BILL ANALYSIS �
AB 689
Page 1
Date of Hearing: April 2, 2013
ASSEMBLY COMMITTEE ON HEALTH
Richard Pan, Chair
AB 689 (Bonta) - As Amended: March 20, 2013
SUBJECT : Health facilities: influenza.
SUMMARY : Requires each general acute care hospital annually,
beginning no later than October 1 and ending on the following
April 1, except when there is a national vaccine shortage or
when a physician does not recommend that the patient receive an
influenza vaccine due to potential health hazards, to offer
onsite vaccinations for influenza to all patients at discharge,
pursuant to the procedures of the facility and in accordance
with the recommendations of the Advisory Committee on
Immunization Practices (ACIP) of the Centers for Disease Control
and Prevention (CDC) of the US Department of Health and Human
Services, as the recommendations exist and are annually updated,
if applicable, on January 1 of the year in which the vaccine is
offered. Provides that this bill shall not be construed to
require a hospital to cover the cost of vaccination.
EXISTING LAW :
1)Establishes the Division of Communicable Disease Control
within the Department of Public Health (DPH) to promptly
identify, prevent, and control infectious diseases that pose a
threat to public health, including emerging and re-emerging
infectious diseases, vaccine-preventable agents, bacterial
toxins, bioterrorism, and pandemics.
2)Requires DPH to provide appropriate flu vaccine to local
governmental or private, nonprofit agencies at no charge in
order that the agencies may provide the vaccine, at a minimal
cost, at accessible locations. Requires DPH and the
California Department of Aging to prepare, publish, and
disseminate information regarding the availability of the
vaccine and the effectiveness of the vaccine in protecting the
health of older persons.
3)Requires a general acute care hospital to offer, prior to
discharge, immunizations for influenza and pneumococcal
disease to inpatients, aged 65 year or older, based upon the
adult immunization recommendations of ACIP of the CDC, and the
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recommendations of appropriate entities for the prevention,
detection, and control of influenza outbreaks in California
acute care hospitals.
4)Establishes the federal Vaccine for Children Program that
offers vaccines at no cost for eligible children.
FISCAL EFFECT : This bill has not yet been analyzed by a fiscal
committee.
COMMENTS :
1)PURPOSE OF THIS BILL . According to the author, current law
requires a general acute care hospital to offer immunizations
for influenza and pneumococcal disease to inpatients, prior to
discharge, aged 65 years or older, based on recommendations of
the ACIP of the federal CDC. Since the time this statute was
chaptered, ACIP has updated its recommendations and expanded
the age range to all persons six months of age and up for
influenza vaccinations. The original statute is out of date,
thus the goal of this bill is to update these statutes to
better reflect the current recommendations. Influenza
diseases pose a threat to public health. It has been
recognized for many years that influenza is infrequently
listed on death certificates and testing for seasonal
influenza complications is usually not done, particularly
among the elderly who are at greatest risk of seasonal
influenza complications and death.
2)BACKGROUND .
a) Influenza . According to DPH's Website, influenza is a
contagious respiratory illness caused by influenza viruses,
can cause mild to severe illness, and at times can lead to
death. The best way to prevent influenza is by getting a
flu vaccination each year. The CDC recommends a yearly
flu vaccine for everyone six months of age and older as the
first and most important step in protecting against this
serious disease. While there are many different flu
viruses, the flu vaccine is designed to protect against the
three main flu strains that research indicate will cause
the most illness during the flu season. The importance of
obtaining a flu vaccine was highlighted in 2009 with the
H1N1 outbreak in the US. H1N1 is a new strain of the
influenza virus that first appeared in April 2009 in the US
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and spread worldwide. The symptoms of H1N1 are similar to
the regular human seasonal flu infection. According to
DPH's Website, by December 2009, 8,003 people in California
were hospitalized, and 449 people died from H1N1.
In February 2010, the ACIP, which advises the CDC on vaccine
issues, voted to recommend that all people aged six months
and older obtain a flu vaccine (universal recommendation
for vaccination). However, the CDC also points out that
while everyone should get flu vaccine each flu season, it
is especially important that the following groups get
vaccinated either because they at a are high risk of having
serious flu-related complications or because they live with
or care for people at high risk for developing flu-related
complications: pregnant women; children younger than five;
but especially children younger than two years old, people
50 years of age and older; people of any age with certain
chronic medical conditions; people who live in nursing
homes and other long-term care facilities; and, people who
live with or care for those at high risk for complications
from flu, as specified.
b) Hospitalizations and Deaths Due to Influenza.
Protection against influenza virus is important because of
serious complications, including death, which may arise. A
study conducted by CDC and published in the Journal of
American Medical Association in September 2004 provided
information on the number of people in the US that are
hospitalized from seasonal influenza-related complications
each year. The study was based on records from 1979 to
2001 from about 500 hospitals across the US. The study
concluded that, on average, more than 200,000 people in the
US are hospitalized each year for respiratory and heart
conditions illnesses associated with seasonal influenza
virus infections. Older adults, specifically those 65
years of age and older, typically account for 60% of these
flu-related hospitalizations each year and about 90% of
flu-related deaths.
A new study published this year and conducted by researchers
from Vanderbilt University Medical Center in collaboration
with CDC entitled "Effectiveness of Influenza Vaccine for
Preventing Laboratory-Confirmed Influenza Hospitalizations
in Adults, 2011-2012 Season," found that flu vaccination
reduced the risk of flu-related hospitalization by 71.4%
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among adults of all ages and by 76.8% in study participants
50 years of age and older during the 2011-2012 flu season.
The authors of the study also indicated that the results of
the study provide additional evidence for increasing
vaccination rate in adults over 50 years of age and older.
c) Facilities Required to Offer Influenza Immunizations .
Existing law requires a general acute care hospital, if it
has vaccine in its possession, to offer, prior to
discharge, immunizations for influenza and pneumococcal
disease to inpatients, aged 65 years or older , based upon
the adult immunization recommendations of ACIP, and the
recommendations of appropriate entities for the prevention,
detection, and control of influenza outbreaks in California
general acute care hospitals.
Additionally, skilled nursing facilities, intermediate care
facilities, and nursing facilities must offer immunizations
for influenza and pneumococcal disease residents, aged 65
years of older, receiving services at the facility. These
facilities shall be reimbursed the standard Medi-Cal rate
for an immunization provided to a Medi-Cal recipient,
unless he or she is also a Medicare recipient whose
coverage includes reimbursement for the immunization.
Additionally, the health care facility is not required to
offer the immunizations under the following circumstances:
i) the facility is unable to obtain the vaccine due to a
shortage of the supply of vaccine; or ii) the resident
refuses to pay for the vaccine and there is no other
funding source available to pay for the cost of the
vaccine.
The law also provides that no person who has been offered the
vaccine may receive either an influenza or pneumococcal
vaccine if any of the following conditions exist: i) The
vaccine is medically contraindicated, as described in the
product labeling approved by the FDA or by the
recommendations established by ACIP that are in effect at
the time of vaccination; ii) Receipt of the vaccine is
against the resident's personal beliefs; or, iii) Receipt
of the vaccine is against the resident's wishes, or, if the
person lacks the capacity to make medical decisions, is
against the wishes of the person legally authorized to make
medical decisions on the resident's behalf.
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3)ISSUES . The California Black Health Network indicates that
"people of color tend to have lower rates of flu vaccination;
this (bill) could be seen as a way to increase the percentage
of those vaccinated. While we agree with the overall policy
of vaccination, we do have concerns about how it may interfere
with the medical home concept. For those with a medical home,
how would the hospital let the primary care physician know
this vaccination occurred other than depending on the patient
to remember to let their primary care physician know?
Additionally and most critically, children 6 months to 8 years
may require two flu shots, the second coming 4 weeks from the
first. How do you envision that occurring if some of these
infants and children do not have a consistent source of health
care? To that end, who has the responsibility to inquire and
counsel the patient prior to discharge?"
4)SUPPORT IF AMENDED . The California Chapter of the American
College of Emergency Physicians (Cal/ACEP) indicates that it
understands the importance of vaccinating Californians to
control the spread of flu and pneumonia. However, it is not
clear in the bill if emergency departments (EDs) would be
required to offer vaccines when a patient is released. If
hospitals are required to provide vaccines in the ED this will
extent the length of stay of many patients, further increasing
ED wait times, further straining our emergency care safety
net, and placing patient safety at risk. Studies show longer
ED wait times lead to longer lengths of stay in the hospital
and poorer patient outcomes. Cal/ACEP is requesting
amendments to exclude from this bill patients being discharged
from the ED. However, it should be noted that Health & Safety
Code (H&S Code) Section 120392.9 which requires general acute
care hospitals to offer immunizations for influenza to
inpatients aged 65 years or older applies to EDs.
5)SUPPORT . Sanofi Pasteur states that this bill increases the
opportunity for influenza immunizations and this would help
ensure that qualified individuals are given an opportunity to
receive an important preventive health service they might
otherwise overlook or miss.
6)RELATED LEGISLATION . AB 599 (Donnelly), pending in Assembly
Rules Committee, provides that existing law provisions which
allow a minor who is 12 years of age or older and who may have
come into contact with an infectious, contagious, or
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communicable disease to consent to medical care related to the
diagnosis or treatment of the disease, if the disease or
condition is one that is required by law to be reported to the
local health officer, or is a related sexually transmitted
disease, as specified, does not authorize a minor to receive a
vaccine without the consent of the parent or guardian of the
minor.
7)PREVIOUS LEGISLATION .
a) AB 2109 (Pan), Chapter 821, Statutes of 2012, requires
on and after January 1, 2014, a separate form prescribed by
the DPH to accompany a letter or affidavit to exempt a
child from immunization requirements under existing law on
the basis that an immunization is contrary to beliefs of
the child's parent or guardian.
b) SB 1318 (Wolk) of 2012 would have required clinics and
licensed health care facilities to institute measures
designed to maximize influenza vaccination rates and to
prevent persons with privileges on the medical staff and
onsite health care workers affiliated with the clinics or
health care facilities from contracting, and transmitting
to patients, the influenza virus. SB 1318 was vetoed by
the Governor who indicated "Encouraging health care workers
to be vaccinated against influenza is good policy, and I
support the national goal of achieving a 90 percent
compliance rate by 2020. Indeed, several counties and many
hospitals have already adopted strict mandatory vaccination
policies for their employees, and others are moving
voluntarily in this direction. This bill would move the
date up to 2015 and make compliance mandatory, which are
requirements I do not believe are reasonable. I have
confidence that local governments and health facilities are
well equipped to make these decisions on their own."
c) AB 106 (Berg), Chapter 378, Statutes of 2007, requires a
general acute care hospital to offer, prior to discharge,
immunizations for influenza and pneumococcal disease to its
inpatients, aged 65 years of age or older, as specified.
d) AB 691 (Daucher), Chapter 36, Statutes of 2004, requires
specified nursing facilities to offer immunizations for flu
and pneumococcal disease to residents that are 65 years or
older.
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e) AB 1711 (Strickland), Chapter 58, Statutes of 2005,
authorizes a registered nurse or licensed pharmacist to
administer in skilled nursing facilities influenza and
pneumococcal immunizations to a patient over 50 years of
age, pursuant to standing orders and without
patient-specific orders, if the immunization standing
orders that are not patient-specific meet prescribed
federal recommendations and are approved by the medical
director of the facility.
8)SUGGESTED TECHNICAL AMENDMENTS.
a) Placement of this bill . This bill is being added in
Section 1250 of the H&S Code which is the chapter dealing
with health facilities licensing. A more appropriate
placement would be in the Communicable Disease and
Prevention and Control Division of the H & S Code,
specifically the chapter relating to Influenza and
Pneumococcal Immunizations. Staff recommends that instead
of adding this bill's provisions in Section 1250.12, it
should instead be added in Section 120392.10 of the H & S
Code.
b) Clarify Definition of General Acute Care Hospital .
Staff recommends that reference to the definition of
general acute care hospital, as defined in Section 1250
subdivision (a) of the H & S Code be included in the bill.
9)POLICY CONSIDERATIONS .
a) Should general acute care hospitals under this bill
offer vaccines pursuant to its standardized procedures and
only if it has possession of these vaccines ? Current law
requires general acute care hospitals to offer, prior to
discharge, immunizations for influenza and pneumococcal
disease to inpatients, aged 65 years or older pursuant to
its standardized procedures and if it has the vaccine in
its possession. Staff recommends that this bill be amended
to apply the same requirements to this bill.
b) Who pays for the influenza vaccine ? Current law
provides that if a skilled nursing facility, an
intermediate care facility, or a nursing facility offers a
vaccine to its residents aged 65 years or older, the
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facility shall be reimbursed the standard Medi-Cal rate for
an immunization provided to a Medi-Cal recipient unless he
or she is also a Medicare recipient whose coverage includes
reimbursement for the immunization. Additionally, these
facilities are not required to offer immunizations for
influenza and pneumococcal disease if the resident refuses
to pay for the vaccine and there is no funding source
available to pay for the cost of the vaccine. This bill
indicates that the hospital is not required to cover the
cost of vaccination. As such, who should pay the cost of
the vaccination? Should this bill be amended to provide
that when a general acute care hospital offers the vaccine
to the patient, that it must inform the patient that he or
she may pay for the cost of the vaccine?
REGISTERED SUPPORT / OPPOSITION :
Support
American Federation of State, County and Municipal Employees,
AFL-CIO
BayBio
Sanofi Pasteur
Opposition
None on file.
Analysis Prepared by : Rosielyn Pulmano / HEALTH / (916)
319-2097