Health (Protection) Amendment Bill

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13 February 2015

Health (Protection) Amendment Bill

Thank you for the opportunity for the Auckland Regional Public Health Service (ARPHS) to provide a submission on the proposed Health (Protection) Amendment Bill.

The following submission represents the views of the ARPHS and does not necessarily reflect the views of the three District Health Boards it serves. Please refer to Appendix 2 for more information on ARPHS.

The primary contact point for this submission is: Andrew Phillipps

Policy Analyst – Environmental Health Auckland Regional Public Health Service Private Bag 92 605 Symonds Street Auckland 1150 09 623 4600 ext. 27105 aphillipps@adhb.govt.nz Yours sincerely,

Jane McEntee Dr. Cathy Pikholz

General Manager Medical Officer of Health

Auckland Regional Public Health Service Auckland Regional Public Health Service Auckland Regional Public Health Service

Cornwall Complex Floor 2, Building 15 Greenlane Clinical Centre Private Bag 92 605 Symonds Street Auckland 1150 New Zealand Telephone: 09-623 4600 Facsimile: 09-623 4633

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2 General support

1. ARPHS generally supports the proposed amendments to the Health Act 1956 (the Act) through the introduction of the Health (Protection) Amendment Bill (the Bill). In particular ARPHS supports incorporation of tuberculosis into the updated legislation, the notification of HIV (in addition to AIDS), change of status of other sexually transmitted infections, and regulation and specification of control measures for notifiable infectious diseases.

2. However, we have identified a number of issues that, in our opinion, warrant further consideration and/or clarification. In particular, this submission considers the scope of the Bill, as well as matters relating to ‘identifying information’.

3. The table in Appendix 1 suggests some minor amendments not discussed in the body of this document.

Repeal section 79 of the Act and amendments to HIND Regulations

4. Section 79 of the Act needs to be repealed in light of the proposed insertion of ‘Part 3A – Management of infectious diseases’, which effectively replaces the existing provisions in section 79 relating to a medical officer of health (or any health protection officer) making an order to isolate any person deemed likely to cause the spread of any infectious disease. 5. The Health (Infectious and Notifiable Diseases) Regulations 1966 will also need to be

amended, including Regulation 3 (which makes direct reference to section 79 of the principal act) and Part 3 (Regulations 7-17).

6. BCG vaccination and gazetting of BCG vaccinators is currently covered in the Tuberculosis Regulations 1951, which the Bill proposes to revoke (along with the repeal of the Tuberculosis Act 1948). Regulation of BCG vaccination practices is still required, and therefore relevant provisions for BCG vaccination and gazetting of BCG vaccinators need to be catered for elsewhere. We believe the updated HIND Regulations would be an appropriate place for these provisions. Irrespective of where the BCG provisions may sit, any regulation addressing these matters should relate to the following Ministry of Health documents:

 Technical Guidelines for Tuberculin Skin Testing and BCG Vaccination, and;

 Protocol for Approval as a Gazetted BCG Vaccinator in New Zealand.

Notification (amendments to section 74): Identifying and anonymised information

7. The amended section 74 (3A) requires that a medical practitioner must not disclose identifying information for notifiable diseases contained in the new section C of Part 1 of Schedule 1, unless the identifying information is necessary to respond effectively to a public health risk (section 74 (3B)). Section 74 (3C) then outlines what type of information is considered ‘identifying information’.

8. Disease notification is a critical part of public health surveillance. The information provided needs to be sufficient to enable different types of public health interventions while remaining within privacy and human rights requirements.

9. In the case of the infections specified in the new Schedule 1 Part 1 Section C (AIDS, gonorrhoea, HIV infection and syphilis) notification information can be used at the national and regional level to monitor the incidence and prevalence of these diseases, detect changing patterns of infection, and assist planning and implementation of prevention and intervention programmes and clinical services. More detailed information would also be needed to investigate and control outbreaks or address public health and clinical problems such as antibiotic resistance.

10. It is important that any information defined as ‘identifying information’ under section 74 (3C) is carefully considered as this will impact on the effectiveness of public health surveillance. In

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3 this regard, we do not consider ‘sex’ to be identifiable information as stipulated by section 74 (3C) (a) (ii).

11. A form of unique identification is necessary if there is a need to differentiate between repeat laboratory results from a person, repeated infection of a person and new infection for a person with similar characteristics to another person previously notified.

12. Currently, information for AIDS notification requires initials, sex, date of birth, district of usual residence, ethnicity, clinical information, mode of infection, laboratory results and current status1. The sex and date of birth would not be able to be disclosed under the proposed amendment, and whether the person’s initials would be able to be included is not clear. This would make AIDS surveillance and control more difficult.

13. We believe it would be appropriate for the Bill to contain a provision that specifies what information a medical practitioner can provide for anonymised notifications.

14. We note that the existing Form 1A in Schedule 1 of Health (Infectious and Notifiable Diseases) Regulations 1966 could help frame this proposed provision. To assist medical practitioners and public health units, greater clarification is required on this matter.

15. ARPHS supports the provisions for the new section 74 (3B) in the Bill for medical officers of health to request further identifying information if control measures and contact tracing are required.

Sending a copy of every direction to the Director General

16. We note a standard clause contained within proposed sections 92G to 92J requires a medical officer of health to send the Director General a copy of every direction.

17. ARPHS does not consider that sending copies of all directions to the Director General is warranted. If these directions become used in a similar way to current practice, many directions will be routine and relatively minor, for example requiring a person to be away from work or school for a short period. These may sometimes be issued, for example, to support parents’ request for sick leave to look after children excluded from school or for insurance or regulatory purposes. Notification to the Director General would also involve disclosure of identifying and clinical information. Instead we support sending copies to the Director General where there is high public health risk or on request, with regular reporting of the number and nature of the directions issued.

18. ARPHS recommends deleting sections 92G (8), 92H (8) and 92I (8) and insert either a new subclause in 92M or a separate clause:

“The medical officer of health must send to the Director-General (i) a regular report on the number and nature of directions given under section 92G, 92H or 92I; (ii) a copy of the direction where the medical officer of health considers the public health risk to be high; and (iii) a copy of the direction when requested by the Director General.”

19. The provisions for sending copies to the Director General of directions for closure of educational institutions (92J (4)) and any urgent public health orders (92Z (5)) should remain.

Written directions and notices to be served on individual

20. ARPHS seeks further clarification around the provisions contained in section 92K. In particular, we request clarity around ‘how’ a written direction or notice may be served on an individual, and how service will need to be effected (i.e. what measures will satisfy compliance with these provisions).

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4 21. Ideally, serving in person is preferred because you can say with certainty that the individual received the notice, and understood that they had to read it and follow the directions. However, serving in person may not always be practical, especially when the individual may choose to avoid service.

22. We consider service can be effected in other ways, when serving in person is not practical, or when a person is attempting to avoid service. For example, a notice may be served via post, or by leaving it with a family member of the individual.

23. We recognise that this matter could be addressed at a later date when the Health (Infectious and Notifiable Diseases) Regulations 1966 are amended to align with the proposed changes to the Act.

Contact Tracing

24. Both sections 92ZW and 92ZX consider the ability, willingness and appropriateness of an individual with an infectious disease to undertake the contact tracing, as requested by the contact tracer. We believe there needs to be clear guidance around this process to ensure an acceptable standard of contact tracing occurs, regardless of who undertakes it. Again, we recognise that this could be addressed via the updated regulation.

Management of other notifiable diseases

25. The explanatory note provided with the Bill refers to an intention to protect the public from risks associated with infectious diseases, rather than all notifiable diseases. ARPHS understands the intention of limiting the scope of the Bill. However, we believe there is merit in managing the public health risks associated with several of the non-infectious notifiable diseases listed in Schedule 2 Section B in a similar manner to managing infectious notifiable diseases. For instance, there are some notifiable diseases that are non-infectious where ‘contact tracing’ is still required to identify others who may have been exposed to the disease causing agent. These situations were addressed to some extent in the Public Health Bill, which was reported back to the House in 2008.

26. The diseases of interest are (a) lead absorption; and (b) poisoning arising from chemical contamination of the environment (Schedule 2, Section B) 2.

27. Some aspects of the investigation and management of lead and environmental poisoning can be covered under the nuisance provisions in the Health Act (s. 29-35), the Resource Management Act and Hazardous Substance and New Organisms Act. However these provisions do not directly cover the assessment of human health or reduction of health risk. 28. The following examples illustrate this point further:

Contact tracing is still necessary when individuals are exposed to or come in contact with a common environmental contamination event, as the majority of such individuals (other than an individual who may have directly caused the contamination and has been diagnosed following medical examination and testing) will not be aware of the risk to their health. Contacts may include vulnerable members of the population such as children and women of childbearing age. Treatment is often available that can mitigate adverse effects on contacts. Case histories of contacts who have been poisoned may reveal further sources of contamination that will need to be remediated to mitigate the risk to other individuals.

2 The other listed conditions are several nematode (tapeworm) infections which are contracted

through eating undercooked meat but are not transmitted directly between people, and

decompression sickness. The proposed methods are not relevant. Follow-up for these conditions is undertaken by the Ministry for Primary Industries.

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Giving directions to when an individual poses a public health risk – people may be engaged in activities that spread an environmental contaminant, causing exposure to others using that environment.

Direction for medical examination – when an individual has been exposed to an environmental contaminant, there may be a need to direct such contacts to receive testing, especially when those exposed are children, infants, or women of child bearing age.

Medical examination orders - The examination provisions of the bill can also relate to non-infectious notifiable diseases. An appropriate circumstance where such examination may be justified is where an activity has been undertaken that is likely to have resulted in environmental contamination of a residence or public area, and where environmental testing is difficult, or impossible (e.g. due to environmental contamination no longer being present or being difficult to sufficiently locate), and the only indicator of environmental contamination will be poisoning of individuals exposed to the contamination as determined by case history, medical examination and testing. The finding of poisoning in an individual then allows further case finding of individuals similarly exposed to proceed. Sometimes the person responsible for the contamination is the individual tested for the contaminant and notified to the medical officer of health, and may be unwilling for other members of his or her household, who are also likely to have been exposed, to be examined or tested by referral to a physician – members of the household are likely to include children and women of childbearing age.

29. We recognise the introduction of new provisions to manage the risks associated with non-infectious notifiable diseases may require a rethink of how the Bill is structured. However, we believe the introduction of this Bill provides a good opportunity to ensure all notifiable diseases are managed in an appropriate manner. A number of similar provisions were included in the Public Health Bill, reported back to the House in 2008.

30. ARPHS recommends insertion of a new Part 3B – “Other Notifiable Diseases”, which includes appropriate provisions similar to those in the new Part 3A.

Part 5 - Artificial UV Tanning Services

31. ARPHS understands Palmerston North City Council’s (the Council) submission to the Health Select Committee is recommending that the Bill prohibit commercial artificial UV tanning services altogether. ARPHS fully supports the Council’s position on this particular point, as the risk to health benefits from UV exposure is significant.

32. Nonetheless, we are pleased to see that the proposed Bill bans persons under the age of 18 from accessing artificial UV tanning services.

33. To ensure compliance with this provision, we believe the Bill should also direct all local councils to undertake an auditing and licensing role, which includes:

 Keeping an up-to-date register of solaria in their region.

 Auditing of premises providing artificial UV tanning services, and undertaking 12 monthly visits.

 Renewal and issuing of licences.

34. The above measures were recently adopted by Auckland Council with the introduction of its Health and Hygiene Bylaw and Code of Practice 2013. In accordance with the Bylaw, Auckland Council requires all commercial solaria businesses in the Auckland region to be licensed and comply with a new code of practice.

35. We support Auckland Council’s approach, and believe the Bill could ensure a nationally consistent approach for managing artificial UV tanning services, by placing the onus on local authorities to enforce proposed section 114.

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6 Conclusion

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Appendix 1

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Part 1 – Infectious diseases (Notification)

2 (1) Interpretation (i.e. definitions)

health provider means a person or an organisation that provides, or arranges the provision of, personal health services or public health services

The terminology is inconsistent with the NZ Public Health and Disability Act, which defines “health service”. More appropriate term is “health service provider”

Amend to read “health service provider”. This also applies to the following:

 92G (4) (a)  92H (4) (a)  92I (2)  92I (3) (a)  92U (1) (f)  92U (1) (g) medical examination means the physical

examination or testing of a person for the purpose of determining whether the person has or is likely to have an infectious disease, and includes—

(a) the taking of a sample of tissue, blood, urine, or other bodily material for medical testing; and

(b) any diagnostic tests required to detect the presence of an infectious disease in a person

The application of medical examinations under this Bill should acknowledge that immunological testing for infectious

disease may be necessary to ascertain an individual’s or contact’s risk of developing an infectious disease. This may impact on how an individual or contact is managed from a public health perspective. Testing can be undertaken to exclude disease, identify immunity, or differentiate between acute and chronic infection.

Amend subclause (b) to read:

“(b) any diagnostic tests required to detect the presence or immunity to an infectious disease”.

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has an infectious disease includes an

individual who harbours the disease, even if the individual does not exhibit any of the symptoms of the disease.

individual who harbours the disease is infected or colonised by or is a carrier of an organism capable of causing the disease even if …

PART 3A – Management of infectious diseases (new section inserted)

Subpart 2 – Directions

92G Medical officer of health may give directions to individual posing public health risk (4) The medical officer of health may direct the individual to—

(a) participate in any of the following that are conducted by a health provider:

(i) counselling: (ii) education:

(iii) other activities related to the infectious disease:

b) refrain from carrying out specified activities (for example, undertaking employment, using public trans- port, or travelling within and outside New Zealand) either absolutely or unless stated conditions are observed:

92G (4) (b): Minor amendment suggested. specified activities (for example including but not limited to, undertaking employment…

92I Direction for medical examination

(7) Any medical examination an individual is directed to undergo must be—

See comment above regarding immunological testing for individuals and contacts.

Amend 92I (7) (a) to read: “…the infectious disease and or establishing

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(a) in accordance with current best

practice in diagnosing the infectious disease; and

(b) the least invasive type of examination that is necessary to establish whether the individual has the infectious disease.

immunity to the infectious disease; and

Amend 92I (7) (b) to read: “…whether the individual has the infectious disease

or immunity to the infectious disease.

General provisions concerning directions and notices 92K Written directions and notices to be served

on individual

(1) A direction or notice under this Part must be in writing and must be served on the individual to whom it is given.

(2) If the person to whom the direction or notice relates is a minor or otherwise lacks legal capacity, a medical officer of health must serve the direction or notice on the parent, guardian, or other person having the care of the person to whom the direction or notice relates.

Delete “a medical officer of health” from clause 92K (2), and rephrase “the direction or notice must be served on the parent, guardian…”

Subpart 3 - Orders

Medical examination orders and orders concerning contacts 92ZB Medical examination orders

(5) If the court makes a medical examination order under this section, any medical

examination an individual is directed to

See comment above regarding immunological testing for individuals and contacts.

Amend 92ZB (5) (a) to read: “…the infectious disease and or establishing

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undergo must be—

(a) in accordance with current best practice in diagnosing the infectious disease; and

(b) the least invasive type of examination that is necessary to establish whether the individual has the infectious disease.

immunity to the infectious disease; and

Amend 92ZB (5) (b) to read: “…whether the individual has the infectious disease

or immunity to the infectious disease. Subpart 5 – Contact tracing

92ZS What contact tracing involves

Contact tracing, in respect of an individual with an infectious disease, involves—

(a) ascertaining the identity of each of the individual’s contacts; and

(b) talking to each contact, so far as this is practicable and appropriate; and

(c) ascertaining the circumstances in which the infectious disease may have been

transmitted to or by the contact; and (d) providing information and advice to the contact about the risks that the contact faces because of his or her exposure to the infectious disease, including, where appropriate, advice about—

(i) medical examinations for the infectious disease;

(b) Contact tracing may involve communicating with individuals in a variety of ways (i.e. email).

(b) talking to

communicating with each contact, so far as this is practicable and

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(ii) the risk that the contact may have

transmitted the infectious disease to others; and

(iii) the risk that the contact may pose to others; and

(iv) appropriate exclusion, treatment, and prophylaxis; and

(e) obtaining information about the contacts of that contact, including information required under section 92ZV in relation to those other contacts.

92ZT Who may be contact tracer

For the purposes of this Part, in any case involving proposed or actual contact tracing in respect of an individual, the contact tracer may be a—

(a) medical officer of health: (b) health protection officer:

(c) suitably qualified person nominated to undertake contact tracing by a district health board or medical officer of health.

Minor amendment: Although subclause (c) could cater for nurses with training in contact tracing, ARPHS sees merit in specifically identifying registered nurses as potential contact tracers.

“(c) registered nurse nominated by the District Health Board or medical officer of health.”

(d) suitably qualified person nominated…

92ZV

Duty of individual with infectious disease to provide information about contacts

(1) If the contact tracer has, under section 92ZU, formed the view that contact tracing in respect of an individual with an infectious disease should be undertaken, the contact

The use of the verb ‘direct’ should be applied carefully throughout the Bill due to the potential for confusion with issuing directions.

We recommend the use of the word ‘instruct’ as a replacement.

Amend 92ZV to read: Duty of individual with infectious disease to provide information about contacts

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tracer may direct the individual to give the

contact tracer information about the

circumstances in which the infectious disease may have been transmitted to, or by, the individual.

(2) Before directing an individual under subsection (1), the contact tracer must inform the individual of the reasons for the direction. (3) An individual with an infectious disease must, if directed by the contact tracer, provide information about—

(a) those people with whom he or she is, and has been, in contact:

(b) the circumstances in which he or she believes he or she contracted, or may have transmitted, the infectious disease.

(4) For the purposes of subsection (3), the information the individual with an infectious disease may be required to provide about each person with whom he or she has been in contact includes—

(a) the name of each contact: (b) the age of each contact: (c) the sex of each contact:

(d) the address and other contact details of each contact:

(e) any other information required by

(1) If the contact tracer has, under section 92ZU, formed the view that contact tracing in respect of an individual with an infectious disease should be undertaken, the contact tracer may direct instruct

the individual to give the contact tracer information about the circumstances in which the infectious disease may have been transmitted to, or by, the individual.

(2) Before directing

instructing an individual under subsection (1), the contact tracer must inform the individual of the reasons for the direction. (3) An individual with an infectious disease must, if directed instructed by the contact tracer, provide information about— (a) those people with whom he or she is, and has

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regulations made under this Act. been, in contact:

(b) the circumstances in which he or she believes he or she contracted, or may have transmitted, the infectious disease.

(4) For the purposes of subsection (3), the

information the individual with an infectious disease may be required to provide about each person with whom he or she has been in contact includes— (a) the name of each contact:

(b) the age of each contact:

(c) the sex of each contact:

(d) the address and other contact details of each contact:

(e) any other information required by regulations made under this Act.

92ZW

Consideration as to whether contact tracing

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(1) Before requiring information from an

individual under section 92ZV, the contact tracer must consider whether the information is necessary, taking into account—

(a) the seriousness of the public health risk posed by the individual; and

(b) the ability and willingness of the individual to undertake the contact tracing. (2) If the contact tracer considers that it would be appropriate for the individual to undertake the contact tracing, the contact tracer must ask the individual to undertake the contact tracing, to the extent of the individual’s ability, and to report back to the contact tracer by a time specified by the contact tracer.

Minor amendment suggested. Contact tracing may either involve (i) asking the affected person to identify and give information to their contacts, or (ii) the affected person informing the contact tracer of their contacts, and the contact tracer then contacting and informing the person. Both need to be allowable. Recommend changing term “undertake” to “participate in”

(1)(b) and (2): “the individual to undertake participate in

the contact tracing…

92ZY Contact tracer may require certain persons to provide information

(2) The persons are—

(a) the employer of the individual: (b) an educational institution attended by the individual:

(c) any business or other organisation that the individual has dealt with.

The individual with the infectious disease may not know the contact details of the contact. Therefore this information may need to be obtained from a third party associated with the contact, for example, an employer.

Amend 92ZY (2) to read: (2) The persons are— (a) the employer of the individual or the contact:

(b) an educational institution attended by the individual or the contact: (c) any business or other organisation that the individual or the contact

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Rationale for addition: The proposed provisions in 92ZY (2) do not cover social and casual events where lists of contacts may need to be obtained.

Suggested addition to 92ZY (2):

(d) the organiser of any event attended by the individual or contact

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Appendix 2 - Auckland Regional Public Health Service

Auckland Regional Public Health Service (ARPHS) provides public health services for the three district health boards (DHBs) in the Auckland region (Auckland, Counties Manukau and Waitemata District Health Boards), with the primary governance mechanism for the Service resting with Auckland District Health Board.

ARPHS has a statutory obligation under the New Zealand Public Health and Disability Act 2000 to improve, promote and protect the health of people and communities in the Auckland region. The Medical Officer of Health has an enforcement and regulatory role under the Health Act 1956 and other legislative designations to protect the health of the community.

ARPHS’ primary role is to improve population health. It actively seeks to influence any initiatives or proposals that may affect population health in the Auckland region to maximise their positive impact and minimise possible negative effects on population health.

The Auckland region faces a number of public health challenges through changing demographics, increasingly diverse communities, increasing incidence of lifestyle-related health conditions such as obesity and type 2 diabetes, outstanding infrastructure needs, the balancing of transport needs, and the reconciliation of urban design and urban intensification issues.

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