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Adopted Rules: Closed to Comments

Adopted Rules Content: 

 

 

Statement of Basis and Purpose of the Amendment

 

The authority for this amendment is found in §§556 and 558 of the New York City Charter.   Sections 558(b) and (c) of the Charter empower the Board of Health to amend the Health Code and to include in the New York City Health Code (the “Health Code”) all matters to which the Department’s authority extends. Section 1043 grants the Department rule-making authority. 

 

    The Charter provides the New York City Department of Health and Mental Hygiene (the “Department” or “DOHMH”) with jurisdiction to protect and promote the health of all New Yorkers.

The Bureau of Child Care, in the Department’s Division of Environmental Health, enforces Article 47 (Child Care Services) of the Health Code, which regulates all public and private group day care services providing care for children under six years of age. Health and safety standards for school-based programs for children ages three through five are established in Article 43 of the Health Code.     

At its meeting on December 10, 2013, the Board of Health amended Articles 43 and 47 to add a new requirement that children between 6 and 59 months of age attending school based programs and child care services receive annual influenza vaccinations.  The resolution as adopted contained a drafting error in §47.25(a)(2)(C), which used the term “school” instead of “permittee,” to refer to the entity holding a child care service permit.   

The Board of Health is amending Article 47 to correct the error and substitute the term “permittee” for “school” in this provision.

 

Effective Date: 
Mon, 07/21/2014

Proposed Rules: Closed to Comments

Agency:
Comment By: 
Monday, April 21, 2014
Proposed Rules Content: 

Statement of Basis and Purpose of the Proposed Amendment

 

The authority for these amendments is found in §§556 and 558 of the New York City Charter.   Sections 558(b) and (c) of the Charter empower the Board of Health to amend the Health Code and to include in the New York City Health Code (the “Health Code”) all matters to which the Department’s authority extends. Section 1043 grants the Department rule-making authority. 

 

    The Charter provides the New York City Department of Health and Mental Hygiene (the “Department” or “DOHMH”) with jurisdiction to protect and promote the health of all New Yorkers.

The Bureau of Child Care, in the Department’s Division of Environmental Health, enforces Article 47 (Child Care Services) of the Health Code, which regulates all public and private group day care services providing care for children under six years of age. Health and safety standards for school-based programs for children ages three through five are established in Article 43 of the Health Code.     

At its meeting on December 10, 2013, the Board of Health amended Articles 43 and 47 to add a new requirement that children between 6 and 59 months of age attending school based programs and child care services receive annual influenza vaccinations.  The resolution as adopted contained a drafting error in §47.25(a)(2)(C), which used the term “school” instead of “permittee,” to refer to the entity holding a child care service permit.   

The Department is requesting that the Board amend Article 47 to correct the error and substitute the term “permittee” for “school” in this provision.

 

Subject: 
Download Copy of Proposed Rule (.pdf): 

Adopted Rules: Closed to Comments

Adopted Rules Content: 

 

 

Statement of Basis and Purpose

 

Statutory Authority

 

These amendments to the New York City Health Code (the “Health Code”) are issued according to §§556, 558 and 1043 of the New York City Charter (the “Charter”).

 

·         Section 556 of the Charter provides the Department of Health and Mental Hygiene (the “Department” or “DOHMH”) with authority to regulate all matters affecting health in the City of New York.

·         Section 558(b) and (c) of the Charter empowers the Board of Health (the “Board”) to amend the Health Code and to include in the Health Code all matters over which the Department has authority.

·         Section 1043 of the Charter gives the Department rulemaking powers.

 

Introduction and Background

 

The Board of Health is amending Health Code §49.06, repealing required tuberculosis (TB) testing for secondary school new entrants, and as amended will authorize the Commissioner to require testing for TB infection in schools only when testing is necessary for epidemiologic or other public health purposes.

 

Between 2001 and 2010, the TB case1rate among persons18 years of age and younger in New York City declined 42%, from 4.8 to 2.8 cases per 100,000 persons.  As TB rates continue to decline, the Department has found that screening school children is currently not an effective way to identify new cases of active TB or TB infection.

 

In the 1980s, TB incidence in New York City was rising and high rates of TB were found during voluntary TB screenings. As a result, the Board of Health adopted Health Code §49.06 in 1989 to require that all new school entrants from pre-kindergarten to 12th grade have a tuberculin skin test. In 1996, the Board of Health amended §49.06 to eliminate mandatory TB testing except for new entrants to secondary schools within any public or non-public school system in New York City. Secondary school is defined in the Health Code as including junior high school and higher grade levels. This change was based on data showing that the prevalence of TB infection was low among young school age children but increased with age.

 

Mandatory TB testing of school children had the following objectives:

1)    Identify children with TB disease and provide appropriate medication and follow up;

2)    Identify TB disease through investigation of family contacts that may be the source of infection;

3)    Identify children with latent TB infection and provide preventive therapy to them; and

4)    Provide valid data on the prevalence of TB infection in school children.

 

School Screening and TB Control

 

In recent years, DOHMH data suggest that the school TB screening requirement has not achieved the first three objectives as stated above. From September 2010 to August 2011, no TB cases were found through the school screening requirement. However, DOHMH identified 32 cases of active TB among persons 10-18 years old in New York City through other means. Twenty persons (63%) were evaluated as a result of symptoms consistent with TB; 10 (31%) had a chest radiograph, a medical evaluation or an incidental laboratory result that led to their TB diagnosis; and 2 (6%) were identified through DOHMH screening of newly arrived immigrants. In 2009, TB preventive therapy was initiated in only 59% of 10-18 year olds with TB infection who were not contacts to active cases and had received a normal chest radiograph in a DOHMH TB clinic.2Only 27% that initiated therapy actually completed therapy.3

 

The fourth objective of §49.06 has been met. Based on data from the New York City Department of Education (DOE), the overall latent TB infection (LTBI) prevalence for new entrants tested from September to December 2011 was 8% (458 out of 5,643). Prevalence by secondary school grade level did not differ substantially: 7% (42 of 618 persons tested) below 7th grade, 8% (109 of 1,408) for grades 7 and 8; and 8% (307 of 3,617) for 9th through 12th grade. This prevalence rate is much lower than in children who were tested in DOHMH TB clinics between 2002 and 2004, when 21% (2,742 of 13,311) had LTBI, including 6% (177 of 2,918) among US born and 24% (2,565 of 10,569) among foreign born.4   This finding is consistent with the decline in the overall TB case rate among persons aged 18 years and younger in New York City.

 

Resources Saved By Eliminating the TB Testing Requirement

 

DOHMH TB clinics currently provide TB testing and follow-up evaluation for new secondary school entrants who need to be tested as a result of this Health Code mandate. Every year approximately 3,300 children in the secondary school age group2 are referred to one of the clinics for TB testing and follow-up.

 

In addition, two DOHMH bureaus, Bureau of TB Control (BTBC) and Bureau of School Health (BSH), and the DOE oversee compliance with this mandate in schools. At the beginning of each school year, DOE staff identifies eligible entrants in public schools and informs parents of the mandate. School principals are required to follow up on TB testing, reading TB tests, and chest x-ray results of identified students, and then report results back to DOE. DOE collects the data, enters it into an electronic system, and submits follow-up reports to the DOHMH and BSH on a monthly basis. BTBC also mails packets of information about the TB testing requirement and copies of the reporting forms to hundreds of private, parochial, and charter schools. After schools submit their reporting forms to DOHMH, data are compiled and entered into a database.

 

Over the past several years, DOE’s compliance with this provision of the Health Code improved from 30% to 90% for public schools. Obtaining compliance, however, is extremely resource intensive for both DOE and DOHMH. Moreover, children who visit DOHMH clinics are missing school and their parents or guardians are missing work to comply with the testing requirement.

 

Children and adolescents are considered to be at low risk for exposure to TB and should be tested only if one or more risk factors5are present.  Since the mid 1990’s, mandated TB testing for low risk school entrants has not been recommended by both the Centers for Disease Control and Prevention (CDC) and American Academy of Pediatrics in the absence of risk factors.6

 

Conclusion

 

Mandatory testing of new entrants in secondary schools consumes substantial resources while contributing little to TB prevention and control in New York City. Eliminating this mandate will allow DOHMH to direct increasingly limited resources to screen, identify and treat TB among persons at highest risk, and allow the DOE to focus its resources on higher priority adolescent health issues.

 

Instead of mandatory testing of all new entrants in secondary schools, the provision in current subdivision (g) of this section has been amended to authorize the testing of persons in a school only when such testing is considered by the Department as necessary for epidemiologic and other public health purposes, such as in an investigation to determine if any students or staff may have had contact with a TB case in a school.

 

Although the proposal was circulated to many NYC pediatricians, the Department received only four e- mail comments, including one in favor of and two opposed to the amendment.  One comment indicated it was too soon for the requirement to be repealed, without stating more, and another indicated that without the mandate, children would not return for readings of TB tests. The Department, as noted above, has found that although compliance with the TB testing requirement has been fairly high, at over 90% of eligible students, the numbers and percent of cases of TB infection and active disease identified has been very low, and do not justify maintaining the testing requirement. With increasingly limited resources, it is important that the Department focus its efforts on individuals who are at highest risk for infection and developing active disease, including people who are contacts of cases of active disease, or who have become recently infected and are likely to develop active disease. Accordingly, no change has been made in the resolution.

 

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1A TB case is a person who shows signs and/or symptoms of active TB disease, as defined in Health Code §11.03 (a). TB infection or latent TB infection (LTBI) occurs in persons who have been exposed to a person with active TB disease, test positive for TB infection on a tuberculin skin test or blood test, and who have become infected with the TB bacillus, but do not show signs and/or symptoms of active TB disease.

2DOHMH TB clinic data do not specifically capture the school entry requirement as a reason for obtaining a TB test or chest radiograph, but it can be assumed that children who are not contacts come to the clinic for this reason.

3This includes all children in the age group that were started on isoniazid (INH) preventative treatment regardless of TB test or chest radiograph result.

4Li, J, Munsiff , SS, Agerton, T. Prevalence of tuberculin skin test positivity in clinical population in New York City. J Immigrant Minor Health. 2010. 12(6):816-22

5Risk factors for TB disease and latent TB infection: Contact to a TB case; immigrated in the past 5 years from high TB incidence areas; prolonged stay in high TB incidence areas; work in clinical or institutional settings such as nursing home or homeless shelters; individuals with certain clinical conditions, i.e. HIV, cancer, etc. and children/adolescents exposed to adults in high-risk categories.

6Centers for Disease Control and Prevention. 2000. Targeted tuberculosis testing and treatment of latent tuberculosis infection. MMWR 49(No. RR-6): 7-10; Pediatric TB Collaborative Group. Targeted tuberculin skin testing and treatment of latent TB infection in children and adolescents. Pediatrics. 2004;114:1175-1201.

 

 

Effective Date: 
Thu, 07/19/2012

Proposed Rules: Closed to Comments

Agency:
Comment By: 
Thursday, April 19, 2012
Proposed Rules Content: 

 Click here (.pdf) for the complete text of the proposed rule.