BILL ANALYSIS �
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 1667
AUTHOR: Williams
AMENDED: June 9, 2014
HEARING DATE: June 18, 2014
CONSULTANT: Moreno
SUBJECT : Tuberculosis testing in schools.
SUMMARY : Replaces current mandatory tuberculosis (TB) testing
for school employees and volunteers with a TB risk assessment
administered by a health care provider.
Existing law:
1.Prohibits a person from being initially employed, or put under
contract with a school district in a certified or classified
position, unless they have had a TB test within the past 60
days to determine if he or she has TB. Applies to public
schools, private or parochial elementary or secondary schools,
or any nursery school.
2.Requires the TB test to consist of an approved intradermal TB
test or any other test for TB that is recommended by the
federal Centers for Disease Control and Prevention (CDC) and
licensed by the federal Food and Drug Administration (FDA),
and requires if the test is positive, that the test be
followed by an X-ray of the lungs.
3.Allows a district superintendent or the governing authority of
a private school to exempt a pregnant employee who tests
positive for TB from the requirement for an X-ray of the lungs
for up to 60 days following termination of the pregnancy.
4.Requires employees who test negative for TB to be tested at
least once every four years.
5.Requires that once an employee has been documented as having
TB, the test is no longer required, and requires the employee
to be referred within 30 days to the local health officer to
determine the need for follow-up care.
6.Requires employees, after the test, to file a certificate from
the physician showing the employee was examined and found free
from active TB. Allows the county board of education, to
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AB 1667 | Page 2
require that the certificates be filed in the office of the
county superintendent if a majority of school boards in the
county petition the county board of education, and allows a
school district with an average daily attendance of 60,000 or
more to maintain the files for its employees in that district.
7.Requires all volunteers in a school to have a certificate on
file showing that within the last four years the person
submitted to a TB test and was found free of communicable TB.
Allows the governing authority of a school to determine that a
TB test is not necessary if the volunteer does not have
frequent or prolonged contact with pupils.
8.Allows the governing board of a school to pass a resolution,
after a hearing which finds that the health of pupils in the
district would not be jeopardized, allowing employees to file
an affidavit stating that they adhere to the faith or
teachings of any well-recognized religious sect that depends
upon prayer for healing and that to the best of their
knowledge, they are free of TB.
9.Allows employees transferring from one district to another or
from a public to a private school, to provide a certificate
from the previous employer showing that they were examined
within the past four years and found to be free of
communicable TB.
10. Requires all
drivers, as a condition of contract with a governing board or
county superintendent of schools for providing the
transportation of pupils, to be examined for and be found free
of active TB. Exempts private contracted drivers from the TB
test requirement who transport students infrequently, not to
exceed once a month.
This bill:
1.Replaces current mandatory TB testing for school employees and
volunteers with a TB risk assessment administered by a health
care provider. Prohibits a person from being initially
employed or from being employed under contract by a school
district in a certified or classified position unless the
person has had a TB risk assessment within the past 60 days.
Applies to public schools, private or parochial elementary or
secondary schools, or any nursery school.
2.Specifies that if no risk factors are identified by a TB risk
AB 1667 | Page
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assessment, an examination is not required.
3.Requires, if TB risk factors are identified by a TB risk
assessment, those employees to be examined by a physician to
determine if they are free of infectious TB. Permits a person
who is subject to these requirements to take an examination
that complies with 4) below instead of submitting to a
tuberculosis risk assessment.
4.Requires the examination to consist of either an approved
intradermal TB test or any other test for TB that is
recommended by the CDC and licensed by the FDA and requires,
if the test is positive that the test be followed by an X-ray
of the lungs.
5.Requires employees who have no identified risk factors, or who
test negative, to undergo a TB risk assessment at least once
each four years.
6.Specifies that once an employee has been documented as having
TB, the risk assessment is no longer required.
7.Requires employees, after a TB risk assessment and, if
necessary, an examination, to file with the district
superintendent, a certificate from the physician and surgeon
showing the employee was examined and found free from
infectious TB. Allows the county board of education to
require certificates be filed in the office of the county
superintendent if a majority of school boards in the county
petition the county board of education, and allows a school
district with an average daily attendance of 60,000 or more to
maintain the files for its employees in that district.
8.Permits a governing board of a school district or the
governing authority of a private school, upon recommendation
of the local health officer, to require more extensive or
frequent physical exams.
9.Makes the risk assessment and, if indicated, the TB test a
condition of employment and requires the cost to be borne by
the applicant. Allows schools or districts to reimburse
applicants once they are hired.
AB 1667 | Page 4
10.Requires existing employees to be reimbursed for the expense
of the TB assessment and test.
11.Requires a volunteer in a school to have a certificate on
file showing that the person submitted to a TB risk
assessment, and if necessary, a TB test. Allows a school
board to determine that a TB risk assessment is not necessary
if the volunteer does not have frequent or prolonged contact
with pupils. Permits a person who is subject to these
requirements to take an examination that complies with 4)
above instead of submitting to a TB risk assessment.
12.Requires DPH, in consultation with the California
Tuberculosis Controllers Association (CTCA), to develop a risk
assessment questionnaire, to be used to conduct TB risk
assessments. Requires the questionnaire to be administered by
a health care provider and to be specified on the
questionnaire.
13.Requires all drivers, as a condition of contract with a
governing board or county superintendent of schools for
providing the transportation of pupils, to have a TB risk
assessment and, if indicated, the examination for TB within 60
days of initial hire and be found free of infectious TB.
Exempts, at the discretion of the governing board or county
superintendent of schools drivers from the TB assessment and
test requirement who transport students infrequently without
prolonged contact with the pupils.
FISCAL EFFECT : According to the Assembly Appropriations
Committee:
1.Minor staff costs to the Department of Public Health (DPH) to
develop a TB risk assessment questionnaire.
2.Unknown, potentially significant, annual state reimbursable
mandate costs if schools are successful in filing mandate
claims for the addition of contractors to the TB requirements.
As many school districts are choosing to receive a block
grant in lieu of filing mandate claims, actual potential
mandate costs are unknown, but costs could easily exceed
$150,000 annually.
PRIOR VOTES :
Assembly Health: 18- 0
Assembly Education: 7- 0
AB 1667 | Page
5
Assembly Appropriations:16- 0
Assembly Floor: 76- 1
COMMENTS :
1.Author's statement. According to the author, AB 1667 replaces
mandated TB testing for school employees and volunteers with a
TB risk assessment and follow up testing based on the results
of that assessment. This targeted approach will allow for
efficient use of TB testing drugs, which have been
experiencing nationwide shortages since April 2013. A targeted
approach will also lead to fewer false positives, thus
reducing employee exposure to unnecessary treatments that have
their own side effects. This bill does not affect the current
testing protocols in place when an infection is detected and
there is a need for targeted local testing. In fact, it
preserves skin tests for just these cases. AB 1667 is
consistent with guidelines from numerous expert bodies
including the Center for Disease Control and Prevention and
will allow the TB control programs to work most effectively to
detect and control TB in California.
2.Background. According to the CDC, TB is a disease that is
spread through the air from one person to another. There are
two kinds of tests that are used to determine if a person has
been infected with TB bacteria: the tuberculin skin test and
TB blood tests. A positive TB skin test or TB blood test only
tells that a person has been infected with TB bacteria. It
does not tell whether the person has latent TB infection or
has progressed to TB disease. Other tests, such as a chest
X-ray and a sample of sputum, are needed to see whether the
person has TB disease. According to the CDC, TB tests are
generally not needed for people with a low risk of infection
with TB bacteria. Certain people should be tested for TB
bacteria because they are more likely to get TB disease,
including:
a. People who have spent time with someone who has TB
disease;
b. People with HIV infection or another medical
problem that weakens the immune system;
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c. People who have symptoms of TB disease (fever,
night sweats, cough, and weight loss);
d. People from a country where TB disease is
common (most countries in Latin America, the
Caribbean, Africa, Asia, Eastern Europe, and Russia);
e. People who live or work somewhere in the
United States where TB disease is more common
(homeless shelters, prison or jails, or some nursing
homes); and,
f. People who use illegal drugs.
The two purified protein derivatives licensed by the FDA that
serve as antigens for TB tests have been experiencing
nationwide shortages since April 2013. In their September 4,
2013 health update, the CDC recommends allocating TB tests to
priority usages as determined by public health authorities.
Since 2000, the CDC has stated that screening of low-risk
persons and testing for administrative purposes should be
replaced by targeted testing. In 2006, DPH and CTCA issued
joint guidelines, Targeted Testing and Treatment of Latent
Tuberculosis Infection in Adults and Children, which state
that tuberculin skin testing of low risk populations will
result in unnecessary treatment because of false-positive test
results. Currently, five states (Florida, Texas, New Mexico,
Nebraska, and North Dakota) do not require teachers to be
tested for TB.
3.Prior legislation. AB 1323 (DeSaulnier), Chapter 24, Statutes
2007, expanded the types of TB testing that may be used to
screen for, or to report, cases of active TB, to include the
use of any test recommended by the CDC and licensed by the
FDA.
4.Support. The Health Officers Association of California, the
sponsor of this bill, writes that school employees and
volunteers are not considered high-risk populations and
replacing mandated universal testing of school personnel with
targeted screening will be more cost effective while still
protecting the state's teachers, volunteers, school employees,
and children from TB. CTCA supports the bill and references
an American Academy of Family Physicians statement noting,
"Routine screening outside?high-risk groups dissipates
resources and leads to high false-positive test rates." The
California School Nurses Association supports this bill
because it has been demonstrated that school staff and
volunteers are a low risk population and thus the revised
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policy and protocol for universal TB risk assessment and
testing, if warranted, is more efficacious and efficient.
5.Amendments. The author is requests that the Committee approve
the following amendments:
a. Change the word "take" to "submit to" on page
2 line 16 and on page 6 line 24.
b. Change "subdivision (b)" to "Section 121530"
on page 6 line 25, to reference the Section that
explicitly describes the requirements of the TB test.
c. Add nurse practitioners (in addition to
physicians and physician assistants) to those who can
administer the TB skin test.
SUPPORT AND OPPOSITION :
Support: Health Officers Association of California (sponsor)
American Academy of Pediatrics
American Lung Association in California
California Academy of Family Physicians
California Academy of Preventative Medicine
California Medical Association
California School Nurses Organization
California Tuberculosis Controllers Association
County Health Executives Association of California
Oppose: None received.
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