MINUTES OF THE SENATE COMMITTEE ON HUMAN RESOURCES AND FACILITIES Sixty-eighth Session January 25, 1995 The Senate Committee on Human Resources and Facilities was called to order by Chairman Raymond D. Rawson, at 1:45 p.m., on Wednesday, January 25, 1995, in Room 226 of the Legislative Building, Carson City, Nevada. Exhibit A is the Agenda. Exhibit B is the Attendance Roster. COMMITTEE MEMBERS PRESENT: Senator Raymond D. Rawson, Chairman Senator Sue Lowden, Vice Chairman Senator Maurice Washington Senator Kathy M. Augustine Senator Joseph M. Neal, Jr. Senator Bob Coffin Senator Bernice Mathews GUEST LEGISLATORS PRESENT: Senator Ernest E. Adler STAFF MEMBERS PRESENT: Kerry Carroll Davis, Senior Research Analyst Pepper Sturm, Chief Principal Research Analyst, Legislative Counsel Bureau Mary Gavin, Committee Secretary Judi Bishop, Primary Secretary to Senator Rawson OTHERS PRESENT: Rick Millsap, President, Nevada State Education Association Mary Peterson, Superintendent of Public Instruction, State of Nevada Frank South, Director, State of Nevada, Department of Education, Elementary and Secondary Education Branch Debbie Cahill, Assistant Executive Director, Legislative & Legal Affairs, Nevada State Education Association Ray Bacon, Executive Director, Nevada Manufacturers Association Henry Etchemendy, Executive Director, Nevada Association of School Boards Keith Rheault, Deputy Superintendent, Department of Education David B. Nelson, Manager, Nevada State Immunization Program, Health Division, Department of Human Resources David B. Rowles, Director of Administration, Clark County Health District Lezlie Porter, Concerned Citizen Steven E. Kutz, R.N., CHN, Immunization Coordinator, Division of Community & Clinical Health Services, District Health Department, Washoe County Carla Bennett, Concerned Citizen Lucille Lusk, Legislative Liaison, Nevada Concerned Citizens Juanita Cox, Chairman, People Organized for the Next Generation Janine Hansen, State President, Nevada Eagle Forum Keith W. Macdonald, Executive Secretary, State Board of Pharmacy, State of Nevada Frank Adams, Deputy Chief, Division of Investigation, State of Nevada Chairman Rawson opened the hearing on Senate Bill (S.B.) 33. SENATE BILL 33: Requires all public schools in this state to be accredited. Rick Millsap, President, Nevada State Education Association, testified in support of S.B. 33 from prepared text (Exhibit C). Mr. Millsap addressed the major concerns of the Nevada State Education Association regarding accreditation. The first point was the phase-in period for this program, the general consensus being that it should be 5 years or more. The second concern was the bill, as written, requires accreditation results be published in newspapers. The association feels it would be easier to publish results in the annual accountability reports already required from school districts. The last point suggested the committee consider some level of funding for accreditation, which Mr. Millsap indicated would be nominal. Senator Lowden recommended the state look at a 5- to 8-year phase-in period. Senator Augustine requested clarification of the publication requirements. There were some questions from committee members regarding cost. The chairman suggested these be deferred until figures are presented. Pepper Sturm, Chief Principal Research Analyst, Legislative Council Bureau, then made a presentation to the committee (Exhibit D) regarding S.B. 33, which again addressed many of the committee's previous questions to Mr. Millsap regarding the process of accreditation. He set forth the systems for accreditation being used in the western states and the advantages of establishing accreditation requirements. Senator Mathews asked how they arrived at the year 1997. She felt it was a very ambitious program to be accomplished in such a short time and have everyone on- line. Mr. Sturm stated he did not believe the committee made a commitment. The chairman pointed out section 7 on page 2 of S.B. 33 states the initial inspection by the State Board of Education of all public schools in this state, and the initial determinations concerning the accreditation of those schools, as required by section 3 of this act, must be completed not later than July 1, 1997. He felt they had given themselves some room by simply saying the initial inspection must be completed by 1997. Mary Peterson, Superintendent of Public Instruction, introduced Frank South, Director, Elementary and Secondary Education, Department of Education, and also a commissioner for the Northwest Accrediting Association, who was with her to answer any questions the committee might have about the accrediting process. Ms. Peterson advised the committee that the Department of Education is not opposed to the accreditation concept as written in S.B. 33, but because of costs and lack of time for implementation, she testified in opposition from prepared text (Exhibit E). The chairman asked Ms. Peterson what the effect would be on the fiscal impact if the time line were extended from 2 years to a 5- or 10-year time line. Ms. Peterson felt sure this would reduce the fiscal impact significantly from approximately $600,000 to $250,000 or $300,000. Chairman Rawson asked Mr. South how he was selected as a commissioner. Mr. South advised that because the commission requires someone from the Department of Education, he was appointed directly by the superintendent. The chairman then asked Mr. South if his position as a commissioner for the Northwest Accrediting Association is paid through the State Department of Education or if he is paid as a commissioner. Mr. South replied that the Northwest Accrediting Association has four commissioners in the State of Nevada who serve on a voluntary basis without pay. The chairman asked if there was a feeling as to whether or not Nevada should have a dual system or a single system. Mr. South said this has not been discussed by the commissioner's group. He personally felt the dual system would probably be best because it gives both the national and regional link-up, as well as the state system. The state could have stricter requirements than national or regional requirements. In response to Senator Washington's question regarding the standards used, Mr. South advised these are developed by the commissioners from all states, and Nevada does have a definite input in those standards. The commissioners are currently working with the full association to move from a more number-oriented accreditation process to one that is focused more on the school improvement model. Chairman Rawson inquired further as to how schools are currently evaluated. Mr. South advised the annual accountability report is in place, is mandatory and is a very effective way of taking a look at what is happening in the schools. This report provides information, not only to the state board, but to the district officials, on where their schools are, and districts are using such information to provide some direction to schools where they would like to see some improvement. Senator Augustine asked how many states are currently accredited. Mr. South replied he did not know for sure, but would get that information for her. There being no further testimony either for or against S.B. 33, the chairman asked staff to give a fiscal note on this bill before action is taken. He further requested note be taken of the two or three items in question; that is, phase-in time, cost and publication, so they can be dealt with in the work session. The hearing on S.B. 33 was then closed, and Chairman Rawson opened the hearing on Senate Bill (S.B.) 32. SENATE BILL 32: Creates council for collaborative preparation of teachers. Mr. Sturm presented a summary of the history and background of this bill (Exhibit F). Mr. Sturm also submitted Exhibit G entitled "A Shared Vision: Policy Recommendation Linking Teacher Education to School Reform" by Calvin M. Frazier, Associate Director and Professor, School of Education, University of Denver. Debbie Cahill, Assistant Executive Director, Legislative & Legal Affairs, Nevada State Education Association (NSEA), said NSEA had a number of concerns, but given Mr. Sturms' explanation of the bill and the effort to coordinate policies, NSEA would be very supportive and happy to be a part of this council. The first concern is fiscal, and NSEA would like to see what the impact would be and to ascertain if this is to be an unfunded mandate. The bill does specify that the members of the council would be entitled to travel expenses. Mrs. Cahill inquired if there will be money available in the department's budget and, if not, could it be funded. NSEA would not want this to be put into place and then not be able to function. Also, since it is a collaborative effort, NSEA is concerned about the structure of the council of four administrators from the public schools, three from the university and community college system and one teacher. Given that in section 5 of the bill it would say that the council could establish policy, then certainly if it is a collaborative effort, NSEA would like to have those numbers changed to three administrators from the public schools, three from the university system and three recommended by NSEA. If that number basically keeps the size to the same number, the committee could also say that the council number could be reduced by establishing two of each of those entities. If the committee did not want to change the structure, then she recommended the word "establishing" in line 11 on page 2 of S.B. 32 be changed to "coordinate." This does seem to give them some statutory authority to establish policy, when technically the concern was to be able to coordinate policies against already statutorily created entities that also have the authority to create regulations. Ms. Cahill said NSEA feels the bill needs some work. If there is any desire to create this council, NSEA would certainly like to be involved in that entity. Chairman Rawson complimented Ms. Cahill on being very reserved as she dealt with the issue of the makeup of the council. The first thing that caught his attention was if this is a collaborative preparation of teachers, should there not be more teachers on the council? Ray Bacon, Executive Director, Nevada Manufacturers Association (NMA) appeared in opposition to this bill, stating that he had been involved with the K-16 councils in Washoe County and the Carson City area. They have been very successful. He felt part of the reason for this is that employers and community members have been involved in them. Mr. Bacon advised that if it is to be a collaborative effort, the process needs some input from the customers, and those customers are typically the employers in this state. He stated if something like this is going to be done, there probably should be consideration for the employers or community members that have been involved. Mr. Bacon said he considered the next issue to be very touchy. Someone from the university will take exception to it. Sierra College at Incline Village is now certifying certain teachers. Some of the comments he has heard from at least one principal in the state is they actually go into the classroom better prepared than some of the people out of the university system. The NMA feels if this is going be a collaborative effort, they should be included. Chairman Rawson asked if he meant they should not be included by name so much, but private schools should be allowed into this program? Mr. Bacon agreed. Henry Etchemendy, Executive Director, Nevada Association of School Boards, next appeared in favor of S.B. 32. He agreed there is a concern with the makeup of council, should this bill be processed, adopted and enacted. He directed the attention of the committee to page 1, lines 7 through 11, with respect to the four administrators who would be appointed to this council. It states that at least one administrator would be from a school within a county with a population of 100,000 or more. That would mean the combined Washoe and Clark Counties would have anywhere from one to three administrators on the council. Also, referring to line 10, at least one administrator from a school within a county with a population of less than 35,000 could have from one to three. This totally disenfranchises one school district in the state, and that is Carson City, which is the sole county with a population of between 35,000 and 100,000. Mr. Etchemendy further stated he thinks a more appropriate representation here might be two administrators from counties with a population in excess of 100,000, and two administrators from counties of less than 100,000. Chairman Rawson asked Mr. Etchemendy if there was money found to put this into effect? Is it superfluous, or would it be beneficial? Mr. Etchemendy responded he really did not think it was 100 percent necessary. He stated it would not hurt anything, but there is a professional standards commission; the colleges are working together right now, and they have representation on the standards commission. He said he did not know that it is really necessary. There are other things that are needed more. Keith Rheault, Deputy Superintendent, Department of Education, appeared to testify in favor of this bill. He stated that the department would support the intent of this bill regarding the improvement of programs related to teacher preparation, training and evaluation. Mr. Rheault's comments are included as Exhibit H. Chairman Rawson asked what kind of constitutional amendments would be necessary, and Mr. Rheault responded that none would be necessary. Since no further testimony, either for or against this bill, was forthcoming, the hearing on S.B. 32 was closed, and the hearing on Senate Bill (S.B.) 35 was opened by the chairman. Senate Bill 35: Revises requirements concerning signing of certificates of immunization required of children attending schools and child care facilities. David Nelson, Manager, Nevada State Immunization Program, Health Division, Department of Human Resources, presented his statement (Exhibit I) in support of the bill. Chairman Rawson asked what the Nevada State Immunization Program perceived to be the problem. Are there large numbers of children that are not actually immunized, but are showing certificates? Mr. Nelson said no, that the actual problem is when a certificate of immunization is prepared, someone is signing it. The person who signs the certificate is not actually the person who has given the immunizations. In practice, this is almost impossible to do. The proposed language would change the state law so that according to our medical records, the information is certified accurate. The Health Division does not certify who has actually given the shots. Chairman Rawson asked if this was not, in a way, a lessening of the standards, or at least is taking the nurse out of the position of actually having to be there to sign the certificate. Mr. Nelson stated that Senator Rawson was correct. Chairman Rawson stated that on these kinds of issues, and as the state has dealt with the communicable disease statute, people not wanting to be immunized have expressed concern about religious objections or other objections of conscience. He stated that the bill does not leave any option here. Chairman Rawson asked Mr. Nelson if he had any objection to putting some provision in that will allow those who, for whatever reason on their part, would want to seek an exemption? Mr. Nelson said there is already language in this bill that allows a religious exemption or a specific medical exemption due to a contra-indication for the vaccines. Chairman Rawson asked if that was in the bill, and Mr. Nelson advised that it is in the language already, section 1. The chairman then asked how this works. If people that don't want to have an immunization performed, what would they have to do? Mr. Nelson explained that if anyone has a religious belief against immunization, that person would sign a statement saying they have a religious belief that exempts them from this requirement, and they send it either to the child care center or to the school. David Rowles, Director of Administration, Clark County Health District, responded to Chairman Rawson's question, saying from time to time there are written requests from parents who claim the religious exclusion. He stated he represents Dr. Ravenholt, who does sign those after reviewing them and discussing the religious exemptions with the individuals. Those are not handed out as a matter of course without review and without consideration. Possibly a dozen or so come across a health officer's desk in any given year. Chairman Rawson inquired regarding the case of someone who has a strong belief which may be misdirected; it may not even be accurate, but they have a strong feeling about not having a particular immunization. They may not be able to give a religion that would satisfy someone who is keeping track of religions, but to them that may be a very strong belief. Would they be allowed an exemption at this point? Mr. Nelson replied that they would be and they have been. The Clark County Health District has done a great deal to try and educate the public on the purpose, functions and access to vaccines and immunizations. The district takes them out into the community, and in Clark County in over 30 different places which are provided for weekly immunization access. However, occasionally there are those who are very committed to a belief that immunizations are not appropriate, and the law does provide exemption for that. The Clark County Health District tries not to make that an open gateway that flies in the face of the intent of the law, but the district does consider them and does grant them an exemption. Chairman Rawson asked if with those exemptions, there is a level of immunity in the population so that children are protected at school? Mr. Nelson answered that at the present time, the Clark County Health District has a 98 percent compliance rate of immunizations for school children and a 93 percent compliance rate for those in child care facilities. He stated with the new vaccines for children programs and the continuation of immunization initiatives, part of which are funded through legislatively authorized dollars as well as local dollars and input, the district feels that will increase and continue to provide a source of protection to our children, the children of Nevada and to other children constantly coming into this state with their parents. Chairman Rawson asked if there are published rates of reaction to immunization. He felt there must be known rates, which should be small. Mr. Nelson replied that in terms of reactions to vaccines, the Center for Disease Control (CDC) in Atlanta has a specific requirement and a specific format in which the reactions to a vaccine are given and are reported, and this is public information. The CDC publishes statements for each vaccine, and in each of those statements, it details the level of adverse reactions to each vaccine and what those reactions are. For all vaccines, this is very, very low. Mr. Rowles interjected that in addition, if a parent is obtaining an immunization for their child, they must sign an informed consent. An informed consent is very detailed, and actually it is almost in booklet form. It identifies the vaccine and the potential for reaction. He stated he thought, for instance, for measles, mumps and rubella, the ratio is 1 to 1.25 per million. That informed consent is signed before an immunization is ever given. Senator Neal stated that in reading the bill, he understands the qualifications for a physician, he understands the qualifications for a registered nurse, but what are the qualifications of the designee? It doesn't say. He said, "In fact, it could be me, and could I attest to a person getting a shot?" Mr. Nelson responded that it was a good point, and that is why the Department of Human Resources wants to leave it up to the physician to decide whether the person who is signing the certificate in his or her practice is indeed qualified. Senator Neal said it appears to him that this need not be a medical person. Mr. Nelson concurred. Senator Neal further stated he felt the bill was only serving the doctor, not the kids who are going to be immunized. Mr. Nelson said his experience has been that he has seen clerical staff in his office and also in the state public health clinic who work with immunizations every day, who know the immunization schedule very well. Senator Neal asked if this would allow the clerk or the receptionist in the doctor's office to sign the certificate. Mr. Nelson said they can attest that it is an accurate reflection of what immunizations have actually been given. What they are putting on the certificates are dates of the immunizations. Mr. Rowles stated that one of the concerns they have seen in Clark County is that for the last 5 or 6 years, there has been a reduction in the number of physicians giving immunizations because of the liability concerns. He felt that one of the issues a physician who is designating another to give the immunizations will be concerned about is obviously protecting his own liability as far as the medical record goes. Clark County has found no problem with somebody certifying that a shot was given on a particular date. Senator Coffin remarked that by the wording of the bill, there would actually be a third generation removed from the doctor, and he was not comfortable with that. Mr. Rowles replied the reason it is included is that in public clinics, there is often no physician present on a daily basis. The nurse who is in charge of the community health nursing clinic is working under standing orders from a physician. He stated the nurse actually runs the clinic. In that case, the nurse who is running the clinic and who is giving the immunizations could designate somebody in the office to certify. Chairman Rawson commented that such a designee is still an agent. Mr. Rowles stated that they are under the auspices of the chief health officer of the Clark County Health District. They have three clerks; patients come in to the desk to get their immunizations, clinic personnel pull up the patient's chart to see what immunizations are needed and whether they are current. Clinic personnel will update the card, stamp it and they do all of the tracking of the dates that are entered in for those immunizations. The nurse giving the immunization will initial off on the informed consent. Later on, this data is input by those same clerks into the counties' computerized data base. They have been doing that for the last 15 years as a way of processing a large demand for immunizations. It does function under strict protocol and rule. Senator Mathews commented that when she first read the bill, she thought the third party could do the immunization. In further reading the bill, she realized this is not true; the third party is simply signing off that the patient has been given the immunization by either the doctor or nurse, so it is not an invasive procedure done by a third party. That is where her concern came in. Mr. Rowles remarked that they would consider this a form of housekeeping. Senator Augustine said that based on personal experience with her children, when they take their certificates in, it is the nurse who gives the shot. The physicians just do not do that anymore. At that point, the nurse signs the certificate, the clerk at the desk stamps whatever else needs to be done, but the nurse is signing the certificate once the vaccine has been given. Mr. Rowles agreed that the nurse does sign the certificate once the vaccine is given because she does have to identify what quadrant or what part of the body in which the vaccination is given. The nurse has to identify the lot number of the vaccine. That is pertinent information. Senator Augustine asked if Mr. Rowles was talking about the chart, not the form that is given by the school? Chairman Rawson explained that the nurse is making a medical record, and then a front desk person is translating that medical record to what is necessary for the schools. Senator Augustine stated that, further, they send back the actual school immunization form to the nurse, and the nurse signs it at the same time as the chart is signed. Mr. Rowles explained there are times when the Clark County Health District does that, but there are also times when they are extremely rushed. For instance, last summer in the space of 5 weeks, they did over 30,000 immunizations. That was through August and the first week in September. This situation created a tremendous workload on staff. The forms are processed by having clerks assume the responsibility of keeping track of them. That way, the nurse can continue to give the immunizations. Chairman Rawson commented that this may be the problem of having too specific legislation in the first place. The chairman then asked for anyone in opposition to the bill to come forward. Lezlie Porter, a Concerned Citizen, stated she has a problem with the bill without the proposed amendment to expand the language. As a result, she did not know whether to speak for or against the bill. Senator Rawson advised that if she would like to propose the amendment, her testimony would be taken. Ms. Porter testified from a prepared statement, (Exhibit J), saying that particularly in light of some of the comments just made about the ease with which a person may get an immunization exemption, she asks the committee for their consideration of the amendment which will give parents the right to choose what they feel is best for their children. Also, Ms. Porter presented an article by Tedd Koren, D.C., and a letter from Chris Kelly, a concerned parent, which was read into the record by Ms. Porter and which is a part of Exhibit J. Starting in paragraph 4 of her letter, Ms. Kelly stated, "When I moved to Nevada, I was shocked to learn that I had no choice in the immunization process of my children. It was the law, and they could not enter Washoe County School District without them. I was upset and scared to have my children immunized. I waited until they were older in hopes that their bodies could withstand the effect better. I also took my children to a homeopathic doctor to reverse the effects of the shots." Senator Coffin stated that he believed people should have access to alternative medicine, and feels that immunizations are a form of alternative medicine in that they prevent illness. Ms. Porter indicated that she did not know anyone in alternative health care that would agree with that. Senator Coffin concurred and asked how the homeopath reverses the effects of an immunization? Ms. Porter advised that she did not know, but they use homeopathic remedies of drops or shots. It was her understanding that immunization utilizes a dead form of the virus or bacteria for which the shot is given. Ms. Porter then referred to the article by Tedd Koren, D.C., which is a part of Exhibit J, regarding research done in Australia by a Dr. Coulter indicating a link between crib death and immunization. Ms. Porter then reiterated that she is not against immunization; she wants a parental option, and referred to Mr. Rowles' testimony wherein he said that the Clark County Health District had 30,000 immunizations in 5 weeks. She is just asking for that small number who wish to exercise an option, the bill be broadened because medical and religious objections are not adequate to give parents a choice. Steven E. Kutz, Immunization Program Coordinator, District Health Department, Washoe County, testified in support of S.B. 35. Mr. Kutz stated that the parents may bring in their child's immunization record, which may have immunizations from multiple providers, if not from multiple cities, in order to get a certification card to enroll their child into child care, preschool or school. The District Health Department certifies as is written on the official immunization record that the child's immunizations are up to date, meeting the applicable Nevada Revised Statutes (NRS). Mr. Kutz advised the current procedure at the District Health Department is effective and efficient. To require signatures from all providers, certifying the immunization status of children during school or child care, would become a very inefficient, time-consuming process and an unreasonable burden on parents. Mr. Kutz stated that as a father, his children have received immunizations from multiple providers utilizing the practices that S.B. 35 is intended to formalize. He stated he can quickly bring in their immunization records and receive certification to enroll them in child care, as required per NRS. With both he and his wife working, he does not have the time to go back to the children's providers, one of whom has since retired, to obtain the required signatures. He stated that both as an individual and as the Washoe County District Health Department Immunization Coordinator, he is in agreement with the testimony presented by Mr. Nelson. If S.B. 35 is passed, it will formalize the current practices of the Washoe County District Health Department, which have been efficient and effective. In addition, regarding the comments on religious exemptions, Washoe County does not require a religious statement from a church. Senator Rawson asked if Washoe County was required to have a form that a parent could sign as an objection, would that be seen as a problem? Mr. Kutz replied that the Health Department likes the standards that are in place with just the religious and medical exemptions, and that these standards cover all the required areas. Carla Bennett, Concerned Citizen, testified that her experience in taking children into the school system in Washoe County is that their records have been lost, and the children have to be reimmunized. Ms. Bennett indicated that her children were immunized at the proper time and that in 1989, Ms. Bennett went to mid-wife school; a form of alternative medicine. It was there she started hearing disturbing information which she wanted to share with the committee. Although her children have been immunized, she did not have the privilege in Washoe County to just walk in and say that she didn't want to have them immunized because she has some concerns, but not on religious grounds. She stated that she would like to share her concerns with the committee and presented Exhibit K, which shows risk factors involved in various types of immunization, according to several doctors from Australia and from Physicians' Desk Reference, The People's Doctor, Medical Newsletter for Consumers from April 1978. Ms. Bennett stated that her only reason for testifying is that she wants parents to have an option. Chairman Rawson indicated that it was not his intention to debate with Ms. Bennett or to judge her comments; only to hear her concerns, and he felt there was some misinformation in her presentation. He acknowledged that there are some side effects and some of those are serious, and the committee is not objecting to a parent expressing her concern about that. The chairman explained that one of the reasons that children do not die from measles is that most of the population has been immunized; one of the reasons that children are not coming down with all of these serious conditions is because the bulk of the population is immunized. He stated immunization is of great concern in public health, and the bulk of the population has been faced with a decision on this matter and out of that decision, there have been individuals hurt by it. Ms. Bennett stated that she disagreed with the chairman because in 1985, there was an outbreak in two secondary schools, and 99 percent of the children who had the outbreak were immunized. She further commented that immunizations do not work with everyone, and also between 1860 to 1948, there was a dramatic decrease in measles of 94.1 percent; scarlet fever, 99.7 percent; whooping cough, 91 percent, and these were people who were not immunized. With diphtheria, and there was an immunization serum at the time, the decrease was less significant. Chairman Rawson indicated that he would not argue with Ms. Bennett's belief. He stated that her concern is valid, and the committee does appreciate her concern. Lucille Lusk, Legislative Liaison, Nevada Concerned Citizens, indicated the reason why these diseases are not occurring anymore is that they have been eradicated in our country. Further, she stated that she was in a delegation to Russia last year where there is no such thing as immunization, and Russian authorities are pulling the children out of the homes because they are testing positive for diphtheria and other diseases, and they are put into institutions, and these children are not going to get better. She further stated Russians were begging for immunizations. Ms. Bennett asked that the committee would just look at the incidence of increased sanitation, increased nutrition, and how that has affected the diseases, like, for example, in India. She further recommended that the committee read the many books on the market, and she reiterated her request that parents can have the option of not having their children immunized. Ms. Lusk continued her testimony for the purpose of proposing an amendment to S.B. 35. Ms. Lusk testified that Nevada Concerned Citizens are in full support of the bill as it is written. Nevada Concerned Citizens would like to see it amended because it would resolve some significant parent concerns. She stated having listened to the testimony of Mr. Rowles of the Clark County Health District and the representative of the Washoe County Health District, both indicated that they do not require a specific religious statement and they do allow exemptions for strongly held beliefs under the current practice. Ms. Lusk further stated that is not how the law reads, and some the law is not consistently and uniformly applied. The amendment which she offered, Exhibit L, would change the existing language of the bill by inserting the following wording on page 1, line 3, immediately following the reference to religious belief or medical condition: ...or upon the completion of a statement of objection filed by the parent or legal guardian on a form to be available at the county health department. Ms. Lusk explained the reason for the wording of the amendment is because Nevada Concerned Citizens did not want it to simply be a matter of neglect. For example, if someone did not get around to getting the immunizations and said, "Well, it is easier just to say I object." This would require the same process that is currently in place for a person who has a religious or a medical objection of consideration by the health department and would need to be a seriously considered decision and not simply a quick decision. Nevada Concerned Citizens suggested that the form be available at the health department rather than at the schools for the same reason....that it assists in making this a seriously considered decision and not one where a parent simply drops by the local school. The Nevada Concerned Citizens feel strongly that it is important to have this exemption. There are some reasons to believe that in some instances the reactions to vaccines and belief systems are such that this should be a viable choice open to parents. Further, she noted a couple of comments made by Mr. Rowles. He mentioned that parents are required to sign an informed consent prior to getting these vaccines for their children. Having seen that informed consent and looking at the potential difficulties resulting from vaccines, the parents then have no choice but to sign it in order to send their children to school or to put them in a preschool system. That is not a true informed consent in the opinion of the Nevada Concerned Citizens; that is a coerced consent, and Nevada Concerned Citizens would like to see the informed consent have real meaning. Chairman Rawson noted that is a valid legal principle and asked for any response. Mr. Rowles indicated that it is a point of clarification. The informed consent must be signed before the Clark County Health District would do anything. It has nothing to do with whether or not the district is keeping that child out of school. In order to get the immunization, the parent has to sign that they consent for the Clark County Health District to give that immunization. Also recorded on that informed consent is the information relating to the vaccine so if there is a reaction, the Clark County Health District can identify the lot and case number, and that is correlated very carefully with the Center for Disease Control (CDC) in case there is ever a drug recall or a vaccine recall. That is what the informed consent means. It points out the current knowledge regarding the risks involved. Chairman Rawson stated this is not something the Clark County Health District has set up, but this turns out in this case to be a complication of two requirements of law. The health district has no choice. That is not their fault. It is understood that health officials are meeting requirements by doing an informed consent, and it is the other regulation that has put this pressure on it. Mr. Rowles indicated that this also comes from the federal Center for Disease Control, too. That is the form they provide to Clark County Health District as part of the distribution of vaccine to states. The district needs to use that form also to keep track. The chairman agreed that it would be a mistake to lose that trail. Senator Coffin asked if the chairman could answer whether or not there is such a thing as a testing or pretesting program somewhat like is used for allergies to find out if there is in fact in your family a predisposition to having a reaction to the vaccine. Chairman Rawson replied that in his training they taught serums used to test for the allergy will create as many allergies as would be obtained with a vaccine. The risk is the same with the test as it is with the vaccine. Why not go ahead with the vaccine? In a way, that becomes a test and what happens if it is a horse serum, and the child has a reaction to that, medical practitioners will know never to give that child another horse serum injection. If it is a different formulation, then out of the process there will be a medical record that develops to tell medical personnel what might be fatal the next time. Senator Coffin asked if there was a way for a family to be able to communicate to health authorities that they know of a genetic predisposition to reactions. Chairman Rawson indicated that he thinks there is. Usually the families that have had problems would not just stand in a line and have the shot. They will talk with the nurse or physician and advise that their child had a reaction to such and such, and every practitioner takes it seriously. Senator Coffin inquired if they could then get an exemption, and Chairman Rawson indicated that they could. That is a medical reason not to have an immunization. The chairman then asked for questions. Senator Augustine asked why the "must" was changed to "shall" in the amendment. Senator Mathews commented that they are equally strong. The chairman commented that bill drafters have a strong feeling about those words, and every 5 or 6 years, all legislation is changed accordingly. Janine Hansen, State President, Eagle Forum, testified not only for Eagle Forum, but for herself, stating that Eagle Forum is in support of the bill and in support of the amendment which Ms. Lusk presented. She related her personal experience with the Washoe County Health District regarding the immunization for her daughter who had serious health problems when she was younger. Consequently, some of her immunizations had been delayed until she was almost 6 years old. Before her child went to kindergarten, Ms. Hansen tried to have the immunizations finalized. She read the informed consent very carefully and found it very long with very small print, hard to read and frightening. It stated that if a child had had seizures, the child should not have the vaccine, and her daughter had a seizure a couple of years prior to this time and had been in the hospital several times with other problems. Previous to that, her son had a near drowning experience. As a result of these experiences, she advised the Washoe County Health Department representative that she could not sign the informed consent and refused to have her child immunized. She was advised that she had to go ahead with the immunization. She was not advised of the exemption for religious or medical reasons. She then went to her daughter's pediatrician, and he wrote a letter explaining the situation with the seizure and said that she should be excused. The doctor also stated that since she was almost 6 years old, there is no need for the pertussis immunization anymore. Ms. Hansen took this letter to the Washoe County Department of Health, but they still refused to exempt her from the immunization, so there was no medical exemption for her daughter. She then read the information on the informed consent for the polio vaccine which said if a child was was in close association with someone who had cancer or where their immune system was depressed, the child should not receive live polio vaccine. Ms. Hansen's father, with whom she was living at the time, had active leukemia. She advised the Washoe County Health Department of this situation, but they would not accept her word and did not offer her a medical exemption, at which time she refused to have her child immunized. Ms. Hansen stated that her father's doctor sent a letter and called the Washoe County Health Department on the phone and insisted that this was the case. There was a lot of hassle and a lot of intimidation involved, but in the end a compromise was reached. The vaccine was changed from a live polio to another one, and she was able to comply with their regulations. Ms. Hansen said that her concerns were increasing over immunizations, and she feels that the exemptions for religious or medical reasons are really not available unless some tremendous hassle occurs. She stated that the Washoe County Health Department did not let her know that there were exemptions available. She suggested there are other reasons, such as deep-seated personal beliefs and family history and other reasons why there should be additional exemptions where people can, in an informed way, go to the health department and have their child exempted from this process. Ms. Hansen indicated that she recently spoke at a conference in Salt Lake City and a man named Jeff Ostler also attended, and he had done a study of research on the issue of vaccine and presented that at the meeting. A copy of this report is included as Exhibit M. Ms. Hansen concluded by stating her concern that a real medical exemption be there; a form that is made available to people they know about and can use, and that an exemption for sincere beliefs and concerns about the health of their family be available. Chairman Rawson asked for questions and Senator Augustine asked that if Ms. Hansen was aware that if another form is created, there is an added fiscal note to this bill because another form has to be created and dispersed in a paper push that is already ominous. Ms. Hansen replied that perhaps a form is not the best way to do it, but something has to be made available so that unlike what happened to her, at least people will be able to find out that there is such an exemption. Senator Augustine remarked that she would have been exempt, the way the statute reads, because it says "or medical condition." Ms. Hansen said that she personally talked with the doctor in charge, who was Dr. Trudy Larson, and she refused to allow a medical exemption, even with the letter from the doctor. Senator Rawson asked if anyone else wished to speak on this bill. Juanita Cox, Chairman, People Organized for the Next Generation, and a member of National Health Freedom Association and a member of Nevadans for Health Freedom and other organizations concerned with inoculations and this bill, testified that she could relate a story about her niece who, upon receiving her first immunization for diphtheria (DPT) in Washoe County, actually died in the doctor's office. Fortunately, the doctor was able to revive her. She stated her niece then moved to Nye County, where she was forced to have the next shot at the hospital because they did not inform her of the medical exemption. She testified that parents just do not seem to know about the exemption, they are not informed, and they do not know every law in the NRS, and no parental exemption is given in Washoe County. She asked the committee if since the people run the government and dictate what they want, should they not be able to determine what is right for themselves and their families? The People Organized for the Next Generation recommend and support the Lusk amendment to S.B. 35. The chairman thanked Ms. Cox and asked if there were any questions or further testimony, for or against. There being no questions or further testimony to be received, the hearing on S.B. 35 was closed, and the hearing on Senate Bill (S.B.) 36 was opened. Senate Bill 36: Requires development of program to track prescriptions for controlled substances filled by pharmacies. Chairman Rawson asked for testimony on S.B. 36. Senator Ernest Adler stated that S.B. 36 is a product of the interim study committee on criminal justice. Essentially, how this came about was the pharmacy board and Nevada Division of Investigations (NDI) came to the committee with a problem they were having with prescription drugs. With the current system, investigators from both agencies go to pharmacies and go through all the prescriptions and look for irregularities in prescriptions to pinpoint people who are abusing controlled substances by going to multiple doctors for prescriptions, forging prescriptions, and so forth. That is the problem. Even though this information is confidential, the amount of privacy normal patients have is reduced when there is somebody manually going through all the records to try and find out who is abusing the system. Senator Adler advised that Keith Macdonald of the State Board of Pharmacy, has recommended a computerized system to replace the existing system where the pharmacy inputs into the computer system the dangerous drugs or controlled substances that are being prescribed throughout the state. The computer program essentially just sorts out those individuals who are using multiple doctors and taking above the recommended amount of a controlled substance. That information then is given to the pharmacy board and NDI or local law enforcement agency through the pharmacy board. Their first concern really is before somebody becomes involved in the criminal system, to deal with these people and tell them we think you have or are starting to have an overuse problem and intervene here before it gets into the criminal justice system. That is really not happening now because of the manual sorting system. The second thing the Board of Pharmacy could do, if it rises to the level of criminal abuse of the drugs, would be to refer the individual to the appropriate law enforcement agency. That is basically the reason for this bill. There has been some feedback that this bill interfered with confidentiality, but this actually expands confidentiality over what it is presently Keith Macdonald, Executive Secretary, State Board of Pharmacy, testified next from prepared text (Exhibit N) on S.B. 36. Chairman Rawson asked if every practitioner would be required to keep records on this or just the pharmacies? Mr. Macdonald replied that it would be strictly pharmacies; there would be no additional requirements of practitioners. Chairman Rawson asked if the bill allowed the practitioners to charge an additional fee. Mr. Macdonald replied that the bill, on the second page, suggests the board may charge an additional fee for dispensing controlled substances. Practitioners are registered, and with the controlled substance registration, the bill does allow an increase, but Board of Pharmacy does not feel it is necessary at this time. Senator Mathews referred to line 4 on page 2 which says "the board may charge additional fees," and she remarked that usually the opportunity to charge an additional fee was utilized, and that fee passed on to the consumer. She asked if this would drive up the cost to those people who are already strapped or already burdened with the escalating cost of medicines? Mr. Macdonald replied the board would be agreeable to having that section regarding additional fees removed from the bill. Senator Mathews asked if Nevada State Board of Pharmacy would be comfortable with the committee taking this provision out of the bill. Mr. Macdonald replied that the board would have no objection. Senator Augustine remarked that she agreed with the concept, but finds it a bit ironic that when she had concerns last session over pharmaceutical assistants handling controlled narcotics and controlled substances at pharmacies that board members did not want to address that issue, and assured her it would be addressed by the board after the session. To date, the committee has received nothing from the board indicating that has actually been done, and she stated she feels that this is the other side of that coin and, in fact, the board does want to have some control over substance or narcotic abuse that may be going on. She stated she does agree with this concept, but questions the wisdom of high-school-educated assistants working in the pharmacies and having access to these same controlled substances. Mr. Macdonald said that the board had addressed this, and he apologized for not getting this information to her. He went on to state that a pharmacy technician can do nothing without a pharmacist being there to supervise the activities of the technician on a one-on-one basis. The technicians have no authority to dispense any drugs on their own and other than preparing the prescriptions, they have no authority to handle drugs. Senator Augustine asked if he was saying that under the regulations, the assistant cannot handle the controlled substances that are in a locked cage? Mr. Macdonald advised that what he actually said was the technicians have to be supervised by the pharmacist at all times. They can handle prescriptive medicines, but they do not dispense them to patients or make the decision about the prescription quantity or strength, unless it is checked by the pharmacist and the pharmacist has to review and initial that prescription, along with any other person who touched it, such as a technician. Chairman Rawson noted that the concerns on this bill have been well stated. He commented that his worry was that when patients come in with obvious drug problems and the patients appear to be in pain, the way of all practitioners who deal with that is they will give them a prescription for two or three pills to get them through. He stated that some of these patients may visit ten doctors' offices in an afternoon and get those two or three tablets. It gets to be an issue and, as a practitioner, he stated he has always wanted some way to be able to check this. Senator Rawson questioned the best way to protect privacy, and asked if there was any assurance that not just anybody can have access to this proposed computer system. Mr. Macdonald answered that this is a system that would be downloaded into only the board's computers and could not be tapped into by others. Senator Adler commented that the bill says: "Information obtained from this program is confidential and, except as otherwise provided by this subsection, must not be disclosed to any person." There is some amendatory language where Mr. Macdonald and some health care professionals have access on a need-to-know basis, but essentially it is going to be very tight. Chairman Rawson commented that practitioners are going to be sensitive about their patients, the patients that feel they have a right to their anonymity and a drug agent or someone will contact them and say that they may have a drug problem. He asked if any regulation or protocol has been worked out on that question. Mr. Macdonald advised that the purpose of some of the amendatory language will set the policies in that regard. Obviously, oncology patients, AIDS patients, people in pain management would not be contacted. The computer system would only identify those that are breaking the law and going to multiple doctors. The board would have to sort out those individuals that the board wants to protect. He directed the committee's attention to line 5 and suggested the language be changed to read: "The program shall be directed by a task force of health care practitioners, health care professional associations, the Bureau of Alcohol and Drug Abuse (BADA), the board, the division, related licensing boards and criminal prosecutors to provide inappropriate drug utilization information to pharmacies and practitioners to prevent improper or illegal drug use." Mr. Macdonald testified further that in line 12, section 1, subsection 3, the board would like to add the words "or professional licensing board" following "appropriate law enforcement agency." Again on line 16, change the word "subsection" to "section", which would include all of this bill. Item 4 appears to restrict the disclosure of information to (a) and (b), yet subsection 2 says the board and division must have access to it. That is the reason for changing the wording from subsection to section. Chairman Rawson asked if this would close off any other types of prosecution that might result by cutting off this information? Frank Adams, Deputy Chief, Division of Investigation, State of Nevada, testified that the division supports and works very closely with the Board of Pharmacy and believes that only through a multi-disciplinary approach to this problem can it be successful. The division only wants to target the blatant drug violators; the rest of them should be taken out of the justice system and into some type of treatment. Mr. Adams submitted a prepared statement in support of this bill (Exhibit O). Chairman Rawson asked if individuals wanted to see what type of record was on themselves, is there a way to discover that? Mr. Adams indicated there is a way, and it is covered in 4(a) which says: "Upon the request of a person about whom the information requested concerns or upon the request on his behalf of his attorney..." Yes, they can access it. Senator Neal asked how the board is going to track this? Mr. Macdonald replied that pharmacies now put all of this information into the computer, and once a month they would download it on disk which would dump to a centralized data computer. Senator Neal asked what happens then? Mr. Macdonald stated at that time, they would have programs developed by the cooperating organizations to set the parameters of how they would look at that data and find out what it is. In one case, there is a patient who went to 60 doctors and 30 drug stores. The board would be giving that information to the doctors and pharmacies which they patronize....the law provides for that now....and they would have their patients profiled and determine if they are drug abusers. Senator Neal asked if the controlled substances covered by the bill are in schedules I through V? Mr. Macdonald replied yes, there are only five controlled substances. Senator Neal referred to line 9 of section 1, subsection 2, in which the bill talks about suspected fraudulent or illegal activity, and on line 11 the bill talks about "...activity it reasonably suspects may be fraudulent or illegal..." Senator Neal asked, "When does one become a suspect?" Mr. Macdonald stated that the statutes provide and NRS 453.391, subsection 2, provides that a person cannot go to multiple doctors without advising their doctors they are obtaining controlled substances from someone else. The board would be able to identify those persons going to multiple doctors. The first indication would be if a person is getting the same drug and getting it many times from different places. The practitioners would then be asked if they were aware this person was getting multiple drugs and if practitioners are not, the person would be a suspected drug abuser. Senator Neal advised when in Las Vegas, he has a private doctor and when he comes to Carson City and he gets ill, he might go to the doctor here. Would he be downloaded in the computer? Mr. Macdonald advised that he would not because it would require information indicating that a person did that 2 times a week or 5 times a week, depending on how many doctors and how many times and the type of drugs. Senator Neal referenced line 18, which states: "Upon the request of a person about whom the information requested concerns or upon the request on his behalf by his attorney..." and asked how would a person know when to make a request? Would it be after he was arrested? Mr. Macdonald said no, it would be probably be when the patient approached the doctor, and the doctor said he had obtained information from the Board of Pharmacy that the patient was seeing 12 other doctors and obtaining drugs at 13 different drug stores. The patient may say that information is not right; he would like to find out about it, and he could request it at that point. Senator Neal was concerned that the computer program would show every prescription for every person, and Mr. Macdonald informed him that the proposed computer program would only show multiple prescriptions for the same drug for the same person from different doctors. Senator Washington asked if the patient went to the doctor, and the doctor pulled up the information on the screen regarding that patient and denied the request of the patient for the prescription, then the patient can actually request to see his record. Senator Washington asked if the purpose of this program is to prevent illegal drug use. Senator Adler interjected that the program is twofold; the first is if somebody has a prescription drug problem in its early stages, it is to get them counseling, get them off of drugs and not prosecute them; if it is somebody that is engaged in heavy-duty, illegal prescription drug activities, it is at that point they will be dealt with in the criminal system. The idea is to get in there at the early stages and help these people. Chairman Rawson remarked the worry about these people is that they will be taking a killing dose, they are very fragile and their lives are a stake. This could be a life-saving program to identify such people. Senator Adler indicated that what the parties involved had asked for was to set up an executive board to set policy as to how general situations would be handled. The purpose is to identify the drug abuser and get that person into some type of referred counseling. If a doctor is over-prescribing, then the medical board would address that situation. If it is a group of individuals that go from state to state to state seeing multiple doctors and putting drugs back on the street, the law wants to handle that from a criminal standpoint. The proposed executive board would set policy as to how they would handle general cases. On specific cases, the team would go back to that board and say: "This is what we have; give us a recommendation." This is how the system would handle the day-to-day cases in this type of program. Senator Washington asked who would make up the executive board? Senator Adler replied they were talking about representatives from the division of investigation, the pharmacy board, medical board, pharmacy association, the medical association, the prosecutors, and representatives from alcohol and drug abuse. They would set general policy. The whole idea is to do a multi-disciplinary approach to this program because this problem cannot be solved alone. Senator Washington asked if this program would be statewide, and Senator Adler assured him that it would. Chairman Rawson asked if the board would object if the committee had them refer the regulations back to the legislature; just record them, not saying that approval would be needed, but so that legislators actually have a chance to see the regulations? Mr. Macdonald replied the board would be pleased to do that after the regulation is developed. Chairman Rawson noted there are thousands of regulations in an interim that are produced throughout the government, and this might be an issue where the legislators could specify the health care committee to see them. Mr. Macdonald indicated he would send them to the committee before they are adopted. Senator Neal commented that the board presently has in place a system by which they check the pharmacists who deal with schedule I through V drugs. He asked what is done in that program? Mr. Macdonald replied the board looks through their prescriptions to see if there are irregular prescriptions and/or abuse patterns. Most frequently, a doctor will phone the board saying that a certain patient has appeared in his office five times to get medicine for low back pain, and the doctor will ask if the board has any knowledge of this patient getting drugs elsewhere. Many times, the board will contact a drug store and ask, and the pharmacist will say yes, the patient gets them from two or three doctors. Generally, that is how information is originated. Chairman Rawson asked if there was any testimony in favor or opposition to this bill and received no response. He advised that the committee would schedule this bill for a work session. There being no further business, Chairman Rawson adjourned the meeting at 4:06 p.m. * * * * * RESPECTFULLY SUBMITTED, Mary Gavin, Committee Secretary APPROVED BY: _____________________________________ Senator Raymond D. Rawson, Chairman DATE: ______________________________ Senate Committee on Human Resources and Facilities January 25, 1995 Page