Disease Control

Maricopa County Hepatitis A Outbreak Slowing Because of Quick & Effective  Interventions

Maricopa County has 320 hepatitis A cases with 4 deaths predominantly affecting those experiencing homelessness, substance use and/or recent incarceration. A few months ago, Maricopa County Public Health activated its incident command system and have had all hands on deck with not only members of the County Epi team but also contracted staff and many, many volunteers.

Selecting and Executing an Intervention

After reviewing the data and learning from other jurisdictions around the country, the team determined that the most impactful and cost-effective intervention for quelling the outbreak was to focus on a vaccination campaign among high risk folks.

Of course- that means that they would need some funding to support the intervention. Team MCDPH built a proposal and went to the County Board of Supervisors and were able get a $600K appropriation last fiscal year for the intervention. They were also able to get an additional $1.7M for the current fiscal year. 

The intervention has been focusing on 3 main strategies to vaccinate those at highest risk to prevent further spread including 1) Vaccinating everyone who enters the Maricopa County jail system by hiring temporary staff; 2) Providing vaccine to partners who work with those at risk; and 3) Deploying field teams in partnership with cities to vaccinate people where they are.

AHCCCS stepped in to help as well- facilitating reimbursement to Maricopa County for the vaccinations given to Medicaid members.

By working with healthcare, community, faith-based and local government partners, the public health system has vaccinated over 14,000 residents at risk for hepatitis A. The results have been impressive. They have achieved a 66% reduction in the number of new cases since the peak of the outbreak. Vaccination efforts will continue until they can confirm that the outbreak is over.

Return on Investment

Each prevented hospitalization because of Hepatitis A saves about $25K. Emergency Department visits from Hepatitis A cost less but are still expensive- a few thousand dollars.

Persons experiencing homelessness are at much higher risk for hospitalization when they become infected with the Hepatitis A virus. For example, more than 71% of the 1,521 persons involved in a 2017 Hepatitis A outbreak were hospitalized (1,073) and 41 died.

Kentucky had a similar outbreak but they didn’t jump on it nearly as quick as Maricopa County Department of Public Health (MCDPH) and KY ended up with 4,000 cases. MCDPHs quick response likely prevented hundreds, if not thousands of cases- and untold hospitalization costs to say nothing of the lives saved.  BTW- the Hepatitis A Vaccine is $36 per dose.

Partnerships are Key

There are several keys to the success of this response including doing research to determine the most effective evidence-based interventions to use, working community, government and private partners on solutions, and making a compelling case to the Board of Supervisors to invest county funds on the proposed interventions.

Well done! This is a good example of an effective and targeted response to an important public health problem that has been causing bad health outcomes among a very high-risk population- and causing expensive downstream costs for Arizona’s healthcare system.

Arizona Sexually Transmitted Infection Action Plan in the Works

The Arizona Department of Health Services is developing a Sexually Transmitted Infections Action Plan as part of something state government calls a "Goal Council Action".  I'm not 100% sure what a Goal Council exactly is, but an initial "STD Action Plan" was presented to and approved by the "Goal Council" last week.

The Plan includes numerous actionable interventions (below) - although there's no recommendation to decriminalize syringe service programs- which is a key evidence-based best practice to reducing the spread of some sexually transmitted infections. Below are the action items in the elements in the Plan. 

  • Promote policies that allow providers to prescribe treatment for partners.

  • Improve access to screening and treatment in rural Arizona by implementing standing orders for chlamydia, gonorrhea, and syphilis.

  • Identify ways to encourage expectant mothers to access prenatal care and receive syphilis screening and promote healthy pregnancies.

  • Utilize perinatal caseworkers to better understand the barriers to accessing care and link women to prenatal care and other social services to prevent reinfection and promote healthy pregnancies.

  • Expand partnerships with correctional facilities, home visiting programs, and groups that work with current and recovering drug users to address root causes of STD transmission.

  • On-board additional laboratories to electronic laboratory reporting via HL7 messaging or spreadsheet reporting. Initiate the enhancement of ADHS IT infrastructure to accept electronic case reports (eCR) from providers.

  • Expand multi-site resistance screening in Maricopa County.

  • Develop a plan to respond to emerging STDs like LGV and Chancroid.

The agency will be scheduling follow-up meetings with stakeholder subcommittees to discuss the action plan in more detail and establish next steps for implementation.

WHO Declares the DRC Ebola Outbreak a Public Health Emergency

Decision will Amplify Intervention Efforts

The WHO declared the Ebola virus disease outbreak in the Democratic Republic of the Congo a Public Health Emergency of International Concern this week. The declaration follows several decisions in the last few months to not make that call. 

The WHO cited recent developments in the outbreak in making its recommendation, including the first confirmed case in Goma (a city of almost 2M and a major transportation hub).  The outbreak has been underway for more than a year now and there have been insufficient resources including funding to fight the outbreak - impairing the effectiveness of the public health interventions. 

Policy interventions for controlling Ebola are dicey because of the need to protect livelihoods of the people most affected by the outbreak by keeping transport routes and borders open. Interventions that effect travel and trade can have negative economic consequences, but not implementing some restrictions can impair the public health response.

The WHO made the following recommendations that relate to the declaration:

Strengthen community awareness, engagement, and participation, including at points of entry to identify and address cultural norms and beliefs that are barriers to the response.

Improve cross-border screening and screening at main internal roads to ensure that no contacts are missed and enhance screening through improved sharing of information with surveillance teams.

Enhance coordination with the UN and partners to reduce security threats to enable public health operations.

Strengthen surveillance and reduce the time between detection and isolation and implementing interventions.

Optimal vaccine strategies that have maximum impact on curtailing the outbreak should be implemented rapidly (they are using a ring-vaccination strategy).

The public health tools are available to eliminate the transmission of Ebola in the DRC. The challenge is really getting the resources deployed and implementing the proven intervention methods. Plus, and important new tool- an Ebola vaccination- is now available (it was not widely available during the 2014 West African epidemic). Security concerns, local and regional infrastructure, cultural practices and access to care are all important factors that need to be addressed in order to stop the on-gong transmission of the virus.

In an example of what the Declaration can do- the Congolese government this week tasked the military and policy with enforcing hand-washing and fever checks in Kivu Province.

Maricopa County Seeking Hepatitis A Intervention Strike Team Volunteers 

AHCCCS Policy Change Assisting the Response

Maricopa County is part of a statewide hepatitis A outbreak mostly affecting folks experiencing homelessness, substance use and/or recent incarceration. 229 people have been reported with the disease and more than 80% have been hospitalized. The Maricopa County Department of Public Health is working with community partners to vaccinate the people at highest risk...  both to protect them from getting sick and to stop the disease from spreading further.  

The public health response consists of: 1) vaccinating everyone in the county jail system for the next 8 months; 2) deploying vaccination and service strike teams (with other organizations); and 3) partnering with cities and parks to go to homeless encampments and offer vaccination in Strike Teams.

They're recruiting volunteer healthcare providers and screeners (no healthcare experience needed) for the vaccine outreach events. If you're interested in volunteering, please contact PHVolunteer@maricopa.gov.

In addition, AHCCCS now covers medically necessary covered immunizations for people 19 years of age and up when the vaccines are administered by AHCCCS registered providers through county health departments. Immunizations are covered even if the AHCCCS registered provider isn't in the member’s health plan network. The list of covered vaccinations includes (but isn't necessarily limited to) Hepatitis A & B and Measles.

Policy changes like this make a big difference in the effectiveness of public health interventions like the ones associated with this Hep A outbreak - and they also sets up a system that will be better able to prevent future outbreaks.

New USPSTF Recommendations for HIV Will Have a Powerful Public Health Impact

Ever since the passage of the Affordable Care Act, a prevention model of health has been increasingly weaving its way into the fabric of traditional models of care.  That's because the ACA expanded the role of preventive services in the US health care delivery system via various incentives. 

For example, the “Category A & B” preventive services that are recommended by the United States Preventive Services Task Force (USPSTF) are now included (at no cost to consumers) in all Qualified Health Plans. In addition, many employer-based and state Medicaid programs routinely cover Category A & B services once they're recommended by the USPSTF. 

The USPSTF is an independent, volunteer panel of experts in prevention and evidence-based medicine. The Task Force works to improve the health of all Americans by making evidence-based recommendations about clinical preventive services such as screenings, counseling services, and preventive medications.

The Task Force analyzes priority preventive health services and assigns the a letter grade (an A, B, C, or D grade or an "I Statement") based on the strength of the evidence and the balance of benefits and harms of the preventive service.

Currently, the USPSTF recommends 51 Category A & B Preventive Health Services - which include things like screening tests, counseling, immunizations, and preventive medications for adults, adolescents, and children. 

The preventive services that have an A or B grade are presented in alphabetical order and by the date they were recommended on the Task Force website.

This month they added 2 new recommendations related to HIV: 

You can browse the USPHS website and check out the preventive services that they have evaluated but got a lower grade. Most of the services are broken down by age, gender and other risk factors.

Should Pharmacists Prescribe PrEP as Part of the Solution for HIV Prevention

As I mentioned above, the U.S. Preventive Services Task Force this week put out their final recommendation statement on preexposure prophylaxis (PrEP) for the prevention of HIV infection. The Task Force found that clinicians should offer PrEP to persons at high risk for HIV.
The task force found convincing evidence that PrEP is of substantial benefit in decreasing the risk of HIV infection in persons at high risk of HIV acquisition.  They conclude that PrEP is associated with small harms, including kidney and gastrointestinal adverse effects and that (with high certainty) the benefit of PrEP (with oral tenofovir disoproxil fumarate–based therapy) is substantial. They classified it as a Category A intervention.

The final recommendation statement can also be found in the June 11 issue of JAMA. The impact of the Category A recommendation is important because PrEP will now be included (at no cost to consumers) in Qualified Health Plans offered on the Marketplace.  In addition, many employer-based and state Medicaid programs routinely cover Category A & B services once they're recommended by the USPSTF. 

This week there was an article in the American Journal of Public Health that makes an argument that pharmacists should have a role in HIV prevention related to preexposure prophylaxis (PrEP), postexposure prophylaxis (PEP), and HIV testing and harm reduction.

The authors make a compelling case that, because PrEP and PEP require a prescription, control of the epidemic face hurdles like limited network capacity, physician shortages, and other access to care barriers. They argue that pharmacists are an untapped resource that are more easily accessible and available without appointment. Also, because pharmacies and pharmacists aren’t linked to specific health conditions, the setting is considered largely free of HIV-related stigma.

Of course, expanding into this role would require pharmacists to work within each jurisdiction’s scope of practice laws and policies, ensure HIV literacy through pharmacist training programs and continuing education courses and building infrastructures for billing and reimbursement, and health information technology.

Interesting idea for sure.

WHO Declines to Call Ebola Outbreak a Global Public Health Emergency

The now months-long Ebola outbreak in the Democratic Republic of the Congo (which spread to Uganda this week) is an emergency for the DRC and its neighbors, but according to the WHO this week, it doesn’t constitute a global health emergency.

The core of the decision was that the additional powers that come with an emergency declaration aren’t needed and, if used, may cause more harm than good.  One of those powers would allow the WHO to disclose information about a disease event to other countries without the consent of the outbreak country.  Emergency powers also give the WHO director-general authority to issue temporary recommendations regarding trade and travel.  However, the WHO’s recommendations on travel and trade have sometimes been ignored during other declarations.

On the other hand, declaring an emergency can be quite helpful in raising cash to fund public health and treatment interventions, and not declaring an emergency may miss opportunities to get additional resources to the outbreak areas.

More than 2,100 cases and 1,400 deaths have been reported in the DRC, making this the second largest Ebola outbreak on record.  It’s still 10% the size of the 2014-2016 West African outbreak, but has been difficult to control because of political and civil unrest in the DRC -despite the fact that there is now a vaccine that wasn’t available until the end of the 2016 outbreak.

Merck is making an additional 450,000 doses of the experimental Ebola vaccine for the DRC- but it takes a year from start to finish to make the vaccine. More than 130,000 DRC people have been vaccinated so far.

Measles-response Toolkit Offered to Health Departments

State and local health department are tasked with the difficult job of leading the response to measles outbreaks when they occur in their communities. To assist in the effort, CDC has developed this one-stop-shop digital toolkit with products that can be used to reach a variety of audiences during measles outbreaks.

The products include accurate, science-based evidence that can help to counter misinformation in communities about measles and MMR vaccine. The kit includes answers to frequently asked questions; a place to direct additional public inquiries to CDC; a measles microsite that you can syndicate on your own website; graphics to post on your websites; and modifiable letter templates (to school principals, parents, etc.) to quickly reach key stakeholders during measles outbreaks.

Measles Communication Resources Site

With the rising number of measles cases in the US and globally- and no end in sight for the erosion of immunization rates in Arizona and elsewhere- it’s more important than ever for our public health system to have resources at their fingertips for how to prepare for and to rapidly and effectively respond to vaccine preventable diseases- measles in particular.  Sadly, this is our new reality.

I found a good resource this week that was developed by the National Public Health Information Center- which is basically a Measles Resources website. The site has a Resource Library with fact sheets, infographics, social media tools, a sample op-ed for you to use once a case is identified.  There’s also an Outbreak Communication Guide for actions you can take before, during and after an outbreak, and the CDC's measles microsite.

More Bad about AZ's Immunization Rates

School Vaccination Rates Drop Again this School Year

At the core – vaccines are really about community protection.  Our public health system depends on a solid network of providers that are available to vaccinate kids for all the nasty infectious diseases that have plagued humanity for millenia.  Vaccinating yourself and your kids is more about community protection than personal protection. It’s a social contract that we have with each other to keep all of us healthy.

We need just about everybody to participate in our shared social contract to vaccinate in order to get the herd immunity.  When communities have herd immunity, those who can’t be vaccinated and folks with weakened immune systems will still be protected because the viruses can’t circulate.  Measles needs a 95% community vaccination rate to achieve herd immunity.

As a means to maintaining herd immunity, Arizona law (ARS-872 & ARS-873) requires that all children attending school or child care have certain vaccines unless they're exempted by a doctor for medical reasons or by a parent for personal reasons.  

Each year, schools (6th grade, kindergarten, and child care/preschool) are supposed to turn in data about the vaccine exemptions in their school to the ADHS.  

There's bad news again in this year's report- continuing a multi-year trend toward higher exemption rates (worse vaccination rates). For the current school year:

  • 6th grade exemption rates went from 5.4% last year to 6.1% this year

  • Kindergarten exemption rates went from 5.4% to 5.9% 

  • Child care exemption rates increased from 4.3% percent to 4.5%

This year's results can be found on the ADHS' Immunization Coverage Level page.  You can check out individual school exemption rates on the Arizona School Vaccine Exemption Spreadsheet.

There are some pretty discouraging results in this year's results. For example, only 27% of Yavapai County schools (12/44) have herd immunity among 6th graders. Coconino County is only at 33% on the same measure (6/18). As in previous years, charter schools tend to have higher exemption rates than public schools. Lots of data to dive into in the spreadsheet. 

Arizona School Vaccine Exemption Spreadsheet

Sadly, several bills that would have improved rates weren't even heard in committee this year like HB 2162 which would have removed the personal exemption and HB 2352 which would have required schools to post on their school's immunization rates.

However, several bills were heard that would have eroded immunization rates even further including SB 1115, HB 2471, HB  2472, SB 1116, and HB 2470.  Fortunately those bills appear to be dead for this year- but may very well return.

Measles & Mumps Cases in AZ

Arizona Has Lost Community Immunity in Many Places

In the last 2 weeks AZ public health officials have identified and confirmed cases of measles and mumps.  The mumps cases (2) were found in the SE valley and are under investigation by Maricopa County Public Health folks. Another mumps case has been confirmed in Cochise County.  The measles case was found in Tucson in a 12 month old- and appears to have been acquired after travelling to Asia. That case is being investigated by Pima County public health epidemiologists.

The basic detective work will include looking for susceptible contacts and conducting interventions to control the spread. Kids don't get the MMR vaccine until their first birthday, so infants are at high risk of getting the disease if they're exposed... so that group along with unvaccinated contacts (whether for medical or choice reasons) will be among the high priority contacts to identify.  You can see the investigation and control measures for both illnesses in Arizona's communicable disease rules (Pages 34-39).

Measles is more contagious than mumps- but both are easily spread (direct contact isn't needed to spread the virus).  Both are vaccine preventable diseases.  For measles (the most contagious disease), 95% of children need to be vaccinated to prevent spread.  

Whether these cases transition to an outbreak or epidemic will depend on where the index cases were prior to diagnosis, who was potentially exposed and the vaccination status of the contacts.  If the index cases were isolated or if they were in communities (or medical facilities) with vaccination rates above 95% it's unlikely that measles will spread beyond the first case. If they were among communities with lower vaccination levels, there's a good chance there will be more cases. Another wildcard will be whether there were potential infant contacts in doctors offices or clinics if potential exposures happened there.

Many parts of Arizona have vaccination levels lower than "herd immunity" levels, meaning that in many parts of the state we've lost community immunity.  Fortunately, Pima County has among the highest vaccination rates in the state, meaning there's a better chance of containing the disease.  Had the index case been from one of the many communities in AZ with much lower vaccination rates the risk would be higher. Of course- there are pockets of under vaccinated areas in every county- so many communities are at risk these days.  

Arizona is one of eighteen states that allows parents to opt out of vaccinating their child with a non-medical exemption Click this link to view the full report.  In fact, Maricopa County leads the nation in the highest number of non-medical exemptions.  

There are 30 Legislative Districts in AZ. You can click here to find out what District you live in so you can communicate with your elected officials about the importance of community immunity and ensuring they understand you support public policies that encourage immunizations.

BTW: there are science-based resources available to help parents make informative decisions about vaccines such as the CDC, Children’s Hospital of Philadelphia and TAPI.

Public Health Bills that have Passed a Chamber

Access to Care & Healthcare Workforce

SB 1088 Dental Care During Pregnancy (Carter) – AzPHA Position: YES

Passed the Senate 27-3.  Assigned to House Health & Human Services Committee.

SB 1354 Graduate Medical Information & Student Loan Repayment (Carter) AzPHA Position: Yes

Passed Senate 28-2.  Not assigned to a House Committee yet. 


SB 1089Telemedicine Insurance Coverage (Carter) – AzPHA Position: Yes

Passed Senate 30-0. Assigned to House Health & Human Services Committee.


SB 1174 Tribal Area Health Education Center – AzPHA Position: Yes

Passed Senate 30-0. Assigned to Senate Education Committee.


SB 1355 Native American Dental Care – AzPHA Position: Yes

Passed Senate 25-5.  Assigned to House Health & Human Services Commottee.


SB 1456 Vision Screening- AzPHA Position: Yes

Passed Senate 29-0. Assigned to Senate Education Committee.

** Kids Care: The Kids Care Reauthorization bills have all languished in their chamber of origin, however, we have good reason to believe that reauthorizing Kids Care including the appropriation needed to pay the state match (10%) will be negotiation in the state budget bills.


Injury Prevention

SB 1165 Texting and Driving Prohibition (Brophy McGee) – AzPHA Position: YES

Passed Senate 20-10. Assigned to House Transportation Committee. 


Licensing & Vital Records

SB 1247 Residential Care Institutions (Brophy McGee) AzPHA Position: Yes

Passed the Senate 30-0.  Assigned to House Health and Human Services Committee.


SB 1211 Intermediate Care Facilities (Carter) AzPHA Position: Yes

Passed the Senate 30-0. Assigned to House Health & Human Services Committee.


SB 1245 Vital Records- Death Certificates (Brophy McGee) AzPHA Position: Yes

Passed the Senate 30-0.  Assigned to House Health and Human Services Committee.


Tobacco & Nicotine

SB 1009 Electronic Cigarettes, Tobacco Sales (Carter) – AzPHA Position: YES

Passed the Senate 30-0. Not assigned to a House Committee yet.


SB 1060 (Strike-all Amendment) Electronic Cigarettes. Smoke Free Arizona Act (Carter) – AzPHA Position: YES

Passed the Senate 28-0. Not assigned to a House Committee yet.


Surveillance & Social Determinants

HB 2125 Child Care Subsidies (Udall) – AzPHA Position: YES

Passed House 46-13.  Assigned to House Health and Human Services Committee.


HB 2488 Veteran Suicide Annual Report (Lawrence) AzPHA Position: Yes

Passed House 60-0. Assigned to Senate Health and Human Services Committee.


SB 1040 Maternal Mortality Report (Brophy-McGee) – AzPHA Position: YES

Passed the Senate 30-0. Assigned to House Health and Human Services Committee.


HB 2718 Syringe Services Programs (Rivero) AzPHA Position: Yes

This terrific bill stalled in the House after not being heard by the Rules Committee. Perhaps it can be restored somehow in the Senate with a Strike Amendment.

Here's this week's detail report

More States Moving to Eliminate Non-Medical Exemptions (not in AZ)

There have been 127 cases of measles were confirmed in 10 states this year with outbreaks in Texas, Washington, and multiple jurisdictions in New York. The reported cases are centered primarily within communities where rates of children who are vaccinated against measles are below herd immunity (due to its high level of communicability, measles require a high rate of vaccination, between 95% to reach herd immunity).  

There are many communities in Arizona and across the country where the rates are much lower than 95%. For example, in Clark County, Washington (where a recent measles outbreak originated) the percentage of kindergarteners who received a vaccine for measles fell from 96% in 2004 to 85% in 2017.

Every state has vaccination requirements for kids starting school, and all states also have medical exemptions.  All but three states—California, Mississippi, and West Virginia—also allow non-medical exemptions (i.e., exemptions based on religious, philosophical, or personal beliefs).

Arizona currently has medical and religious exemptions for pre-school & medical and personal exemptions for public school attendance. HB 2070, which passed the House Health and Human Services Committee Thursday (5-4) would add a new religious exemption for public school.

Over the past 10 years, the number of non-medical exemptions has increased, especially in states that allow both religious and philosophical exemptions. Additionally, researchers have identified several areas in the US where large numbers of non-medical exemptions are granted, including in the Portland metro area, where Clark County, Washington, is located.

Some states are now beginning to do away with non-medical exemptions for school vaccination requirements.

In 2015, following an outbreak of measles at Disneyland, CA eliminated its non-medical exemptions (and immunization coverage recovered dramatically).  In California, vaccination rates rebounded substantially after the personal exemption was eliminated.  Vermont also eliminated its philosophical belief exemption in 2015 (but kept their religious exemption).

This year, a bill to remove the personal belief exemption for the MMR vaccine has passed the State of Washington's House of Representatives (HB 1638).  Many other states have also proposed eliminating non-medical exemptions, including Arizona (HB 2162 - which has not received a hearing), Iowa (HF 206), Maine (LD 798), Minnesota (SF 1520), and New York (S 2994 and A 2371).

Sadly, the bills that have received hearings in Arizona all work against improving our immunization rates, including HB 2470 Vaccination Religious Exemptions, HB 2471 Informed Consent, and HB  2472 Vaccinations- Antibody Titer.  All 3 Bills received Pass Recommendations in the Senate Health and Human Services Committee this week (by a 5-4 margin). They will likely be up for floor votes this week in the AZ House.

Legislative Update

All the legislative committees have big long agendas this week – as the deadline for bills to be head in their house of origin committees is rapidly approaching.  So, this will be a busy week. 

Our policy interns Tim Giblin and Annissa Biggane have been doing a great job tracking all the bills that we’re signed up for and against and monitoring amendments and the like. Here’s their detailed summary of all the various public health related bills and where they are in the system right now.

We have an Action Alert this week regarding some bills that will have a detrimental effect on vaccination rates- so please follow through on that this week- you can see more about that below.

Bills to Be Heard in Committee This Week


HB 2597  School Safety Plan Task Force (Hernandez) AzPHA Position: Yes

This well-researched bill came out of a workgroup established by students at Mountain View High School. It takes a proactive approach to prevent school violence.  The Bill asks schools to develop plans to outline how teachers and staff will respond to crisis situations, how they respond to warning signs of emotional or behavioral distress among students, partnerships with agencies to refer students to support services, and what services they’ll provide after a violent incident. This important bill will be heard in the House Education Committee on Monday, February 18 at 2pm.  We’re signed up in favor of the bill.



SB1399  School Health Pilot Program (Pace) AzPHA Position: Yes

This bill charges the AZ Department of Education with conducting a 3-year physical and health education professional development pilot program to improve the ability of physical and health educators in this state to provide high quality physical and health education to students in this state, improving student health and reducing Arizona health care cost containment 10 system and other health-related costs.  Appropriates $9.5M for planning, implementing, and evaluating the pilot.  This important bill will be heard in the Senate Education Committee on Tuesday, February 18 at 2pm. We’re signed up in favor of the bill and I’ll be speaking in Committee.



SB 1165 Texting and Driving Prohibition (Brophy McGee) – AzPHA Position: YES

This bill prohibits using a hand-held cell phone while driving.  There are some common-sense exemptions for example if the person is using it hands free etc.  Penalties are a civil penalty (no driving points) with the first offense being between $75- $150 and the 2nd offense between $150 and $250.  We are signed up in support of this bill.  Will be heard in Senate Transportation Wednesday at 9 am.  We’re signed up in favor of the bill and I’ll be speaking in Committee.



HB 2471 Informed Consent (Barto) - AzPHA Position: Opposed

This bill would add a requirement that physicians provide to parents and guardians the full vaccine package insert and excipient summary for each vaccine that will be administered.  Physicians already provide a Vaccine Information Summary to parents and guardians for each vaccine administered, which is noted in the medical record.

This new requirement would mandate provision of the 12-15 page insert, which is not presented in a format that incorporates health literacy principles. Hearing will be Thursday, February 21 at 9 am in the House of Representatives Health and Human Services Committee.  We’re signed up opposed to the the bill and I’ll be speaking in Committee.


HB  2472 Vaccinations- Antibody Titer (Barto) - AzPHA Position: Opposed

These bills would mandate that doctors inform parents and guardians that antibody titer tests (which involve a venous draw) are an option in lieu of receiving a vaccination and that there are exemptions available for the state requirements for attending school.   Hearing will be Thursday, February 21 at 9 am in the House of Representatives Health and Human Services Committee.  Hearing will be Thursday, February 21 at 9 am in the House of Representatives Health and Human Services Committee.  We’re signed up opposed to the bill and I’ll be speaking in Committee.

HB 2470 Vaccination Religious Exemptions (Barto) - AzPHA Position: Opposed

This bill would add an additional exemption to the school vaccine requirements into state law.  Currently there are medical and personal exemptions.  The bill doesn't include any verification of the religious exemption from a religious leader, just a declaration from the parent that they are opposed to vaccines on religious grounds.  Hearing will be Thursday, February 21 at 9 am in the House of Representatives Health and Human Services Committee.  We’re signed up opposed to the bill and I’ll be speaking in Committee.

ACTION ALERT: Please contact the following Representatives and let them know that you oppose HB 2470, HB 2471 & 2472 as they will decrease immunization coverage and jeopardize herd immunity.

Please focus your attention on the lawmakers in bold- especially those of you that know them!


John Allen


Nancy Barto


Kelli Butler


Gail Griffin


Alma Hernandez


Jay Lawrence


Becky A. Nutt


Pamela Powers Hannley


Amish Shah


Bills Heard in Committee Last Week

SB 1247 Residential Care Institutions (Brophy McGee) AzPHA Position: Yes

This good bill will require more robust staffing background checks for facilities that provide services for children and will remove the “deemed status” designation for child residential behavioral health facilities.  Under current law, facilities in this category (e.g. Southwest Key) can be accredited by a third party (e.g. Council on Accreditation) and avoid annual surprise inspections by the ADHS.

This intervention will provide more oversight to ensure background checks are done and that the facilities are compliant with state regulations.  This bill passed through the Senate Health & Human Services this week and will be moving to the floor.

SB 1211 Intermediate Care Facilities (Carter) AzPHA Position: Yes

Like SB 1247, this bill closes a licensing loophole.  This good bill will require more robust staffing background checks for facilities that provide services to people with disabilities at intermediate care facilities.  These facilities would also require a license to operate from the Arizona Department of Health Services beginning on January 1, 2020. 

Under current law these facilities (Hacienda de los Angeles and similar facilities run by the ADES are exempt from state licensing requirements This Bill passed the Senate Health & Human Services this week and will be moving to the floor.


SB 1088 Dental Care During Pregnancy (Carter) AzPHA Position: Yes

This bill would expand AHCCCS covered services to include comprehensive dental coverage during pregnancy and appropriate the required state match funding. Passed the Senate Health & Human Services Committee on 1/23.  This Bill passed through the Senate Appropriation Committee this week and will be headed to the floor next.


HB 2073 Vapor Products; Regulation (Shope) – AzPHA Position: Opposed

This bill would basically set up a quasi-regulatory program at the ADHS to license electronic cigarette manufacturers in Arizona and specify that only licensed electronic cigarette manufacturers can sell products in Arizona.  It gives no regulatory authority to the ADHS to enforce that vape shops get licensed and they only must do it every 5 years. There are no penalties for noncompliance and penalties are against the purchaser instead of the retailer.  This bill passed the House Health Committee by a 5-4 vote this week.


Bills that Have Passed a Chamber

SB 1009 Electronic Cigarettes, Tobacco Sales (Carter) – AzPHA Position: YES

Expands the definition of tobacco products to include e-cigarettes. Among other things, it'll make it clear that it's illegal to sell e-cigarettes to minors. The penalty for selling to minors remains at $5K. Unanimously passed in the full Senate and was transmitted to the House this week.

SB 1040 Maternal Mortality Report (Brophy-McGee) – AzPHA Position: YES

This bill would require the Child Fatality Review Team subcommittee on maternal mortality to compile an annual statistical report on the incidence and causes of "severe maternal morbidity" with recommendations for action.  The current law requires a review of the data but no report.

State Legislature Bill Update

More than 700 bills have so far been proposed by members of the Arizona State Legislature so far.  Our Public Health Policy Committee is busy sifting through them and looking for those that will have a public health impact.  We’re not done looking through them yet- but below is a summary of what we know so far.

Tobacco Bills:

SB 1009 Electronic Cigarettes, Tobacco Sales (Carter)

Expands the definition of tobacco products to include e-cigarettes. Among other things, it'll make it clear that it's illegal to sell e-cigarettes to minors. The penalty for selling to minors remains at $5K. Being heard in Senate Health & Human Services Committee Wednesday Feb 23 at 9 am.

HB 2024 Electronic Cigarettes. Smoke Free Arizona Act (Kavanaugh)

Includes e-cigarettes in the definition of tobacco products and smoking for the purposes of the Smoke Free Arizona Act.  Because the Act was voter approved- this modification to the law will require a 3/4 majority of both houses.

HB 2073 Vapor Products; Regulation (Shope)

This bill would basically set up a regulatory program at the ADHS to inspect and license electronic cigarette manufacturers in Arizona and specify that only licensed electronic cigarette manufacturers can sell products in Arizona.  It’s unclear what the objective of this bill is and we have not yet taken a position on it yet.

Maternal & Child Health:

SB 1088 Dental Care During Pregnancy (Carter)

This bill would expand AHCCCS covered services to include comprehensive dental coverage during pregnancy and appropriate the required state match funding.

SB 1040 Maternal Mortality Report (Brophy-McGee)

This bill would require the Child Fatality Review Team subcommittee on maternal mortality to compile an annual statistical report on the incidence and causes of "severe maternal morbidity" with recommendations for action.  The current law requires a review of the data but no report.


HB 2125 Child Care Subsidies (Udall)

Makes a supplemental appropriation of $56 million from the Federal Child Care and Development Fund block grant in FY2018-19 to the Department of Economic Security for child care assistance. Another bill, HB 2124 would allocate the money as follows: $26.7 million for provider rate increases, $14 million to serve children on the waiting list, and $13.1 million to increase tiered reimbursement for infants, toddlers and children in the care of DCS. HB 2436 is a similar bill.

HB 2337 Family Planning (Salman)

Would repeal the statute requiring the Department of Health Services to apply for the federal Title X family planning grant.

Injury Prevention:

HB 2069 Texting and Driving (Kavanaugh)

Makes texting while driving on a highway a nonmoving civil traffic violation.  The penalty for the 1qst violation would be $100 and the second offense would be $300.  If a crash is involved the penalty would be $500 but if someone died it would be $10K.   subject to a civil penalty of $500, except that if the accident results in the death of another person, the civil penalty is $10,000.

HB 2165  Distracted Driving (Townsend)

A person who drives a vehicle while participating in an activity that willfully distracts the person from safely operating the vehicle is guilty of reckless driving, a class 2 (mid-level) misdemeanor.  I’m not sure if texting and driving would qualify or not- it probably does.

HB 2172  Rear Facing Car Seats (Bolding)

Kids under two years of age need to be in a rear-facing restraint system unless the child weights at least 40 pounds or is at least 40 inches tall.

HB 2246  Motorcycle Helmets (Friese)

Motorcycle riders over 18 would be required to wear a helmet unless they pay a fee that would be set by ADOT. Violations would be a $500 civil penalty, but no points or other sanctions. 

HB 2075  Electronic Prescribing (Cobb)

Pushes the electronic prescribing requirement in last year’s Opioid Epidemic Act back to January 2, 2020 in all counties.  Being heard in House Health & Human Services Committee Thursday Feb 24 at 9 am.

Firearm Safety

HB 2247 Bump Stocks (Friese)

This bill would outlaw the sale of bump stocks on firearms.

HB 2248 Firearm Sales (Friese)

This bill would require a background check for all sales at gun shows.

HB 2161 Order of Protection (Hernandez)

A person who is at least 18 years of age and who is either a law enforcement officer, a “family or household member” (defined), a school administrator or teacher or a licensed behavioral health professional who has personal knowledge that the respondent is a danger to self or others is permitted to file a verified petition in the superior court for a one-year Severe Threat Order of Protection (STOP order), which prohibits the respondent from owning, purchasing, possessing or receiving or having in the respondent’s custody or control a firearm or ammunition for up to one year.

HB 2249  Mental Health and Firearm Possession (Friese)

An immediate family member or a peace officer is authorized to file a verified petition with a magistrate, justice of the peace or superior court judge for an injunction that prohibits a person from possessing, controlling, owning or receiving a firearm. Any court may issue or enforce a mental health injunction against firearm possession, regardless of the location of the person. Information that must be included in the petition is specified. If the court finds that there is clear and convincing evidence to issue a mental health injunction against firearm possession, the court must issue the injunction. Information that must be included in the injunction is specified.

Harm Reduction:

HB 2148 Syringe Access Programs (Rivero)

Decriminalizes syringe access programs, currently a class 6 felony. To qualify, programs need to list their services including disposal of used needles and hypodermic syringes, injection supplies at no cost, and access to kits that contain an opioid antagonist or referrals to programs that provide access to an opioid antagonist.

SB 1119 Tanning Studios (Mendez)

Would require people under 18 that want to use a commercial tanning bed service to have permission from their parent or guardian.


HB 2162 Vaccine Personal Exemptions (Hernandez)

This bill would remove the personal exemption option for parents to enroll in school even though they haven’t had all the required immunizations.

HB 2352 School Nurse and Immunization Postings (Butler)

School districts and charter schools would be required to post on their websites whether a registered nurse is assigned to each school as well as required reports on immunization rates.

Agency Administration

HB 2004 Nuclear Management Fund (Kavanaugh)

Assesses the Palo Verde nuclear plant $2.55M and gives it to ADEM, ADHS and other jurisdictions to compensate them for off-site nuclear emergency response plan response activities.  Being heard in House Appropriations Committee Wednesday Feb 23 at 2 pm.


HB 2280  Interfacility Ambulance Transports (Weninger)

A person may operate an "interfacility transfer ambulance service" by applying to the Department of Health Services for a certificate of operation with defined requirements.   The requirement to transport a patient under medical direction to the nearest, most appropriate facility as defined by federal medicare guidelines does not apply to an interfacility transfer ambulance service with a certificate of operation.

SB 1011 Information and Referral Service (Carter)

Appropriates $1.5 million from the general fund in FY2019-20 to the ADES for a statewide information and referral service for health care services, community services, human services and governmental services.  

AHCCCS Coverage & Services

HB 2347 Medicaid Buy-in (Butler)

Would require AHCCCS to set up a program in which eligible people could pay a premium and receive Medicaid health insurance.

HB 2350 HB2513 SB1134 Kids Care (Butler, Brophy-McGee, Cobb)

These bills Would appropriate funding so that Kids Care could continue after the federal match rate goes below 100% on October 1, 2019.

HB 2351 Medical Services Study Committee (Butler)

Establishes a 14-member Medical Services Purchase Program Study Committee to research and make recommendations for establishing and implementing a medical services purchase program. The Committee is required to submit a report of its findings and recommendations to the Governor

HB 2120  Chiropractic Coverage (Barto)

Would add chiropractic services to the list of reimbursable services under AHCCCS.  Being heard in House Health & Human Services Committee Thursday Feb 24 at 9 am.

SB 1088 Dental Care During Pregnancy (Carter)

This bill would expand AHCCCS covered services to include comprehensive dental coverage during pregnancy and appropriate the required state match funding.

Food Safety & Insecurity

HB 2178  Milk Manufacturing License Exemption

A restaurant wouldn’t be required to get a license to manufacture or distribute frozen desserts or frozen milk products if the product is manufactured or distributed and sold at the same facility for on-site consumption

HB 2186  School Meals (Udall)

Schools are required to provide a school meal to a student who requests it regardless of whether the student pays for a school meal or owes money for previous meals. Local education agencies are prohibited from taking a list of specified actions relating to unpaid school meal fees, including announcing or publicizing the names of students with unpaid school meal fees, requiring a student who cannot pay for a meal or who owes unpaid meal fees to work for a meal, and attempting to collect unpaid school meal fees from a student. Local education agencies are prohibited from using a debt collector to attempt to collect unpaid school meal fees.

Access to Care

HB 2218 State Loan Repayment (Blanc)

Makes a supplemental appropriation of $250,000 from the general fund in FY2019-20 to the Department of Health Services to pay off portions of education loans taken out by physicians, dentists, pharmacists, advance practice providers and behavioral health providers participating in the primary care provider loan repayment program. 

HB 2376  Associated Health Plans (Barto)

An association health plan is authorized to operate in Arizona if the plan is in compliance with federal laws and regulations, and if the plan's governing documents require the plan to be actuarially sound and the plan is actuarially sound.

Medical Marijuana

HB 2149  Cannabis Definition (Rivero)

Syncronizes the definitions of marijuana and cannabis in the state criminal code and the Arizona Medical Marijuana Act.  There has been some confusion in certain counties- as medical marijuana patients have been prosecuted for possessing extracts and preparations of marijuana that they bought at dispensaries. The appeal of this prosecutions will be heard by the state supreme court. This would make it more clear in state law that extracts and preparations are included in the Act.

HB 2412  Medical Marijuana Cards (Powers Hannley)

This bill would make medical marijuana cards valid for 2 years instead of the current 1 year.

There's Hope for More Valley Fever Research Funds

Representatives Kyrsten Sinema and David Schweikert introduced a bill last week that, if it passes, will increase the funding that’s available for valley fever research.  The bill supports new research and incentivizes the development of innovative treatments to fight the disease. The bill would:

  • Provide incentives to researchers working to find new treatments for Valley Fever;
  • Streamline the approval and review process for new treatments of the disease;
  • Direct HHS to conduct research on Valley Fever and sets up a Valley Fever Advisory Committee to oversee the work; and
  • Establish a grant program to facilitate Valley Fever research by universities, hospitals, and non-profits.

Valley fever (Coccidiomycosis) treatment research funds are extremely limited, in part, because it’s a regional illness (unique to the desert southwest).  If the entire country were susceptible to the illness, there would probably be more private research funds invested because there would be a large commercial market for a treatment. 

Basically, that’s why we need an investment of federal funds and policy, because the return on the research investment for valley fever isn’t adequate to recoup costs of developing a treatment because not enough people are susceptible to the illness (because it’s limited to the desert southwest).

Immigration Status, Public Benefits, Health & Access to Care: A Primer

With all the attention on immigration status and its intersection with public benefits and access to health care- I thought I’d take a crack at summarizing these issues for our membership.  Here goes:

Noncitizens make up about 7%  percent of the US population. It’s not surprising that they’re more likely to be low-income and uninsured than citizens- in part because of the opportunity limitations. In fact, 71% of undocumented adult noncitizens are uninsured.  By and large, many of them rely on Federally Qualified Health Centers for their primary care and other healthcare- in part because FQHCs have sliding fee scale service fees and serve immigrants regardless of their immigration status.

Medicaid generally limits eligibility for immigrants to qualified immigrants with refugee status or veterans and people lawfully present in the US for 5 years or more.  State Medicaid programs can elect to provide coverage to legally present immigrants before the 5-year waiting period ends (Arizona does not).

The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (often referred to as PRWORA or welfare reform) is the federal law that created Medicaid’s “qualified immigrant” standard.

Other federal safety net programs like Temporary Assistance for Needy Families and the Supplemental Nutrition Assistance Program (food stamps) also apply the five-year waiting period for legally present immigrants.

States can get matching funds from Medicaid (CMS) when they choose to provide Medicaid coverage to legally present immigrants who are children or pregnant women before the end of the 5-year waiting period.  33 states have elected to cover lawfully residing immigrant children, and 25 states cover legally present pregnant women (Arizona does not).

The Affordable Care Act made it possible for the legally present immigrants who are ineligible for Medicaid due to being in the five-year waiting period to qualify for commercial coverage and subsidies on the Federal health insurance marketplace.

Immigrants eligible for Medicaid or employer-sponsored insurance face several coverage and service barriers.  As I mentioned in a blog a few weeks ago immigration officials consider the likelihood of individuals and families becoming a “public charge,” which can result in denied admission to the US or status as a lawful permanent resident.

Fear that using safety net services will mean that they’ll be considered a public charge contributes to some families of mixed immigration status avoiding use of services like TANF, Medicaid, SNAP etc.  Some eligible immigrants avoid services because they think family members will become involved in immigration enforcement actions.

Research findings by the Kaiser Family Foundation found that changes in healthcare use and decreased participation in Medicaid and the Children’s Health Insurance Program because of this immigration policy.

Anyway, it’s a complicated system but I hope this makes it a little clearer.