Witness Testimony of Dr. Paul Etkind, Senior Director of Infectious Diseases National Association of County and City Health Officials
Chairman Coffman, Ranking Member Kirkpatrick and members of the Subcommittee, the National Association of County and City Health Official (NACCHO) appreciates the opportunity to submit testimony for the legislative hearing on H.R. 1490 “Veterans’ Privacy Act;” H.R. 1792, “Infectious Disease Reporting Act;” and H.R. 1804, “Foreign Travel Accountability Act.” NACCHO is a membership organization comprised of the nation’s 2,800 local health departments. These city, county, metropolitan, district, and tribal departments work every day to ensure the safety of the water we drink, the food we eat, and the air we breathe, and to protect every resident from disease and disaster.
NACCHO and local health departments across the country recognize and appreciate the Chairman Coffman’s leadership on the issue of disease reporting to federal, state, and local health authorities.
NACCHO is pleased that the Subcommittee is considering the Infectious Disease Reporting Act (H.R. 1792). The bill directs the Secretary of Veterans Affairs to report each case of reportable infectious disease that occurs at a medical facility of the Department of Veterans Affairs (VA) to the appropriate state entity, as well as to the accrediting organization of such facility. The bill is an important step to ensuring coordination between state and local health departments and the VA health care facilities located in their jurisdictions.
NACCHO believes it is critical for disease surveillance, identifying disease outbreaks, and recognizing disease trends in a community that reportable disease notices go to the health department of the county or community where the person with this diagnosed disease or condition resides. Each state has its own legal mandates for what is reported and to whom, but there is a robust system of notification and referral between the states and between the states and their local health departments. Even if a VA facility is a regional reference institution drawing patients from different states and locales, this notification and referral system assures that the right locale will be rapidly informed and prevention follow-up will be instituted.
Although there may be minor differences between reportable disease lists between some of the states, a standard list of reportable diseases and conditions would most closely look like the list issued by the Centers for Disease Control and Prevention (“CDC”) through its National Notifiable Disease Surveillance System (NNDSS). The list can be accessed at http://wwwn.cdc.gov/nndss/document/nndss_event_code_list_July_28_final.pdf.
Although there may be variances in the reporting conventions between some states, often the first responders to a notice of a reportable disease is the local health department. The impact of prevention and control activities, which are the result of case investigations, is enhanced when cases are reported earlier. The VA is one of the largest medical care systems in our nation. Their facilities are an important part of the healthcare provider network in our nation’s communities, and are therefore important to public health surveillance activities as well as disease prevention activities.
It is important to note that the legionellosis at the Pittsburgh VA has resulted in a VA/Allegheny County Advisory Group reviewing the policies relevant to legionella prevention and control. Similarly, the VA in St. Louis and the city health department collaborated in notifying 1,800 patients who may have been exposed to Hepatitis B, Hepatitis C and HIV because of a breakdown in dental equipment sterilization procedures in 2009-2010. Further, the Danville (IL) VA recently instituted a policy of restricting visitors from the community because 6 patients began exhibiting flu-like symptoms. These prevention activities recognize the connections between the institution and the community. Both need to be engaged for their activities to have the desired impact.
Timely disease surveillance is critical to preventing infectious disease morbidity and mortality. Incomplete reporting, lack of consistent national standards, and a lack of timely reporting have created significant barriers to appropriate and effective disease-specific control measures since delays between the onset of illness and receipt of disease notification can allow for additional transmission to occur and additional people to become ill, thereby facilitating further spread of infection.
In December 2012, NACCHO wrote the VA urging they reaffirm the importance of achieving timely and complete reporting of reportable diseases and conditions from all of its health care facilities. Local health departments around the country have varying relationships with these facilities. Whether a VA reports notifiable disease to the health department should not be dependent upon individual relationships; rather, it should be established as a system-wide expectation.
In addition to reporting communicable diseases, NACCHO urges amending the legislation to include timely and complete reporting of other conditions such as cancer, genetic diseases and birth defects, and vital records such as births and deaths. Many states also have some chronic diseases and occupational injuries/conditions included in their reportable disease list.
Unfortunately, healthcare-associated infections (HAIs), such as those that occurred at the Pittsburgh VA facility are far too common. Since 2001, more than 150,000 patients have been potentially exposed to hepatitis B and C viruses and HIV due to unsafe medical practices in American healthcare facilities. One of the most recent examples, and one of the highest profile outbreaks, occurred last year when the CDC and state and local health departments notified nearly 14,000 patients of their possible exposure during a multistate outbreak of fungal meningitis and other infections.
At any given time, about one in every 20 hospitalized patients has an HAI, while over one million HAIs occur across health care every year. Hospital-acquired HAIs alone are responsible for $28 billion to $33 billion in potentially preventable health care expenditures annually. Scientific evidence has shown that certain types of HAIs can be drastically reduced to save lives and avoid excess costs.
The federal government has made progress in recent years to reduce HAIs and has developed a National Action Plan to Prevent Health Care-Associated Infections. While the Department of Veterans Administration participates on the federal steering committee, we believe there is more to be done. We believe this legislation is an important first step to ensuring possible HAI’s are reported and investigated as early as possible.
Most, if not all, states require that diseases be reported by the diagnosing physician, or the institution in which the diagnosis was made. NACCHO recommends that the bill reflect reporting a case diagnosed rather than occurring at a medical facility. A case that occurs at a healthcare facility would only capture someone who became ill while in the care of the medical facility.
The bill calls for penalties for non-reporting. In practice, penalties are rarely assessed for cases that are not reported. That puts the health department and the physician/medical facility into an adversarial position, which most health departments prefer not to do since it may negatively affect future dealings between the entities. NACCHO recommends that the VA health facility be subject to the same penalties as a medical facility not owned by the federal government. That keeps the option of a financial penalty but opens the institution up for other possible penalties which some states may have on their books.
This bill will have the added importance of being a pilot, or test, of having a large federal medical care system formally entering the nation’s public health surveillance and care system. NACCHO has no doubt that the results will be positive for disease prevention and will provide a formal mechanism for developing relationships between the VA at all levels with public health authorities at all levels. This will not only help with disease prevention and control, but these relationships are the bedrock of responding to and mitigating the effects of any kind of emergency that a community, state or nation might encounter.
The relationships built with the help of emergency preparedness funding between public health, medical care, emergency response, and public safety officials in the first decade of this century played a huge part in the successful response to the H1N1 influenza pandemic. How much will our emergency response system, and national security, be improved if other large federal medical care systems were to be formally joined to the public health and private medical care sectors? The National Institutes of Health has several large care facilities, one of which only recently had an outbreak of a resistant bacterium that was difficult to control. The same threat exists in the Department of Defense, with its hospitals and clinics on bases across the nation. Armed forces personnel are not restricted to these bases: they live, shop and enjoy the recreational facilities of the surrounding communities. There are a myriad of opportunities for infectious diseases to pass between the bases and their surrounding communities. Another setting at risk is the federal prison system, with its numerous clinics and hospitals. Employees do not live on prison grounds. They move back and forth between the prisons and their respective neighboring communities, creating the same opportunities for pathogens to similarly move between institutions and communities. I would ask that you consider the even broader, and positive, implications of this bill.
NACCHO appreciates the opportunity to submit testimony and thanks the Subcommittee for their attention to this important public health issue. NACCHO looks forward to continuing to work with the Subcommittee as the legislation moves forward. If there are questions about this statement, please contact me at email@example.com or (202) 507-4260.