Auckland Regional Public Health Service

Auckland Regional Public Health Service Ritonga Hauora i lwi o Tamaki Makaurau AUCKLAND... T.. j f ULf"... T T ol: 'TtrJIIJ"' Waitemata District Health Doard ButCanfaf wfyane COUNTIES MANUKAU HEALTH 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 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, J e centee General Manager Auckland Regional Public Health Service Dr. Cathy Pikholz Medical Officer of Health Auckland Regional Public Health Service 1

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 Section 79 of the Act needs to be repealed in light of the proposed insertion of 'Part 3A Management of infectious diseases', which effectively replaces the existing provisions in section 79 relating to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 2

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 status 1 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 921 (8) and insert either a new subclause in 92M or a separate clause: "The medical officer of health must send to the Director-Genera/ (i) a regular report on the number and nature of directions given under section 92G, 92H or 921; (ii) a copy of the direction where the medical officer of health considers the public health risk to be high; and (iilj 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). 1 Health (Infectious and Notifiable Diseases) Regulations 1966, Schedule 1, Form la. 3

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 whict) 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. 4

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 noninfectious 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 years of age 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. 5

Conclusion 36. Thank you for the opportunity to submit on the proposed Health (Protection) Amendment Bill. 6

Appendix 1 c Provision ARPHS comment Suggested 0 amendment Part!-Infectious diseases (Notification) 2 (1) Interpretation (i.e. definitions} health provider means a person or an The terminology is inconsistent with the NZ Public Health organisation that provides, or arranges the and Disability Act, which defines "health service". More provision of, personal health services or public appropriate term is "health service provider" health services Amend to read "health service provider". This also applies to the following: 92G (4) (a) 92H (4) (a) 921 (2) 921 (3) (a) 92U (1) (f) 92U (1) (g) medical examination means the physical The application of medical examinations under this Bill should Amend subclause (b) to examination or testing of a person for the acknowledge that immunological testing for infectious read: purpose of determining whether the person disease may be necessary to ascertain an individual's or has or is likely to have an infectious disease, contact's risk of developing an infectious disease. This may "(b) any diagnostic tests and includes- impact on how an individual or contact is managed from a required to detect the (a) the taking of a sample of tissue, blood, public health perspective. Testing can be undertaken to presence or immunity to an urine, or other bodily material for medical exclude disease, identify immunity, or differentiate between infectious disease". testing; and acute and chronic infection. (b) any diagnostic tests required to detect the presence of an infectious disease in a person 2(4) In this Act, a reference to an individual who. This definition is clinially inaccurate. Amend to: "includes an 7

Provision ARPHS comment Suggested I s amendment 92G 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. Medical officer of health may give directions to individual posing public health risk PART 3A- Management of infectious diseases (new section inserted) Subpart 2 -Directions individual who l:lare1::1rs tl:le EJisease is infected or colonised by or is a carrier of an organism capable of causing the disease even if... (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 92G (4) (b): Minor amendment suggested. specified activities (.f&f activities (for example, undertaking employment, using public trans- port, or limited to, undertaking travelling within and outside New employment... Zealand) either absolutely or unless stated conditions are observed: e)(afrie including but not 921 Direction for medical examination See comment above regarding immunological testing for Amend 921 (7} (a) to read: (7) Any medical examination an individual is individuals and contacts. directed to undergo must be- "... the infectious disease ar9 or establishing 8

c Provision ARPHS comment Suggested 0 amendment (a) in accordance with current best immunity to the infectious disease; and 92K 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. 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. General provisions concerning directions and notices Amend 921 (7) (b) to read: "... whether the individual has the infectious disease or immunity to the infectious disease. (2) If the person to whom the direction or Delete "a medical officer of notice relates is a minor or otherwise lacks health" from clause 92K legal capacity, a medical officer of health must (2), and rephrase "the serve the direction or notice on the parent, direction or notice must be guardian, or other person having the care of served on the parent, the person to whom the direction or notice guardian..." relates. Subpart 3 - Orders Medical examination orders and orders concerning contacts 92ZB Medical examination orders See comment above regarding immunological testing for Amend 92ZB (5) (a) to read: (5) If the court makes a medical examination individuals and contacts. order under this section, any medical "... the infectious disease examination an individual is directed to ar9 or establishing 9

: Provision ARPHS comment Suggested 0 amendment J( 92Z5 undergo must be- immunity to the infectious (a) in accordance with current best disease; and 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. What contact tracing involves Subpart 5 - Contact tracing Amend 92ZB (5) (b) to read: "... whether the individual has the infectious disease or immunity to the infectious disease. 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) Contact tracing may involve communicating with (b) talkirg te (b) talking to each contact, so far as this is individuals in a variety of ways (i.e. email). communicating with each practicable and appropriate; and contact, so far as this is (c) ascertaining the circumstances in which practicable and the infectious disease may have been appropriate; and 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 (i) medical examinations for the infectious disease; - - 10

.. 1: I Provision 1 ARPHS comment I Suggested 0 amendment "" cu U) I --- (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 I Who may be contact tracer Minor amendment: Although subclause (c) could cater for "(c) registered nurse For the purposes of this Part, in any case nurses with training in contact tracing, ARPHS sees merit in nominated by the District involving proposed or actual contact tracing in specifically identifying registered nurses as potential contact Health Board or medical respect of an individual, the contact tracer tracers. officer of health." maybe a- (d) suitably qualified (a) medical officer of health: person nominated... (b) health protection officer: (c) suitably qualified person nominated to undertake contact tracing by a district health board or medical officer of health. Duty of individual with infectious disease to The use of the verb 'direct' should be applied carefully I Amend 92ZV to read: 92ZV I provide information about contacts throughout the Bill due to the potential for confusion with (1) If the contact tracer has, under section issuing directions. Duty of individual with 92ZU, formed the view that contact tracing in infectious disease to respect of an individual with an infectious We recommend the use of the word 'instruct' as a provide information about disease should be undertaken, the contact replacement. contacts 11

c 0 cu V) Provision 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 ARPHS comment Suggested amendment (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 EHfeEt 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 c;iireetirg 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 c;iireetec;i instructed by the contact tracer, provide information about- (a) those people with whom he or she is, and has 12

c Provision ARPHS comment Suggested I 0 amendment +i u cu U') 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. Consideration as to whether contact tracing 92ZW can be undertaken by lndivid_ual Amend wording of 92ZW I 13

c Provision ARPHS comment Suggested 0 amendment (1) Before requiring information from an Minor amendment suggested. Contact tracing may either (l)(b) and (2): individual under section 92ZV, the contact involve (i) asking the affected person to identify and give "the individual to tracer must consider whether the information information to their contacts, or (ii) the affected person l:irelertake participate in I is necessary, taking into account- informing the contact tracer of their contacts, and the the contact tracing... I I (a) the seriousness of the public health risk contact tracer then contacting and informing the person. posed by the individual; and Both need to be allowable. Recommend changing term (b) the ability and willingness of the "undertake" to "participate in" 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 ofthe individual's ability, and to report back to the contact tracer by a time specified by the contact tracer. 92ZY Contact tracer may require certain persons to The individual with the infectious disease may not know the Amend 92ZY (2) to read: provide information contact details of the contact. Therefore this information may need to be obtained from a third party associated with (2) The persons are- (2) The persons are- the contact, for example, an employer. (a) the employer of (a) the employer ofthe individual: the individual or the (b) an educational institution attended by contact: the individual: (b) an educational (c) any business or other organisation institution attended by the that the individual has dealt with. individual or the contact: (c) any business or other organisation that the individual or the contact has dealt with. 14

c: Provision ARPHS comment Suggested 0 amendment u Ql U) Suggested addition to 92ZV at 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. (d) the organiser of any event attended by the individual or contact 15

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. 16