Existing law requires the State Department of Public Health to examine into the causes of communicable disease in man and domestic animals occurring or likely to occur in this state, and to establish a list of reportable diseases and conditions. Existing law requires a health officer knowing or having reason to believe that any case of the diseases made reportable by regulation of the department, or any other contagious, infectious or communicable disease exists, or has recently existed, within the territory under the local health officers jurisdiction, to take measures to prevent the spread of the disease or occurrence of additional cases.

This bill would require a local health officer, during an outbreak of a communicable disease, or upon the imminent and proximate threat of a communicable disease outbreak or epidemic that threatens the publics health, to notify and update governmental entities within the health officers jurisdiction about certain communicable diseases that may affect them, if, in the opinion of the local health officer, action or inaction on the part of the governmental entity might affect outbreak response efforts. The bill would require the local health officer to make any relevant information available to those governmental entities, as specified, and would require both the local health officer and the governmental entities to comply with applicable state and federal privacy laws with regard to information that the health officer provides to the governmental entities. The bill would authorize the local health officer to issue orders to other governmental entities within the local health officers jurisdiction to take any action the local health officer deems necessary to control the spread of the communicable disease.

By imposing new requirements on local health officers, this bill would create a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that, if the Commission on State Mandates determines that the bill contains costs mandated by the state, reimbursement for those costs shall be made pursuant to the statutory provisions noted above.

CONCURRENCE IN SENATE AMENDMENTS

CSA1 Bill Id:AB 262

Author:(Gloria and Gonzalez)

As Amended Ver:June 11, 2019

Majority vote

SUMMARY:

Requires, during an outbreak of a communicable disease, or upon the imminent and proximate threat of a communicable outbreak or epidemic that threatens the public's health, a local health officer (LHO) to: 1) promptly notify and update the governmental entities within the LHO's jurisdiction about communicable diseases, as specified; and, 2) make relevant information available to governmental entities, including, but not limited to, the locations of concentrations of cases, the number of residents affected, and the measures that the governmental entities should take to assist with outbreak response efforts. Authorizes a LHO to issue orders to other governmental entities to take any action the LHO deems necessary to control the spread of communicable disease.

The Senate Amendments:

1. Clarify that a LHO must notify and update government entities within its jurisdiction if, in the opinion of the LHO, action or inaction on the part of the governmental entity might affect outbreak response efforts.
2. Require the LHO and governmental entity to comply with applicable state and federal privacy laws relating to the notification.

COMMENTS:

In early March 2007, San Diego's (SD's) Health and Human Services Agency (HHSA) announced an increase in the number of reported Hepatitis A virus (HAV) cases. This outbreak was affecting individuals experiencing homelessness and those who use illegal drugs, and the majority of the cases occurred within the city of SD. On March 10, 2017, a health advisory was issued by HHSA to the SD medical community that an outbreak of HAV was occurring among these two at-risk populations. According to this advisory, at that time there were 19 cases of HAV in SD from November 2016 through early March 2017. However, by the end of March 2017, SD's data showed it had identified 42 cases, 33 hospitalizations and one death. At the end of April 2017, SD identified a three-pronged approach to addressing the outbreak: vaccination, sanitation, and education. SD began administering vaccinations in May 2017 at several locations, including homeless service provider facilities, and mobile vans. SD also deployed foot teams of nurses, public safety officers, and social service providers who located homeless individuals and administered vaccinations in the field. SD also coordinated the distribution of education materials to inform residents about the disease. From the end of March through the end of May 2017, the number of HAV cases more than quadrupled to 180, the number of hospitalizations more than tripled to 120, and the number of deaths increased to four.

According to the Author:

On September 1, 2017, SD declared a public health emergency in response to the HAV outbreak. As of April 11, 2018, DPH reported 704 cases, 461 hospitalizations, and 21 deaths related to the HAV outbreak statewide. State intervention became so desperately needed as a result of the HAV outbreak originating in SD that former Governor Brown issued an emergency proclamation on October 13, 2017. Following the containment of the outbreak, the State Auditor found that the City and County of SD could have done more to prevent the spread of the outbreak. This bill makes clear the responsibility of local government and public health officers to protect the public against future communicable disease outbreaks.

Arguments in Support:

The SD County Board of Supervisors is the sponsor of this bill and states that this bill seeks to clarify the law as it relates to notification and direction given to jurisdictions under the purview of local health officers during a communicable disease outbreak. Following the HAV outbreak in SD, findings from various reports identified ambiguity around the roles, responsibilities, and authority of SD Public Health Officer to inform and direct the actions of other governmental entities within the public health officer's jurisdiction during a local health emergency.

Arguments in Opposition:

A Voice for Choice Advocacy opposes this bill and states that although it agrees with the intent of this bill to alert the public about communicable disease and ensure it is addressed effectively and quickly, it believes this bill is overly broad and could result in an abuse of power.

FISCAL COMMENTS:

None

VOTES:

ASM HEALTH: 13-0-2

YES: Wood, Mayes, Aguiar-Curry, Bigelow, Bonta, Burke, Carrillo, Limón, McCarty, Nazarian, Ramos, Chu, Santiago

ABS, ABST OR NV: Flora, Waldron

ASM APPROPRIATIONS: 17-0-1

YES: Gonzalez, Bigelow, Bonta, Brough, Calderon, Carrillo, Chau, Diep, Eggman, Fong, Gabriel, McCarty, Maienschein, Obernolte, Petrie-Norris, Quirk, Robert Rivas

ABS, ABST OR NV: Bloom

ASSEMBLY FLOOR: 71-0-9

YES: Aguiar-Curry, Bauer-Kahan, Berman, Bigelow, Bloom, Boerner Horvath, Bonta, Burke, Calderon, Carrillo, Cervantes, Chau, Chen, Chiu, Choi, Chu, Cooper, Cunningham, Dahle, Daly, Diep, Eggman, Fong, Frazier, Friedman, Gabriel, Gallagher, Cristina Garcia, Eduardo Garcia, Gipson, Gloria, Gonzalez, Gray, Grayson, Holden, Irwin, Jones-Sawyer, Kalra, Kamlager-Dove, Lackey, Levine, Limón, Low, Maienschein, Mayes, McCarty, Medina, Melendez, Muratsuchi, Nazarian, O'Donnell, Obernolte, Patterson, Petrie-Norris, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Salas, Santiago, Smith, Mark Stone, Ting, Voepel, Weber, Wicks, Wood, Rendon

ABS, ABST OR NV: Arambula, Brough, Cooley, Flora, Kiley, Mathis, Mullin, Quirk, Waldron

SENATE FLOOR: 39-0-1

YES: Allen, Archuleta, Atkins, Bates, Beall, Borgeas, Bradford, Caballero, Chang, Dahle, Dodd, Durazo, Galgiani, Glazer, Lena Gonzalez, Grove, Hertzberg, Hill, Hueso, Hurtado, Jackson, Jones, Leyva, McGuire, Mitchell, Monning, Morrell, Nielsen, Pan, Portantino, Roth, Rubio, Skinner, Stern, Stone, Umberg, Wieckowski, Wiener, Wilk

ABS, ABST OR NV: Moorlach

UPDATED:

VERSION: June 11, 2019

CONSULTANT: Rosielyn Pulmano / HEALTH / (916) 319-2097 FN: 0001866

 THIRD READING  

Bill No: AB 262

Author: Gloria (D) and Gonzalez (D), et al.

Amended: 6/11/19 in Senate

Vote: 21

SENATE HEALTH COMMITTEE: 9-0, 6/19/19

AYES: Pan, Stone, Lena Gonzalez, Grove, Hurtado, Leyva, Mitchell, Monning, Rubio

SENATE APPROPRIATIONS COMMITTEE: Senate Rule 28.8

ASSEMBLY FLOOR: 71-0, 5/2/19 - See last page for vote

SUBJECT: Local health officers: communicable diseases

SOURCE: San Diego County Board of Supervisors

DIGEST:

• 1. This bill requires local health officers (LHOs), during an outbreak of a communicable disease, or upon the imminent and proximate threat of a communicable disease outbreak or epidemic that threatens the public’s health, to notify and update governmental entities within the LHO’s jurisdiction, as specified, and make relevant information available to governmental entities, as specified.

ANALYSIS:

Existing law:

1. Requires Department of Public Health (DPH) to examine the causes of communicable disease in man and domestic animals occurring or likely to occur in this state. [HSC §120125]
2. Gives the State Public Health Officer, as the director of DPH, broad authority to detect, monitor, and prevent the spread of communicable disease in the state, including:
   1. Require reporting of communicable disease that DPH identifies, on timelines and in a manner determined by DPH;
   2. Adopt and enforce regulations requiring strict or modified isolation, or quarantine, for any of the contagious, infectious, or communicable diseases, if in the opinion of DPH, the action is necessary for the protection of the public health;
   3. Take measures as are necessary to ascertain the nature of the disease and prevent its spread. Permits DPH, to that end, if it considers it proper, to take possession or control of the body of any living person, or the corpse of any deceased person;
   4. Quarantine, isolate, inspect, and disinfect persons, animals, houses, rooms, other property, places, cities, or localities, whenever in its judgment the action is necessary to protect or preserve the public health; and,
   5. Destroy such objects as bedding, carpets, household goods, furnishings, materials, clothing, or animals, when ordinary means of disinfection are considered unsafe, and when the property is in its judgment, an imminent menace to the public health. [HSC §120130, et seq.]
3. Requires LHOs knowing or having reason to believe that any case of reportable diseases, or any other contagious, infectious or communicable disease exists, or has recently existed, within the territory under his or her jurisdiction, to take measures as may be necessary to prevent the spread of the disease or occurrence of additional cases. [HSC §120175]
4. Requires specified health care providers, facilities, and health plans, during an outbreak of communicable disease, or upon the imminent and proximate threat of communicable disease outbreak or epidemic that threatens the public’s health, upon request, to disclose to the LHO inventories of critical medical supplies, equipment, pharmaceuticals, vaccines, or other products that may be used for the prevention of, or may be implicated in the transmission of communicable disease. [HSC §120176, 17 CCR §2500].
5. Requires an LHO, in the case of a local epidemic of disease, to report at those times as are requested by DPH all facts concerning the disease, and the measures taken to abate and prevent its spread. [HSC §120185]
6. Requires LHOs to immediately report to DPH every discovered or known case or suspect case of a designated disease. Requires LHOs to make reports that DPH requires within 24 hours after investigation. [HSC §120190]

This bill:

1. Requires LHOs, during an outbreak of a communicable disease, or upon the imminent and proximate threat of a communicable disease outbreak or epidemic that threatens the public’s health, to:
   1. Promptly notify and update governmental entities within the LHO’s jurisdiction about communicable diseases required to be reported under existing law that may affect them if, in the opinion of the health officer, action or inaction on the part of the entity might affect outbreak response efforts; and,
   2. Make any relevant information available to governmental entities, including, but not limited to, the locations of concentrations of cases, the number of residents affected, and the measures that the governmental entities should take to assist with outbreak response efforts.
2. Permits LHOs to issue orders to other governmental entities within his or her jurisdiction to take any action he or she deems necessary to control the spread of the communicable disease.
3. Requires LHOs that provide the notification and information to a governmental entity and the entity that receives this information to comply with all applicable state and federal privacy laws.

Comments

1. Author’s statement. According to the author, on September 1, 2017, the County of San Diego (County) declared a public health emergency in response to the Hepatitis A virus (HAV) outbreak. As of April 11, 2018, DPH reported 704 cases, 461 hospitalizations, and 21 deaths related to the HAV outbreak statewide. State intervention became so desperately needed as a result of the HAV outbreak originating in the County, former Governor Brown issued an emergency proclamation on October 13, 2017. Following the containment of the outbreak, the State Auditor found that the City and County of San Diego could have done more to prevent the spread of the outbreak. This bill makes clear the responsibility of local government and public health officers to protect the public against future communicable disease outbreaks.
2. Hepatitis and hepatitis A. According to the Centers for Disease Control and Prevention (CDC), hepatitis means inflammation of the liver. When the liver is inflamed or damaged, its function can be affected. Heavy alcohol use, toxins, some medications, and certain medical conditions can cause hepatitis but a virus often causes hepatitis. In the United States, the most common hepatitis viruses are HAV, hepatitis B virus, and hepatitis C virus. Hepatitis A is a highly contagious infection caused by the HAV. It can range from a mild illness lasting a few weeks to a severe illness lasting several months. Although rare, hepatitis A can cause death in some people. Hepatitis A usually spreads when a person unknowingly ingests the virus from objects, food, or drinks contaminated by small, undetected amounts of stool from an infected person. Most people who get hepatitis A feel sick for several weeks, but they usually recover completely and do not have lasting liver damage. In rare cases, hepatitis A can cause liver failure and death; this is more common in people older than 50 and in people with other liver diseases. The following groups are at highest risk for acquiring hepatitis A infection or developing serious complications from hepatitis A infection in these outbreaks and should be offered the hepatitis A vaccine in order to prevent or control an outbreak:
   1. People who use drugs (injection or non-injection);
   2. People experiencing unstable housing or homelessness;
   3. Men who have sex with men;
   4. People who are, or were recently, incarcerated; and,
   5. People with chronic liver disease, including cirrhosis, hepatitis B, or hepatitis C.

According to the CDC, the hepatitis A vaccine is the best way to prevent infection, and provides up to 95% seroprotection in healthy individuals for up to 11 years. Hepatitis A rates have declined by more than 95% since the hepatitis A vaccine first became available in 1995.

1. Hepatitis A outbreaks. The CDC reports that, nationwide as of June 7, 2019, hepatitis A outbreaks (which began in 2016 and have been reported in 22 states) have resulted in 19,723 cases, 11,331 hospitalizations, and 189 deaths. According to DPH, California experienced a large hepatitis A outbreak in 2017 and 2018, primarily among persons experiencing homelessness and/or using illicit drugs in settings of limited sanitation. This outbreak began in San Diego County in November 2016 and spread to Santa Cruz, Los Angeles, and Monterey counties. As of April 11, 2018 and following intensive efforts by LHOs and their clinical and community partners, including vaccination campaigns targeting the at-risk population, education, obtaining and managing vaccine, and many other interventions, the outbreak has resolved in California.
2. San Diego outbreak. In March 2017, San Diego County officials identified a hepatitis A outbreak, tracing cases back to November 2016. The County declared a local health emergency on September 1, 2017, which ended on January 23, 2018. According to the County, vaccination events started in March 2017 and remain ongoing in order to prevent another outbreak. Through October 3, 2018, more than 203,850 hepatitis A vaccines have been given in response to the outbreak through healthcare providers and vaccination events. The response to the outbreak featured a number of new or untried strategies, such as sending “foot-teams” of nurses with homeless outreach workers and law enforcement to give vaccinations to at-risk individuals where they were residing. The County worked with cities and provided sanitation protocols to clean areas frequently used by homeless, and deployed handwashing stations in public areas. In October 2018, the County announced that the hepatitis A outbreak had officially ended. 
3. State Auditor report. On December 20, 2018, the State Auditor submitted a report to the Legislature in response to a Joint Legislative Audit Committee request regarding the response to the San Diego hepatitis A outbreak. This report concludes that the County took steps to understand the increasing number of reported hepatitis A cases, determine the necessary interventions to contain the outbreak, and identify the characteristics and size of the at‑risk populations. However, the County failed to include critical details in planning its response such as identifying the number of vaccinations it would administer, the timelines for administering them, and the resources, primarily nursing staff, needed to carry out the vaccination program. As a result, the County did not accelerate vaccination efforts until September and October 2017. Had the County hastened its vaccination efforts, it may have more quickly reduced the risk of the disease’s spread.

The report also states that although adequate sanitation is critical to controlling the spread of HAV, neither the County nor the City of San Diego (City) promptly implemented measures to improve sanitation and hygiene conditions for the at-risk populations in the City. Discussions occurred in June and August 2017 between the County and the City on these sanitation measures but it was not until September 2017 when the LHO issued a directive telling the City it had to take action on sanitation measures that any action was taken. According to the report, the LHO did not issue a directive sooner because she wanted to collaborate with the City instead of mandating its compliance. The report states that because the County did not do enough to inform and involve the City, the City lacked information that would have enabled it to understand the severity of the outbreak and the need to implement sanitation measures. The State Auditor made several recommendations, including:

• 1. The Legislature should clarify existing law to specify that the LHO for each geographic jurisdiction may issue directives to other governmental entities within that jurisdiction to take action, as the LHO deems necessary to control the spread of communicable diseases;
  2. The City and the County should enter into an agreement or negotiate revisions in their contract to clarify each entity’s roles and responsibilities over public health matters, and to include City leadership in coordinating response efforts when public health matters, such as disease outbreaks, affect the City’s residents; and,
  3. DPH should amend its HAV Outbreak Response Plan (Response Plan), to recommend that jurisdictions set vaccination targets as soon as possible, establish dates by when they expect to achieve those targets, and determine the quantities of resources necessary to administer the vaccination by those dates. Additionally, DPH should finalize and issue its Public Health and Medical Emergency Powers Guide (Emergency Powers Guide), and describe to the greatest extent possible the types of actions that LHOs can take within their jurisdictions to prevent or contain the spread of infectious disease.

1. San Diego’s response to the Auditor’s report. The County is sponsoring this bill to address the Auditor’s recommendation under a) above. Additionally, a Memorandum of Agreement was signed by the County Chief Administrative Officer on March 27, 2019, and by the City Chief Operating Officer on March 28, 2019. The two jurisdictions submitted their response to the State Auditor on April 29 indicating that they met the Auditor’s recommendation.
2. DPH Response Plan. DPH published a revised Response Plan on January 9, 2019. Although the CDC did not recognize those experiencing homelessness and/or using illicit drugs as an at-risk group, as a result of California’s outbreak, this group was recommended for vaccination by DPH. The CDC was consulted and supported recommending this group to be added in the at-risk population that are indicated for routine vaccination. The updated Response Plan articulated priority activities by objectives. The objectives include: a) procuring, distributing, and monitoring HAV vaccine to enable LHOs to administer to at-risk populations to halt transmission and prevent future outbreaks; and, b) establishing streamlined internal and external communication so that partners, the media, and the public receive accurate information about the outbreak and control measures; and, level of risk of HAV infection for different populations.
3. DPH Emergency Powers Guide. The 2019 Emergency Powers Guide identifies the various types of emergencies relevant to the State of California and the powers and responsibilities assigned by statute to various state and local officials during a proclaimed emergency. For example, during a proclaimed local emergency, the LHO does not have the authority to independently issue orders and regulations, and must work with the local governing body to have such orders and regulations issued if needed to protect the public health. However, the LHO may have the authority during the local emergency to independently issue orders related to communicable disease control. In response to the Auditor’s report, the Emergency Powers Guide specifies that the LHO has the power to take measures as may be necessary to prevent the spread or occurrence of additional cases of communicable disease in his/her jurisdiction. This could include orders for isolation, quarantine or “social distancing.” The exercise of this power does not depend upon a declaration or proclamation of emergency, and continues after a proclamation of emergency, but is limited to the control of communicable disease.

FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: Yes

SUPPORT: (Verified 7/8/19)

San Diego County Board of Supervisors (source)

California Academy of Preventive Medicine

California Life Sciences Association

City of San Diego

OPPOSITION: (Verified 7/8/19)

A Voice for Choice Advocacy

Eagle Forum of California

One individual

ARGUMENTS IN SUPPORT: The San Diego County Board of Supervisors writes that following the 2017 outbreak of hepatitis A in the County, findings from various after-action reports identified ambiguity around the roles, responsibilities and authority of the County’s LHO to inform, as well as direct the actions of, other governmental entities within the LHO’s jurisdiction during a local health emergency. This bill addresses this issue and seeks to clarify and strengthen the authority of LHOs as it relates to communicating relevant information and directing action of jurisdictions under the purview of the LHO during a communicable disease outbreak. California Life Sciences Association writes that while California has done a great deal in terms of mandated infectious disease reporting, we can still do more to empower local health authorities to ensure outbreaks in California do not become epidemics. To this end, formalizing the duties of prompt notification by LHOs and facilitating their issuance of directives at the local level are steps in the right direction.

ARGUMENTS IN OPPOSITION: A Voice for Choice Advocacy writes that this bill is overly broad and could result in an abuse of power as it gives unilateral authority to the LHO to issue directives to other governmental entities within that jurisdiction to take “any” action the LHO deems necessary to control the spread of the communicable disease or upon imminent and “proximate threat” of a communicable disease outbreak. A Voice for Choice Advocacy requests amendments to ensure the LHO chooses the most effective and least invasive action to respond to a health threat, rather than any action they deem necessary at any time they feel there may be a threat. Additionally, A Voice for Choice Advocacy also requests amendments addresses the fiscal responsibility of the LHO by specifying that the most effective and financially sound, and least invasive, action must be taken. This bill should also make the LHO responsible for post-outbreak identification for future outbreak prevention – so that the lessons and pitfalls learned from one outbreak can be used in the next one.

ASSEMBLY FLOOR: 71-0, 5/2/19

AYES: Aguiar-Curry, Bauer-Kahan, Berman, Bigelow, Bloom, Boerner Horvath, Bonta, Burke, Calderon, Carrillo, Cervantes, Chau, Chen, Chiu, Choi, Chu, Cooper, Cunningham, Dahle, Daly, Diep, Eggman, Fong, Frazier, Friedman, Gabriel, Gallagher, Cristina Garcia, Eduardo Garcia, Gipson, Gloria, Gonzalez, Gray, Grayson, Holden, Irwin, Jones-Sawyer, Kalra, Kamlager-Dove, Lackey, Levine, Limón, Low, Maienschein, Mayes, McCarty, Medina, Melendez, Muratsuchi, Nazarian, Obernolte, O'Donnell, Patterson, Petrie-Norris, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Salas, Santiago, Smith, Mark Stone, Ting, Voepel, Weber, Wicks, Wood, Rendon

NO VOTE RECORDED: Arambula, Brough, Cooley, Flora, Kiley, Mathis, Mullin, Quirk, Waldron

Prepared by: Melanie Moreno / HEALTH / (916) 651-4111

7/10/19 14:34:13

**** END ****

SENATE COMMITTEE ON HEALTH

Senator Dr. Richard Pan, Chair

BILL NO: AB 262

SUBJECT: Local health officers: communicable diseases

SUMMARY:

• 1. Requires local health officers (LHOs), during an outbreak of a communicable disease, or upon the imminent and proximate threat of a communicable disease outbreak or epidemic that threatens the public’s health, to notify and update governmental entities within the LHO’s jurisdiction, as specified, and make relevant information available to governmental entities, as specified.

Existing law:

1. Requires Department of Public Health (DPH) to examine the causes of communicable disease in man and domestic animals occurring or likely to occur in this state. [HSC §120125]
2. Gives the State Public Health Officer (PHO), as the director of DPH, broad authority to detect, monitor, and prevent the spread of communicable disease in the state, including:
   1. Require reporting of communicable disease that DPH identifies, on timelines and in a manner determined by DPH;
   2. Adopt and enforce regulations requiring strict or modified isolation, or quarantine, for any of the contagious, infectious, or communicable diseases, if in the opinion of DPH, the action is necessary for the protection of the public health;
   3. Take measures as are necessary to ascertain the nature of the disease and prevent its spread. Permits DPH, to that end, if it considers it proper, to take possession or control of the body of any living person, or the corpse of any deceased person;
   4. Quarantine, isolate, inspect, and disinfect persons, animals, houses, rooms, other property, places, cities, or localities, whenever in its judgment the action is necessary to protect or preserve the public health; and,
   5. Destroy such objects as bedding, carpets, household goods, furnishings, materials, clothing, or animals, when ordinary means of disinfection are considered unsafe, and when the property is in its judgment, an imminent menace to the public health. [HSC §120130, et seq.]
3. Requires LHOs knowing or having reason to believe that any case of reportable diseases, or any other contagious, infectious or communicable disease exists, or has recently existed, within the territory under his or her jurisdiction, to take measures as may be necessary to prevent the spread of the disease or occurrence of additional cases. [HSC §120175]
4. Requires specified health care providers, facilities, and health plans, during an outbreak of communicable disease, or upon the imminent and proximate threat of communicable disease outbreak or epidemic that threatens the public’s health, upon request, to disclose to the LHO inventories of critical medical supplies, equipment, pharmaceuticals, vaccines, or other products that may be used for the prevention of, or may be implicated in the transmission of communicable disease. [HSC §120176, 17 CCR §2500].
5. Requires an LHO, in the case of a local epidemic of disease, to report at those times as are requested by DPH all facts concerning the disease, and the measures taken to abate and prevent its spread. [HSC §120185]
6. Requires LHOs to immediately report to DPH every discovered or known case or suspect case of a designated disease. Requires LHOs to make reports that DPH requires within 24 hours after investigation. [HSC §120190]

This bill:

1. Requires LHOs, during an outbreak of a communicable disease, or upon the imminent and proximate threat of a communicable disease outbreak or epidemic that threatens the public’s health, to:
   1. Promptly notify and update governmental entities within the LHO’s jurisdiction about communicable diseases required to be reported under existing law that may affect them if, in the opinion of the health officer, action or inaction on the part of the entity might affect outbreak response efforts; and,
   2. Make any relevant information available to governmental entities, including, but not limited to, the locations of concentrations of cases, the number of residents affected, and the measures that the governmental entities should take to assist with outbreak response efforts.
2. Permits LHOs to issue orders to other governmental entities within his or her jurisdiction to take any action he or she deems necessary to control the spread of the communicable disease.
3. Requires LHOs that provide the notification and information to a governmental entity and the entity that receives this information to comply with all applicable state and federal privacy laws.

FISCAL EFFECT:

According the Assembly Appropriations Committee, unknown, likely minor potential state-reimbursable costs to share available information with other public entities during an outbreak.

COMMENTS:

1. Author’s statement. According to the author, On September 1, 2017, the County of San Diego (County) declared a public health emergency in response to the Hepatitis A virus (HAV) outbreak. As of April 11, 2018, DPH reported 704 cases, 461 hospitalizations, and 21 deaths related to the HAV outbreak statewide. State intervention became so desperately needed as a result of the HAV outbreak originating in the County, former Governor Brown issued an emergency proclamation on October 13, 2017. Following the containment of the outbreak, the State Auditor found that the City and County of San Diego could have done more to prevent the spread of the outbreak. This bill makes clear the responsibility of local government and public health officers to protect the public against future communicable disease outbreaks.
2. Hepatitis and hepatitis A. According to the CDC, hepatitis means inflammation of the liver. When the liver is inflamed or damaged, its function can be affected. Heavy alcohol use, toxins, some medications, and certain medical conditions can cause hepatitis but a virus often causes hepatitis. In the United States, the most common hepatitis viruses are HAV, hepatitis B virus, and hepatitis C virus. Hepatitis A is a highly contagious liver infection caused by the HAV. It can range from a mild illness lasting a few weeks to a severe illness lasting several months. Although rare, hepatitis A can cause death in some people. Hepatitis A usually spreads when a person unknowingly ingests the virus from objects, food, or drinks contaminated by small, undetected amounts of stool from an infected person. Most people who get hepatitis A feel sick for several weeks, but they usually recover completely and do not have lasting liver damage. In rare cases, hepatitis A can cause liver failure and death; this is more common in people older than 50 and in people with other liver diseases. The following groups are at highest risk for acquiring hepatitis A infection or developing serious complications from hepatitis A infection in these outbreaks and should be offered the hepatitis A vaccine in order to prevent or control an outbreak:
   1. People who use drugs (injection or non-injection);
   2. People experiencing unstable housing or homelessness;
   3. Men who have sex with men (MSM);
   4. People who are, or were recently, incarcerated; and,
   5. People with chronic liver disease, including cirrhosis, hepatitis B, or hepatitis C

According to the CDC, the hepatitis A vaccine is the best way to prevent infection, and provides up to 95% seroprotection in healthy individuals for up to 11 years. Hepatitis A rates have declined by more than 95% since the hepatitis A vaccine first became available in 1995.

1. Hepatitis A outbreaks. The CDC reports that, nationwide as of June 7, 2019, hepatitis A outbreaks (which began in 2016 and have been reported in 22 states) have resulted in 19,723 cases, 11,331 hospitalizations, and 189 deaths. According to DPH, California experienced a large hepatitis A outbreak in 2017 and 2018, primarily among persons experiencing homelessness and/or using illicit drugs in settings of limited sanitation. This outbreak began in San Diego County in November 2016 and spread to Santa Cruz, Los Angeles, and Monterey counties. As of April 11, 2018 and following intensive efforts by local health departments and their clinical and community partners, including vaccination campaigns targeting the at-risk population, education, obtaining and managing vaccine, and many other interventions, the outbreak has resolved in California.

1. San Diego outbreak. In March 2017, San Diego County officials identified a hepatitis A outbreak, tracing cases back to November 2016. The County declared a local health emergency on September 1, 2017, which ended on January 23, 2018. According to the County, vaccination events started in March 2017 and remain ongoing in order to prevent another outbreak. Through October 3, 2018, more than 203,850 hepatitis A vaccines have been given in response to the outbreak through healthcare providers and vaccination events. The response to the outbreak featured a number of new or untried strategies, such as sending ‘foot-teams’ of nurses with homeless outreach workers and law enforcement to give vaccinations to at-risk individuals where they were residing. The County worked with cities and provided sanitation protocols to clean areas frequently used by homeless, and deployed handwashing stations in public areas. In October 2018, the County announced that the hepatitis A outbreak had officially ended. 
2. State Auditor report. On December 20, 2018, the State Auditor submitted a report to the Legislature in response to a Joint Legislative Audit Committee request regarding the response to the San Diego hepatitis A outbreak. This report concludes that the County took steps to understand the increasing number of reported hepatitis A cases, determine the necessary interventions to contain the outbreak, and identify the characteristics and size of the at‑risk populations. However, the County failed to include critical details in planning its response such as identifying the number of vaccinations it would administer, the timelines for administering them, and the resources, primarily nursing staff, needed to carry out the vaccination program. As a result, the County did not accelerate vaccination efforts until September and October 2017. Had the County hastened its vaccination efforts, it may have more quickly reduced the risk of the disease’s spread.

The report also states that although adequate sanitation is critical to controlling the spread of HAV, neither the County nor the City of San Diego (City) promptly implemented measures to improve sanitation and hygiene conditions for the at-risk populations in the City. Discussions occurred in June and August 2017 between the County and the City on these sanitation measures but it was not until September 2017 when the LHO issued a directive telling the City it had to take action on sanitation measures that any action was taken. According to the report, the LHO did not issue a directive sooner because she wanted to collaborate with the City instead of mandating its compliance. The report states that because the County did not do enough to inform and involve the City, the City lacked information that would have enabled it to understand the severity of the outbreak and the need to implement sanitation measures. The State Auditor made several recommendations, including:

• 1. The Legislature should clarify existing law to specify that the LHO for each geographic jurisdiction may issue directives to other governmental entities within that jurisdiction to take action, as the LHO deems necessary to control the spread of communicable diseases;
  2. The City and the County should enter into an agreement or negotiate revisions in their contract to clarify each entity’s roles and responsibilities over public health matters, and to include City leadership in coordinating response efforts when public health matters, such as disease outbreaks, affect the City’s residents; and,
  3. DPH should amend its HAV Outbreak Response Plan (Response Plan), to recommend that jurisdictions set vaccination targets as soon as possible, establish dates by when they expect to achieve those targets, and determine the quantities of resources necessary to administer the vaccination by those dates. Additionally, DPH should finalize and issue its Public Health and Medical Emergency Powers Guide (Emergency Powers Guide), and revise it to describe to the greatest extent possible the types of actions that LHOs can take within their jurisdictions to prevent or contain the spread of infectious disease.

1. San Diego’s response to the Auditor’s report. The County is sponsoring this bill to address the Auditor’s recommendation under a) above. Additionally, a Memorandum of Agreement was signed by the County Chief Administrative Officer on March 27, 2019 and by the City Chief Operating Officer on March 28, 2019. The two jurisdictions submitted their response to the State Auditor on April 29 indicating that they met the Auditor’s recommendation.
2. DPH Response Plan. DPH published a revised Response Plan on January 9, 2019. Although the CDC did not recognize those experiencing homelessness and/or using illicit drugs as an at-risk group, as a result of California’s outbreak, this group was recommended for vaccination by DPH. The CDC was consulted and supported recommending this group to be added in the at-risk population that are indicated for routine vaccination. The updated Response Plan articulated priority activities by objectives. The objectives include: a) procuring, distributing, and monitoring HAV vaccine to enable LHOs to administer to at-risk populations to halt transmission and prevent future outbreaks; b) establishing streamlined internal and external communication so that partners, the media, and the public receive accurate information about the outbreak and control measures; and, level of risk of HAV infection for different populations.
3. DPH Emergency Powers Guide. The 2019 Emergency Powers Guide identifies the various types of emergencies relevant to the State of California and the powers and responsibilities assigned by statute to various state and local officials during a proclaimed emergency. For example, during a proclaimed local emergency, the LHO does not have the authority to independently issue orders and regulations, and must work with the local governing body to have such orders and regulations issued if needed to protect the public health. However, the LHO may have the authority during the local emergency to independently issue orders related to communicable disease control.

In response to the Auditor’s report, the Emergency Powers Guide specifies that the LHO has the power to take measures as may be necessary to prevent the spread or occurrence of additional cases of communicable disease in his/her jurisdiction. This could include orders for isolation, quarantine or “social distancing.” The exercise of this power does not depend upon a declaration or proclamation of emergency, and continues after a proclamation of emergency, but is limited to the control of communicable disease. Examples of some actions that a LHO could take to contain an infectious disease outbreak include:

• • 1. Engage and involve Behavioral Health Services, Environmental Health, Integrative Services (Housing), Office of Emergency Services, Department of Environmental Health, Emergency Medical Services, and other County departments that contribute to the overall effort to respond;
    2. Enhance surveillance for outbreak-associated cases;
    3. Develop and implement plans to work with partners to ensure targeted populations have access to medications and vaccines needed to contain the outbreak;
    4. Increase sanitation by providing toilets, handwashing facilities, and waste removal at encampments of people who are homeless; expanding hours of public restrooms in parks and other locations;
    5. In the event that an outbreak occurs in the homeless population or other at-risk population such as those using illicit drugs, alert non-medical organizations (board and care homes, food pantries, substance use treatment programs, etc.) that provide services to people experiencing homelessness or using illicit drugs so they recognize symptoms associated with the outbreak, know how to refer persons with symptoms to a health care provider, report suspected cases to the local health departments, practice proper handwashing and hygiene, adequately clean restrooms used by clients and staff, and ensure that anyone serving food (including holiday meals) is aware of the outbreak and any recommended actions;
    6. Alert clinical sites of outbreaks to ensure the reporting of suspected cases to the LHO;
    7. Engage with local correctional facilities as appropriate; and,
    8. Increase awareness among local employers who may have employees at risk of occupational exposure as needed based on the type of outbreak.

1. Related legislation. SB 768 (Hueso) requires the County to operate a three-year pilot program to provide general health care outreach and triage care for hepatitis A for the county’s homeless population, as specified. SB 768 is pending in this Committee.
2. Support. The San Diego County Board of Supervisors writes that following the 2017 outbreak of hepatitis A in the County, findings from various after-action reports identified ambiguity around the roles, responsibilities and authority of the County’s LHO to inform, as well as direct the actions of, other governmental entities within the LHO’s jurisdiction during a local health emergency. This bill addresses this issue and seeks to clarify and strengthen the authority of LHOs as it relates to communicating relevant information and directing action of jurisdictions under the purview of the LHO during a communicable disease outbreak. California Life Sciences Association writes that while California has done a great deal in terms of mandated infectious disease reporting, we can still do more to empower local health authorities to ensure outbreaks in California do not become epidemics. To this end, formalizing the duties of prompt notification by LHOs and facilitating their issuance of directives at the local level are steps in the right direction.
3. Oppose unless amended. A Voice for Choice Advocacy writes that this bill is overly broad and could result in an abuse of power as it gives unilateral authority to the LHO to issue directives to other governmental entities within that jurisdiction to take “any” action the LHO deems necessary to control the spread of the communicable disease or upon imminent and “proximate threat” of a communicable disease outbreak. A Voice for Choice Advocacy requests amendments to ensure the LHO chooses the most effective and least invasive action to respond to a health threat, rather than any action they deem necessary at any time they feel there may be a threat. Additionally, A Voice for Choice Advocacy also requests amendments addresses the fiscal responsibility of the LHO by specifying that the most effective and financially sound, and least invasive, action must be taken. This bill should also make the LHO responsible for post-outbreak identification for future outbreak prevention – so that the lessons and pitfalls learned from one outbreak can be used in the next one.

SUPPORT AND OPPOSITION:

Support: San Diego County Board of Supervisors (sponsor)

California Life Sciences Association

City of San Diego

Oppose: A Voice for Choice Advocacy (unless amended)

Eagle Forum of California

One individual

-- END --

ASSEMBLY THIRD READING

ATR Bill Id:AB 262

Author:(Gloria and Gonzalez)

As Amended Ver:March 27, 2019

Majority vote

SUMMARY:

Requires, during an outbreak of a communicable disease, or upon the imminent and proximate threat of a communicable outbreak or epidemic that threatens the public's health, a local health officer (LHO) to: 1) promptly notify and update the governmental entities within the LHO's jurisdiction about communicable diseases, as specified; and, 2) make relevant information available to governmental entities, including, but not limited to, the locations of concentrations of cases, the number of residents affected, and the measures that the governmental entities should take to assist with outbreak response efforts. Authorizes a LHO to issue orders to other governmental entities to take any action the LHO deems necessary to control the spread of communicable disease.

Major Provisions

COMMENTS:

Hepatitis A virus (HAV) Outbreak in San Diego (SD). In early March 2007, SD's Health and Human Services Agency (HHSA) announced an increase in the number of reported HAV cases. This outbreak was affecting individuals experiencing homelessness and those who use illegal drugs, and the majority of the cases occurred within the city of SD. On March 10, 2017, a health advisory was issued by HHSA to the SD medical community that an outbreak of HAV was occurring among these two at-risk populations. According to this advisory, at that time there were 19 cases of HAV in SD from November 2016 through early March 2017. However, by the end of March 2017, SD's data showed it had identified 42 cases, 33 hospitalizations and one death. At the end of April 2017, SD identified a three-pronged approach to addressing the outbreak: vaccination, sanitation, and education. SD begun administering vaccinations by May 2017 at several locations, including homeless service provider facilities, and mobile vans. SD also deployed foot teams of nurses, public safety officers, and social service providers who located homeless individuals and administered vaccinations in the field. SD also coordinated the distribution of education materials to inform residents about the disease. From the end of March through the end of May 2017, the number of HAV cases more than quadrupled to 180, the number of hospitalizations more than tripled to 120, and the number of deaths increased to four.

According to the Author:

Arguments in Support:

The SD County Board of Supervisors is the sponsor of this bill and states that this bill seeks to clarify the law as it relates to notification and direction given to jurisdictions under the purview of local health officers during a communicable disease outbreak. Following the HAV outbreak in SD, findings from various reports identified ambiguity around the roles, responsibilities, and authority of SD Public Health Officer to inform and direct the actions of other governmental entities within the public health officer’s jurisdiction during a local health emergency.

Arguments in Opposition:

A Voice for Choice Advocacy opposes this bill and states that although it agrees with the intent of this bill to alert the public about communicable disease and ensure it is addressed effectively and quickly, it believes this bill is overly broad and could result in an abuse of power.

FISCAL COMMENTS:

According the Assembly Appropriations Committee, unknown, likely minor potential state-reimbursable costs to share available information with other public entities during an outbreak.

VOTES:

ASM HEALTH: 13-0-2

YES: Wood, Mayes, Aguiar-Curry, Bigelow, Bonta, Burke, Carrillo, Limón, McCarty, Nazarian, Ramos, Chu, Santiago

ABS, ABST OR NV: Flora, Waldron

ASM APPROPRIATIONS: 17-0-1

YES: Gonzalez, Bigelow, Bonta, Brough, Calderon, Carrillo, Chau, Diep, Eggman, Fong, Gabriel, McCarty, Maienschein, Obernolte, Petrie-Norris, Quirk, Robert Rivas

ABS, ABST OR NV: Bloom

UPDATED:

VERSION: March 27, 2019

CONSULTANT: Rosielyn Pulmano / HEALTH / (916) 319-2097 FN: 0000199

Date of Hearing: April 10, 2019

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez, Chair

ABPCA Bill Id:AB 262

Author:(Gloria) – As Amended Ver:March 27, 2019

Urgency: No State Mandated Local Program: Yes Reimbursable: No

SUMMARY:

This bill requires local health officers to notify, update and make specified information available to governmental entities about specified communicable disease outbreaks that may affect them.

It also allows a local health officer to issue orders to other governmental entities to take any action the health officer deems necessary to control the spread of the communicable disease.

FISCAL EFFECT:

Unknown, likely minor potential state-reimbursable costs to share available information with other public entities during an outbreak.

COMMENTS:

1. Purpose. This bill is intended to address shortcomings in the local response to an outbreak of hepatitis A in San Diego County in 2018. Specifically, it implements state auditor recommendations related to the local outbreak response.
2. Background. According to the U.S. Centers for Disease Control and Prevention (CDC), hepatitis A is a highly contagious liver disease that can range in severity from a mild illness lasting a few weeks to a severe illness lasting several months. Hepatitis A is vaccine‑preventable and is transmitted through the ingestion of fecal matter, which can occur when infected individuals touch objects or food that others subsequently touch or ingest.

Local, state and national entities collaborate to control the spread of communicable disease.  State law requires local health officers to take measures necessary to prevent the occurrence or spread of communicable diseases within the officer’s jurisdiction (generally a county). Health officers assert current law already provides authority to issue orders during an outbreak and this bill merely clarifies that authority.

In early March 2017, San Diego County detected and began investigating an increase in the number of hepatitis A cases. On March 10, it issued a health advisory to the San Diego medical community stating that an outbreak of hepatitis A had occurred. The outbreak affected two primary populations: individuals experiencing homelessness and individuals who use illegal drugs. The number of cases continued to climb until September 2017, when the county declared a local health emergency. This coincided with more aggressive local actions to vaccinate at-risk individuals and implement sanitation efforts like hand-washing stations and improved restroom access. These actions are credited with stemming the outbreak.

1. Auditor’s Recommendations. The Bureau of State Audits examined the communicable disease response to the San Diego County hepatitis A outbreak and issued a report in December 2018. While a number of actions were found to be consistent with best practices, the state auditor also issued a number of recommendations. Specifically, the report found, had the county hastened its vaccination efforts, it may have more quickly reduced the risk of the disease’s spread.

The report called on CDPH to further clarify the authority of local health officers by revising its “medical powers guide” by April 30, 2019, to enumerate the types of actions that local health officers can take within their jurisdictions to control infectious disease. CDPH concurs with the recommendation and is in the process of revising the guide.

1. Support and Opposition. This bill is supported by the California Life Sciences Association and the San Diego County Board of Supervisors. A Voice for Choice Advocacy—which advocates for the rights of those who wish to refuse vaccines, among other issues— opposes the bill, expressing concerns about the broad powers granted and potential abuses of power.

Analysis Prepared by: Lisa Murawski / APPR. / (916) 319-2081

Date of Hearing: March 19, 2019

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 262

Author:(Gloria) – As Introduced Ver:January 24, 2019

SUBJECT: Local health officers: communicable diseases.

SUMMARY: Requires a local health officer (LHO) to promptly notify and update the local public entities within their jurisdictions about communicable disease outbreaks and to make relevant information available to the local public entities. Authorizes a LHO to issue directives to other governmental entities to take any action the LHO deems necessary to control the spread of communicable disease. Specifically, this bill:

1. Requires the LHO to do both of the following:
   1. Promptly notify and update the local public entities within the health officer’s jurisdiction about communicable disease outbreaks that may affect them; and,
   2. Make relevant information available to the local public entities, including but not limited to, the locations of the concentration of cases, the number of residents affected, and the measures that the local public entities should take to assist with outbreak response efforts.
2. Authorizes the LHO, if the local health officer knows or has reason to believe that any case of the diseases made reportable by regulation of the Department of Public Health (DPH), or any other contagious, infectious or communicable disease exists, or has recently existed, within the territory under that health officer’s jurisdiction, may issue directives to other governmental entities within that jurisdiction to take any action the health officer deems necessary to control the spread of the communicable disease.

EXISTING LAW:

1. Establishes DPH to protect and improve the health of communities through education, promotion of healthy lifestyles, and research for disease and injury prevention.
   
2. Requires DPH to establish a list of reportable diseases and conditions, and to specify the timeliness requirements related to the reporting of each disease and condition, and the mechanisms required for, and the content to be included in the reporting. Permits the list to include communicable and noncommunicable diseases and may be modified at any time by DPH, after consultation with the California Conference of Local Health Officers.
   
3. Permits DPH to establish and maintain places of quarantine or isolation.
   
4. Authorizes DPH, upon being informed by a health officer of any contagious, infectious, or communicable disease, to take measures as are necessary to ascertain the nature of disease and prevent its spread. Authorizes DPH, if it considers proper, to take possession or control of the body of any living person, or the corpse of any deceased person.
   
5. Provides that each health officer knowing or having reason to believe that any case of the disease made reportable by regulation to DPH, or any other contagious, infections or communicable disease exists, or has recently existed, within the territory of jurisdiction, to take measures as may be necessary to prevent the spread of the disease or occurrence of additional cases.
6. Requires a health officer, in the case of a local epidemic of disease, to report at those times as requested by DPH all facts concerning the disease, and the measures taken to abate and prevent its spread.
   
7. Requires each health officer, whenever required by DPH, to establish and maintain places of quarantine or isolation, as specified.
   
8. Defines a LHO as any county health, city health officers, and district health officers.

FISCAL EFFECT: This bill has not yet been analyzed by a fiscal committee.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, on September 1, 2017, SD of San Diego (SD) declared a public health emergency in response to the Hepatitis A virus (HAV) outbreak. As of April 11, 2018, DPH reported 704 cases, 461 hospitalizations, and 21 deaths related to the HAV outbreak statewide. State intervention became so desperately needed as a result of the HAV outbreak originating in SD that former Governor Brown issued an emergency proclamation on October 13, 2017. Following the containment of the outbreak, the State Auditor found that the City and County of SD could have done more to prevent the spread of the outbreak. This bill makes clear the responsibility of local government and public health officers to protect the public against future communicable disease outbreaks.
2. BACKGROUND. On August 15, 2017, DPH issued an All Facilities Letter (AFL 17-13) detailing that SD and Santa Cruz Counties were experiencing outbreaks of HAV infection among their homeless populations and/or users of illicit drugs. Overall, Santa Cruz County saw 76 confirmed cases of HAV, including one death where HAV was a contributing factor. In SD, when the local emergency ended, there were 583 confirmed cases, 403 hospitalizations, and 20 deaths.
   1. HAV. According to the Centers for Disease Control and Prevention (CDC), HAV is a vaccine-preventable, communicable disease of the liver caused by the HAV. It is usually transmitted person-to-person through the fecal-oral route or consumption of contaminated food or water. Most adults with HAV have symptoms, including fatigue, low appetite, stomach pain, nausea, and jaundice, that usually resolve within two months of infection; most children less than six years of age do not have symptoms or have an unrecognized infection. Antibodies produced in response to HAV infection last for life and protect against reinfection. The best way to prevent HAV infection is to get vaccinated. The vaccine is a two-dose series, with the second dose recommended no sooner than six months after the first dose. According to the CDC, the first dose may be 95% effective, with the second dose nearly 100% effective. Immunity is thought to be lifelong.
   2. HAV Outbreak in SD. In early March 2007, SD’s Health and Human Services Agency (HHSA) announced an increase in the number of reported HAV cases. This outbreak was affecting individuals experiencing homelessness and those who use illegal drugs, and the majority of the cases occurred within the city of SD. On March 10, 2017, a health advisory was issued by HHSA to the SD medical community that an outbreak of HAV was occurring among these two at-risk populations. According to this advisory, at that time there were 19 cases of HAV in SD from November 2016 through early March 2017. However, by the end of March 2017, SD’s data showed it had identified 42 cases, 33 hospitalizations and one death. At the end of April 2017, SD identified a three-pronged approach to addressing the outbreak: vaccination, sanitation, and education. SD begun administering vaccinations by May 2017 at several locations, including homeless service provider facilities, and mobile vans. SD also deployed foot teams of nurses, public safety officers, and social service providers who located homeless individuals and administered vaccinations in the field. SD also coordinated the distribution of education materials to inform residents about the disease. From the end of March through the end of May 2017, the number of HAV cases more than quadrupled to 180, the number of hospitalizations more than tripled to 120, and the number of deaths increased to four.
   3. Health Officer Practice Guide for Communicable Disease Control in California (Practice Guide). This practice guide was created to provide guidance to local health officers in California when responding to bioterrorism, and to actual or suspected cases of naturally-occurring communicable disease. The practice guide includes various topics of general application, including a discussion of the general authority of the health officer constitutional limitations on this authority; enforcement of health officer authority; interjurisdictional coordination and cooperation; and confidentiality of health information.
      
      This bill would permit a LHO to issue directives to other governmental entities within their jurisdiction. According to the practice guide, one of the methods used to control the spread of communicable disease is the issuance of orders by the health officer. These orders are a demand by the health officer to persons or businesses to either do something or refrain from doing something. The authority to enforce health officer orders is derived from the police power of the state, county, and/or city. The practice guide points out that there is no statutorily prescribed procedure for the enforcement of health officer orders – the most common route involve both the civil and criminal court processes.
   4. State Auditor Report. As a result of the HAV outbreak in SD, the Joint Legislative Audit Committee approved an audit regarding the response to the outbreak. On December 20, 2018, the State Auditor submitted its report to the Legislature, which among other findings, state that SD was slow to mitigate the risk that more members of the two at-risk-populations might acquire the highly contagious disease and spread it to others. The report identified several problems with the response to the outbreak. For example, although adequate sanitation is critical to controlling the spread of HAV, neither SD nor the city promptly implemented measures to improve sanitation and hygiene conditions for the at-risk populations in the city. Discussions occurred in June and August 2017 between SD and the city on these sanitation measures but it was not until September 2017 when SD’s health officer issued a directive telling the city it had to take action on the sanitation measure, that any action was taken. According to the report, SD health officer did not issue a directive sooner because she wanted to collaborate with the city instead of mandating its compliance.
      
      Additionally, the report points out that although SD identified vaccination as critical, SD did not consistently set measurable targets and timeframes for administering vaccinations to the at-risk populations early in the response to the outbreak. The report also states that SD did not do enough to inform and involve the city; the city lacked information that would have enabled it to understand the severity of the outbreak; and, the need to implement sanitation measures.
      In the report, the State Auditor made several recommendations, including the following:
      1. The Legislature should clarify existing law to specify that the LHO for each geographic jurisdiction may issue directives to other governmental entities within that jurisdiction to take action, as the officer deems necessary to control the spread of communicable diseases;
      2. The City and County of SD should enter into an agreement to negotiate revisions in their contracts to clarify each entity’s roles and responsibilities over public health matters, and to include city leadership in coordinating response efforts when public health matters, such as disease outbreaks, affect the city’s residents; and,
      3. DPH should amend its HAV Outbreak Response Plan (Response Plan), to recommend that jurisdictions set vaccination targets as soon as possible, establish dates by when they expect to achieve those targets, and determine the quantities of resources necessary to administer the vaccination by those dates. Additionally, DPH should finalize and issue its medical powers guide by April 30, 2019, and revise it to describe to the greatest extent possible the types of actions that LHOs can take within their jurisdictions to prevent or contain the spread of infectious disease
   5. DPH Response to the Audit Report. Consistent with the recommendations of the State Auditor, DPH amended its Response Plan and finalized the Public Health and Medical Emergency Powers guide (guide).
      
      According to the Response Plan, although the CDC did not recognize those experiencing homelessness and/or using illicit drugs as an at-risk group, as a result of the outbreak, this group was recommended for vaccination by DPH, and the CDC was consulted and supported recommending this group to be added in the at-risk population that are indicated for routine vaccination. The updated Response Plan articulated priority activities by objectives. The objectives include: i) procuring, distributing, and monitoring HAV vaccine to enable local health directors to administer to at-risk populations to halt transmission and prevent future outbreaks; ii) establish streamlined internal and external communication so that partners, the media, and the public receive accurate information about the outbreak, control measures; and iii) level of risk of HAV infection for different populations.
      
      The state audit also calls on DPH to issue the guide and to describe the types of actions that LHOs can take to prevent or contain the spread of infectious disease. The draft guide released by DPH to this Committee includes an extensive discussion and analysis of the various types of emergencies relevant to the State of California; and the powers and responsibilities assigned by statute to various state and local officials during a proclaimed emergency. For example, during a proclaimed emergency, the LHO does not have the authority to independently issue orders and regulations, and must work with the local governing body to have such orders and regulations issued if needed to protect the public health. However, the LHO may have the authority during the local emergency to independently issue orders related to communicable disease control.
      
      In response to the audit, the guide specifies that the LHO has the power to take measures as may be necessary to prevent the spread or occurrence of additional cases of communicable disease in his/her jurisdiction. This could include orders for isolation, quarantine or “social distancing.” The exercise of this power does not depend upon a declaration or proclamation of emergency, and continues after a proclamation of emergency, but is limited to the control of communicable disease.
      
      Examples of some actions that a LHO could take to contain an infectious disease outbreak include:
      1. Engage and involve Behavioral Health Services, Environmental Health, Integrative Services (Housing), Office of Emergency Services, Department of Environmental Health, Emergency Medical Services, and other County departments that contribute to the overall effort to respond;
      2. Enhance surveillance for outbreak-associated cases;
      3. Develop and implement plans to work with partners to ensure targeted populations have access to medications and vaccines needed to contain the outbreak;
      4. Increase sanitation by providing toilets, handwashing facilities, and waste removal at encampments of people who are homeless; expanding hours of public restrooms in parks and other locations; and,
      5. In the event that an outbreak occurs in the homeless population or other at-risk population such as those using illicit drugs, alert non-medical organizations (board and care homes, food pantries, substance use treatment programs, etc.) that provide services to people experiencing homelessness or using illicit drugs so they recognize symptoms associated with the outbreak, know how to refer persons with symptoms to a health care provider, report suspected cases to the local health departments, practice proper handwashing and hygiene, adequately clean restrooms used by clients and staff, and ensure that anyone serving food (including holiday meals) is aware of the outbreak and any recommended actions;
      6. Alert clinical sites of outbreaks to ensure the reporting of suspected cases to the local health department;
      7. Engage with local correctional facilities as appropriate; and,
      8. Increase awareness among local employers who may have employees at risk of occupational exposure as needed based on the type of outbreak.
3. CONCERNS. The Health Officers Association of California expresses the following concerns: the notification to local public entities should be limited to cities; the notification requirement be limited to confirmed outbreaks of diseases reportable under Title 17 of the California Code of Regulations; and, that the city can take action to affect; and the bill should specify that any notification should comply with state and federal laws protecting privacy.
4. SUPPORT. The SD County Board of Supervisors is the sponsor of this bill and states that this bill seeks to clarify the law as it relates to notification and direction given to jurisdictions under the purview of local health officers during a communicable disease outbreak. Following the HAV outbreak in SD, findings from various reports identified ambiguity around the roles, responsibilities, and authority of SD Public Health Officer to inform and direct the actions of other governmental entities within the public health officer’s jurisdiction during a local health emergency.
   
5. OPPOSITION. A Voice for Choice Advocacy opposes this bill and states that although it agrees with the intent of this bill to alert the public about communicable disease and ensure it is addressed effectively and quickly, it believes this bill is overly broad and could result in an abuse of power.
6. SUGGESTED AMENDMENTS.
   1. To clarify that this bill applies during an outbreak of communicable disease, Committee staff recommends adding the following on page 3, line 3:
      
      “During an outbreak of communicable disease, or upon the imminent and proximate threat of communicable disease outbreak or epidemic that threatens the public’s health,”
   2. The author proposes to clarify that this bill applies to governmental entities instead of local public entities; and the notification and update applies to communicable diseases listed in the California Code of Regulations.
   3. Delete reference to “directives” and replace with “order,” consistent with the term used in the Practice Guide.
7. PRIVACY CONCERNS. As drafted, this bill requires a LHO to make relevant information available to local public entities, including, but not limited to, the locations of concentrations of cases, the number of residents affected, and the measures that the local public entities should take to assist with outbreak response efforts. Recognizing the complexity of striking a balance between privacy concerns and public protection, the author has committed to continue working with stakeholders and Committee staff on the privacy protection provisions.

REGISTERED SUPPORT / OPPOSITION:

Support

California Life Sciences Association

SD County Board of Supervisors

Opposition

A Voice for Choice Advocacy

Analysis Prepared by: Rosielyn Pulmano / HEALTH / (916) 319-2097