BILL ANALYSIS Ó
SB 1318
Page 1
Date of Hearing: June 26, 2012
ASSEMBLY COMMITTEE ON HEALTH
William W. Monning, Chair
SB 1318 (Wolk) - As Amended: June 14, 2012
SENATE VOTE : 23-9
SUBJECT : Health facilities: flu vaccinations.
SUMMARY : Requires licensed clinics and licensed health care
facilities, commencing on January 1, 2015, to require onsite
health care workers affiliated with the clinic and health care
facility and persons with privileges on the medical staff to
either annually receive an influenza (flu) vaccination or, as an
alternative wear a clinic and health facility-provided surgical
or procedural mask, as specified, while performing their duties
in any patient care area during the flu season, as defined.
Specifically, this bill :
1)Declares that mandatory mask-wearing policies for health care
workers who have not been immunized have proven effective to
increase vaccination rates in health care workers. States
that while studies have not yet proven that masking is
effective to protect transmission of flu in the asymptomatic
phase of the flu illness, wearing a mask has proven effective
in preventing the transmission of other respiratory pathogens.
2)Requires clinics and health care facilities to institute
measures designed to maximize flu vaccination rates and to
prevent persons with privileges on the medical staff and
onsite health care workers affiliated with the clinic from
contracting and transmitting to patients the flu virus.
States that these measures shall include, but not be limited
to, aerosol transmissible diseases training (ATD), as
specified.
3)Requires clinics and health care facilities to annually offer
employees onsite flu vaccinations, if available, at no cost to
the employee.
4)Requires clinics and health care facilities to require all
onsite health care workers affiliated with the clinic and
health care facility and persons with privileges on the
medical staff to either annually receive a flu vaccination or,
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as an alternative wear a clinic- and health care
facility-provided surgical or procedural mask, or other mask
that covers the mouth and nose area of the face, while
performing his or her duties in any patient care area of the
clinic and health care facility during the flu season, as
defined by the State Health Officer or a local health officer
(LHO), or both.
5)Provides that in meeting the requirements of 4) above, clinics
and health care facilities:
a) Must maintain flu vaccination records of employees and
may maintain flu vaccination records of the other onsite
health care workers affiliated with, but who are not
employees of, the clinic and of persons with privileges on
the medical staff. If the clinic and health care facility
do not have records of an onsite health care worker or
person with privileges on the medical staff being
vaccinated onsite, they may require the worker or medical
staff person to either provide documentation of vaccination
or documentation that he or she refused the vaccination.
b) Allow language to be included in its business contracts
to require a contract worker to maintain records of the
verification of offsite vaccination or documentation that
he or she refused the vaccination and require this
documentation be made available to the clinic and health
care facility upon request. The clinic and health care
facility are not required to maintain separate vaccination
records or to provide vaccinations at no cost to a contract
worker who is not an employee of the clinic and health care
facility.
6)Requires each clinic and health facility to develop policies
to comply with items 3) through 5) above and to ensure its
onsite health care workers affiliated with the clinic are in
compliance with the vaccination requirements. Requires the
medical staff to develop policies to ensure that persons who
have privileges on the medical staff are in compliance with
the vaccination requirements of this section that have been
implemented by the clinic and health care facility.
7)Defines the following terms:
a) "Employee" means an individual who works for the clinic,
is listed on the payroll records, and is under the clinic's
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direction and control.
b) "Medical staff" means professional medical personnel who
are approved and given privileges to provide health care to
patients while onsite in a clinic and health care facility
and who are responsible for the adequacy and quality of
care rendered to patients. Includes, but is not limited
to, physicians and surgeons, and, if dental or podiatric
services are provided, dentists or podiatrists.
c) "Onsite health care worker affiliated with the clinic
and health care facility" means 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 and health
care facility, who performs some or all of his or her
duties in a patient care area of the facility. The patient
care area of the facility shall be determined by the clinic
and health care facility and is where onsite health care
workers and medical staff are within close proximity to
patients receiving care. Includes, but is not limited to,
employees, physicians, nurses, nursing assistants,
therapists, technicians, emergency medical service
personnel, dental personnel, pharmacists, laboratory
personnel, autopsy personnel, students and trainees,
contractual staff, and registry staff who perform direct
patient care duties but are not employed by the clinic and
health care facility.
8)Allows the Department of Public Health (DPH) to implement this
bill by sending letters or similar instruction to all
applicable facilities without taking regulatory action.
9)Requires a clinic and health care facility to annually report
their average vaccination compliance rate for onsite health
care workers who are employees and of medical staff who have
been vaccinated for that year to DPH.
10)Requires, in addition to the other requirements of this bill,
general acute care hospitals to also do the following:
a) Institute respiratory hygiene and cough etiquette
protocols, develop and implement procedures for the
isolation of patients with flu, and adopt a seasonal flu
plan; and,
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b) Revise an existing or develop a new disaster plan that
includes a pandemic flu component. Requires the plan to
also document any actual or recommended collaboration with
local, regional, and state public health agencies or
officials in the event of a flu pandemic.
11)Makes this bill operative on January 1, 2015.
12)Sunsets existing law that requires DPH to require each
general acute care hospital to offer onsite flu vaccinations,
if available to all hospital employees at no cost to the
employee by January 1, 2015.
13)Exempts from the provisions of this bill, except for the
reporting of compliance rate as specified in 9) above, clinics
that have a combined average vaccination compliance rate of
90% or higher for its onsite health care workers who are
employees and medical staff.
14)Exempts health care facilities that have a combined average
vaccination compliance rate of 90% or higher for its onsite
health care workers that are employees and medical staff from:
a) The requirement to annually offer its employees flu
vaccinations;
b) The additional requirements for general acute care
hospitals, specified in 10) above; and
c) The reporting of compliance rate as specified in 9)
above.
EXISTING LAW :
1)Provides for the licensure and regulation of clinics and
health facilities, including acute care hospitals by DPH.
2)Defines a clinic as an organized outpatient health facility
that provides direct medical, surgical, dental, optometric, or
podiatric advice, services, or treatment to patients who
remain less than 24 hours, and that may also provide
diagnostic or therapeutic services to patients in the home as
an incident to care provided at the clinic facility.
3)Defines a health facility as any facility, place, or building
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that is organized, maintained, and operated for the diagnosis,
care, prevention, and treatment of human illness, physical or
mental, including convalescence and rehabilitation and
including care during and after pregnancy, or for any one or
more of these purposes, for one or more persons, to which the
persons are admitted for a 24-hour stay or longer, and
includes: general acute care hospitals, acute psychiatric
hospitals, skilled nursing facilities, several categories of
intermediate care facilities, congregate living health
facilities, correctional treatment centers, as defined, and
nursing facilities.
4)Requires DPH to require each general acute care hospital, in
accordance with the Centers for Disease Control and Prevention
(CDC) Guidelines to take all of the following actions:
a) Annually offer onsite flu vaccinations, if available, to
all hospital employees at no cost to the employee;
b) 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 flu, and adopt a seasonal flu
plan; and,
d) Revise an existing or develop a new disaster plan that
includes a pandemic flu component. Requires the plan to
also document any actual or recommended collaboration with
local, regional, and state public health agencies or
officials in the event of a flu pandemic.
FISCAL EFFECT : According to the Senate Appropriations
Committee, potential increased costs to review compliance by
clinics, up to $150,000 (Licensing and Certification Fund). DPH
may need additional resources to review hospital and clinic
records of vaccinations by employees and others. Because DPH
already performs periodic inspections of health facilities as
part of its licensing program, total additional costs to gather
this information is not likely to be significant.
COMMENTS :
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1)PURPOSE OF THIS BILL . The California Medical Association, the
Health Officers Association of California, and the California
Association for Nurse Practitioners are the sponsors of this
bill. According to the author, this bill ensures that all
health care workers in clinics and health facilities,
including physicians, either receive the flu vaccination or
wear a mask in an effort to help prevent the spread of the flu
virus, and protect vulnerable patients. According to the CDC,
health care workers who get vaccinated reduce the transmission
of flu, staff illness, and absenteeism, and flu-related
illness and death, especially among people in health care
facilities who are at increased risk for severe flu illnesses.
Additionally, reports have shown that higher vaccination
levels among staff have been associated with a lower risk of
hospital-acquired flu cases, while lower flu vaccination rate
have led to greater number of flu outbreaks in hospitals and
long term care facilities. Nationwide, the CDC notes that
during the 2010-11 flu season, coverage for flu vaccination
among health care workers was estimated at 63.5%. However,
vaccination rates for health care workers who had an employer
requirement were at 98.1%. This discrepancy shows the success
of these mandatory vaccination programs. The United States
Health and Human Services (HHS) has a 90% vaccination rate
goal for health care personnel (HCP) by 2020.
2)BACKGROUND .
a) Flu . 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:
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children younger than five, but especially children younger
than two years old; adults over 65 years of age; pregnant
women; and, people with certain medical conditions
(including asthma, neurological and neurodevelopmental
conditions, chronic lung disease, heart disease, blood
disorders, diabetes, kidney disorders, liver disorders, and
weakened immune systems).
b) 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 flu 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 (HICPAC)
also recommend that all health care workers get vaccinated
annually against flu. 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% in 2008-09 and has grown since: 63% in
2009-10 and 64.3% in 2010-11. The goal of HHS is a 90%
vaccination rate by 2020.
c) Flu Vaccination among HCP . SB 739 (Speier), Chapter
526, Statutes of 2006, among other provisions, requires:
DPH to require each general acute care hospital to annually
offer onsite flu vaccinations, if available, to all
hospital employees at no cost to the employee; hospital
employees to be vaccinated, or if an employee elects not to
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be vaccinated, to declare in writing that he or she
declines the vaccination; hospitals to adopt a seasonal flu
plan; and, report to DPH implementation of SB 739
requirements, including the percentage of those who are
vaccinated.
Pursuant to SB 739, in 2011, DPH published a report entitled
"Flu Vaccination among Health Care Personnel in California
General Acute Care Hospitals for the 2010-2011 Respiratory
Season (DPH Report)." The DPH Report indicated that "the
2010-11 flu season was the third for which hospitals
submitted flu vaccination information. The flu season is
defined as September 1, 2010 through March 31, 2011. The
mean hospital-specific employee vaccination percentage of
64.3% was only modestly higher compared with 2008-09 (55%)
and 2009-10 (63%). This indicates that the statewide
mandatory written declination policy has not significantly
increased hospital HCP flu vaccination coverage. Half of
California hospitals failed to meet the Healthy People 2010
target of 60% HCP vaccination, and few reached the Healthy
People 2020 target of 90%." The DPH Report also indicated
that flu vaccination surveillance data for non-employee HCP
was incomplete, with the vaccination status for more than
50% of some non-employee personnel categories remaining
unknown. A comprehensive online survey conducted by DPH on
flu vaccination policies and practices revealed that
hospitals are using strategies recommended by HICPAC and
ACIP to promote flu vaccination among HCP. These
strategies include comprehensive flu vaccination campaigns,
multiple vaccination opportunities during all shifts,
education on flu and vaccination, and including all
personnel in vaccination promotion strategies and
vaccination opportunities. Hospitals that met the Healthy
People 2020 target of 90% were more likely to use a
mandatory participation vaccination policy with multiple
enforcement strategies. However, fewer than 5% of
hospitals exceeded 90% vaccination coverage, indicating
that meeting the Healthy People 2020 target may not be
feasible without some form of mandatory vaccination policy.
The DPH Report also pointed out that the H1N1 pandemic in
2009-10 failed to increase appreciable HCP vaccination
coverage, and transmission of H1N1 flu was documented among
HCP.
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The following recommendations were contained in the DPH
Report which could improve flu vaccination coverage among
HCP in California general acute care hospitals:
i) Hospitals should consider more rigorous flu
vaccination policies, such as mandatory participation or
vaccination, to increase flu vaccination percentages.
ii) Hospitals should ensure that flu vaccination status
is a requirement of contracts with physician groups,
registry organizations, fellowships, and student training
programs.
iii) Hospitals should account for the vaccination status
of all non-employee HCP, including registry and contract
personnel, students, and trainees.
iv) Hospitals should implement robust data collection
and management systems to document the vaccination status
of all HCP.
d) Counties with Mandatory Masking Policies . According to
background information submitted by the author, the
counties of San Francisco, Yolo, and Sacramento have
masking policies that are similar to those proposed by 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 flu 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
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requiring that all healthcare workers either receive
the flu vaccine or wear a mask during flu season. All
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 flu 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 flu 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, 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 a
"flu 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
were to be removed from working in patient care areas.
e) 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
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Epidemiology, the Infectious Diseases Society of America,
and the National Business Group on Health.
The CDC, ACIP, and HICPAC recommend that all U.S. health care
workers get vaccinated annually against flu. CDC points
out those health care workers who get vaccinated help
reduce the transmission of flu, staff illness and
absenteeism, and flu-related illness and death, especially
among people at increased risk for severe flu illness.
Higher vaccination levels among staff have been associated
with lower risk of hospital-acquired flu cases; flu
outbreaks in hospitals and long-term care facilities have
been attributed to low flu vaccination coverage among
health care workers in those facilities; and higher flu
vaccination levels among health care workers can reduce
flu-related illness, and even deaths, in settings like
nursing homes.
f) Aerosol Transmissible Diseases (ATD) Regulations . In
2009, ATD regulations were adopted by the California
Occupational Safety and Health Administration (Cal/OSHA) to
create an occupational safety standard requiring certain
protections for workers who may be exposed to ATD. The ATD
standard is not for seasonal flu, although it would cover
new variants of flu (swine and bird flu, for example). The
ATD standards apply to various facilities, including
hospitals, skilled nursing facilities, clinics, home health
care, long term care facilities, and medical transport.
Among other things, the ATD regulations require health
facilities to establish, implement, and maintain an
effective, written ATD Exposure Control Plan 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.
g) Other states . On February 15, 2012, the Colorado state
Board of Health passed a rule regarding influenza
vaccinations for health care workers. The rule requires
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licensed health care facilities to submit data regarding
their employee vaccinations to the state Department of
Public Health and Environment on an annual basis. Some of
the details of the rule are as follows:
A facility must meet vaccination rates for each given
year to be exempt from the rule. If the facility can
meet or exceed the target vaccination percentages listed
below for each given year, the facility will be exempt
from the rule for the following year as long as it
continues to use the same or more stringent methods of
promoting or mandating influenza vaccinations for its
employees. The targets required for this exemption are
as follows:
60% of all employees vaccinated from Oct. 1,
2012, to Dec. 31, 2012.
75% of all employees vaccinated from Oct. 1,
2013, to Dec. 31, 2013.
90% of all employees vaccinated from Oct. 1,
2014, to Dec. 31, 2014, and every year thereafter.
A hospital, hospital unit, ambulatory surgical center, or
long-term nursing care facility that does not achieve the
target vaccination rates of 60%-75%-90% will be required
to implement an influenza vaccination policy for that
includes a medical exemption. A medical exemption must
be signed by a Colorado licensed physician, physician's
assistant, advanced practice nurse, or nurse midwife
stating the vaccination is medically contraindicated as
described in the federal Food and Drug Administration
product labeling. This means that the only health care
workers who are not required to receive an annual
influenza vaccine are those who have a confirmed medical
reason that they cannot receive the vaccine because it
will be harmful to their health. If a health care worker
has a medical exemption, the policy also must require
that the health care worker wears a surgical or procedure
mask during influenza season (November - March) when in
direct contact with patients and in common areas as
specified by the facility's policy.
1)SUPPORT . The California Medical Association, the Health
Officers Association of California, and the California Primary
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Care Association state that this bill will improve the public
health and protect the staff and patients at clinics and
health care settings in the most proven effective and
efficient way possible. The California Hospital Association
states that voluntary immunization programs have failed to
increase immunization rates among health care workers to
acceptable levels required to substantially reduce health
care-acquired flu. Institutions that have implemented a
mandatory policy have dramatically reduced employee
absenteeism as well as health care associated flu, improving
patient safety and reducing health care costs.
2)OPPOSITION . The California Labor Federation (CLF) states that
it does not believe that masking is the most effective
strategy to achieve the goal of protecting patients from flu
transmission. To truly prevent transmission of flu, employers
must implement a comprehensive infection control program that
includes a range of measures, robust education, and training
programs for workers, reasonable access to vaccination, and
adequate sick time policies. It opposes the masking of health
care workers who decline the vaccine because there is no
scientific evidence that wearing surgical masks by
unvaccinated workers protects patients. In fact, research
shows that masking can lead to more contamination and
potential for infection from the frequent mouth, nose, and eye
contact necessitated when workers adjust or take off their
masks. Masks also interfere with communication between
healthcare workers and patients. CLF states they have offered
amendments to meet the goal of a 90% vaccination rate in
health care facilities without using masking. That proposal
includes a set goal of 90% vaccination for all health
facilities: phase-in education requirements based on the ATD
standards; and, requirements of additional measures to ensure
that all health care facilities reach a 90% vaccination rate
if they do not achieve that goal by the set date.
The California Nurses Association (CNA), also in opposition,
states that consumers should know the flu vaccination rates of
health care facilities and has suggested amendments to include
a public posting that displays vaccination rates in all
licensed health facilities. CNA believes that a comprehensive
solution to infection control is the best strategy to protect
hospitalized Californians, including a broad educational and
training program for workers on overall infection control,
reasonable access to vaccination, and adequate sick time
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policies. CNA agrees with the concerns raised by the CLF.
The American Federation of State, County and Municipal Employee
indicates that it is more sensible to work on educating health
care workers on better infection control and improving
screening and triaging of patients, families, and visitors who
enter health care facilities. Hospitals, clinics, and
doctors' offices should work to ensure environmental cleaning
staff has the training, equipment, and time to do all the
cleaning required to clean surfaces routinely, especially
around symptomatic patients, which would require facilities to
have adequate staffing levels.
SEIU California states that it takes issue with any measure
which has the effect of coercing people to undergo a medical
procedure or risk sanction. There is no demonstrated public
health purpose served by the mask itself other than the effect
of coercing workers to get the vaccine. SEIU California
indicates that this bill should instead fund Cal/OSHA and
require health care facilities to fully implement the ATD
standards.
3)RELATED LEGISLATION . AB 2009 (Galgiani) allows DPH to provide
guidance to local agencies as to whether one or more
population groups have priority to receive the flu vaccine
under a flu vaccine program administered by DPH for older
adults (60 years or older). AB 2009 is pending in the Senate.
AB 2064 (V. Manuel Pérez) requires 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 pending in the Assembly
Appropriations Committee.
AB 2109 (Pan) specifies certain requirements for parents and
guardians of school-aged children who wish to seek an
exemption from immunization requirements. AB 2109 is pending
in the Senate.
4)PREVIOUS LEGISLATION . SB 739 among other things, requires all
California general acute care hospitals, based on CDC
guidelines, to:
a) Annually offer onsite flu vaccinations, if available, to
all hospital employees at no cost to the employee.
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Requires each general acute care hospital 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.
b) Institute respiratory hygiene and cough etiquette
protocols, develop and implement procedures for the
isolation of patients with flu, and adopt a program plan
for vaccinating healthcare personal during the flu season.
c) Revise an existing or develop a new disaster plan that
includes a pandemic flu 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 a flu pandemic.
REGISTERED SUPPORT / OPPOSITION :
Support
California Medical Association (cosponsor)
California Association for Nurse Practitioner (cosponsor)
Health Officers Association of California (cosponsor)
American Academy of Pediatrics
American Congress of Obstetricians and Gynecologists, District
IX California
California Academy of Physician Assistants
California Hospital Association
California Pharmacists Association
California Primary Care Association
California Psychiatric Association
California Society of Health-System Pharmacists
County Health Executives Association of California
Santa Clara County Board of Supervisors
One individual
Opposition
American Federation of State, County and Municipal Employees,
AFL-CIO
California Alliance for Retired Americans
California Labor Federation
California Nurses Association
California School Employees Association, AFL-CIO
Laborers' Locals 777 & 792
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SEIU California
United Nurses Associations of California/Union of Health Care
Professionals
Analysis Prepared by : Rosielyn Pulmano / HEALTH / (916)
319-2097