BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 1318
AUTHOR: Wolk
AMENDED: April 11, 2012
HEARING DATE: April 18, 2012
CONSULTANT: Moreno
SUBJECT : Health facilities: influenza vaccinations.
SUMMARY : Requires hospitals and clinics, after July 1, 2013, to
require all employees, contractors, students, volunteers,
persons with privileges on the medical staff, and all other
onsite health care workers affiliated with the clinic to either
annually receive an influenza vaccination or, as an alternative
to the annual influenza vaccination, wear a surgical or
procedural mask, or other mask that covers the mouth and nose
area of the face while this person is performing his or her
duties in any patient care area of the clinic during the
influenza season, as defined by the State Health Officer (SHO)
or a local health officer (LHO), or both.
Existing law:
1.Provides for the licensure and regulation of health
facilities, including acute care hospitals, by the Department
of Public Health (DPH).
2.Requires DPH to require that each general acute care hospital,
in accordance with the Centers for Disease Control and
Prevention (CDC) guidelines, take all of the following
actions:
a. Annually offer onsite influenza vaccinations, if
available, to all hospital employees at no cost to the
employee.
b. Requires hospitals to require its employees to be
vaccinated, or if the employee elects not to be vaccinated,
to declare in writing that he or she has declined the
vaccination.
c. Institute respiratory hygiene and cough etiquette
protocols, develop and implement procedures for the
isolation of patients with influenza, and adopt a seasonal
influenza plan.
d. Revise an existing or develop a new disaster plan that
includes a pandemic influenza component. The plan is
required to document any actual or recommended
Continued---
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collaboration with local, regional, and state public health
agencies or officials in the event of an influenza
pandemic.
This bill:
1.Requires clinics to annually offer its employees influenza
vaccines, if available, at no cost to the employee.
2.Requires hospitals and clinics, after July 1, 2013, to require
all employees, contractors, students, volunteers, persons with
privileges on the medical staff, as defined, and all other
onsite health care workers, as defined, to either annually
receive an influenza vaccination or wear a surgical or
procedural mask, or other mask that covers the mouth and nose
area of the face while this person is performing his or her
duties in any patient care area of the clinic during the
influenza season, as defined by the SHO or a LHO, or both.
3.Defines "medical staff" as professional medical personnel who
are approved and given privileges to provide health care to
patients in a clinic and who are responsible for the adequacy
and quality of care rendered to patients. States that medical
staff includes physicians and surgeons, and, where dental or
podiatric services are provided, dentists or podiatrists.
Defines "health care worker" affiliated with the facility as a
person who is either a volunteer or is employed by, paid by,
or receives credit or any other form of compensation from the
clinic. Requires a health care worker affiliated with the
facility to include, but not be limited to, physicians,
nurses, nursing assistants, therapists, technicians, emergency
medical service personnel, dental personnel, pharmacists,
laboratory personnel, autopsy personnel, students and
trainees, and contractual staff not employed by the facility.
4.Requires clinics and hospitals to develop policies to ensure
its employees, contractors, students, volunteers, and other
onsite health care workers affiliated with the clinic, not
including medical staff, are in compliance with the
vaccination requirements imposed by this bill. Requires
medical staff to develop policies independent of the policies
established by the facility to ensure that persons who have
privileges on the medical staff are in compliance with the
vaccination requirements of this bill.
5.Prohibits anything in this bill from being construed to
prevent a facility from instituting additional measures to
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maximize influenza vaccination rates and to prevent health
care workers affiliated with the clinic from contracting and
transmitting the influenza virus.
FISCAL EFFECT : This bill has not been analyzed by a fiscal
committee.
COMMENTS :
1.Author's statement. According to the author, influenza is a
contagious respiratory virus and is the eighth leading cause
of death in the United States. The majority of
influenza-related illnesses and deaths occur among our most
vulnerable that are at a high risk for serious flu
complications, such as, infants, young children, seniors and
those with certain health conditions. SB 1318 will ensure that
all health care workers in health care facilities, including
physicians, either receive the influenza vaccination or wear a
mask during flu season, in an effort to help prevent the
spread of the virus. The U.S. Department of Health and Human
Services has a 90 percent vaccination rate goal for health
care personnel by 2020. This bill is an essential step toward
reaching our national goal and preventing the outbreak of
influenza in California's health care facilities and
protecting vulnerable patients.
2.Background. According to the CDC, the flu is a contagious
respiratory illness caused by viruses that infect the nose,
throat, and lungs. It can cause mild to severe illness, and at
times can lead to death. Most experts believe that flu viruses
spread mainly by droplets made when people with flu cough,
sneeze or talk, which can land in the mouths or noses of
people who are nearby. Less often, a person might also get flu
by touching a surface or object that has flu virus on it and
then touching their own mouth, eyes or possibly their nose.
The flu can be passed to someone else before symptoms appear,
as well as while a person is symptomatic. Most healthy adults
may be able to infect others beginning one day before symptoms
develop and up to five to seven days after becoming sick. Some
people, especially young children and people with weakened
immune systems, might be able to infect others for an even
longer time. There are a number of groups of people considered
at high risk to develop flu-related complications, including:
children younger than 5, but especially children younger than
2 years old; adults over 65 years of age; pregnant women; and
people with certain medical conditions (including asthma,
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neurological and neurodevelopmental conditions, chronic lung
disease, heart disease, blood disorders, diabetes, kidney
disorders, liver disorders, and weakened immune systems).
3.Flu vaccine. According to the CDC, the single best way to
prevent the flu is to get a flu vaccine each season. There are
two types of flu vaccines: flu shots, which are inactivated
vaccines that are given with a needle and the nasal-spray flu
vaccine (a vaccine made with live, weakened flu viruses that
is given as a nasal spray. About two weeks after vaccination,
antibodies develop that protect against influenza virus
infection. Driven by the H1N1 pandemic, in February 2010, the
Advisory Committee on Immunization Practices (ACIP) voted to
recommend that all people six months and older should obtain a
flu vaccine (universal recommendation for vaccination). ACIP
and the Healthcare Infection Control Practices Advisory
Committee also recommend that all health care workers get
vaccinated annually against influenza. According to the CDC,
health care workers include, but are not limited to,
physicians, nurses, nursing assistants, therapists,
technicians, emergency medical service personnel, dental
personnel, pharmacists, laboratory personnel, autopsy
personnel, students and trainees, contractual staff not
employed by the health care facility, and persons (e.g.,
clerical, dietary, housekeeping, laundry, security,
maintenance, administrative, billing, and volunteers) not
directly involved in patient care but potentially exposed to
infectious agents that can be transmitted to and from health
care workers and patients. According to DPH, the mean
hospital-specific employee vaccination percentage in
California was 55 percent in 2008-09 and has grown since: 63
percent in 2009-10 and 64.3 percent in 2010-11. The U.S.
Department of Health and Human Services' goal is a 90 percent
vaccination rate by 2020.
4.Previous statewide efforts. Upon passage of SB 739 (Speier),
Chapter 526, Statutes of 2006, DPH's Healthcare Associated
Infections (HAI) Program was tasked with increasing patient
protection from influenza in hospitals through vaccination of
healthcare personnel. The Department of Industrial Relation's
Division of Occupational Safety and Health (Cal/OSHA) also
promulgated (aerosol transmissible diseases) ATD regulations
(effective August 5, 2009), establishing procedures for ATD in
health care facilities. Among other things, the ATD
regulations require health facilities to establish, implement,
and maintain an effective, written ATD Exposure Control Plan
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which is specific to the workplace or operations. While the
ATD regulations are meant to address more than just the
transmission of the flu, there are some provisions that could
be related to the provisions of this bill. For example, with
regard to "medical services," which the regulation states
includes vaccinations, tests, examinations, evaluations,
determinations, procedures, and medical management and
follow-up, the law requires them to be, among other things,
provided in a manner that ensures the confidentiality of
employees and patients.
5.National recommendations. A number of national organizations
have recommendations for mandatory flu vaccines for healthcare
workers, including the American Academy of Pediatrics, the
American Medical Directors Association, and the American
Pharmacists Association. Some organizations support
immunization as a condition of employment and/or masking
policies, including the American Academy of Family Physicians,
the American College of Physicians, the American Hospital
Association, the Association for Professionals in Infection
Control and Epidemiology, the Infectious Diseases Society of
America, and the National Business Group on Health.
6.Existing masking policies. Currently, Sacramento, San
Francisco, and Yolo counties have in effect similar masking
policies to the one proposed in this bill. In July 2011, the
LHOs of Sacramento and Yolo counties sent letters to all
hospitals, physicians, medical practices, community clinics,
and ambulatory care centers that stated, in part:
Vaccination of healthcare workers reduces infection and
absenteeism among them, prevents mortality in their
patients, and results in financial savings to sponsoring
health institutions. The best way to prevent transmission
of a disease like influenza to those persons we serve is to
mandate vaccination of healthcare workers and there are now
two laws in California requiring flu vaccine for healthcare
workers and other personnel at hospitals (CA Health &
Safety Code §1288.7, effective January 1, 2007 and §5199
Aerosol Transmissible Diseases standard of Cal OSHA,
effective September 1, 2010).
In addition to full adherence to these laws, I am requiring
that all healthcare workers either receive the influenza
vaccine or wear a mask during influenza season. All
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inpatient and ambulatory healthcare facilities in
(Sacramento and Yolo) must implement a masking program,
requiring that all healthcare workers who do not receive
the flu vaccine wear a mask for the duration of the
influenza season while working in their facility. I am also
recommending that healthcare administrators adopt an easy
way to identify the healthcare workers who have received
their influenza vaccine. One example of this type of
concept is to place a sticker on the healthcare worker's
badge following vaccination.
In September 2011, the San Francisco LHO sent a substantially
similar letter out, and also stated that this was already the
policy at University of California, San Francisco (UCSF)
Medical Center, San Francisco General Hospital, Laguna Honda
Hospital, and Kaiser San Francisco. UCSF Medical Center's
masking policy was instituted in 2009 and requires anyone who
declines a flu vaccination to wear a protective mask, supplied
by UCSF, while in patient care areas, which is specified as
places where patients are seen, evaluated and treated as well
as in lobbies and waiting rooms. According to the Immunization
Action Coalition, as of November 1, 2010, there were at least
16 other hospitals in California with masking policies. In
September 2011, Kaiser North Valley (KNV) implemented an
"influenza vaccine mask policy." All physicians were sent an
email stating that they were required to get the flu vaccine
or wear a mask while in patient care areas of the KNV
hospitals and clinics. In Kaiser facilities in those counties
with masking requirements, personnel who are not compliant
with the mask requirement in mandated counties will be removed
from working in patient care areas.
7.Use of masks in preventing spread of the flu. There is some
question about the value of surgical masks protection against
the flu, and several studies point to differing outcomes. For
example, a 2009 study published in JAMA found that surgical
masks appear to be nearly as effective as N95 respirators
(which the CDC recommends for the protection of health care
workers who come in direct contact with patients with H1N1) at
preventing flu in health care workers performing routine care.
On the other hand, a 2008 CDC study in the journal Emerging
Infectious Diseases concluded that health care workers could
contaminate their skin or clothes with pathogens during the
removal of personal protection equipment (such as surgical
masks), resulting in accidental self-inoculation and virus
spread to patients and other health care workers.
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8.Related legislation. AB 2009 (Galgiani) would include persons
under 18 years of age among those who have priority to receive
flu vaccine under a flu vaccine program administered by DPH
for older adults (60 years or older). AB 2009 passed by a vote
of 18-0 when heard in the Assembly Health Committee on April
10, 2012.
AB 2064 (V. Manuel Pérez) would require health care service
plans and health insurers that provide coverage for childhood
and adolescent immunizations to reimburse physicians for the
costs of vaccines, as specified. AB 2064 is set to be heard in
the Assembly Health Committee on April 24, 2012
AB 2109 (Pan) would specify certain requirements for parents
and guardians of school-aged children who wish to seek an
exemption from immunization requirements. AB 2109 is set to be
heard in the Assembly Health Committee on April 17, 2012
9.Prior legislation. SB 739 among other things, requires all
California general acute care hospitals, based on CDC
guidelines, to:
a. Annually offer onsite influenza vaccinations, if
available, to all hospital employees at no cost to the
employee. Each general acute care hospital shall require
its employees to be vaccinated, or if the employee elects
not to be vaccinated, to declare in writing that he or she
has declined the vaccination.
b. Institute respiratory hygiene and cough etiquette
protocols, develop and implement procedures for the
isolation of patients with influenza, and adopt a program
plan for vaccinating healthcare personal during the
influenza season.
c. Revise an existing or develop a new disaster plan that
includes a pandemic influenza component. The plan must also
document any actual or recommended collaboration with
local, regional, and state public health agencies or
officials in the event of an influenza pandemic.
10.Support. The California Medical Association (CMA),
co-sponsor of this bill, argues that masking policies have
proven to be the most effective policy to increase vaccination
compliance rates and protect its patients. CMA states that
California hospitals with the highest vaccine compliance rate
are those that have such policies in place. CMA asserts that
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the sole purpose of this bill is to protect patients from
contracting the flu virus in health care settings and do it in
the most proven effective and efficient way possible. The
Health Officers Association of California (HOAC), co-sponsor
of this bill, states that this bill will increase influenza
vaccination rates at hospitals in California, resulting in a
healthier workforce and a healthier population. According to
The American Congress of Obstetricians and Gynecologists,
District IX (California), SB 739 required California's acute
care hospitals to offer the vaccine free of charge, but
unfortunately the success of that legislation has fallen short
of achieving desired compliance rates, and we need to look at
other options to protect our most vulnerable populations. The
California Association for Nurse Practitioners (CANP),
co-sponsor of this bill, writes that several counties and
numerous hospitals have gone beyond state law and have
established mandatory vaccination policies. CANP states that
according to their members, receiving an annual flu vaccine
has become a standard practice for health care providers, and
this bill will ensure that this practice becomes even more
firmly entrenched as a practice.
The California Pharmacists Association (CPA) states that
reports have shown that higher vaccination levels among staff
have been associated with a lower risk of hospital-acquired
influenza cases, while lower influenza vaccination coverage
has led to a greater number of influenza outbreaks in
hospitals and long-term care facilities. CPA asserts that
strict vaccination policies that include a masking requirement
for those who decline vaccinations have proven to be the most
effective way of increasing vaccination rates and protecting
patients. The California Psychiatric Association writes that
many of the circumstances which bring individuals to these
facilities, such as protracted homelessness, present decreased
immune response to viruses and increased risks of contraction
of infectious disease, and that it is imperative that simple
measures of vector control, such as vaccinations or masks, be
provided to facility staff. The California Society of
Health-System Pharmacists states that influenza is a
contagious respiratory disease and without proper prevention
and vaccination, the general public is placed at undue risk.
11.Opposition. The American Federation of State, County and
Municipal Employees, AFL-CIO (AFSCME) and the United Nurses
Associations of California/Union Health Care Professionals
(UNAC/UHCP) write that it is unreasonable to mandate a
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questionably effective vaccine on onsite health care workers
and that it is more sensible to work on educating workers on
better infection control and improve screening and triaging of
patients, families, and visitors who enter health care
facilities. AFSCME and UNAC/UHCP state that that hospitals,
clinics, doctors' offices should work to ensure environmental
cleaning staff have the training, equipment, and time
(adequate staffing levels) to do all the cleaning required to
clean surfaces routinely, especially around symptomatic
patients.
The California Nurses Association (CNA) writes that this bill
provides for the medical staff at health facilities and
clinics to develop an independent influenza policy, and that
having two separate influenza policies for employees who work
in the same clinics and health facilities is confusing for
those attempting to implement the new policy, and in
particular for the employees who are navigating through two
separate policies. CNA also asserts that transmission of the
influenza virus does not delineate between classifications of
health care workers and that having two policies jeopardizes
patients, workers and the public who enter the health
facilities and clinics. CNA states that there is no sound
public policy that supports two standards, and they strongly
object, stating it is divisive and could lead to future
discrimination issues in the workplace. CNA further states
that requiring health care workers who decline vaccination to
wear a mask will not properly stem the transmission of
influenza. CNA points to a 2008 CDC study that concludes that
although personal protection equipment is usually worn only a
short time, viruses such as influenza can survive for hours on
surfaces, and viral infection can be spread by surface-to-hand
and hand-to-hand contact by adjusting or removing the mask,
and that masking creates a false sense of protection for
employees and patients. Laborers' Locals 777 and 792 writes
that current data do not dictate that everyone who works in a
health facility should get a flu shot, there are reasons an
employee may be disinclined to get a flu shot, and they should
not be forced to wear the "Scarlett Letter" of a mask just
because they've chosen not to get a flu shot.
12.Oppose unless amended. The Service Employees International
Union (SEIU) writes that they are highly supportive of
educating the public, particularly workers in health
facilities, about the importance of all disease prevention
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including those measures designed to prevent transmission of
flu virus. SEIU applauds expanding the current law to all
health facilities and states that to the extent that we can
prevent the transmission of flu virus, it makes no sense to
limit our protections to acute care hospitals when there are
very vulnerable patients in so many other health care
settings. SEIU takes issue with any measures which have the
effect of coercing people to undergo a medical procedure (in
this case vaccination) or risk sanction. SEIU states that
this is precisely the effect that both the sponsor and author
say they intend by requiring employees to wear a mask, and
there is no public health purpose served by the mask itself
other than the effect of coercing workers to get the vaccine.
Further, SEIU contends that one of the many reasons that no
other state in the nation requires health care workers to get
these vaccines or face disciplinary proceedings and wearing
masks is because it may be unconstitutional to do so, and when
this is coupled with a mandate for wearing masks (unsupported
by compelling scientific evidence), the risk is having this
law overturned by the courts.
SUPPORT AND OPPOSITION :
Support: California Association for Nurse Practitioners
(co-sponsor)
California Medical Association (co-sponsor)
Health Officers Association of California (co-sponsor)
American Congress of Obstetricians and Gynecologists -
District IX California
California Association for Nurse Practitioners
California Pharmacists Association
California Psychiatric Association
California Society of Health-System Pharmacists
Californians for Patient Care
Santa Clara County Board of Supervisors
Oppose:American Federation of State, County and Municipal
Employees, AFL-CIO
California Labor Federation
California Nurses Association
Laborers' Locals 777 and 792
Service Employees International Union (unless amended)
United Nurses Associations of California/Union of
Health Care Professionals
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