection,                                                               
analysis,  and  interpretation  of population  health  data  that                                                               
forms the  backbone of public  health practice.  This  is closely                                                               
integrated with timely dissemination  of data to key stakeholders                                                               
such as health  care providers, the public, and many  others.  He                                                               
directed   attention  to   slide   7,   "Why  Do   Surveillance?"                                                               
Surveillance allows  epidemiologists to directly measure  what is                                                               
going on  in the  population with respect  to diseases  and other                                                               
key health  outcomes, he stated.   The surveillance  data enables                                                               
us to get  answers to the fundamental  epidemiologic questions of                                                               
who, what,  where, why, and  when.  It further  allows assessment                                                               
of  trends over  time to  determine  the need  for public  health                                                               
intervention, prioritize  resources, evaluate  effectiveness, and                                                               
provide critical feedback to stakeholders.                                                                                      
                                                                                                                                
DR.  McLAUGHLIN  directed  attention   to  slide  8,  "Conditions                                                               
Reportable  to Public  Health  in Alaska,"  stating  a number  of                                                               
conditions that were legally reportable  by health care providers                                                               
and   laboratories   in   Alaska,  including   approximately   50                                                               
infectious   diseases,  cancer,   and  birth   defects.     These                                                               
reportable   conditions   are   summarized  in   the   reportable                                                               
conditions manual,  which is available  online at the  Section of                                                               
Epidemiology's website at www.epi.alaska.gov.                                                                                   
                                                                                                                                
REPRESENTATIVE   TALERICO   asked    about   legally   reportable                                                               
conditions and  whether the Section of  Epidemiology was required                                                               
to report them.                                                                                                                 
                                                                                                                                
DR. McLAUGHLIN answered yes.                                                                                                    
                                                                                                                                
DR.  McLAUGHLIN  directed  attention to  slide  9,  "Surveillance                                                               
Conditions  Reportable," noting  the amount  of time  that health                                                               
care  providers and  labs  are  given to  report  depends on  the                                                               
condition and ranges from an  immediate reporting requirement for                                                               
public  health  emergencies  as shown  on  the  slide,  including                                                               
anthrax,  botulism,  diphtheria, and  polio  to  as long  as  six                                                               
months for other diagnosis, such as cancer.                                                                                     
                                                                                                                                
DR. McLAUGHLIN  directed attention  to slide  10, "Report  Out to                                                               
Stakeholders,"  and noted  that  all of  the  Division of  Public                                                               
Health's sections that collect  reportable conditions data report                                                               
out their findings to stakeholders in  a variety of formats.  For                                                               
example  the  Infectious  Disease   Program  provides  an  annual                                                               
summary  of reportable  infectious disease  case counts  over the                                                               
past two  years in an  epidemiology bulletin.  In  addition, some                                                               
of   the  infectious   diseases   warrant   their  own   specific                                                               
epidemiology bulletins  that provide more  detailed epidemiologic                                                               
information,  for  example,  tuberculosis,  HIV,  and  gonorrhea.                                                               
Turning  to the  next  slide 11,  entitled  "Monitor Trends,"  he                                                               
noted  that the  Section of  Epidemiology can  track trends  over                                                               
time,  for  example,  reviewing influenza  surveillance  data  to                                                               
determine  when the  seasonal influenza  epidemic is  peaking and                                                               
when  the  epidemic will  end.    In addition,  epidemiology  can                                                               
follow  yearly trends  to determine  variations in  diseases from                                                               
year  to year.   He  turned to  slide 12,  "Provide Reassurance,"                                                               
stating  that  sometimes   surveillance  data  provides  critical                                                               
reassurance  to the  public.   For  example,  the statewide  Hair                                                               
Mercury  Bio-monitoring  Program  allows women  of  child-bearing                                                               
ages to submit hair samples to  the state public health lab to be                                                               
analyzed for  mercury content since  elevated mercury  content in                                                               
the  blood can  affect  brain development  in  their fetuses  and                                                               
breast-feeding infants.   Parents  are naturally  concerned about                                                               
this  contaminant  in their  foods,  which  is of  in  particular                                                               
importance   to  people   consuming  lots   of  fish   and  other                                                               
subsistence  foods.   Fortunately  the  feedback  the Section  of                                                               
Epidemiology can  provide mothers and communities  indicates that                                                               
the vast majority  of people whose hair was tested  came back far                                                               
below the threshold level of  concern.  This information provides                                                               
evidence based reassurance to the public, he said.                                                                              
                                                                                                                                
3:21:37 PM                                                                                                                    
                                                                                                                                
DR.   McLAUGHLIN  directed   attention  to   slide  13,   "Detect                                                               
Outbreaks,"  noting that  surveillance allows  epidemiologists to                                                               
detect, respond  to, and stop  epidemics.  This slide  depicts an                                                               
outbreak  of campylobacter  bacterial  infection associated  with                                                               
consumption  of raw,  unpasteurized milk  that occurred  in 2013.                                                               
Since   the   state   public  health   lab   performs   molecular                                                               
characterization  of   campylobacter  strains,  the   Section  of                                                               
Epidemiology  was  able  to  quickly  determine  that  the  first                                                               
several  cases  in   this  outbreak  were  the   same  strain  of                                                               
campylobacter.      This   prompted   a   quick   public   health                                                               
investigation   that   uncovered   the   outbreak   and   enabled                                                               
epidemiologists  to encourage  people not  to drink  the infected                                                               
milk.    Thus  shortly  thereafter  the  outbreak  stopped.    He                                                               
directed  attention  next to  slide  14,  "Essential Service  #2:                                                               
Investigate,"   which   means    epidemiologists   diagnose   and                                                               
investigate health problems and hazards  in the community.  These                                                               
investigation  are often  prompted  by an  unusual clustering  of                                                               
cases.  However, for very  serious diseases, only one constitutes                                                               
an outbreak and requires prompt  investigation, for example, food                                                               
borne botulism.   He advised that botulism  is a life-threatening                                                               
illness  caused   by  consumption   of  food   contaminated  with                                                               
botulinum  toxin, which  is one  of the  most potent,  naturally-                                                               
occurring neurotoxins on the planet.   Alaska has the unfortunate                                                               
distinction  of having  one of  the highest  rates of  food-borne                                                               
botulism  in  the world,  he  said.    This bacteria  thrives  in                                                               
oxygen-poor  conditions, which  are the  conditions required  for                                                               
fermenting  and putrefying  foods.   Many cultures  ferment food,                                                               
such as  some cheeses and sauerkraut.   All of Alaska's  cases of                                                               
botulism  have  been caused  by  the  consumption of  traditional                                                               
Alaskan Native  foods that were  aged or putrefied,  for example,                                                               
aged  fish  heads,  fish  eggs,  and seal  flipper,  as  well  as                                                               
putrefied seal oil.                                                                                                             
                                                                                                                                
DR. McLAUGHLIN  directed attention to slide  15, "Recent Outbreak                                                               
Example,  12/19/14,"  depicting a  botulism  case  that began  on                                                               
12/19/14 at 3:30 p.m. when  an epidemiology nurse received a call                                                               
from the Yukon-Kuskokwim Delta Regional  Hospital (YKDRH) and was                                                               
informed  that  botulinum  anti-toxin  was  administered  to  two                                                               
adults  who manifested  classic signs  and symptoms  of botulism,                                                               
including neuro-paralysis.   The  two adults  shared a  meal that                                                               
included rendered  seal oil consumed  in a  village at 6  p.m. on                                                               
12/18/14.  Their symptoms emerged  12-16 hours after consumption.                                                               
Both adults  with respiratory  muscle involvement  were medivaced                                                               
to Alaska Native  Medical Center's intensive care  unit.  Another                                                               
adult and  two children,  ages 8  and 12, also  ate the  meal but                                                               
were asymptomatic.  The seal  oil was obtained from a distributor                                                               
in another village, he said.                                                                                                    
                                                                                                                                
DR. McLAUGHLIN said  he was contacted on the same  day and he and                                                               
the  nurse epidemiologist  developed  an  immediate action  plan,                                                               
including sending  additional antitoxin  kits to the  YKDRH since                                                               
at least three other people had  been exposed [slide 16].  Public                                                               
health nurses  were called in to  do initial field work  and pull                                                               
contaminated seal  oil from refrigerators  and monitor  those who                                                               
were  exposed for  any symptoms.    The plan  included flying  an                                                               
epidemiology  nurse to  the village  for an  onsite investigation                                                               
and flying the two exposed children to Bethel.                                                                                  
                                                                                                                                
3:29:54 PM                                                                                                                    
                                                                                                                                
DR. BUTLER  added that the  first rule of outbreak  public health                                                               
was that all outbreaks are identified after 3 p.m. on Friday.                                                                   
                                                                                                                                
3:30:09 PM                                                                                                                    
                                                                                                                                
DR. McLAUGHLIN directed attention  to slide 17, "12/21/14," which                                                               
fell on a  Sunday.  One of the medical  doctors at YKDRH reported                                                               
that  the foregoing  8-year-old child  who consumed  contaminated                                                               
seal  oil had  fixed  and dilated  pupils  and excessive  thirst,                                                               
signs of  botulism.  The  Section of Epidemiology  determined the                                                               
child  probably  had  botulism  and the  doctor  was  advised  to                                                               
administer antitoxins and continue monitoring both children.                                                                    
                                                                                                                                
3:31:06 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE WOOL  asked whether  any harm  can occur  with the                                                               
administration  of   the  antitoxin   to  someone  who   had  not                                                               
contracted botulism.                                                                                                            
                                                                                                                                
DR. McLAUGHLIN  replied that  it was  not medically  indicated to                                                               
administer antitoxins in the absence  of clinical botulism due to                                                               
potential side  effects, although the newer  anti-toxin has fewer                                                               
side effect risks.                                                                                                              
                                                                                                                                
3:32:06 PM                                                                                                                    
                                                                                                                                
DR.  McLAUGHLIN   directed  attention   to  slide   18,  entitled                                                               
"12/22/14," noting  that specimens of  seal oil were sent  to the                                                               
state lab for  testing, the distributor was contacted,  and up to                                                               
eight other people were identified  as potentially being exposed.                                                               
Public  health nurses  had daily  contact with  everyone who  had                                                               
consumed seal  oil to monitor them  for symptoms.  By  that point                                                               
up to 18  exposed individuals had been identified.   An itinerant                                                               
nurse manager  flew to Dillingham to  assist follow up on  all of                                                               
them.                                                                                                                           
                                                                                                                                
DR.  McLAUGHLIN   directed  attention   to  slide   19,  entitled                                                               
"12/23/14," noting that  public health nurses were  unable to fly                                                               
to village  B, where  the supplier  lived due to  weather.    Lab                                                               
results were  provided to  public health  nurses, the  YKDRH, and                                                               
health care providers in Dillingham.   The lab indicated that the                                                               
seal  oil had  the  highest percentage  of  botulinum toxin  ever                                                               
encountered  by  the  lab.  He referred  to  slide  20,  entitled                                                               
"12/24/14," stated  that another  epidemiology nurse  who brought                                                               
three additional  antitoxin kits to assist  with surveillance and                                                               
monitoring  of exposed  persons  was flown  to  Dillingham.   The                                                               
Section of Epidemiology held a  meeting with the Bristol Bay Area                                                               
Health Corporation  and hospital, medical, and  clinical staff to                                                               
develop a collaborative  plan since botulism can  incubate in the                                                               
system for weeks.   The plan included media  interviews to inform                                                               
people of the outbreak.                                                                                                         
                                                                                                                                
DR.  McLAUGHLIN  directed  attention  to slide  21,  "Summary  of                                                               
Botulism Surveillance," noting this  case involved three cases of                                                               
botulism,  that  all  survived, but  over  20  additional  people                                                               
consumed  some  of the  highly  toxic  seal  oil.   He  expressed                                                               
concern over  the number of  cases and  the outcome if  more seal                                                               
oil  was  distributed  to  people   and  they  had  consumed  the                                                               
contaminated seal oil.                                                                                                          
                                                                                                                                
3:36:54 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  WOOL, in  reference to  slide 21,  asked how  two                                                               
people in Wasilla had been possibly exposed.                                                                                    
                                                                                                                                
DR. McLAUGHLIN explained  that some of the  contaminated seal oil                                                               
had been shipped to Wasilla.                                                                                                    
                                                                                                                                
3:37:17 PM                                                                                                                    
                                                                                                                                
DR.  McLAUGHLIN  directed  attention   to  slide  22,  "Essential                                                               
Service #3: Educate,"  which provides a nice  segue to education,                                                               
mentioning a number of ways  the division provides information on                                                               
botulism to  communities, including  on the  department's website                                                               
and in educational talks to medical staff.                                                                                      
                                                                                                                                
DR. McLAUGHLIN directed attention to  slide 23, "Working with the                                                               
Media," noting  the Section of  Epidemiology works with  media to                                                               
keep   the  public   informed.     He  referred   to  slide   24,                                                               
"Epidemiology,"   describing   the  epidemiology   website   that                                                               
highlights  current  events  in  Alaska   as  well  as  links  to                                                               
programmatic webpages.                                                                                                          
                                                                                                                                
DR.  McLAUGHLIN directed  attention to  slide 25,  "Alaska Public                                                               
Health  Advisory," explaining  that the  Section of  Epidemiology                                                               
releases  public  health  advisories  when  necessary,  with  the                                                               
primary audience  being health  care providers  in order  to keep                                                               
them   informed  of   any  emerging   issues  of   public  health                                                               
importance.    He  next  directed attention  to  slide  26,  "Epi                                                               
Bulletins," which he said he  previously mentioned; however, this                                                               
slide highlights the bulletins, which are generally widely read.                                                                
                                                                                                                                
DR.  McLAUGHLIN   directed  attention  to  slide   27,  "Bulletin                                                               
Recommendations  and  Reports,"  noting multi-page  reports  have                                                               
been issued and  are available.  One recent  report provided fish                                                               
consumption  advice for  Alaskans, noting  that Alaska's  fish is                                                               
considered very safe, that salmon are  low in mercury and high in                                                               
nutrients.                                                                                                                      
                                                                                                                                
3:41:50 PM                                                                                                                    
                                                                                                                                
DR. McLAUGHLIN directed attention to  slide 28, "Phone Calls from                                                               
the  Public,"  noting that  the  Section  of Epidemiology  fields                                                               
numerous calls  about public concerns  24 hours  a day, 7  days a                                                               
week, (24/7) including  all holidays, responding to  a wide range                                                               
of topics  such as  bedbugs and  sexually-transmitted infections.                                                               
Referring to slide 29, "Essential  Service #4: Mobilize Community                                                               
Partnerships,"  stating that  this plays  into all  of the  other                                                               
essential services  that the  Section of  Epidemiology does.   It                                                               
involves  collaboration  on projects,  conducting  investigations                                                               
and  community outreach  with key  partners  out-of-state and  in                                                               
Alaska,  including physicians,  hospitals, other  state agencies,                                                               
and tribal or  governmental organizations.  The  majority of what                                                               
the Section of Epidemiology  does involves partner collaboration,                                                               
recalling  one   recent  far-reaching  effort  was   the  Healthy                                                               
Alaskans 20-20  Project, which involved  leaders from  the Alaska                                                               
Native Tribal Health Consortium and  the Department of Health and                                                               
Social Services  (DHSS), as well  as an advisory  team consisting                                                               
of  stakeholders from  across Alaska.   The  team has  considered                                                               
hundreds of health  priorities and has narrowed them  down to 25-                                                               
leading health  priorities.  The purpose  was to set up  a health                                                               
framework  that  will  serve as  the  foundation  for  collective                                                               
accountability.                                                                                                                 
                                                                                                                                
DR.  McLAUGHLIN  directed  attention   to  slide  30,  "Essential                                                               
Service   #5:   Develop   Policies   and   Plans   that   Support                                                               
Individual/Community   Health,"   including  emergency   response                                                               
planning.   Turning to  slide 31, "The  2014 Ebola  Epidemic," he                                                               
highlighted one recent example of  an infectious disease response                                                               
planning  during the  Ebola outbreak  - the  largest outbreak  in                                                               
history -  primarily affecting three  West African  countries and                                                               
resulting in  over 25,000 cases  and 10,000 deaths.   He reported                                                               
that the  US had 2 imported  cases and one death.   This resulted                                                               
in a  massive burden  for state and  local health  departments to                                                               
monitor  travelers   returning  from  affected  countries.     He                                                               
directed attention  to slide 32,  "Case Counts and  Deaths," that                                                               
list total cases in Guinea, Liberia, and Sierra Leone.                                                                          
                                                                                                                                
DR.   McLAUGHLIN  directed   attention   to   slide  33,   "Ebola                                                               
Preparedness in  Alaska," stating a multi-agency  Ebola Taskforce                                                               
was promptly created  in the fall 2014,  with representatives and                                                               
participation from the House Health  and Social Services Standing                                                               
Committee,  Municipality  of   Anchorage,  law  enforcement,  the                                                               
military,  and  other  governmental  agencies.   The  Section  of                                                               
Epidemiology   informed  hospitals   about  Ebola   and  provided                                                               
education and  guidance for preparedness, including  developing a                                                               
website.  In addition, they  had ongoing monitoring of travelers.                                                               
He  noted a  total of  20 returning  travelers arrived  in Alaska                                                               
from Ebola-affected  countries.   The Alaska State  Public Health                                                               
Laboratory  brought  Ebola  testing   on  line  and  successfully                                                               
processed specimens.   He directed  attention to slide  34, "DHSS                                                               
Ebola Response  Plan," noting that  the Department of  Health and                                                               
Social Services  Ebola Response plan contained  ten sections that                                                               
address  the major  health concern  regarding Ebola  preparedness                                                               
and response.                                                                                                                   
                                                                                                                                
3:48:47 PM                                                                                                                    
                                                                                                                                
DR.  McLAUGHLIN  directed attention  to  slide  35, "All  Hazards                                                               
Example," noting  one example was  the Fukushima  nuclear reactor                                                               
accident  in  northeast  Japan  on  March 11,  2011.    When  the                                                               
Fukushima   power  plant   disaster  occurred   the  Section   of                                                               
Epidemiology worked  with its partners to  provide subject matter                                                               
expertise  to the  public  by creating  a  website, publishing  a                                                               
bulletin, and testifying before the  legislature on risk, as well                                                               
as  providing guidance  on food  and drinking  water safety.   He                                                               
turned to  slide 36, "Where  were samples  collected?," declaring                                                               
to  date  the FDA  has  tested  20  composite fish  samples  from                                                               
multiple areas  in Alaska, with  all samples as  "non-detect" for                                                               
radiation.   He directed  attention to  slide 37,  "Water Samples                                                               
Tested  for  Radiation,"  which highlighted  the  sampling  sites                                                               
depicted  on the  slide,  from the  western coast  of  the US  to                                                               
Canada and Alaska.  All of  these samples have come back as "non-                                                               
detect" for radiation, he said.                                                                                                 
                                                                                                                                
DR.  McLAUGHLIN  directed  attention   to  slide  38,  "Essential                                                               
Service #7: Linking  People to Needed Services  and Assure Access                                                               
to Care," highlighting another  essential service, linking people                                                               
to infectious  disease, HIV/STD, and immunization  care.  Turning                                                               
to  slide 39,  "Tuberculosis Control  Program," stating  that the                                                               
program  performs  case management  for  all  suspect and  active                                                               
tuberculosis cases to ensure appropriate  follow-up to reduce the                                                               
risk of  transmission.  The epidemiologists  also perform contact                                                               
investigations  for  those in  close  contact  with persons  with                                                               
active  tuberculosis,   including  offering   consultations,  and                                                               
interpreting X-rays.   Unfortunately,  Alaska has  typically been                                                               
number one  or two in terms  of incidence of tuberculosis  in the                                                               
US, he said.                                                                                                                    
                                                                                                                                
3:51:34 PM                                                                                                                    
                                                                                                                                
CHAIR  SEATON asked  what efforts  the epidemiologist  makes when                                                               
advised of an active tuberculosis case within a community.                                                                      
                                                                                                                                
DR.  McLAUGHLIN explained  that after  identifying a  person with                                                               
active  tuberculosis, it's  important that  the patient  receives                                                               
adequate  care.     The  epidemiologist  team   performs  contact                                                               
investigations to  identify anyone who  has been in  contact with                                                               
the patient  and subsequently screens  them, typically with  a TB                                                               
skin test.   If multiple people are  identified, the epidemiology                                                               
screens everyone in the village or community, he said.                                                                          
                                                                                                                                
3:53:59 PM                                                                                                                    
                                                                                                                                
DR.  McLAUGHLIN directed  attention  to  slide 40,  "Tuberculosis                                                               
incidence  rates,   1952-70,"  and   spoke  about   the  dramatic                                                               
tuberculosis  rates in  Alaska Native  population, which  are the                                                               
highest in the world.   The historical rates still affect today's                                                               
rates, he said, noting that  Alaska has ongoing challenges due to                                                               
a number  of factors, including access  to care.  He  referred to                                                               
slide 41,  "Active TB  Rate by  year, Alaska,"  which illustrates                                                               
the active cases  since 1991.  Although the  cases have continued                                                               
to drop, Alaska's  rates are higher than in the  Lower 48.  About                                                               
50  percent   of  the  infectious  disease   program  deals  with                                                               
tuberculosis, he said.  He referred  to slide 42, "AK TB Cases by                                                               
Race,"  which shows  the  highest rates,  about  70 percent  fall                                                               
within the Alaska Native population.                                                                                            
                                                                                                                                
CHAIR  SEATON asked  whether the  proportion  of tuberculosis  in                                                               
rural Alaska is  the same or if more tuberculosis  has been found                                                               
in villages in the Alaska native population.                                                                                    
                                                                                                                                
DR.  McLAUGHLIN replied  that  what seems  to  contribute to  the                                                               
problem  is the  lack  of infrastructure  and  limited access  to                                                               
care; for example,  many homes are small  dwellings, housing lots                                                               
of multi-generational people.  Some  villages do not have running                                                               
water, which tends to hamper  general cleanliness and sanitation.                                                               
He wondered  if the question  was more about whether  white cases                                                               
occur in  Alaska Native villages.   In fact,  a lot of  the white                                                               
cases are found in urban settings in the homeless population.                                                                   
                                                                                                                                
DR.  BUTLER  stated that  there  was  substantial variability  in                                                               
incidence year to  year so when clusters occur they  tend to bias                                                               
the figures.   He stated  in the past  10 years, there  have been                                                               
more urban cases,  as stated earlier.  He  suggested that perhaps                                                               
the Alaska Native population was  overrepresented in the homeless                                                               
population and he  was not certain if he could  answer whether it                                                               
was  urban/rural  or a  non-Native/Alaska  Native  issue, but  it                                                               
tends to be domestic and  the disease can reactivate years later.                                                               
He suggested  that tuberculosis in  other states has  been driven                                                               
more by immigrants.                                                                                                             
                                                                                                                                
CHAIR  SEATON  noticed  the  relationship  between  Asian/Pacific                                                               
Islanders was higher.  He  asked for further clarification on the                                                               
location  of  the  incidence of  tuberculosis  in  the  foregoing                                                               
population.                                                                                                                     
                                                                                                                                
DR.  McLAUGHLIN  said that  vast  majority  of the  Asian/Pacific                                                               
Islander  population  are  foreign-born and  have  immigrated  to                                                               
Alaska.                                                                                                                         
                                                                                                                                
4:00:11 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  TALERICO asked  if tuberculosis  was a  bacterial                                                               
infection.                                                                                                                      
                                                                                                                                
DR. McLAUGHLIN said that was correct.                                                                                           
                                                                                                                                
REPRESENTATIVE   VAZQUEZ    asked   whether    tuberculosis   was                                                               
contagious.                                                                                                                     
                                                                                                                                
DR.  McLAUGHLIN answered  that tuberculosis  was contagious,  but                                                               
not as  much as  measles, noting tuberculosis  typically requires                                                               
closer contact.                                                                                                                 
                                                                                                                                
REPRESENTATIVE VAZQUEZ  reflected on  a serious case  in southern                                                               
Florida.                                                                                                                        
                                                                                                                                
DR.  BUTLER  replied  that   certain  viral  illnesses  including                                                               
measles  and  tuberculosis are  airborne  and  the infection  can                                                               
become  airborne  and  spread through  the  ventilation  systems.                                                               
Thus patients  are placed in  airborne infection  isolation rooms                                                               
for precaution and  the ventilation system does  not circulate to                                                               
other parts  of the  hospital.   Tuberculosis can  be transmitted                                                               
via the ventilation systems, he said.                                                                                           
                                                                                                                                
4:02:49 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE VAZQUEZ  asked how  many cases in  Alaska required                                                               
that type of care.                                                                                                              
                                                                                                                                
DR.  McLAUGHLIN said  the  figures varied  from  50-70 cases  per                                                               
year.                                                                                                                           
                                                                                                                                
4:03:14 PM                                                                                                                    
                                                                                                                                
DR. McLAUGHLIN  directed attention to slide  43, "HIV/STD Program                                                               
- Direct Patient Services and  Linkage to Care," stating that the                                                               
staff performs disease investigative  follow-up on HIV, syphilis,                                                               
gonorrhea,  and  chlamydia  cases.     The  epidemiologists  also                                                               
perform  partner  notification  services to  inform  people  they                                                               
potentially  have been  exposed to  the  disease.   He turned  to                                                               
slide  44, "Chlamydia  Infection Rates  - Alaska  and the  United                                                               
States,"  showing   high  rates  in  Alaska,   stating  that  the                                                               
chlamydia  infection rates  in the  US continues  to climb,  with                                                               
Alaska  having one  of the  highest rates  in the  country.   The                                                               
epidemiologists  do follow-up  on  most of  the chlamydia  cases,                                                               
which  means  Alaska  probably identifies  more  disease  through                                                               
active  surveillance.    He  directed   attention  to  slide  45,                                                               
"Gonococcal  Infection Rates  -  Alaska and  the United  States,"                                                               
noting that  Alaska has been in  the middle of the  pack in terms                                                               
of  national rates;  however, during  2009,  gonorrhea cases  has                                                               
spiked several times.                                                                                                           
                                                                                                                                
4:06:45 PM                                                                                                                    
                                                                                                                                
DR.  McLAUGHLIN   directed  attention  to  slide   46,  "Primary,                                                               
Secondary, Early  Latent and Congenital Syphilis  Cases, Alaska,"                                                               
stating that syphilis cases have  increased since 2008, primarily                                                               
with men who  have sexual contact with other men  (MSM).  Many of                                                               
these  cases   are  anonymous  MSM,  with   Internet  and  mobile                                                               
applications  that  promote  anonymous   sexual  activity.    The                                                               
Section of  Epidemiology actively  works with any  new incidence.                                                               
Most of  these syphilis cases  are concentrated in  Anchorage and                                                               
Fairbanks.   He turned to slide  47, "Percentage of HIV  Cases by                                                               
Region  of Diagnosis,"  slide 48,  noting that  Alaska has  a low                                                               
incidence state for HIV, with  the highest rates in the Anchorage                                                               
and  Mat-Su area.   He  emphasized that  HIV was  the Section  of                                                               
Epidemiology's number  one priority  to help  ensure it  does not                                                               
spread.    Referring  to  slide  49, "2014  Cases  of  HIV  First                                                               
Diagnosed  in Alaska  by Age  at Diagnosis,"  he pointed  out the                                                               
highest incidence of  HIV was in Whites (49  percent, followed by                                                               
Alaska  Native  (26  percent),   and  the  Black  population  (19                                                               
percent).    He  turned  to  slide 50,  "Linkage  to  Care  (L2C)                                                               
Program," which  showed the 2014  cases with the highest  rate in                                                               
the 25-34 years  of age and the second highest  rate in the 15-24                                                               
years of age  group.  The Linkage to Care  (L2C) Program uses HIV                                                               
surveillance data  to identify  individuals newly  diagnosed with                                                               
HIV and  previously diagnosed with  HIV who are living  in Alaska                                                               
and not  accessing medical care.   The Section  of Epidemiology's                                                               
goal is to  link them to medical  care.  In 2015,  56 people were                                                               
identified  as eligible  and were  offered linkage  to care.   Of                                                               
those,  98  percent subsequently  re-engaged  or  engaged in  HIV                                                               
medical  care.   He  said that  71 percent  of  the HIV  patients                                                               
achieved  "viral suppression,"  meaning that  the virus  has been                                                               
suppressed in  their system  and making it  much less  likely for                                                               
the disease to progress and for HIV transmission to occur.                                                                      
                                                                                                                                
4:11:19 PM                                                                                                                    
                                                                                                                                
DR.  McLAUGHLIN directed  attention  to  slide 51,  "Immunization                                                               
Program Activities  that Improve Access to  Care," He highlighted                                                               
the  program as  the Section  of Epidemiology's  largest program.                                                               
He reported  that this  program works  to procure  and distribute                                                               
vaccines  to health  care providers  statewide.   He pointed  out                                                               
several  features  of the  program,  VacTrAK,  which is  Alaska's                                                               
immunization registry.   All immunizations issued  in Alaska must                                                               
be entered into  the database, which he characterized  as a great                                                               
tool   to  help   epidemiologists  understand   the  immunization                                                               
coverage rates in  Alaska.  It helps improve  portability of care                                                               
since all  providers can  access the history.   In  addition, the                                                               
Section  of   Epidemiology  has  an  Alaska   Vaccine  Assessment                                                               
Program, which  creates a vaccine  assessment account,  funded by                                                               
insurance companies and other payers.   It enables the program to                                                               
purchase  and  distribute   state-supplied  vaccines  to  improve                                                               
access and affordability to life-saving vaccines statewide.                                                                     
                                                                                                                                
4:13:35 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE   VAZQUEZ  asked   if  there   was  any   disaster                                                               
preparedness done in his office.                                                                                                
                                                                                                                                
DR.  McLAUGHLIN answered  yes; again  referencing  the Ebola  and                                                               
Fukishima efforts, in  fact, disaster preparation was  one of the                                                               
key things the  department does.  The  Emergency Program Section,                                                               
an entire  section within  the Division  of Public  Health, works                                                               
24/7  on  preparedness  and   is  responsible  for  orchestrating                                                               
preparedness efforts for the department.                                                                                        
                                                                                                                                
DR. BUTLER offered to do  a presentation on disaster preparedness                                                               
and emergency programs.   He explained that  recently the program                                                               
held a mock  disaster in Homer, working with  the Alaska National                                                               
Guard, as well as local responders  on disasters.  The Section of                                                               
Epidemiology has  been focused  on pandemic  preparedness control                                                               
of infectious diseases.                                                                                                         
                                                                                                                                
4:16:01 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  VAZQUEZ  said she  has  been  impressed with  the                                                               
Division of Public Health.                                                                                                      
                                                                                                                                
REPRESENTATIVE TALERICO commented on  the Section of Epidemiology                                                               
Bulletin.   He said it  was impressive amount of  information and                                                               
is very well done.                                                                                                              
                                                                                                                                
DR. BUTLER offered to send the Bulletins by e-mail.                                                                             
                                                                                                                                
CHAIR SEATON asked to put members on the e-mail alerts.                                                                         
                                                                                                                                
REPRESENTATIVE  VAZQUEZ  asked  whether  he  had  any  Vitamin  D                                                               
alerts.                                                                                                                         
                                                                                                                                
CHAIR  SEATON  pointed  to  Vitamin   D  and  rickets  in  Native                                                               
Alaskans.  He  said he shared an article with  Dr. Butler on core                                                               
symptoms of autism  improvements with Vitamin D  supplements.  It                                                               
seemed as  if all the  data was  observational, but the  focus of                                                               
the committee  was on  prevention instead  of response.  He asked                                                               
how to  implement observational data  when looking  at prevention                                                               
or  if  that  data  is   solely  used  when  responding  to  life                                                               
threatening situations or  outbreaks.  He remarked  that costs to                                                               
treat autism per individual was very high in Alaska.                                                                            
                                                                                                                                
4:20:03 PM                                                                                                                    
                                                                                                                                
DR. BUTLER  replied that  substantial epidemiology  is hypothesis                                                               
generating  looking  for  association  and then  causation.    He                                                               
acknowledged that sometimes the  answers are straightforward, but                                                               
other  times they  are more  nuanced.   In terms  of when  it was                                                               
appropriate to move beyond medical  practice toward public health                                                               
intervention,  cautioned it  is necessary  to ensure  no harm  is                                                               
done when making  a direct jump to intervention.   Ultimately the                                                               
goal is  to determine  the right intervention  at the  right time                                                               
with a minimum of cost.   He acknowledged the Vitamin D story was                                                               
intriguing.   He  suggested that  the health  care community  has                                                               
been struggling  through the details.   He raised the  issue some                                                               
have about the  efficacy of monthly injections.   He acknowledged                                                               
there  was  a  pragmatic  side  to consider,  noting  it  can  be                                                               
frustratingly slow,  but the importance of  balancing cost, risk,                                                               
and benefit and  that decisions are made on  the best information                                                               
available.                                                                                                                      
                                                                                                                                
CHAIR SEATON stated that prevention is a key for the committee.                                                                 
                                                                                                                                
4:23:39 PM                                                                                                                    
                                                                                                                                
              HB 99-VOLUNTARY TERMINATION OF LIFE                                                                           
                                                                                                                                
DRAFT                                                                                                                         
                                                                                                                                
4:23:53 PM                                                                                                                    
                                                                                                                                
CHAIR SEATON announced that the  final order of business would be                                                               
HOUSE BILL NO. 99, "An  Act relating to the voluntary termination                                                               
of  life by  terminally  ill individuals;  and  providing for  an                                                               
effective date."                                                                                                                
                                                                                                                                
4:24:04 PM                                                                                                                    
                                                                                                                                
CHAIR SEATON  explained that  there were  three amendments  to be                                                               
introduced,  although the  committee  did not  plan  to move  the                                                               
proposed bill at this time.                                                                                                     
                                                                                                                                
REPRESENTATIVE  WOOL  moved to  adopt  Amendment  1, labeled  29-                                                               
LS0112\W.1, Bannister, 4/11/15, which read:                                                                                     
                                                                                                                                
     Page 2, line 3:                                                                                                            
          Delete "an adult"                                                                                                     
          Insert "21 years of age or older"                                                                                     
                                                                                                                                
     Page 4, line 2:                                                                                                            
          Delete "an adult"                                                                                                     
          Insert "21 years of age or older and"                                                                                 
                                                                                                                                
     Page 12, line 30:                                                                                                          
          Delete all material.                                                                                                  
                                                                                                                                
     Renumber the following paragraphs accordingly.                                                                             
                                                                                                                                
CHAIR SEATON objected for discussion.                                                                                           
                                                                                                                                
REPRESENTATIVE  WOOL explained  that  he was  concerned with  the                                                               
appropriate age for access to  the prescription, and offered that                                                               
21 years  of age  was more  appropriate for  an age  to terminate                                                               
your life without parental consent.                                                                                             
                                                                                                                                
4:26:21 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  HARRIET   DRUMMOND,  Alaska   State  Legislature,                                                               
stated that she was amenable  with the proposed amendment for the                                                               
time  being.    She  noted  that, should  the  proposed  bill  be                                                               
forwarded,  its   next  committee  of  referral   was  the  House                                                               
Judiciary  Standing Committee  and they  could also  consider the                                                               
legal issues.   She opined that  18 was the age  of legal consent                                                               
for medical  procedures, which  was the  reason the  bill sponsor                                                               
had maintained  the age similar to  the Oregon law.   She offered                                                               
her belief that  only one person under 30 years  of age had taken                                                               
the prescription in  Oregon.  She declared that  she would accept                                                               
this proposed amendment for the benefit of the committee.                                                                       
                                                                                                                                
CHAIR  SEATON  offered his  belief  that  the proposed  amendment                                                               
would resolve some of the issues that people had.                                                                               
                                                                                                                                
CHAIR  SEATON removed  his  objection.   There  being no  further                                                               
objection, Amendment 1 was adopted.                                                                                             
                                                                                                                                
4:27:43 PM                                                                                                                    
                                                                                                                                
CHAIR SEATON  explained that  Amendment 2  had been  suggested by                                                               
the court system,  and that it deleted "a court"  on page 2, line                                                               
4.  He  said that this would no longer  supersede an individual's                                                               
attending  physician,  as the  court  did  not believe  this  was                                                               
within its purview.                                                                                                             
                                                                                                                                
4:28:56 PM                                                                                                                    
                                                                                                                                
CHAIR SEATON  moved to adopt Amendment  2, labeled 29-LS0112\W.2,                                                               
Bannister, 4/11/15, which read:                                                                                                 
                                                                                                                                
     Page 2, line 4:                                                                                                            
          Delete "a court,"                                                                                                     
                                                                                                                                
REPRESENTATIVE TALERICO objected for discussion.                                                                                
                                                                                                                                
REPRESENTATIVE TALERICO  removed his  objection.  There  being no                                                               
objection, Amendment 2 was adopted.                                                                                             
                                                                                                                                
4:29:32 PM                                                                                                                    
                                                                                                                                
CHAIR SEATON  moved to adopt Amendment  3, labeled 29-LS0112\W.3,                                                               
Bannister, 4/13/15, which read:                                                                                                 
                                                                                                                                
     Page 13, lines 19 - 20:                                                                                                    
          Delete    "correctional    facility    owned    or                                                                    
     administered by the state;"                                                                                                
                                                                                                                                
     Page 13, line 25, following "includes":                                                                                    
          Insert "a state correctional facility as defined                                                                      
     in AS 33.30.901 and"                                                                                                       
                                                                                                                                
REPRESENTATIVE TALERICO objected for discussion.                                                                                
                                                                                                                                
CHAIR SEATON explained that this amendment had been proposed by                                                                 
the correctional system, and changed the way the proposed bill                                                                  
specified the correctional facilities.                                                                                          
                                                                                                                                
REPRESENTATIVE TALERICO removed his objection.  There being no                                                                  
further objection, Amendment 3 was adopted.                                                                                     
                                                                                                                                
CHAIR SEATON asked if Representative Drummond was supportive of                                                                 
Amendment 2 and Amendment 3.                                                                                                    
                                                                                                                                
[HB 99 was held over]                                                                                                           
                                                                                                                                
4:31:14 PM                                                                                                                    
                                                                                                                                
ADJOURNMENT                                                                                                                   
                                                                                                                                
There being no further business before the committee, the House                                                                 
Health and Social Services Standing Committee meeting was                                                                       
adjourned at 4:31 p.m.                                                                                                          

Document Name Date/Time Subjects
HB99 Support - emails 4.13.2015.pdf HHSS 4/14/2015 3:00:00 PM
HB 99
HB99 Opposition - Assorted emails - 4.13.2015.pdf HHSS 4/14/2015 3:00:00 PM
HB 99
HB99 Support -Written testimony - Dechman - 4.9.2015.pdf HHSS 4/14/2015 3:00:00 PM
HB 99
HB99 Proposed amendments - 1-3.pdf HHSS 4/14/2015 3:00:00 PM
HB 99
HB99 Opposition- Written Testimony- Miller - 04-09-15.pdf HHSS 4/14/2015 3:00:00 PM
HB 99
HB99 Version W.PDF HHSS 4/9/2015 3:00:00 PM
HHSS 4/14/2015 3:00:00 PM
HB 99
HB99 Sponsor Statement.pdf HHSS 4/9/2015 3:00:00 PM
HHSS 4/14/2015 3:00:00 PM
HB 99
HHSS Presentation_Epidemiology_2015Apr14.pdf HHSS 4/14/2015 3:00:00 PM
Presentations by DHSS
HB99 Proposed CS Version H.pdf HHSS 4/14/2015 3:00:00 PM
HB 99