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MEETING PACKET JULY 2012 1 .. .. .. CITY OF SALEIVI; NLASSr1CHUSETTS BOARD or.F-IEALTi-i blicHea . 120 DV�kSHINGTON STREET,Ott,FL(:)C)R PC lthtrevrnt.trummc:Proles. Tti:(978)7414800 FAx (978)745-0343 . { KIMBERLEY DRISCbLL likAdirt o 01ein.com MAYOR...: L\Il Rl'RAKDIN,RS/RI_,t.TS,C;i HE.A1 t'iiAGPNT NOTICE OF MEETING You are hereby notified that the Salem Board of Health will hold its,regularly.scheduled meeting Tuesday, July 10, 2012 at 7.00 PM City Hall Annex, 120 Washington St Room 311 i . . . . . . . MEETING AGENDA j 1. Call to 2. Approval.of Minutes from June 19, 2012 3. Chairperson Announcements .4. Public.Health Announcements/Reports/Updates r a. :Health Agent b. Public Health Nurse:Report c. Administrative d. . Council Liaison S. Tobacco Regulations.Hearing. 1 6. Miscellaneous 7. Adjournment Larry Ramdin Health Agent cc: Mayor Kimberley Driscoll, Board of Health, City Councilors Next regularly scheduled meeting is July.24,2012 at 7pm at City Hall Annex 120 Washington Street Room311 Know your rights under the open meeting law MGL Chapter 39 Section 23B and City Ordinance section:2-2028 through 2-2033 It • JUSTINA POLVERE SALEM BOARD Of HEALTH PUBLIC HEALTH NURSE PUBLIC HEALTH NURSE REPORT JULY 2012 ACTIVITIES Disease Prevention • Investigated 4 reportable diseases and reported case information to MDPH. • In contact with North Shore Pulmonary Clinic on current active cases, and case contacts. ■ DOT for 1 active TB cases Meetings/Clinics • Met with 1 TB case contacts privately to PPD skin test /give results -Home visits of 3 Salem residents with David Greenbaum. Met with 1 elderly male resident and checked on living status/offered services; will be checking back with him in 2 weeks. * (Other 2 home visits were unsuccessful because residents were either not home or did not answer on multiple occasions). -Attended two day ICS 400 training and received certificate for the course. -Inspected Leggs Hill YMCA summer camp with David Greenbaum — permitted to open for 2012 season -Inspected Children's Island summer camp with Elizabeth Gagakis- permitted to • open for 2012 season •Inspected Campfire summer camp with David Greenbaum- permitted to open for • 2012 season Inspected Salem Boys and Girls club summer camp with Elizabeth Gagakis permitted to open for 2012 season •Inspected Naumkeag summer camp with Elizabeth Gagakis- permitted to open for 2012 season •Inspected Salem YMCA summer camps with Elizabeth Gagakis- permitted to open for 2012 season Inspected Salem State College summer camp with Elizabeth Gagakis- permitted to open for 2012 season •Inspected Rebel Shakespeare summer camp with Elizabeth Gagakis-permitted to open for 2012 season Monthly Report of Communicable Disease • May 2012 Disease # Of Cases New Carry Over Discharged Reported campylobacter 2 2 0 1 Salmonella 0 0 0 0 Pertussis 0 0 0 0 HGA 1 1 0 0 Tuberculosis 2 0 2 0 • J • Summary of Communicable Diseases for July 2012 Campylobacteriosis: Case #1: During incubation period case ate at many restaurants on her vacation in Florida, no suspect food or restaurant. Zero animal contact. Pt. is not a food handler and does not work in daycare setting (nor does any close contacts) No one else around her is or became ill. Pt. recovered. Case #2: Currently being investigated Human Granulocytic Anaplasmosis (Ehrlichiosis): Currently being further investigated; contacting case in progress. Case denied tick bite to physician. Presented with mild symptoms; case recovered. • Food Bourne Illness (Unidentified) Case became very ill 2 hours after eating at New Yorker Deli. Pt. did not seek medical attention and no diagnosis was made. Conducted 72 hour food history and an investigation of New Yorker Deli in progress because case believes what he ate from there caused this. He is not a food handler. No one around has any similar symptoms and is not sick. Case recovered. J Health x ,.Human Services . R ; SUMMARY OF THE IPAA PRIVACY RULE wm� _ HIPAA Compliance Assistance • SUMMARY OF • THE HIPAA PRIVACY RULE Contents Introduction......................................................................................................................... I Statutory&Regulatory Background................................................................................... I Who is Covered by the Privacy Rule..................................................................................2 BusinessAssociates.............................................................................................................3 What Information is Protected............................................................................................3 General Principle for Uses and Disclosures........................................................................4 Permitted Uses and Disclosures..........................................................................................4 Authorized Uses and Disclosures........................................................................................9 Limiting Uses and Disclosures to the Minimum Necessary.............................................10 • Notice and Other Individual Rights ..................................................................................11 Administrative Requirements............................................................................................ 14 OrganizationalOptions ..................................................................................................... 15 Other Provisions: Personal Representatives and Minors .................................................. 16 StateLaw...........................................................................................................................17 Enforcement and Penalties for Noncompliance................................................................17 ComplianceDates .............................................................................................................18 Copies of the Rule& Related Materials............................................................................ 18 EndNotes.......................................................................................................................... 19 • i SUMMARY OF THE HIPAA PRIVACY RULE Contents Introduction..........................................................................................................................1 Statutory&Regulatory Background...................................................................................l Who is Covered by the Privacy Rule..................................................................................2 BusinessAssociates.............................................................................................................3 What Information is Protected....................................................... .................................3 General Principle for Uses and Disclosures........................................................................4 Permitted Uses and Disclosures..........................................................................................4 Authorized Uses and Disclosures...............................................................................:......:.9 Limiting Uses and Disclosures to the Minimum Necessary............................................. 10 Notice and Other Individual Rights..................:...............................................................11 Administrative Requirements............................................................................................ 14 OrganizationalOptions ......'...............................................................................................15 Other Provisions:Personal Representatives and Minors.................................................. 16 StateLaw. .........................................................................................................................17 Enforcement and Penalties for Noncompliance................................................................17 ComplianceDates .............................................................................................................18 Copies of the Rule&Related Materials...........................................................I.................18 EndNotes..........................................................................................................................19 i • SUMMARY OF THE HIPAA PRIVACY RULE Introductilon The Standards for Privacy of Individually Identifiable Health Information ("Privacy Rule") establishes, for the first time, a set of national standards for the protection of certain health information. The U.S. Department of Health and Human Services ("HHS") issued the Privacy Rule to implement the requirement of the Health Insurance Portability and Accountability Act of 1996("HIPAA").1 The Privacy Rule standards address the use and disclosure of individuals' health information—called "protected health information" by organizations subject to the Privacy Rule—called "covered entities," as well as standards for individuals' privacy rights to understand and control how their health information is used. Within HHS, the Office for Civil Rights ("OCR") has responsibility for implementing and enforcing the Privacy Rule with respect to voluntary compliance activities and civil money penalties. A major goal of the Privacy Rule is to assure that individuals' health information is properly protected while allowing the flow of health information needed to provide and promote high quality health care and to protect the public's health and well being. The Rule strikes a balance that permits important uses of information, while protecting the privacy of people who seek care and healing. Given that the health care marketplace is diverse, the Rule is designed to be flexible and comprehensive to cover the variety of uses and disclosures that need to be addressed. • This is a summary of key elements of the Privacy Rule and not a complete or comprehensive guide to compliance. Entities regulated by the Rule are obligated to comply with all of its applicable requirements and should not rely on this summary as a source of legal information or advice. To make it easier for entities to review the complete requirements of the Rule,provisions of the Rule referenced in this summary are cited in notes at the end of this document. To view the entire Rule, and for other additional helpful information about how it applies, see the OCR website: http://www.hhs.gov/ocr/hioaa. In the event of a conflict between this summary and the Rule,the Rule governs. Links to the OCR Guidance Document are provided throughout this paper.Provisions of the Rule referenced in this summary are cited in endnotes at the end of this document. To review the entire Rule itself, and for other additional helpful information about how it applies, see the OCR website: http://www.hhs.gov/ocr/hioaa. Statutory & The Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191,was enacted on August 21, 1996. Sections 261 through 264 of HIPAA Regulatory require the Secretary of HHS to publicize standards for the electronic exchange, ]Badieround privacy and security of health information. Collectively these are known as the Administrative Simplification provisions. HIPAA required the Secretary to issue privacy regulations governing individually • identifiable health information, if Congress did not enact privacy legislation within OCR Privacy Rule Summary 1 Last Revised 05/03 three years of the passage of HIPAA. Because Congress did not enact privacy • legislation, HHS developed a proposed rule and released it for public comment on November 3, 1999. The Department received over 52,000 public comments. The final regulation,the Privacy Rule,was published December 28,2000.2 In March 2002, the Department proposed and released for public comment modifications to the Privacy Rule. The Department received over 11,000 comments. The final modifications were published in final form on August 14, 2002.3 A text combining the final regulation and the modifications can be found at 45 CFR Part 160 and Part 164, Subparts A and E on the OCR website: htlp://www.hhs.jzov/oci-/hipaa. Who TS The Privacy Rule, as well as all the Administrative Simplification rules, apply to health plans, health care clearinghouses, and to any health care provider who Covered b the 3' transmits health information in electronic form in connection with transactions for PI'iVaCy Rule - which the Secretary of HHS has adopted standards under HIPAA (the "covered entities"). For helpin determining whether you are covered use the decision tool at: g htt ://www.cros.hhs. ov/hi aa/hi aa2/su ort/tools/decisionsu ort/default.as . P � P p PP Pp p Health Plans. Individual and group plans that provide or pay the cost of medical l care are covered entities.4 Health plans include health, dental, vision, and prescription drug insurers, health maintenance organizations ("HMOs"), Medicare, Medicaid, Medicare+Choice and Medicare supplement insurers, and long-term care insurers (excluding nursing home fixed-indemnity policies). Health plans also include employer-sponsored group health plans, government and church-sponsored • health plans, and multi-employer health plans. There are exceptions—a group health plan with less than 50 participants that is administered solely by the employer that established and maintains the plan is not a covered entity. Two types of government- funded programs are not health plans: (1) those whose principal purpose is not providing or paying the cost of health care, such as the food stamps program; and(2) those programs whose principal activity is directly providing health care, such as a community health center,5 or the making of grants to fund the direct provision of health care. Certain types of insurance entities are also not health plans, including entities providing only workers' compensation, automobile insurance, and property and casualty insurance. Health Care Providers. Every health care provider, regardless of size, who - electronically transmits health information in connection with certain transactions, is a covered entity. These transactions include claims, benefit eligibility inquiries, referral authorization requests, or other transactions for which HHS has established standards under the HIPAA Transactions Rule.b Using electronic technology, such as email, does not mean a health care provider is a covered entity;the transmission must be in connection with a standard transaction. The Privacy Rule covers a health care provider whether it electronically transmits these transactions directly or uses a billing service or other third party to do so on its behalf. Health care providers include all "providers of services" (e.g., institutional providers such as hospitals) and "providers of medical or health services" (e.g., non-institutional providers such as physicians, dentists and other practitioners) as defined by Medicare, and any other person or organization that furnishes,bills,or is paid for health care. • OCR Privacy Rule Summary 2 Last Revised 05/03 160 anart 164, - Subparts A and E on the OCR websi • htty://ww s.gov/ocr/hil2aa. _ b 1S The Privacy Rule, as well as all the Administrative Simplification rules, apply to health plans, health care clearinghouses, and to any health care provider who Covered b. the y transmits health information in electronic form in connection with transactions for Pl'1vaCy Rtlk which the Secretary of HHS has adopted standards under HIPAA (the "covered entities"). For help in determining whether you are covered, use the decision tool at: httD://www.cros.hhs. og v/hipaa/hipaa2/support/tools/decisionsupport/default asp. Health Plans. Individual and group plans that provide or pay the cost of medical care are covered entities.4 Health plans include health, dental, vision, and prescription drug insurers, health maintenance organizations ("HMOs"), Medicare, Medicaid, Medicare+Choice and Medicare supplement insurers, and long-term care insurers (excluding nursing home fixed-indemnity policies). Health plans also include employer-sponsored group health plans, government and church-sponsored health plans,and multi-employer health plans. There are exceptions—a group health plan with less than 50 participants that is administered solely by the employer that established and maintains the plan is not a covered entity. Two types of government- funded programs are not health plans: (1) those whose principal purpose is not providing or paying the cost of health care, such as the food stamps program; and(2) those programs whose principal activity is directly providing health care, such as a community health center,' or the making of grants to fund the direct provision of health care. Certain types of insurance entities are also not health plans, including entities providing only workers' compensation, automobile insurance, and property and casualty insurance. Health Care Providers. Every health care provider, regardless of size, who electronically transmits health information in connection with certain transactions, is a covered entity. These transactions include claims, benefit eligibility inquiries, referral authorization requests, or other transactions for which.HHS has established standards under the HIPAA Transactions Rule 6 Using electronic technology, such as email, does not mean a health care provider is a covered entity; the transmission must be in connection with a standard transaction. The Privacy Rule covers a health care provider whether it electronically transmits these transactions directly or uses a billing service or other third party to do so on its behalf. Health care providers �` include all "providers of services"(e.g., institutional providers such as hospitals) and "providers of medical or health services" (e.g., non-institutional providers such as physicians, dentists and other practitioners) as defined by Medicare, and any other person or organization that furnishes,bills,or is paid for health care. OCR Privacy Rule Summary 2 Last Revised 05/03 • Health Care Clearinghouses. Health care clearinghouses are entities that process nonstandard information they receive from another entity into a standard (i.e., standard format or data content), or vice versa. 7 In most instances, health care clearinghouses will receive individually identifiable health information only when they are providing these processing services to a health plan or health care provider as a business associate.In such instances,only certain provisions of the Privacy Rule are applicable to the health care clearinghouse's uses and disclosures of protected health informations Health care clearinghouses include billing services, repricing companies, community health management information systems, and value-added networks and switches if these entities perform clearinghouse functions. BUS1rieSS Business Associate Defined. In general, a business associate is a person or organization, other than a member of a covered entity's workforce, that performs ASSOC1ateS certain functions or activities on behalf of, or provides certain services to, a covered entity that involve the use or disclosure of individually identifiable health information. Business associate functions or activities on behalf of a covered entity include claims processing, data analysis, utilization review, and billing.9 Business associate services to a covered entity are limited to legal, actuarial, accounting, consulting, data aggregation, management, administrative, accreditation, or financial services. However, persons or organizations are not considered business associates if their functions or services do not involve the use or disclosure of protected health information, and where any access to protected health information by such persons would be incidental, if at all. A covered entity can be the business associate of • another covered entity. Business Associate Contract. When a covered entity uses a contractor or other non- workforce member to perform "business associate" services or activities, the Rule requires that the covered entity include certain protections for the information in a business associate agreement(in certain circumstances governmental entities may use alternative means to achieve the same protections). In the business associate contract, a covered entity must impose specified written safeguards on the individually identifiable health information used or disclosed by its business associates.10 Moreover, a covered entity may not contractually authorize its business associate to make any use or disclosure of protected health information that would violate the Rule. Covered entities that have an existing written contract or agreement with business associates prior to October 15,2002,which is not renewed or modified prior to April 14, 2003, are permitted to continue to operate under that contract until they renew the contract or April 14, 2004, whichever is first." Sample business associate contract language is available on the OCR website at: http://www.hhs.aov/ocr/Iiipaa/contractprov.litml. Also see OCR "Business Associate"Guidance. What Protected Health Information. The Privacy Rule protects all "individually identifiable health information"held or transmitted by a covered entity or its business Information 15 associate, in any form or media,whether electronic,paper, or oral. The Privacy Rule Protected calls this information"protected health information (PHI)."12 • OCR Privacy Rule Summary 3 Last Revised 05/03 "Individually identifiable health information" is information, including demographic • data,that relates to: • the individual's past, present or future physical or mental health or condition, • the provision of health care to the individual,or • the past, present, or future payment for the provision of health care to the individual, and that identifies the individual or for which there is a reasonable basis to believe can be used to identify the individual.13 Individually identifiable health information includes many common identifiers (e.g., name, address, birth date, Social Security Number). The Privacy Rule excludes from protected health information employment records that a covered entity maintains in its capacity as an employer and education and certain other records subject to, or defined in, the Family Educational Rights and Privacy Act,20 U.S.C. §1232g. De-Identified Health Information. There are no restrictions on the use or disclosure of de-identified health information.14 De-identified health information neither identifies nor provides a reasonable basis to identify an individual. There are two ways to de-identify information; either: 1) a formal determination by a qualified statistician; or 2) the removal of specified identifiers of the individual and of the individual's relatives, household members, and employers is required, and is adequate only if the covered entity has no actual knowledge that the remaining information could be used to identify the individual.15 General Basic Principle. A major purpose of the Privacy Rule is to define and limit the • circumstances in which an individual's protected heath information may be used or Tn'nc>< le for. 1� disclosed by covered entities. A covered entity may not use or disclose protected Uses'Ind health information,except either:(1)as the Privacy Rule permits or requires;or(2)as •' the individual who is the subject of the information (or the individual's personal Disclosures: 16 representative)authorizes in writing. Required Disclosures. A covered entity must disclose protected health information in only two situations: (a) to individuals (or their personal representatives) specifically when they request access to, or an accounting of disclosures of, their protected health information; and (b) to HHS when it is undertaking a compliance investigation or review or enforcement action." See OCR "Government Access" Guidance. Perim ttefl USCs : Permitted Uses and Disclosures. A covered entity is permitted, but not required, to use and disclose protected health information, without an individual's authorization, -and D kWC ures for the following purposes or situations: (1) To the Individual (unless required for access or accounting of disclosures); (2) Treatment, Payment, and Health Care Operations; (3) Opportunity to Agree or Object; (4) Incident to an otherwise permitted use and disclosure;(5)Public Interest and Benefit Activities; and I • OCR Privacy Rule Summary 4 Last Revised 05/03 • includes common identifiers (e.g., name, address, birth date, Social Sec Number). The Privacy Rule excludes from protected health information employment records ` that a covered entity maintains in its capacity as an employer and education and R F certain other records subject to, or defined in, the Family Educational Rights and r Privacy Act,20 U.S.C. §1232g. 5 t; tF De-Identified Health Information. There are no restrictions on the use or disclosure of de-identified health information.14 De-identified health information neither identifies nor provides a reasonable basis to identify an individual. There are two ways to de-identify information; either: 1) a formal determination by a qualified j statistician; or 2) the removal of specified identifiers of the individual and of the individual's relatives, household members, and employers is required, and is ade uate only if the covered entity has no actual knowledge that the remaining w q y ' ty g g information could be used to identify the individual.15 z Basic Principle. A ma purpose of the Privacy Rule is to define and limit the or General P J P rP Y circumstances in which an individual's protected heath information may be used or IT e for FT disclosed by covered entities. A covered entity may not use or disclose protected ITSeSw6aind ' health information,except either:(1)as the Privacy Rule permits or requires;or(2)as aN the individual who is the subject of the information (or the individual's personal "Nitogil 16 representative)authorizes in writing. Y Required Disclosures. A covered entity must disclose protected health information in only two situations: (a) to individuals (or their personal representatives) r specifically when they request access to, or an accounting of disclosures of, their protected health information; and (b) to HHS when it is undertaking a compliance y investigation or review or enforcement action." See OCR "Government Access" Guidance. PermYtted-;U5e:S Permitted Uses and Disclosures. A covered entity is permitted, but not required, to #cn 5 use and disclose protected health information, without an individual's authorization, andD><Selosures for the following purposes or situations: (1) To the Individual (unless required for access or accounting of disclosures); (2) Treatment, Payment, and Health Care Operations; (3) Opportunity to Agree or Object; (4) Incident to an otherwise `- permitted use and disclosure;(5)Public Interest and Benefit Activities;and OCR Privacy Rule Summary 4 Last Revised 05/03 • (6) Limited Data Set for the purposes of research, public health or health care operations.18 Covered entities may rely on professional ethics and best judgments in deciding which of these permissive uses and disclosures to make. (1)To the Individual. A covered entity may disclose protected health information to the individual who is the subject of the information. (2) Treatment, Payment, Health Care Operations. A covered entity may use and disclose protected health information for its own treatment, payment, and health care operations activities.19 A covered entity also may disclose protected health information for the treatment activities of any health care provider, the payment activities of another covered entity and of any health care provider, or the health care operations of another covered entity involving either quality or competency assurance activities or fraud and abuse detection and compliance activities, if both covered entities have or had a relationship with the individual and the protected health information pertains to the relationship. See OCR"Treatment, Payment, Health Care Operations"Guidance. Treatment is the provision, coordination, or management of health care and related services for an individual by one or more health care providers, including consultation between providers regarding a patient and referral of a patient by one provider to another.20 Payment encompasses activities of a health plan to obtain premiums, determine or fulfill responsibilities for coverage and provision of benefits, • and furnish or obtain reimbursement for health care delivered to an individual21 and activities of a health care provider to obtain payment or be reimbursed for the provision of health care to an individual. Health care operations are any of the following activities: (a) quality assessment and improvement activities, including case management and care coordination; (b) competency assurance activities, including provider or health plan performance evaluation, credentialing, and accreditation; (c) conducting or arranging for medical reviews, audits, or legal services, including fraud and abuse detection and compliance programs; (d) specified insurance functions, such as underwriting, risk rating, and reinsuring risk; (e) business planning, development, management, and administration; and (f) business management and general administrative activities of the entity, including but not limited to: de-identifying protected health information, creating a limited data set, and certain fundraising for the benefit of the covered entity zz Most uses and disclosures of psychotherapy notes for treatment, payment, and health care operations purposes require an authorization as described below.23 Obtaining "consent" (written permission from individuals to use and disclose their protected health information for treatment, payment, and health care operations) is optional under the Privacy Rule for all covered entities 24 The content of a consent form,and the process for obtaining consent,are at the discretion of the covered entity electing to seek consent. OCR Privacy Rule Summary 5 Last Revised 05/03 (3) Uses and Disclosures with Opportunity to Agree or Object. Informal • permission may be obtained by asking the individual outright, or by circumstances that clearly give the individual the opportunity to agree, acquiesce, or object. Where the individual is incapacitated, in an emergency situation, or not available, covered entities generally may make such uses and disclosures, if in the exercise of their professional judgment, the use or disclosure is determined to be in the best interests of the individual. It is a common practice in man health care facilities _ Facility Directories. , t1' P Y such as hospitals, to maintain a directory of patient contact information. A covered health care provider may rely on an individual's informal permission to list in its facility directory the individual's name, general condition, religious affiliation, and location in the provider's facility.25 The provider may then disclose the individual's condition and location in the facility to anyone asking for the individual by name, and also may disclose religious affiliation to clergy. Members of the clergy are not required to ask for the individual by name when inquiring about patient religious affiliation. For Notification and Other Purposes. A covered entity also may rely on an individual's informal permission to disclose to the individual's family, relatives, or friends, or to other persons whom the individual identifies, protected health information directly relevant to that person's involvement in the individual's care or payment for care. 26 This provision, for example, allows a pharmacist to dispense filled prescriptions to a person acting on behalf of the patient. Similarly, a covered entity may rely on an individual's • informal permission to use or disclose protected health information for the purpose of notifying (including identifying or locating) family members, personal representatives, or others responsible for the individual's care of the individual's location, general condition, or death. In addition, protected health information may be disclosed for notification purposes to public or private entities authorized by law or charter to assist in disaster relief efforts. (4) Incidental Use and Disclosure. The Privacy Rule does not require that every risk of an incidental use or disclosure of protected health information be eliminated. A use or disclosure of this information that occurs as a result of, or as "incident to," an otherwise permitted use or disclosure is permitted as long as the covered entity has adopted reasonable safeguards as required by the Privacy Rule, and the information being shared was limited to the "minimum necessary," as required by the Privacy Rule?' See OCR"hncidental Uses and Disclosures"Guidance. (5) Public Interest and Benefit Activities. The Privacy Rule permits use and disclosure 1 re of protected health information without an individual's authorization or z . These disclosures are permitt ed,permission, for 12 national priority purposes although not required,by the Rule in recognition of the important uses made of health information outside of the health care context. Specific conditions or limitations apply to each public interest purpose, striking the balance between the individual privacy interest and the public interest need for this information. Required by Law. Covered entities may use and disclose protected health information without individual authorization as required by law(including by • OCR Privacy Rule Summary 6 Last Revised 05/03 • (3) Uses and Disclosures with Opportunity to Agree or Object. Informal permission may be obtained by asking the individual outright, or by circumstances that clearly give the individual the opportunity to agree, acquiesce, or object. Where the individual is incapacitated, in an emergency situation, or not available, covered entities generally may make such uses and disclosures, if in the exercise of their professional judgment, the use or disclosure is determined to be in the best interests of the individual. Facility Directories. It is a common practice in many health care facilities, such as hospitals, to maintain a directory of patient contact information. A rr� covered health care provider may rely on an.individual's informal permission to list in its facility directory the individual's name, general condition, religious affiliation, and location in the provider's facility 25 The provider may then disclose the individual's condition and location in the facility to yr T anyone asking.for the individual by name, and also may disclose religious affiliation to clergy. Members of the clergy are not required to ask for the individual by name when inquiring about patient religious affiliation. SrY � ForNoti Notification and OtherPur Purposes. A covered entity also may rely on an s P tY Y Y ' x individual's informal permission to disclose to the individual's family, q # = relatives, or friends, or to other persons whom the individual identifies, protected health information directly relevant to that person's involvement in the individual's care or payment for care. 26 This provision, for example, allows a pharmacist to dispense filled prescriptions to a person acting on • behalf of the patient. Similarly, a covered entity may rely on an individual's informal permission to use or disclose protected health information for the purpose of notifying (including identifying or locating) family members, personal representatives, or others responsible for the individual's care of the m individual's location, general condition, or death. In addition, protected health information may be disclosed for notification purposes to public or F private entities authorized by law or charter to assist in disaster relief efforts. r (4) Incidental Use and Disclosure. The Privacy Rule does not require that every risk of an incidental use or disclosure of protected health information be eliminated. A use or disclosure of this information that occurs as a result of, or as "incident to," an otherwise permitted use or disclosure is permitted as long as the covered entity has adopted reasonable safeguards as required by the Privacy Rule, and the information being shared was limited to,the "minimum necessary," as required by the Privacy Rule?' See OCR"Incidental Uses and Disclosures"Guidance. (5) Public Interest and Benefit Activities. The Privacy Rule permits use and disclosure of protected health information, without an individual's authorization or permission, for 12 national priority purposes.Z$ These disclosures are permitted, although not required,by the Rule in recognition of the important uses made of health information outside of the health care context. Specific conditions or limitations apply to each public interest purpose, striking the balance between the individual x fr privacy interest and the public interest need for this information. Required by Law. Covered entities may use and disclose protected health - information without individual authorization asre required by law(including din g by OCR Privacy Rule Summary 6 Last Revised 05/03 • statute,regulation,or court orders). Public Health Activities. Covered entities may disclose protected health information to: (1) public health authorities authorized by law to collect or receive such information for preventing or controlling disease, injury, or disability and to public health or other government authorities authorized to receive reports of child abuse and neglect; (2) entities subject to FDA regulation regarding FDA regulated products or activities for purposes such as adverse event reporting, tracking of products, product recalls, and post marketing surveillance; (3) individuals who may have contracted or been exposed to a communicable disease when notification is authorized by law; and (4) employers, regarding employees, when requested by employers, for information concerning a work-related illness or injury or workplace related medical surveillance,because such information is needed by the employer to comply with the Occupational Safety and Health Administration (OHSA), the Mine Safety and Health Administration (MHSA), or similar state law 30 See OCR "Public Health" Guidance; CDC Public Health and HIPAA Guidance. Victims of Abuse,Neglect or Domestic Violence. In certain circumstances, covered entities may disclose protected health information to appropriate government authorities regarding victims of abuse, neglect, or domestic violence.31 Health Oversight Activities. Covered entities may disclose protected health • information to health oversight agencies(as defined in the Rule)for purposes of legally authorized health oversight activities, such as audits and investigations necessary for oversight of the health care system and government benefit programs.32 Judicial and Administrative Proceedings. Covered entities may disclose protected health information in a judicial or administrative proceeding if the request for the information is through an order from a court or administrative tribunal. Such information may also be disclosed in response to a subpoena or other lawful process if certain assurances regarding notice to the individual or a protective order are provided.33 Law Enforcement Purposes. Covered entities may disclose protected health information to law enforcement officials for law enforcement purposes under the following six circumstances, and subject to specified conditions: (1) as required by law (including court orders, court-ordered warrants, subpoenas) and administrative requests; (2) to identify or locate_a suspect, fugitive, material witness, or missing person; (3) in response to a law enforcement official's request for information about a victim or suspected victim of a crime; (4)to alert law enforcement of a person's death, if the covered entity suspects that criminal activity caused the death; (5) when a covered entity believes that protected health information is evidence of a crime that occurred on its premises; and (6) by a covered health care provider in a medical emergency not occurring on its premises, when necessary to inform law enforcement about the commission and nature of a crime,the location of • the crime or crime victims,and the perpetrator of the crime 34 OCR Privacy Rule Summary 7 Last Revised 05/03 Decedents. Covered entities may disclose protected health information to • funeral directors as needed,and to coroners or medical examiners to identify a deceased person,determine the cause of death, and perform other functions authorized by law.31 Cadaveric Organ, Eye, or Tissue Donation. Covered entities may use or disclose protected health information to facilitate the donation and transplantation of cadaveric organs,eyes,and tissue.36 Research. "Research" is any systematic investigation designed to develop or contribute to generalizable knowledge.37 The Privacy Rule permits a covered entity to use and disclose protected health information for research purposes, without an individual's authorization, provided the covered entity obtains either: (1) documentation that an alteration or waiver of individuals' authorization for the use or disclosure of protected health information about them for research purposes has been approved by an Institutional Review Board or Privacy Board; (2) representations from the researcher that the use or disclosure of the protected health information is solely to prepare a research protocol or for similar purpose preparatory to research, that the researcher will not remove any protected health information from the covered entity, and that protected health information for which access is sought is necessary for the research; or(3)representations from the researcher that the use or disclosure sought is solely for research on the protected health information of decedents, that the protected health information sought is necessary for the research, and, at the request of the covered entity, • documentation of the death of the individuals about whom information is sought.38 A covered entity also may use or disclose, without an individuals' authorization, a limited data set of protected health information for research purposes ( u oses see discussion below).39 cc See OCR Research" Guidance; N IH Protecting PHI in Research. Serious Threat to Health or Safety. Covered entities may disclose protected health information that they believe is necessary to prevent or lessen a serious is made r n r thepublic, when suc h disclosure and imminent threat to a person 0 P to someone they believe can prevent or lessen the threat(including the target of the threat). Covered entities may also disclose to law enforcement if the information is needed to identify or apprehend an escapee or violent criminal.ao Essential Government Functions. An authorization is not required to use or disclose protected health information for certain essential government functions. Such functions include: assuring proper execution of a military mission, conducting intelligence and national security activities that are authorized by law, providing protective services to the President, making medical suitability determinations for U.S. State Department employees, protecting the health and safety of inmates or employees in a correctional institution,and determining eligibility for or conducting enrollment in certain government benefit programs." OCR Privacy Rule Summary 8 Last Revised 05/03 I - Decedents. Covered entities may disclose protected health information to funeral directors as needed,and to coroners or medical examiners to identify a deceased person,determine the cause of death, and perform other functions authorized by law.ss Cadaveric Organ, Eye, or Tissue Donation. Covered entities may use or disclose protected health information to facilitate the donation and transplantation of cadaveric organs,eyes,and tissue.36 Research. "Research" is any systematic investigation designed to develop or contribute to generalizable knowledge.37 The Privacy Rule permits a covered entity to use and disclose protected health information for research purposes, without an individual's authorization, provided the covered entity obtains either: (1) documentation that an alteration or waiver of individuals' authorization for the use or disclosure of protected health information about them for research purposes has been approved by an Institutional Review Board or Privacy Board; (2) representations from the researcher that the use j or disclosure of the protected health information is solely to prepare a research protocol or for similar purpose preparatory to research, that the researcher will not remove any protected health information from the covered entity, and that protected health information for which access is sought is necessary for the research; or(3)representations from the researcher that the use or disclosure sought is solely for research on the protected health • information of decedents, that the protected health information sought is necessary for the research, and, at the request of the covered entity, documentation of the death of the individuals about whom information is sought.38 A covered entity also may use or disclose, without an individuals' authorization, a limited data set of protected health information for research purposes (see discussion below).39 See OCR "Research" Guidance; NIH Protecting PHI in Research. Serious Threat to Health or Safety. Covered entities may disclose protected health information that they believe is necessary to prevent or lessen a serious and imminent threat to a person or the public, when such disclosure is made to someone they believe can prevent or lessen the threat(including the target of the threat). Covered entities may also disclose to law enforcement if the information is needed to identify or apprehend an escapee or violent criminal ao Essential Government Functions. An authorization is not required to use or disclose protected health information for certain essential government functions. Such functions include: assuring proper execution of a military mission, conducting intelligence and national security activities that are authorized by law, providing protective services to the President, making medical suitability determinations for U.S. State Department employees, protecting the health and safety of inmates or employees in a correctional institution,and determining eligibility for or conducting enrollment in certain government benefit programs.a' OCR Privacy Rule Summary 8 Last Revised 05/03 • Workers' Compensation. Covered entities may disclose protected health information as authorized by, and to comply with, workers' compensation laws and other similar programs providing benefits for work-related injuries or illnesses.42 See OCR"Workers' Compensation"Guidance. (6) Limited Data Set. A limited data set is protected health information from which certain specified direct identifiers of individuals and their relatives, household members, and employers have been removed43 A limited data set may be used and disclosed for research, health care operations, and public health purposes, provided the recipient enters into a data use agreement promising specified safeguards for the protected health information within the limited data set. Authorized Authorization. A covered entity must obtain the individual's written authorization :.1 andfor any use or disclosure of protected health information that is not for treatment, payment or health care operations or otherwise permitted or required by the Privacy DISCIOSure5 Rule. 4 A. covered entity may not condition treatment, payment, enrollment, or benefits eligibility on an individual granting an authorization, except in limited circumstances.as An authorization must be written in specific terms. It may allow use and disclosure of protected health information by the covered entity seeking the authorization, or by a third party. Examples of disclosures that would require an individual's authorization include disclosures to a life insurer for coverage purposes, disclosures • to an employer of the results of a pre-employment physical or lab test, or disclosures to a pharmaceutical firm for their own marketing purposes. All authorizations must be in plain language, and contain specific information regarding the information to be disclosed or used, the person(s) disclosing and receiving the information, expiration, right to revoke in writing, and other data. The Privacy Rule contains transition provisions applicable to authorizations and other express legal permissions obtained prior to April 14,2003.46 Psychotherapy Notes47. A covered entity must obtain an individual's authorization to use or disclose psychotherapy notes with the following exceptions48: • The covered entity who originated the notes may use them for treatment. • A covered entity may use or disclose, without an individual's authorization, the psychotherapy notes, for its own training, and to defend itself in legal proceedings brought by the individual, for HHS to investigate or determine the covered entity's compliance with the Privacy Rules,to avert a serious and imminent threat to public health or safety, to a health oversight agency for lawful oversight of the originator of the psychotherapy notes, for the lawful activities of a coroner or medical examiner or as required by law. Marketing. Marketing is any communication about a product or service that encourages recipients to purchase or.use the product or service49 The Privacy Rule carves out the following health-related activities from this definition of marketing: • Communications to describe health-related products or services, or payment • OCR Privacy Rule Summary 9 Last Revised 05/03 for them, provided by or included in a benefit plan of the covered entity • making the communication; • Communications about participating providers in a provider or health plan network, replacement of or enhancements to a health plan, and health-related products or services available only to a health plan's enrollees that add value to butp are not art of,the benefits plan; • and mm nications for treatment of the individual; Co u • Communications for case management or care coordination for the individual, or to direct or recommend alternative treatments, therapies, health care providers, or care settings to the individual. Marketing also is an arrangement between a covered entity and any other entity whereby the covered entity discloses protected health information, in exchange for direct or indirect remuneration, for the other entity to communicate about its own products or services encouraging the use or purchase of those products or services. A covered entity must obtain an authorization to use or disclose protected health information for marketing, except for face-to-face marketing communications between a covered entity and an individual, and for a covered entity's provision of promotional gifts of nominal value. No authorization is needed, however, to make a communication that falls within one of the exceptions to the marketing definition. An authorization for marketing that involves the covered entity's receipt of direct or indirect remuneration from a third party must reveal that fact. See OCR "Marketing" Guidance. Limiting Uses Minimum Necessary. A central aspect of the Privacy Rule is the principle of • minimum necessary�, use and disclosure. A covered entity must make reasonable :'and Disclosures efforts to use, disclose, and request only the minimum amount of protected health t0 the information needed to accomplish the intended purpose of the use, disclosure, or Minimum request 50 A covered entity must develop and implement policies and procedures to reasonably limit uses and disclosures to the minimum necessary. When the minimum Necessary necessary standard applies to a use or disclosure, a covered entity may not use, disclose, or request the entire medical record for a particular purpose, unless it can specifically justify the whole record as the amount reasonably needed for the purpose. See OCR"Minimum Necessary"Guidance. The minimum necessary requirement is not imposed in any of the following circumstances: (a) disclosure to or a request by a health care provider for treatment; (b) disclosure to an individual who is the subject of the information, or the : individual's personal representative; (c) use or disclosure made pursuant to an authorization; (d) disclosure to HHS for complaint investigation, compliance review or enforcement; (e) use or disclosure that is required by law; or (f) use or disclosure required for compliance with the HIPAA Transactions Rule or other HIPAA Administrative Simplification Rules. Access and Uses. For internal uses, a covered entity must develop and implement policies and procedures that restrict access and uses of protected health information based on the specific roles of the members of their workforce. These policies and procedures must identify the persons, or classes of persons, in the workforce who need access to protected health information to carry out their duties,the categories of • OCR Privacy Rule Summary 10 Last Revised 05/03 • for them, provided by or included in a benefit plan of the covered entity making the communication; • Communications about participating providers in a provider or health plan network, replacement of or enhancements to a health plan, and health-related products or services available only to a health plan's enrollees that add value to,but are not part of,the benefits plan; • Communications for treatment of the individual;and • Communications for case management or care coordination for the individual, or to direct or recommend alternative treatments, therapies, health care providers, or care settings to the individual. Marketing also is an arrangement between a covered entity and any other entity whereby the covered entity discloses protected health information, in exchange for direct or indirect remuneration, for the other entity to communicate about its own products or services encouraging the use or purchase of those products or services. A covered entity must obtain an authorization to use or disclose protected health information "for marketing, except for face-to-face marketing communications between a covered entity and an individual, and for a covered entity's provision of promotional gifts of nominal value. No authorization is needed, however, to make a communication that falls within one of the exceptions to the marketing definition. An authorization for marketing that involves the covered entity's receipt of direct or indirect remuneration from a third party must reveal that fact. See OCR"Marketing," '' Guidance. • ,L><m><hng Minimum Necessary. A central aspect of the Privacy Rule is the principle of Uses. "minimum necessary" use and disclosure. A covered entity must make reasonable and Disclosures efforts to use, disclose, and request only the minimum amount of protected health t0 the information needed to accomplish the intended purpose of the use, disclosure, or request 50 A covered entity must develop and implement policies and procedures to Mlllllllllill reasonably limit uses and disclosures to the minimum necessary. When the minimum NeCeSsal`y necessary standard applies to a use or disclosure, a covered entity may not use, disclose, or request the entire medical record for a particular purpose, unless it can specifically justify the whole record as the amount reasonably needed for the purpose. See OCR"Minimum Necessary"Guidance. The minimum necessary requirement is not imposed in any of the following circumstances: (a) disclosure to or a request by a health care provider for treatment; (b) disclosure to an individual who is the subject of the information, or the individual's personal representative; (c) use or disclosure made pursuant to an authorization; (d) disclosure to HHS for complaint investigation, compliance review or enforcement; (e) use or disclosure that is required by law; or (f) use or disclosure required for compliance with the HIPAA Transactions Rule or other HIPAA Administrative Simplification Rules. Access and Uses. For internal uses, a covered entity must develop and implement policies and procedures that restrict access and uses of protected health information based on the specific roles of the members of their workforce. These policies and procedures must identify the persons, or classes of persons, in the workforce who • need access to protected health information to carry out their duties,the categories of OCR Privacy Rule Summary 10 Last Revised 0510 • protected health information to which access is needed, and any conditions under which they need the information to do their jobs. Disclosures and Requests for Disclosures. Covered entities must establish and implement policies and procedures (which may be standard protocols) for routine, recurring disclosures, or requests for disclosures, that limits the protected health information disclosed to that which is the minimum amount reasonably necessary to achieve the purpose of the disclosure. Individual review of each disclosure is not required. For non-routine, non-recurring disclosures, or requests for disclosures that it makes, covered entities must develop criteria designed to limit disclosures to the information reasonably necessary to accomplish the purpose of the disclosure and review each of these requests individually in accordance with the established criteria. Reasonable Reliance. If another covered entity makes a request for protected health information, a covered entity may rely, if reasonable under the circumstances, on the request as complying with this minimum necessary standard. Similarly, a covered entity may rely upon requests as being the minimum necessary protected health information from: (a) a public official, (b) a professional (such as an attorney or accountant)who is the covered entity's business associate, seeking the information to provide services to or for the covered entity; or (c) a researcher who provides the documentation or representation required by the Privacy Rule for research. NOt1Ce and Privacy Practices Notice. Each covered entity, with certain exceptions, must provide a notice of its privacy practices 51 The Privacy Rule requires that the notice Other • contain certain elements. The notice must describe the ways in which the covered Individual entity may use and disclose protected health information. The notice must state the R><ghtS covered entity's duties to protect privacy, provide a notice of privacy practices, and abide by the terms of the current notice. The notice must describe individuals' rights, including the right to complain to HHS and to the covered entity if they believe their privacy rights have been violated. The notice must include a point of contact for further information and for making complaints to the covered entity. Covered entities must act in accordance with their notices. The Rule also contains specific distribution requirements for direct treatment providers, all other health care providers,and health plans. See OCR"Notice"Guidance. • Notice Distribution. A covered health care provider with a direct treatment relationship with individuals must deliver a privacy practices notice to patients starting April 14,2003 as follows: o Not later than the first service encounter by personal delivery (for patient visits), by automatic and contemporaneous electronic response(for electronic service delivery), and by prompt mailing(for telephonic service delivery); o By posting the notice at each service delivery site in a clear and prominent place where people seeking service may reasonably be expected to be able to read the notice; and o In emergency treatment situations, the provider must furnish its notice as soon as practicable after the emergency abates. • OCR Privacy Rule Summary 11 Last Revised 05/03 Covered entities, whether direct treatment providers or indirect treatment • providers (such as laboratories)or health plans must supply notice to anyone on request.52 A covered entity must also make its notice electronically available on any web site it maintains for customer service or benefits information. The covered entities in an organized health care arrangement may use ajoint privacy practices notice, as long as each agrees to abide by the notice content with respect to the protected health information created or received in connection with participation in the arrangement.53 Distribution of a joint notice by any covered entity participating in the organized health care arrangement at the first point that an OHCA member has an obligation to provide notice satisfies the distribution obligation of the other participants in the organized health care arrangement. A health plan must distribute its privacy practices notice to each of its enrollees by its Privacy Rule compliance date. Thereafter, the health plan must give its notice to each new enrollee at enrollment, and send a reminder to every enrollee at least once every three years that the notice is available upon request. A health plan satisfies its distribution obligation by furnishing the notice to the "named insured," that is, the subscriber.for coverage that also applies to spouses and dependents. • Acknowledgement of Notice Receipt. A covered health care provider with a direct treatment relationship with individuals must make a good faith effort to obtain written acknowledgement from patients of receipt of the privacy • practices notice.54 The Privacy Rule does not prescribe any particular content for the acknowledgement. The provider must document the reason for any failure to obtain the patient's written acknowledgement. The provider is relieved of the need to request acknowledgement in an emergency treatment situation. Access. Except in certain circumstances, individuals have the right to review and obtain a copy of their protected health information in a covered entity's designated record set.55 The "designated record set" is that group of records maintained by or for a covered entity that is used, in whole or part, to make decisions about individuals, or that is a provider's medical and billing records about individuals or a health plan's enrollment, payment, claims adjudication, and case or medical management record systems.56 The Rule excepts from the right of access the following protected health information: psychotherapy notes, information compiled for legal proceedings, laboratory results to which the Clinical Laboratory Improvement Act (CLIA) prohibits access, or information held by certain research laboratories. For information included within the right of access, covered entities may deny an individual access in certain specified situations,such as when a health care professional believes access could cause harm to the individual or another. In such situations, the individual must be given the right to have such denials reviewed by a licensed health care professional for a second opinion.57 Covered entities may impose reasonable,cost-based fees for the cost of copying and postage. Amendment. The Rule gives individuals the right to have covered entities amend their protected health information in a designated record set when that information-Ls- OCR Privacy Rule Summary 12 Last Revised 05/03 i • Covered entities, whether direct treatment providers or indirect treatment providers(such as laboratories)or health plans must supply notice to anyone on request.52 A covered entity must also make its notice electronically available on any web site it maintains for customer service or benefits information. The covered entities in an organized health care arrangement may use a joint privacy practices notice,as long as each agrees to abide by the notice content with respect to the protected health information created or received, in connection with participation in the arrangement.53 Distribution of a joint notice by any covered entity participating in the organized health care arrangement at the first point that an OHCA member has an obligation to provide notice satisfies the distribution obligation of the other participants in the organized health care arrangement. A health plan must distribute its privacy practices notice to each of its enrollees by its Privacy Rule compliance date. Thereafter, the health plan must give its notice to each new enrollee at enrollment, and send a reminder to every enrollee at least once every three years that the notice is available upon request. A health plan satisfies its distribution obligation by furnishing the notice to the "named insured," that is, the subscriber.for coverage that also applies to spouses and dependents. • Acknowledgement of Notice Receipt. A covered health care provider with • a direct treatment relationship with individuals must make a good faith effort to obtain written acknowledgement from patients of receipt of the privacy practices notice.54 The Privacy Rule does not prescribe any particular content for the acknowledgement. The provider must document the reason for any failure to obtain the patient's written acknowledgement. The provider is relieved of the need to request acknowledgement in an emergency treatment situation. Access. Except in certain circumstances, individuals have the right to review and obtain a copy of their protected health information in a covered entity's designated record set.55 The "designated record set" is that group of records maintained by or for a covered entity that is used, in whole or part, to make decisions about individuals, or that is a provider's medical and billing records about individuals or a health plan's enrollment, payment, claims adjudication, and case or medical management record systems.56 The Rule excepts from the right of access the following protected health information: psychotherapy notes, information compiled for legal proceedings, laboratory results to which the Clinical Laboratory Improvement Act (CLIA) prohibits access, or information held by certain research laboratories. For information included within the right of access, covered entities may deny an individual access in certain specified situations,such as when a health care professional believes access could cause harm to the individual or another. In such situations, the individual must be given the right to have such denials reviewed by a licensed health care professional for a second opinion.57 Covered entities may impose reasonable,cost-based fees for the cost of copying and postage. Amendment. The Rule gives individuals the right to have covered entities amend • their protected health information in a designated record set when that information is OCR Privacy Rule Summary 12 Last Revised 05/03 • inaccurate or incomplete. If a covered entity accepts an amendment request,it must make reasonable efforts to provide the amendment to persons that the individual has identified as needing it, and to persons that the covered entity knows might rely on the information to the individual's detriment 59 If the request is denied, covered entities must provide the individual with a written denial and allow the individual to submit a statement of disagreement for inclusion in the record. The Rule specifies processes for requesting and responding to a request for amendment. A covered entity must amend protected health information in its designated record set upon receipt of notice to amend from another covered entity. Disclosure Accounting. Individuals have a right to an accounting of the disclosures of their protected health information by a covered entity or the covered entity's business associates.60 The maximum disclosure accounting period is the six years immediately preceding the accounting request, except a covered entity is not obligated to account for any disclosure made before its Privacy Rule compliance date. The Privacy Rule does not require accounting for disclosures: (a) for treatment, payment, or health care operations; (b) to the individual or the individual's personal representative; (c) for notification of or to persons involved in an individual's health care or payment for health care, for disaster relief, or for facility directories; (d) pursuant to an authorization; (e) of a limited data set; (f) for national security or intelligence purposes; (g)to correctional institutions or law enforcement officials for certain purposes regarding inmates or individuals in lawful custody; or(h)incident to otherwise permitted or required uses or disclosures. Accounting for disclosures to health oversight agencies and law enforcement officials must be temporarily • suspended on their written representation that an accounting would likely impede their activities. Restriction Request. Individuals have the right to request that a covered entity restrict use or disclosure of protected health information for treatment, payment or health care operations, disclosure to persons involved in the individual's health care or payment for health care,or disclosure to notify family members or others about the individual's general condition, location, or death 61 A covered entity is under no obligation to agree to requests for restrictions. A covered entity that does agree must comply with the agreed restrictions,except for purposes of treating the individual in a medical emergency.62 Confidential Communications Requirements. Health plans and covered health care providers must permit individuals to request an alternative means or location for receiving communications of protected health information by means other than those that the covered entity typically employs. 3 For example, an individual may request that the provider communicate with the individual through a designated address or phone number. Similarly, an individual may request that the provider send communications in a closed envelope rather than a post card. Health plans must accommodate reasonable requests if the individual indicates that the disclosure of all or part of the protected health information could endanger the individual. The health plan may not question the individual's statement of endangerment. Any covered entity may condition compliance with a confidential communication request on the individual specifying an alternative address or method • of contact and explaining how any payment will be handled. OCR Privacy Rule Summary 13 Last Revised 05/03 Administrative HHS recognizes that covered entities range from the smallest provider to the largest, • multi-state health plan. Therefore the flexibility and scalability of the Rule are Requirements intended to allow covered entities to analyze their own needs and implement solutions appropriate for their own environment. What is appropriate for a particular covered entity will depend on the nature of the covered entity's business, as well as the covered entity's size and resources. Privacy Policies and Procedures. A covered entity must develop and implement written privacy policies and procedures that are consistent with the Privacy Rule.64 Privacy Personnel. A covered entity must designate a privacy official responsible for developing and implementing its privacy policies and procedures, and a contact person or contact office responsible for receiving complaints and providing individuals with information on the covered entity's privacy practices.61 Workforce Training and Management. Workforce members include employees, volunteers, trainees, and may also include other persons whose conduct is under the direct control of the entity (whether or not they are paid by the entity).66 A covered entity must train all workforce members on its privacy policies and procedures, as necessary and appropriate for them to carry out their functions. 7 A covered entity must have and apply appropriate sanctions against workforce members who violate its privacy policies and procedures or the Privacy Rule.68 Mitigation. A covered entity must mitigate, to the extent practicable, any harmful effect it learns was caused by use or disclosure of protected health information by its • workforce or its business associates in violation of its privacy policies and procedures or the Privacy Rule.69 Data Safeguards. A covered entity must maintain reasonable and appropriate administrative, technical, and physical safeguards to prevent intentional or unintentional use or disclosure of protected health information in violation of the Privacy Rule and to limit its incidental use and disclosure pursuant to otherwise permitted or required use or disclosure.70 For example, such safeguards might include shredding documents containing protected health information before discarding them, securing medical records with lock and key or pass code, and limiting access to keys or pass codes. See OCR "Incidental Uses and Disclosures" Guidance. Complaints. A covered entity must have procedures for individuals to complain about its compliance with its privacy policies and procedures and the Privacy Rule." The covered entity must explain those procedures in its privacy practices notice.'Z Among other things, the covered entity must identify to whom individuals can submit complaints to at the covered entity and advise that complaints also can be submitted to the Secretary of HHS. Retaliation and Waiver. A covered entity may not retaliate against a person for exercising rights provided by the Privacy Rule, for assisting in an investigation by HHS or another appropriate authority, or for opposing an act or practice that the person believes in good faith violates the Privacy Rule.73 A covered entity may not • OCR Privacy Rule Summary 14 Last Revised 05/03 HHS recognizes that covered entities range from the smallest provider to the largest,Admin>istra>hve _ gn� p g , multi-state health plan. Therefore the flexibility and scalability of the Rule are Requirements intended to allow covered entities to analyze their own needs and implement solutions appropriate for their own environment. What is appropriate for a particular covered entity will depend on the nature of the covered entity's business, as well as the covered entity's size and resources. Privacy Policies and Procedures. A covered entity must develop and implement written privacy policies and procedures that are consistent with the Privacy Rule.64 Privacy Personnel. A covered entity must designate a privacy official responsible for developing and implementing its privacy policies and procedures, and a contact person or contact office responsible for receiving complaints and providing individuals with information on the covered entity's privacy practices.65 Workforce Training and Management. Workforce members include employees, volunteers, trainees, and may also include other persons whose conduct is under the direct control of the entity(whether or not they are paid by the entity)66 A covered entity must train all workforce members on its privacy policies and procedures, as necessary and appropriate for them to carry out their functions. 7 A covered entity must have and apply appropriate sanctions against workforce members who violate ` its privacy policies and procedures or the Privacy Rule.68 • Mitigation. A covered entity must mitigate, to the extent practicable, any harmful effect it learns was caused by use or disclosure of protected health information by its workforce or its business associates in violation of its privacy policies and procedures or the Privacy Rule 69 Data Safeguards. A covered entity must maintain reasonable and appropriate administrative, technical, and physical safeguards to prevent intentional or unintentional use or disclosure of protected health information in violation of the Privacy Rule and to limit its incidental use and disclosure pursuant to otherwise permitted or required use or disclosure.70 For example, such safeguards might include shredding documents containing protected health information before discarding them, securing medical records with lock and key or pass code, and limiting access to keys or pass codes. See OCR "Incidental Uses and Disclosures" Guidance. Complaints. A covered entity must have procedures for individuals to complain - about its compliance with its privacy policies and procedures and the Privacy Rule.71 The covered entity must explain those procedures in its privacy practices notice.'Z Among other things,the covered entity must identify to whom individuals can submit complaints to at the covered entity and advise that complaints also can be submitted to the Secretary of HHS. Retaliation and Waiver. A covered entity may not retaliate against a person for exercising rights provided by the Privacy Rule, for assisting in an investigation by HHS or another appropriate authority, or for opposing an act or practice that the • person believes in good faith violates the Privacy Rule.73 A covered entity may not -� OCR Privacy Rule Summary 14 Last Revised 05/03 • require an individual to waive any right under the Privacy Rule as a condition for obtaining treatment,payment,and enrollment or benefits eligibility.74 Documentation and Record Retention. A covered entity must maintain, until six years after the later of the date of their creation or last effective date, its privacy policies and procedures, its privacy practices notices, disposition of complaints, and other actions, activities, and designations that the Privacy Rule requires to be documented.75 Fully-Insured Group Health Plan Exception. The only administrative obligations with which a fully-insured group health plan that has no more than enrollment data and summary health information is required to comply are the (1) ban on retaliatory acts and waiver of individual rights,and(2)documentation requirements with respect to plan documents if such documents are amended to provide for the disclosure of protected health information to the plan sponsor by a health insurance issuer or HMO that services the group health plan.76 -Organizational The Rule contains provisions that address a variety of organizational issues that may Options affect the operation of the privacy protections. Hybrid Entity. The Privacy Rule permits a covered entity that is a single legal entity and that conducts both covered and non-covered functions to elect to be a "hybrid entity."77 (The activities that make a person or organization a covered entity are its "covered functions.,78) To be a hybrid entity, the covered entity must designate in • writing its operations that perform covered functions as one or more "health care components."After making this designation,most of the requirements of the Privacy Rule will apply only to the health care components. A covered entity that does not make this designation is subject in its entirety to the Privacy Rule. Affiliated Covered Entity. Legally separate covered entities that are affiliated by common ownership or control may designate themselves (including their health care components) as a single covered entity for Privacy Rule compliance.79 The designation must be in writing. An affiliated covered entity that performs multiple covered functions must operate its different covered functions in compliance with the Privacy Rule provisions applicable to those covered functions. Organized Health Care Arrangement. The Privacy Rule identifies relationships in which participating covered entities share protected health information to manage and benefit their common enterprise as"organized health care arrangements."80 Covered entities in an organized health care arrangement can share protected health information with each other for the arrangement's joint health care operations.$' Covered Entities With Multiple Covered Functions. A covered entity that performs multiple covered functions must operate its different covered functions in compliance with the Privacy Rule provisions applicable to those covered functions 82 The covered entity may not use or disclose the protected health information of an individual who receives services from one covered function (e.g., health care provider) for another covered function (e.g., health plan) if the individual is not involved with the other function. • OCR Privacy Rule Summary 15 Last Revised 05/03 • Group Health Plan disclosures to Plan Sponsors. A group health plan and the health insurer or HMO offered by the plan may disclose the following protected health information to the "plan sponsor"—the employer, union, or other employee organization that sponsors and maintains the group health plan83: • Enrollment or disenrollment information with respect to the group health plan or a health insurer or HMO offered by the plan. • If requested by the plan sponsor, summary health information for the plan sponsor to use to obtain premium bids for providing health insurance coverage through the group health plan, or to modify, amend, or terminate the group health plan. "Summary health information" is information that summarizes claims history, claims expenses, or types of claims experience of the individuals for whom the plan sponsor has provided health benefits through the group health plan, and that is stripped of all individual identifiers other than five digit zip code (though it need not qualify as de-identified protected health information). • Protected health information of the group health plan's enrollees for the plan sponsor to perform plan administration functions. The plan must receive certification from the plan sponsor that the group health plan document has been amended to impose restrictions on the plan sponsor's use and disclosure of the protected health information. These restrictions must include the representation that the plan sponsor will not use or disclose the protected health information for any employment-related action or decision or in connection with any other benefit plan. • Other Personal Representatives. The Privacy Rule requires a covered entity to treat a 'personal representative" the same as the individual, with respect to uses and Provisions: disclosures of the individual's protected health information, as well as the Personal individual's rights under the Rule.84 A personal representative is a person legally authorized to make health care decisions on an individual's behalf or to act for a Representatives deceased individual or the estate. The Privacy Rule permits an exception when a and Minors covered entity has a reasonable belief that the personal representative may be abusing or neglecting the individual, or that treating the person as the personal representative could otherwise endanger the individual. Special case: Minors. In most cases, parents are the personal representatives for their minor children. Therefore, in most cases,parents can exercise individual rights, such as access to the medical record, on behalf of their minor children. In certain exceptional cases, the parent is not considered the personal representative. In these situations, the Privacy Rule defers to State and other law to determine the rights of parents to access and control the protected health information of their minor children. If State and other law is silent concerning parental access to the minor's protected health information, a covered entity has discretion to provide or deny a parent access to the minor's health information, provided the decision is made by a licensed health care professional in the exercise of professional judgment. See OCR "Personal Representatives"Guidance. • OCR Privacy Rule Summary 16 Last Revised 05/03 • uested by the plan sponsor, summary health information for the • Wor to use to obtain premium bids for providing health insuraW coverage through the group health plan, or to modify, amend, or terminate the group health plan. "Summary health information" is information that summarizes claims history, claims expenses,or types of claims experience of the individuals for whom the plan sponsor has provided health benefits through the group health plan, and that is stripped of all individual identifiers other than five digit zip code (though it need not qualify as de-identified protected health information). • Protected health information of the group health plan's enrollees for the plan sponsor to perform plan administration functions. The plan must receive certification from the plan sponsor that the group health plan document has been amended to impose restrictions on the plan sponsor's use and disclosure of the protected health information. These restrictions must include the representation that the plan sponsor will not use or disclose the protected health information for any employment-related action or decision or in connection with any other benefit plan. Other Personal Representatives. The Privacy Rule requires a covered entity to treat a 'personal representative" the same as the individual, with respect to uses and PrOvisions:. disclosures of the individual's protected health information, as well as the PerSOilal individual's rights under the Rule.84 A personal representative is a person legally ' . authorized to make health care decisions on an individual's behalf or to act for a Re resentat><ves P,:> deceased individual or the estate. The Privacy Rule permits an exception when a and Minors covered entity has a reasonable belief that the personal representative may be abusing or neglecting the individual, or that treating the person as the personal representative could otherwise endanger the individual Special case: Minors. In most cases, parents are the personal representatives for their minor children. Therefore, in most cases,parents can exercise individual rights, such as access to the medical record, on behalf of their minor children. In certain exceptional cases, the parent is not considered the personal representative. In these situations, the Privacy Rule defers to State and other law to determine the rights of parents to access and control the protected health information.of their minor children. If State and other law is silent concerning parental access to the minor's protected health information, a covered entity has discretion to provide or deny a parent access to the minor's health information, provided the decision is made by a licensed health care professional in the exercise of professional judgment. See OCR "Personal Representatives"Guidance. OCR Privacy Rule Summary 16 Last Revised 05/03 • State Law Preemption. In general, State laws that are contrary to the Privacy Rule are preempted by the federal requirements, which means that the federal requirements will apply.85 "Contrary" means that it would be impossible for a covered entity to comply with both the State and federal requirements, or that the provision of State law is an obstacle to accomplishing the full purposes and objectives of the Administrative Simplification provisions of HIPAA.86 The Privacy Rule provides exceptions to the general rule of federal preemption for contrary State laws that (1) relate to the privacy of individually identifiable health information and provide greater privacy protections or privacy rights with respect to such information, (2) provide for the reporting of disease or injury, child abuse, birth, or death, or for public health surveillance, investigation, or intervention, or (3) require certain health plan reporting, such as for management or financial audits. Exception Determination. In addition, preemption of a contrary State law will not occur if HHS determines, in response to a request from a State or other entity or person,that the State law: • Is necessary to prevent fraud and abuse related to the provision of or payment for health care, • Is necessary.to ensure appropriate State regulation of insurance and health plans to the extent expressly authorized by statute or regulation, • Is necessary for State reporting on health care delivery or costs, • Is necessary for purposes of serving a compelling public health, safety, or • welfare need, and, if a Privacy Rule provision is at issue, if the Secretary determines that the intrusion into privacy is warranted when balanced against the need to be served; or • Has as its principal purpose the regulation of the manufacture, registration, distribution, dispensing, or other control of any controlled substances (as defined in 21 U.S.C. 802), or that is deemed a controlled substance by State law. Enforcement Compliance. Consistent with the principles for achieving compliance provided in the Rule, HHS will seek the cooperation of covered entities and may provide and Penalties technical assistance to help them comply voluntarily with the Rule$' The Rule for provides processes for persons to file complaints with HHS, describes the Noncompliance responsibilities of covered entities to provide records and compliance reports and to cooperate with, and permit access to information for, investigations and compliance reviews. Civil Money Penalties. HHS may impose civil money penalties on a covered entity of$100 per failure to comply with a Privacy Rule requirement.$$ That penalty may not exceed $25,000 per year for multiple violations of the identical Privacy Rule requirement in a calendar year. HHS may not impose a civil money penalty under specific circumstances, such as when a violation is due to reasonable cause and did not involve willful neglect and the covered entity corrected the violation within 30 days of when it knew or should have known of the violation. • OCR Privacy Rule Summary 17 Last Revised 05/03 Criminal Penalties. A person who knowingly obtains or discloses individually • identifiable health information in violation of HIPAA faces a fine of$50,000 and up to one-year imprisonment89 The criminal penalties increase to $100,000 and up to five years imprisonment if the wrongful conduct involves false pretenses, and to $250,000 and up to ten years imprisonment if the wrongful conduct involves the intent to sell, transfer, or use individually identifiable health information for commercial advantage, personal gain, or malicious harm. Criminal sanctions will be enforced by the Department of Justice. COIIlplia.11Ce+ Compliance Schedule. All covered entities, except "small health plans," must be compliant with the Privacy Rule by April 14, 2003.90 Small health plans, however, Dates have until April 14,2004 to comply. Small Health Plans. A health plan with annual receipts of not more than $5 million is a small health plan 91 Health plans that file certain federal tax returns and report receipts on those returns should use the guidance provided by the Small Business Administration at 13 Code of Federal Regulations (CFR) 121.104 to calculate annual receipts. Health plans that do not report receipts to the Internal Revenue Service (IRS), for example, group health plans regulated by the Employee Retirement Income Security Act 1974 (ERISA) that are exempt from filing income tax returns, should use proxy measures to determine their annual receipts.92 See What constitutes a small health pan? iti • ;COp1eS Of the:. The entire Privacy Rule, as well as guidance and additional materials y ma be found on our website,http://www.hhs.gov/ocr/hipaa. Rule A.Related Materials OCR Privacy Rule Summary 18 Last Revised 05/03 • Criminal Penalties: A person who knowingly obtains or discloses individually p g y dually _ identifiable health information in violation of HIPAA faces a fine of$50,000 and up to one-year imprisonment.89 The criminal penalties increase to $100,000 and up to five years imprisonment if the wrongful conduct involves false pretenses, and to $250,000 and up to ten years imprisonment if the wrongful conduct involves the intent to sell, transfer, or use individually identifiable health information for commercial advantage, personal gain, or malicious harm. Criminal sanctions will be enforced by the Department of Justice. Compliance Compliance Schedule. All covered entities, except "small health plans," must be compliant with the Privacy Rule by April 14, 2003.90 Small health plans, however, 1)ate5 have until April 14,2004 to comply. R Small Health Plans. A health plan with annual receipts of not more than $5 million is a small health plan 91 Health plans that file certain federal tax returns and report receipts on those returns should use the guidance provided by the Small Business Administration at 13 Code of Federal Regulations(CFR) 121.104 to calculate annual receipts. Health plans that do not report receipts to the Internal Revenue Service (IRS),for example,group health plans regulated by the Employee Retirement Income Security Act 1974 (ERISA) that are exempt from filing income tax returns, should 92 use proxy measures to determine their annual receipts. See What constitutes a small health plan? • CO lea Of the The entire Privacy Rule, as well as guidance and additional materials, may be found p _ on our website'http://www.hhs.gov/ocr/1-iii)aa. Rule & Related�� Materials OCR Privacy Rule Summary 18 Last Revised 05/03 End Notes 'Pub.L. 104-191. 2 65 FR 82462. '67 FR 53182. 4 45 C.F.R.§§ 160.102, 160.103. 5 Even if an entity, such as a community health center, does not meet the definition of a health plan, it may, nonetheless,meet the definition of a health care provider, and, if it transmits health information in electronic form in connection with the transactions for which the Secretary of HHS has adopted standards under HIPAA,may still be a covered entity. 6 45 C.F.R. §§ 160:102, 160.103;see Social Security Act§ 1172(a)(3),42 U.S.C. § 1320d-l(a)(3). The transaction standards are established by the HIPAA Transactions Rule at 45 C.F.R.Part 162. '45 C.F.R.§ 160.103. '45 C.F.R. § 164.500(b). 9 45 C.F.R. § 160.103. 10 45 C.F.R.§§ 164.502(e), 164.504(e). " 45 C.F.R. § 164.532 12 45 C.F.R. § 160.103. • "45 C.F.R.§ 160.103 14 45 C.F.R.§§ 164.502(d)(2), 164.514(a)and(b). 15 The following identifiers of the individual or of relatives,employers,or household members of the individual must be removed to achieve the "safe harbor" method of de-identification: (A) Names; (B) All geographic subdivisions smaller than 'a State, including street address, city, county,precinct,zip code,and their equivalent geocodes,except for the initial three digits of a zip code if, according to the current publicly available data from the Bureau of Census (1) the geographic units formed by combining all zip codes with the same three initial digits contains more than 20,000 people; and(2)the initial three digits of a zip code for all such geographic units containing 20,000 or fewer people is changed to 000; (C) All elements of dates(except year)for dates directly related to the individual,including birth date,admission date,discharge date,date of death;and all ages over 89 and all elements of dates(including year)indicative of such age,except that such ages and elements may be aggregated into a single category of age 90 or older; (D) Telephone numbers;(E)Fax numbers;(F)Electronic mail addresses: (G)Social security numbers; (H) Medical record numbers; (I) Health plan beneficiary numbers; (J) Account numbers; (K) Certificate/license numbers; (L) Vehicle identifiers and serial numbers, including license plate numbers; (M) Device identifiers and serial numbers; (N) Web Universal Resource Locators (URLs); (0) Internet Protocol (IP) address numbers; (P) Biometric identifiers, including finger and voice prints; (Q)Full face photographic images and any comparable images; and®any other unique identifying number, characteristic, or code, except as permitted for re-identification purposes provided certain conditions are met. In addition to the removal of the above-stated identifiers,the covered entity may not have actual knowledge that the remaining information could be used alone or in combination with any other information to identify an individual who is subject of the information. 45 C.F.R. § 164.514(b). 16 45 C.F.R. § 164.502(a). • "45 C.F.R. § 164;502(a)(2). OCR Privacy Rule Summary 19 Last Revised 05/03 '$45 C.F.R. § 164.502(a)(1). • 19 45 C.F.R. § 164.506(c). 20 45 C.F.R. § 164.501. 2' 45 C.F.R.§ 164.501. 22 45 C.F.R. § 164.501. 23 45 C.F.R. § 164.508(a)(2) 24 45 C.F.R. § 164.506(b). 2s 45 C.F.R. § 164.510(a). 26 45 C.F.R. § 164.510(b). 27 45 C.F.R. §§ 164.502(a)(1)(iii). 28 See 45 C.F.R. § 164.512. 29 45 C.F.R.§ 164.512(a). 30 45 C.F.R.§ 164.512(b). 31 45 C.F.R. § 164.512(a),(c). 32 45 C.F.R. § 164.512(d). 33 45 C.F.R. § 164.512(e). 34 45 C.F.R. § 164.512(f). 35 45 C.F.R. § 164.512(g). • 36 45 C.F.R. § 164.512(h). 3' The Privacy Rule defines research as, "a systematic investigation, including research development, testing, and evaluation, designed to develop or contribute to generalizable knowledge."45 C.F.R. § 164.501. 38 45 C.F.R.§ 164.512(i). 39 45 CFR§ 164.514(e). 4°45 C.F.R.§ 164.5120). 4' 45 C.F.R. § 164.512(k). 42 45 C.F.R. § 164.512(1). 43 45 C.F.R. § 164.514(e). A limited data set is protected health information that excludes the following direct identifiers of the individual or of relatives, employers, or household members of the individual: (i)Names; (ii) Postal address information, other than town or city, State and zip code; (iii) Telephone numbers; (iv) Fax numbers; (v) Electronic mail addresses: (vi) Social security numbers; (vii) Medical record numbers; (viii) Health plan beneficiary numbers; (ix) Account numbers; (x) Certificate/license numbers; (xi) Vehicle identifiers and serial numbers, including license plate numbers; (xii)Device identifiers and serial numbers; (xiii)Web Universal Resource Locators (URLs); (xiv) Internet Protocol (IP) address numbers; (xv) Biometric identifiers, including finger and voice prints; (xvi) Full face photographic images and any comparable images. 45 C.F.R. § 164.514(e)(2). 44 45 C.F.R.§ 164.508. 45 A covered entity may condition the provision of health care solely to generate protected health information for disclosure to a third party on the individual giving authorization to disclose the • OCR Privacy Rule Summary 20 Last Revised 05/03 '$45 C.F.R.§ 164.502(a)(1). ) 19 45 C.F.R.§ 164.506(c). 2' 45 C.F.R.§ 164.501. 2' 45 C.F.R.§ 164.501. 22 45 C.F.R. § 164.501. 23 45 C.F.R.§ 164.508(a)(2) 24 45 C.F.R. § 164.506(b). 2s 45 C.F.R. § 164.510(a). 26 45 C.F.R.§ 164.510(b). 2'45 C.F.R.§§ 164.502(a)(1)(iii). 26 See 45 C.F.R. § 164.512. 29 45 C.F.R.§ 164.512(a). 30 45 C.F.R.§ 164.512(b). 31 45 C.F.R.§ 164.512(a),(c). 32 45 C.F.R.§ 164.512(d). 33 45 C.F.R. § 164.512(e). sa 45 C.F.R.§ 164.512(f). • ss 45 C.F.R.§ 164.512(g). 36 45 C.F.R.§ 164.512(h). 3' The Privacy Rule defines research as, "a systematic investigation, including research development, testing, and evaluation, designed to develop or contribute to generalizable knowledge."45 C.F.R. § 164.501. 38 45 C.F.R.§ 164.512(i). 39 45 CFR§ 164.514(e). 40 45 C.F.R.§ 164.5126). 41 45 C.F.R.§ 164.512(k). 42 45 C.F.R.§ 164.512(l). 43 45 C.F.R. § 164.514(e). A limited data set is protected health information that excludes the following direct identifiers of the individual or of relatives, employers, or household members of the individual: (i)Names; (ii) Postal address information, other than town or city, State and zip code; (iii) Telephone numbers; (iv) Fax numbers; (v) Electronic mail addresses: (vi) Social security numbers; (vii) Medical record numbers; (viii) Health plan beneficiary numbers; (ix) Account numbers; (x) Certificate/license numbers; (xi) Vehicle identifiers and serial numbers, including license plate numbers; (xii)Device identifiers and serial numbers;,(xiii)Web Universal Resource Locators (URLs); (xiv) Internet Protocol (IP) address numbers; (xv) Biometric identifiers, including finger and voice prints; (xvi) Full face photographic images and any comparable images. 45 C.F.R. § 164.514(e)(2). as 45 C.F.R. § 164.508. 45 A covered entity may condition the provision of health care solely to generate protected health information for disclosure to a third party on the individual giving authorization to disclose the OCR Privacy Rule Summary 20 Last Revised 05/03 • information to the third party. For example,a covered entity physician may condition the provision of a physical examination to be paid for by a life insurance issuer on an individual's authorization to disclose the results of that examination to the life insurance issuer. A health plan may condition enrollment or benefits eligibility on the individual giving authorization,requested before the individual's enrollment,to obtain protected health information(other than psychotherapy notes)to determine the individual's eligibility or enrollment or for underwriting or risk rating. A covered health care provider may condition treatment related to research(e.g., clinical trials)on the individual giving authorization to use or disclose the individual's protected health information for the research. 45 C.F.R.508(b)(4). 46 45 CFR§ 164.532. 4'"Psychotherapy notes"means notes recorded(in any medium)by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group,joint, or family counseling session and that are separated from the rest of the of the individual's medical record. Psychotherapy notes excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis,functional status,the treatment plan, symptoms,prognosis,and progress to date. 45 C.F.R.§ 164.501. 48 45 C.F.R.§ 164.508(a)(2). 49 45 C.F.R.§§ 164.501 and 164.508(a)(3). so 45 C.F.R. §§ 164.502(b)and 164.514(d). 51 45 C.F.R. §§ 164.520(a)and(b). A group health plan,or a health insurer or HMO with respect to the group health plan, that intends to disclose protected health information (including • enrollment data or summary health information) to the plan sponsor, must state that fact in the notice. Special statements are also required in the notice if a covered entity intends to contact individuals about health-related benefits or services, treatment alternatives, or appointment reminders,or for the covered entity's own fundraising. 12 45 C.F.R. §164.520(c). "45 C.F.R. § 164.520(d). 14 45 C.F.R.§ 164.520(c). ss 45 C.F.R.§ 164.524. 16 45 C.F.R. § 164.501. 57 A covered entity may deny an individual access,provided that the individual is given a right to have such denials reviewed by a licensed health care professional(who is designated by the covered entity and who did not participate in the original decision to deny),when a licensed health care professional has determined,in the exercise of professional judgment,that: (a)the access requested is reasonably likely to endanger the life or physical safety of the individual or another person;(b)the protected health information makes reference to another person(unless such other person is a health care provider)and the access requested is reasonably likely to cause substantial harm to such other person;or(c)the request for access is made by the individual's personal representative and the provision of access to such personal representative is reasonably likely to cause substantial harm to the individual or another person. A covered entity may deny access to individuals,without providing the individual an opportunity for review,in the following protected situations: (a)the protected health information falls under an exception to the right of access;(b)an inmate request for protected health information under certain circumstances;(c)information that a provider creates or obtains in the course of research that includes treatment for which the individual has agreed not to have access as part of consenting • OCR Privacy Rule Summary 21 Last Revised 05/03 to participate in the research(as long as access to the information is restored upon completion of • the research);(d)for records subject to the Privacy Act,information to which access may be denied under the Privacy Act,5 U.S.C.§552a;and(e)information obtained under a promise of confidentiality from a source other than a health care provider,if granting access would likely reveal the source. 45 C.F.R. § 164.524. 58 45 C.F.R. § 164.526. 59 Covered entities may deny an individual's request for amendment only under specified circumstances. A covered entity may deny the request if it: (a)may exclude the information from access by the individual; (b) did not create the information (unless the individual provides a reasonable basis to believe the originator is no longer available),---(c)--determines--that-the information is accurate and complete;or(d)does not hold the information in its designated record set. 164.526(a)(2). 60 45 C.F.R. § 164.528. 61 45 C.F.R. § 164.522(a). 62 45 C.F.R. § 164.522(a). In addition, a restriction agreed to by a covered entity is not effective under this subpart to prevent uses or disclosures permitted or required under §§ 164.502(a)(2)(ii), 164.510(a)or 164.512. 63 45 C.F.R. § 164.522(b). 64 45 C.F.R. § 164.530(i). 66 45 C.F.R. § 164.530(a). 66 45 C.F.R. §160.103. 67 45 C.F.R. § 164.530(b). • 68 45 C.F.R. § 164.530(e). 69 45 C.F.R. § 164.530(f). 70 45 C.F.R. § 164.530(c). " 45 C.F.R. § 164.530(d). 'Z 45 C.F.R. § 164.520(b)(1)(vi). 73 45 C.F.R. § 164.530(g). 74 45 C.F.R. § 164.530(h). 75 45 C.F.R. § 164.5300). 76 45 C.F.R. § 164.530(k). " 45 C.F.R. §§ 164.103,164.105. 78 45 C.F.R. § 164.103. 79 45 C.F.R. §164.105. Common ownership exists if an entity possesses an ownership or equity interest of five percent or more in another entity; common control exists if an entity has the direct or indirect power significantly to influence or direct the actions or policies of another entity. 45 C.F.R. §§ 164.103. 80 The Privacy Rule at 45 C.F.R. § 160.103 identifies five types of organized health care arrangements: • A clinically-integrated setting where individuals typically receive health care from more than one provider. • An organized system of health care in which the participating covered entities hold themselves out to the public as part of a joint arrangement and jointly engage in • OCR Privacy Rule Summary 22 Last Revised 05/03 to participate in the research(as long as access to the information is restored completion upon of P the research);(d)for records subject to the Privacy Act,information to which access may be denied under the Privacy Act,5 U.S.C.§552a;and(e)information obtained under a promise of confidentiality from a source other than a health care provider,if granting access would likely reveal the source. 45 C.F.R.§ 164.524. 58 45 C.F.R.§ 164.526. 59 Covered entities may deny an individual's request for amendment only under specified circumstances. A covered entity may deny the request if it: (a)may exclude the information from access by the individual; (b) did not create the information (unless the individual provides a reasonable basis to believe the originator is no longer available);-(c)—determines--that---the information is accurate and complete;or(d)does not hold the information in its designated record set. 164.526(a)(2). 60 45 C.F.R. § 164.528. 6' 45 C.F.R. § 164.522(a). 62 45 C.F.R. § 164.522(a). In addition, a restriction agreed to by a covered entity is not effective under this subpart to prevent uses or disclosures permitted or required under§§ 164.502(a)(2)(ii), 164.510(a)or 164.512. 63 45 C.F.R.§ 164.522(b). 64 45 C.F.R.§ 164.530(i). 6s 45 C.F.R. § 164.530(a). 66 45 C.F.R. §160.103. • 67 45 C.F.R. § 164.530(b). 68 45 C.F.R. § 164.530(e). 69 45 C.F.R. § 164.530(f). 70 45 C.F.R. § 164.530(c). 71 45 C.F.R. § 164.530(d). 7245 C.F.R.§ 164.520(b)(1)(vi). 73 45 C.F.R. § 164.530(g). 74 45 C.F.R. § 164.530(h). 75 45 C.F.R.§ 164.5300). 76 45 C.F.R.§ 164.530(k). 77 45 C.F.R. §§ 164.103,164.105. 78 45 C.F.R.§ 164.103. 79 45 C.F.R. §164.105. Common ownership exists if an entity possesses an ownership or equity interest of five percent or more in another entity;common control exists if an entity has the direct or indirect power significantly to influence or direct the actions or policies of another entity. 45 C.F.R. §§ 164.103. 80 The Privacy Rule at 45 C.F.R.§ 160.103 identifies five types of organized health care arrangements: • A clinically-integrated setting where individuals typically receive health care from more than one provider. • An organized system of health care in which the participating covered entities hold themselves out to the public as part of a joint arrangement and jointly engage in OCR Privacy Rule Summary 22 Last Revised 05/03 • utilization review,quality assessment and improvement activities,or risk-sharing payment activities. • A group health plan and the health insurer or HMO that insures the plan's benefits,with respect to protected health information created or received by the insurer or HMO that relates to individuals who are or have been participants or beneficiaries of the group health plan. • All group health plans maintained by the same plan sponsor. • All group health plans maintained by the same plan sponsor and all health insurers and HMOs that insure the plans'benefits,with respect to protected health information created or received by the insurers or HMOs that relates to individuals who are or have been participants or beneficiaries in the group health plans. 81 45 C.F.R. § 164.506(c)(5). az 45 C.F.R. § 164.504(g). as 45 C.F.R.§ 164.504 . sa 45 C.F.R.§ 164.502(g). ss 45 C.F.R. §160.203. 86 45 C.F.R.§ 160.202. 87 45 C.F.R.§ 160.304 s8 Pub.L. 104-191;42 U.S.C. §1320d-5. s9 Pub.L. 104-191;42 U.S.C. §1320d-6. 90 45 C.F.R. § 164.534. • 9i 45 C.F.R. § 160.103. 92 Fully insured health plans should use the amount of total premiums that they paid for health insurance benefits during the plan's last full fiscal year. Self-insured plans, both funded and unfunded,should use the total amount paid for health care claims by the employer,plan sponsor or benefit fund,as applicable to their circumstances, on behalf of the plan during the plan's last full fiscal year. Those plans that provide health benefits through a mix of purchased insurance and self-insurance should combine proxy measures to determine their total annual receipts. OCR Privacy Rule Summary 23 Last Revised 05/03 Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and ... Pagel of 5 f Centers for Disease Control and Prevention Morbidi and CDC 24/7,Savhg lives_Protecting P ple.Th9 Mortality Weekly Report (MMWR) Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis (Tdap) Vaccine in Adults Aged 65 Years and Older — Advisory Committee on Immunization Practices (ACIP), 2012 .................................................................................................................................................................................................................................................................................................................................................................. Weekly June 29, 2012/ 61(25);468-470 Since 2005,the Advisory Committee on Immunization Practices (ACIP)has recommended a tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap)vaccine booster dose. for all adolescents aged 11 through 18 years (preferred at 11 through 12 years) and for those adults aged 19 through 64 years who have not yet received a dose (1,22). In October 2010, despite the lack of an approved Tdap vaccine for adults aged 65 years and older,ACIP recommended that unvaccinated adults aged 65 years and older be vaccinated with Tdap if in • close contact with an infant, and that other adults aged 65 years and older may receive Tdap (3). In July 2011,the Food and Drug Administration (FDA) approved expanding the age indication for Boostrix (GlaxoSmithKline Biologicals, Rixensart, Belgium) to aged 65 years and older (4). In February 2012,ACIP recommended Tdap for all adults aged 65 years and older. This recommendation supersedes previous Tdap recommendations regarding adults aged 65 years and older. The Pertussis Vaccines Work Group of ACIP reviewed the epidemiology of pertussis in adults aged 65 years and older and two cost-effectiveness models to assess the epidemiologic and economic impact of pertussis vaccination in this population. The Work Group also considered safety and immunogenicity data from clinical trials and observational studies on the use of Tdap in adults aged 65 years and older (3). The two Tdap vaccines available in the United States, Boostrix and Adacel (Sanofi Pasteur, Toronto, Canada), differ in composition and approved age for use Table). Only Boostrix is approved for adults aged 65 years and older;however,ACIP discussed the use of Adacel in this age group. On February 22, 2012,ACIP approved use of Tdap for all adults aged 65 years and older. This report summarizes data considered and conclusions made by ACIP and provides guidance for implementing the recommendation. The Pertussis Vaccines Work Group of ACIP reviewed the epidemiology of pertussis in adults aged 65 years and older and two cost-effectiveness models to assess the epidemiologic and economic impact of pertussis vaccination in this population. The Work Group also considered • safety and immunogenicity data from clinical trials and observational studies on the use of Tdap in adults aged 65 years and older (3). The Work Group then presented policy options for consideration to the full ACIP. http://www.cdc.gov/mmwr/preview/minwrhtml/mm6l25a4.htm 7/5/2012 Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and ... Page 2 of 5 It Epidemiology of Pertussis in Older Adults Because pertussis is underdiagnosed and underreported substantially in all age groups, the • actual burden of disease in adults aged 65 years and older is unknown (5). During 2000-2010, an annual average of 318 pertussis cases (range: 71-719 cases) in adults aged 65 years and older were reported each year through the National Notifiable Diseases Surveillance System (CDC, unpublished data, 2011). Challenges to diagnosing and reporting pertussis in all adults include 1) underrecognition of pertussis as a cause for cough illness, 2) atypical presentation of symptoms in adults, and 3) a low index of suspicion among providers (6,7). Few studies are focused on the burden of pertussis in adults aged 65 years and older.Among reported prospective studies,the calculated pertussis incidence ranged from 66 to 50o cases per loo,000 persons per year(8-11). Reported pertussis incidence ranges from one to five cases per 100,00o in adults of similar age ranges (CDC,unpublished data, 2011);this 70-fold to loo- fold difference suggests that actual pertussis incidence in older adults is much higher than reported (CDC,unpublished data, 2011). ACIP supported the conclusion that the actual burden of pertussis in adults aged 65 years and older likely is at least loo times greater than that reported. Cost Effectiveness Analysis ACIP reviewed two unpublished cost-effectiveness models, developed independently by GlaxoSmithKline and CDC (12,13). Both models were developed to assess the epidemiologic and economic impact of Tdap vaccination in adults aged 65 years and older and demonstrated that a dose of Tdap for older adults resulted in a moderate decrease in the number of cases and outcomes (e.g., outpatient visits, hospitalizations, and deaths),which might represent a cost- effective intervention. Model results were most sensitive to incidence of pertussis; however, • sensitivity analyses showed that even with a range of underreporting of incidence,Tdap vaccination might be cost-effective in this population. Reassured by the concordance between the two cost-effectiveness models,ACIP's interpretations were that the cost per case averted and cost per quality-adjusted life-year saved were modest, and pertussis incidence estimates accounting for underreporting were reasonable based on limited data and expert opinion. Tdap Products in the United States Safety and immunogenicity data of Tdap administered to adults aged 65 years and older were reviewed by ACIP in October 2010 and in February 2012 (q). Published and unpublished data from clinical trials of Boostrix (N = 1,104) and Adacel (N = 1,170) on the safety and immunogenicity of Tdap in adults aged 65 years and older who received vaccine were provided by G1axoSmithKline and Sanofi Pasteur. Safety. For both Tdap products,the frequency and severity of adverse events in persons aged 65 years and older were comparable to those among persons aged less than 65 years. No increase in local or generalized reactions in Tdap recipients was observed, compared with persons who received Td. No serious adverse events were considered related to vaccination (3). Postmarketing data from the Vaccine Adverse Event Reporting System (VAERS) suggest that the safety profile of Tdap vaccine in adults aged 65 years and older was comparable to that of Td vaccine (14). Boostrix immunogenicity. For diphtheria and tetanus, immune responses to Boostrix were noninferior to the immune responses elicited by a comparator Td vaccine (15). Immune • responses to pertussis antigens (i.e.,pertussis toxin [PT],filamentous hemagglutinin [FHA], and pertactin [PRN])were noninferior to those observed following a 3-dose primary DTaP http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6l25a4.htm 7/5/2012 Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and ... Page 2 of 5 Epidemiology of Pertussis in Older Adults 4PBecause pertussis is underdiagnosed and underreported substantially in all age groups, the actual burden of disease in adults aged 65 years and older is unknown (5). During 2000-2010, an annual average of 318 pertussis cases (range: 71-719 cases) in adults aged 65 years and older were reported each year through the National Notifiable Diseases Surveillance System (CDC,unpublished data, 2011). Challenges to diagnosing and reporting pertussis in all adults include 1) underrecognition of pertussis as a cause for cough illness, 2) atypical presentation of symptoms in adults,and 3) a low index of suspicion among providers (6,7). Few studies are focused on the burden of pertussis in adults aged 65 years and older.Among reported prospective studies,the calculated pertussis incidence ranged from 66 to 05_o cases per 100,00o persons per year(8-11). Reported pertussis incidence ranges from one to five cases per 100,00o in adults of similar age ranges (CDC,unpublished data, 2011);this 70-fold to 100- fold difference suggests that actual pertussis incidence in older adults is much higher than reported (CDC,unpublished data, 2011).ACIP supported the conclusion that the actual burden of pertussis in adults aged 65 years and older likely is at least too times greater than that reported. Cost Effectiveness Analysis ACIP reviewed two unpublished cost-effectiveness models, developed independently by G1axoSmithKline and CDC (12,13). Both models were developed to assess the epidemiologic and economic impact of Tdap vaccination in adults aged 65 years and older and demonstrated that a dose of Tdap for older adults resulted in a moderate decrease in the number of cases and outcomes (e.g.,outpatient visits, hospitalizations; and deaths),which might represent a cost- effective intervention. Model results were most sensitive to incidence of pertussis; however, sensitivity analyses showed that even with a range of underreporting of incidence,Tdap vaccination might be cost-effective in this population. Reassured by the concordance between the two cost-effectiveness models,ACIP's interpretations were that the cost per case averted and cost per quality-adjusted life-year saved were modest, and pertussis incidence estimates accounting for underreporting were reasonable based on limited data and expert opinion. Tdap Products in the United States Safety and immunogenicity data of Tdap administered to adults aged 65 years and older were reviewed by ACIP in October 2010 and in February 2012 (3). Published and unpublished data from clinical trials of Boostrix(N = i,1o4) and Adacel (N = 1,170) on the safety and immunogenicity of Tdap in adults aged 65 years and older who received vaccine were provided by GlaxoSmithKline and Sanofi Pasteur. Safety. For both Tdap products,the frequency and severity of adverse events in persons aged 65 years and older were comparable to those among persons aged less than 65 years. No increase in local or generalized reactions in Tdap recipients was observed,compared with persons who received Td. No serious adverse events were considered related to vaccination ( . Postmarketing data from the Vaccine Adverse Event Reporting System (VAERS) suggest that the safety profile of Tdap vaccine in adults aged 65 years and older was comparable to that of Td vaccine (14). Boostrix immunogenicity. For diphtheria and tetanus, immune responses to Boostrix were • noninferior to the immune responses elicited by a comparator Td vaccine (15). Immune responses to pertussis antigens (i.e.,pertussis toxin [PT],filamentous hemagglutinin [FHA], and pertactin [PRN])were noninferior to those observed following a 3-dose primary DTaP http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6l25a4.htm 7/5/2012 Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and ... Page 3 of 5 I series with Infanrix (G1axoSmithKline),according to predefined criteria discussed with and agreed to by FDA before study initiation (16). Boostrix contains the same three pertussis • antigens as Infanrix,but in reduced quantities. The geometric mean concentrations for antibodies to PT, FHA, and PRN after Boostrix administration increased 7.4-fold to 13.7-fold over baseline levels (15). Adacel immunogenicity. Antibody responses to diphtheria and tetanus toxoids in Adacel were noninferior to a comparator Td vaccine. Because a limited quantity of sera remained from infant efficacy trials, immune responses to three of the four pertussis antigens (FHA, PRN, and fimbriae [FIM]) in Adacel were bridged to a 3-dose DTaP (Daptacel [Sanofi Pasteur])series, and PT was bridged to a 4-dose series. Immune responses were observed to all Adacel pertussis antigens but some did not meet predefined noninferiority criteria as agreed upon by FDA and Sanofi Pasteur (16); however, a 4.4-fold to 15.1-fold increase in anti-pertussis antibodies, depending on the antigen, was observed. Multiple other countries,including Canada,Australia, and European Union members have approved Adacel for use in persons aged 65 years and older.ACIP concluded that Adacel likely would provide protection in adults aged 65 years and older. Guidance for Use Tdap use in adults. ACIP recommends that all adults aged 19 years and older who have not yet received a dose of Tdap should receive a single dose. Tdap should be administered regardless of interval since last tetanus or diphtheria toxoid-containing vaccine.After receipt of Tdap, persons should continue to receive Td for routine booster immunization against tetanus and diphtheria, according to previously published guidelines (1,2). Currently,Tdap is • recommended only for a single dose across all age groups.ACIP will begin discussions on the need for additional doses of Tdap and timing of revaccination of persons who have received Tdap previously. Tdap products in adults aged 65 years and older. Providers should not miss an opportunity to vaccinate persons aged 65 years and older with Tdap. Therefore, providers may administer the Tdap vaccine they have available.When feasible, Boostrix should be used for adults aged 65 years and older; however,ACIP concluded that either vaccine administered to a person 65 years or older is immunogenic and would provide protection. A dose of either vaccine may be considered valid. Tetanus prophylaxis in wound management for adults. As part of standard wound management care to prevent tetanus, a tetanus toxoid—containing vaccine might be recommended for wound management in adults aged 1g years and older if 5 years or more have elapsed since last receiving Td. If a tetanus booster is indicated, Tdap is preferred over Td for wound management in adults aged 19 years and older who have not received Tdap previously. References 1. CDC. Preventing tetanus, diphtheria, and pertussis among adolescents: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccines. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 20o6;55(No. RR-3). 2. CDC. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, • reduced diphtheria toxoid and acellular pertussis vaccine. Recommendations of the Advisory Committee on Immunization Practices (ACIP) and recommendation of ACIP, http://www.edc.gov/mmwr/preview/mmwrhtml/mm6l25a4.htm 7/5/2012 Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and ... Page 4 of 5 t supported by the Healthcare Infection Control Practices Advisojy Committee HICPAC for use of Tdap among health-care personnel. MMWR 20o6;55(No. RR-17). 3. CDC Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and • acellular pertussis(Tdap)vaccine from the Advisory Committee on Immunization Practices, 2010. MMWR 2011;6o:13-5. 4. CDC FDA approval of expanded age indication for a tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine. MMWR 2011;6o:1279-80. 5. Cherry JD, Grimpref E, Guiso N, Heininger U, Mertsola J. Defining pertussis epidemiology: clinical,microbiologic and serologic perspectives. Pediatr Infect Dis J 2005;24(5 Suppl):S25-34• 6. Hoffait M, Hanlon D, Benninghoff B, Calcoen S. Pertussis knowledge, attitude and practices among European health care professionals in charge of adult vaccination. Hum Vaccin 2011;7:197-201. . . Cornia PB Hersh AL Lis BA Newman TB Gonzales R. Does this coughing 7 � Lipsky g g adolescent or adult patient have pertussis?JAMA 2010;304:89o-6. 8. Lasserre A, Laurent E, Turbelin C, Hanslik T, Blanchon T, Guiso N. Pertussis incidence among adolescents and adults surveyed in general practices in the Paris area, France, May 20o8 to March 20o9. Euro Surveill 2011;16. 9. Ward JI, Cherry JD, Chang SJ, et al. Efficacy of an acellular pertussis vaccine among adolescents and adults. N Engl J Med 2005;353:1555-63• 1o. Strebel P, Nordin J, Edwards K, et al. Population-based incidence of pertussis among adolescents and adults, Minnesota, 1995-1996. J Infect Dis 2001;183:1353-9• 11. Nennig ME, Shinefield HR, Edwards KM, Black SB, Fireman BH. Prevalence and incidence of adult pertussis in an urban population. JAMA 1996;275:1672-4. 12. Acosta A. Cost-effectiveness of Tdap substitution for Td in prevention of pertussis in adults 65 years and older. Presented to the Advisory Committee on Immunization Practices (ACIP), February 22, 2012. Atlanta, GA: US Department of Health and Human • Services, CDC; 2012. 13. Krishnarajah G. Cost-effectiveness analysis of Boostrix (tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine, adsorbed) among individuals >_65 years of age in prevention of pertussis. Presented to the Advisory Committee on Immunization Practices (ACIP), February 22, 2012. Atlanta, GA: US Department of Health and Human Services, CDC; 2012. 14. Moro PL,Yue X, Lewis P, Haber P, Broder K. Adverse events after tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap)vaccine administered to adults 65 years of age and older reported to the Vaccine Adverse Event Reporting System (VAERS), 2005-2010. Vaccine 2011;29:9404-8• 15. Weston WM, Friedland LR, Wu X, Howe B.Vaccination of adults 65 years of age and older with tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Boostrix): results of two randomized trials.Vaccine 2012;30:1721-8. 16. Center for Biologics Evaluation and Research, Food and Drug Administration.Vaccines and Related Biological Products Advisory Committee (day one). Bethesda, MD: US Department of Health and Human Services, CDC, Food and Drug Administration; 1997• Available at http://www.fda.gov/ohrms/dockets/ac/97/transcpt ooti.pdf" EY . Accessed June 26, 2012. TABLE. Composition and approved age for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccines,by trade name — United States, 2012 http://www.edc.gov/mmwr/preview/mmwrhtml/mm6l25a4.htm 7/5/2012 ter•-� �.. •w vatuaa�liva�lvu� W1 V JG Ul 1 GLMUS 1 oxola, xeaucea Dipntnena Toxoid, and ... Page 4 of 5 suDDorted by the Healthcare Infection Control Practices Advisory Committee (HICPAC) 3 for use of Tdap among health-care personnel MMWR 20o6;5 No RR 17) 3. CDC. Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and • acellular pertussis a vaccine from the Adviso Committee on Immunization Practices, 2010 MMWR 2011;6o•13-5. 4. CDC. FDA approval of expanded age indication for a tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine MMWR 2011;6o•1279 80 5. Cherry iol Grimprel E, Guiso N, Heininger U, Mertsola J. Defining pertussis epidemiology: clinical, microbiologic and serologic perspectives. Pediatr Infect Dis J 2005;24(5 SuPPl):S25-34. 6. Hoffait M, Hanlon D, Benninghoff B, Calcoen S. Pertussis knowledge, attitude and practices among European health care professionals in charge of adult vaccination: Hum Vaccin 20117197-201. . 7. Cornia PB, Hersh AL, Lipsky BA, Newman TB, Gonzales R. Does this coughing adolescent or adult patient have pertussis?JAMA 2010;304:89o-6. 8. Lasserre A, Laurent E, Turbelin C, Hanslik T, Blanchon T; Guiso N. Pertussis incidence among adolescents and adults surveyed in general practices in the Paris area, France, May 20o8 to March 20o9. Euro Surveill 2011;16. 9. Ward JI, Cherry JD, Chang SJ, et al. Efficacy of an acellular pertussis vaccine among adolescents and adults. N Engl J Med 2005;353:1555-63• 1o. Strebel P, Nordin J, Edwards K, et al. Population-based incidence of pertussis among adolescents and adults, Minnesota, 1995-1996.J Infect Dis 2001;183:1353-9• 11. Nennig ME, Shinefield HR, Edwards KM, Black SB, Fireman BH. Prevalence and incidence of adult pertussis in an urban population.JAMA 1996;275:1672-4. 12. Acosta A. Cost-effectiveness of Tdap substitution for Td in prevention of pertussis in adults 65 years and older. Presented to the Advisory Committee on Immunization Practices (ACIP), February 22, 2012. Atlanta, GA: US Department of Health and Human Services, CDC; 2012. 13. Krishnarajah G. Cost-effectiveness analysis of Boostrix(tetanus toxoid,reduced diphtheria toxoid and acellular pertussis vaccine, adsorbed) among individuals >65 years of age in prevention of pertussis. Presented to the Advisory Committee on Immunization Practices (ACIP), February 22, 2012.Atlanta, GA: US Department of Health and Human Services, CDC; 2012. 14. Moro PL,Yue X, Lewis P, Haber P, Broder K.Adverse events after tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap)vaccine administered to adults 65 years of age and older reported to the Vaccine Adverse Event Reporting System (VAERS), 2005-2010. Vaccine 2011;29:9404-8• 15. Weston WM, Friedland LR, Wu X, Howe B.Vaccination of adults 65 years of age and older with tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Boostrix): results of two randomized trials.Vaccine 2012;30:1721-8. 16. Center for Biologics Evaluation and Research, Food and Drug Administration.Vaccines and Related Biological Products Advisory Committee (day one). Bethesda, MD: US Department of Health and Human Services, CDC, Food and Drug Administration; 1997• Available at httP://www.fda.gov/ohrms/dockets/ac/97/transcptt/33oot1 pdf"; . Accessed June 26, 2012. TABLE. Composition and approved age for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap)vaccines,by trade name — United States, 2012 http://www.cdc.gov/mmwr/preview/nlmwrhtml/mm6l25a4.htm 7/5/2012 Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and ... Page 5 of 5 Trade Manufacturer FDA- Pertussis antigens Diphtheria Tetanus name approved (µg) toxoid (Lf) toxoid age for (Lf) use* (yrs) PT FHA PRN FIM Boostrix G1axoSmithKline io and 8 8 2.5 — 2.5 5 Biologicals older Adacel Sanofi Pasteur ii through 2.5 5 3 5t 2 5 64 Abbreviations:FDA=Food and Drug Administration;PT=pertussis toxin;FHA=filamentous hemagglutinin;PRN= peitactin;FIM=fimbriae;Lf=limit of floccuation units. *Indicated as a single dose. t Types 2 and 3. Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services. References to non-CDC sites on the Internet are provided as a service to MMWR readers and do not constitute or imply endorsement of these organizations or their programs by CDC or the U.S.Department of Health and Human Services.CDC is not responsible for the content of pages found at these sites.URL addresses listed in MMWR were current as of the date of publication. • All MMWR HTML versions of articles are electronic conversions from typeset documents.This conversion might result in character translation or format errors in the HTML version.Users are referred to the electronic PDF version(http://www.cdc.gov/mmwr)and/or the original MMWR paper copy for printable versions of official text, figures,and tables.An original paper copy of this issue can be obtained from the Superintendent of Documents, U.S.Government Printing Office(GPO),Washington,DC 20402-9371;telephone: (202)512-1800.Contact GPO for current prices. **Questions or messages regarding errors in formatting should be addressed to mmwra Pcdc gov. .......................................................................................................................................................................................................................................................................................................................................................:.......... Page last reviewed:June 29,2012 Page last updated:June 29,2012 Content source:Centers for Disease Control and Prevention I--............................................................................................_..................................................................................................................................................................................................................................................... Centers for Disease Control and Prevention 1600 Clifton Rd.Atlanta,GA 30333,USA 800-CDC-INFO(8o0-232-4636)TTY:(888)232-6348-cdcinfo(a)cdc.gov http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6l25a4.htm 7/5/2012 Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and ... Page 1 of 5 Centers for Disease Control and Prevention Morbidi • CDC 24/7:Saying:Lives. Protecting People.m Mortality Weekly • Report MMWR) ..........................................................................................................................................................................................................................................................................................................................................I....................... Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis (Tdap) Vaccine in Adults Aged 65 Years and Older — Advisory Committee on Immunization Practices (ACIP), 2012 .....................................................................................................................................................................................................................................................................................................................................-.......................... Weekly June 29, 2oi2/ 61(25);468-470 Since 2005,the Advisory Committee on Immunization Practices (ACIP)has recommended a tetanus toxoid,reduced diphtheria toxoid, and acellular pertussis (Tdap)vaccine booster dose for all adolescents aged 11 through 18 years (preferred at 11 through 12 years) and for those adults aged 19 through 64 years who have not yet received a dose (1,2). In October 2010, despite the lack of an approved Tdap vaccine for adults aged 65 years and older,ACIP recommended that unvaccinated adults aged 65 years and older be vaccinated with Tdap if in close contact with an infant, and that other adults aged 65 years and older may receive Tdap • (3). In July 2011,the Food and Drug Administration (FDA) approved expanding the age indication for Boostrix (GlaxoSmithKline Biologicals, Rixensart, Belgium) to aged 65 years and older (4). In February 2012,ACIP recommended Tdap for all adults aged 65 years and older. This recommendation supersedes previous Tdap recommendations regarding adults aged 65 years and older. The Pertussis Vaccines Work Group of ACIP reviewed the epidemiology of pertussis in adults aged 65 years and older and two cost-effectiveness models to assess the epidemiologic and economic impact of pertussis vaccination in this population. The Work Group also considered safety and immuno enici data from clinical trials and observational studies on the use of g ty Tdap in adults aged 65 years and older O. The two Tdap vaccines available in the United States, Boostrix and Adacel (Sanofi Pasteur, Toronto, Canada), differ in composition and approved age for use Gable . Only Boostrix is approved for adults aged 65 years and older;however,ACIP discussed the use of Adacel in this age group. On February 22, 2012,ACIP approved use of Tdap for all adults aged 65 years and older. This report summarizes data considered and conclusions made by ACIP and provides guidance for implementing the recommendation. The Pertussis Vaccines Work Group of ACIP reviewed the epidemiology of pertussis in adults aged 65 years and older and two cost-effectiveness models to assess the epidemiologic and economic impact of pertussis vaccination in this population. The Work Group also considered safety and immunogenicity data from clinical trials and observational studies on the use of Tdap in adults aged 65 years and older (3). The Work Group then presented policy options for consideration to the full ACIP. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6l25a4.htm 7/5/2012 Centers for Disease Control and prevention Morbidity and CDC 24/7:Saving Lives. Protecting P@*ple.T" Mortality Weekly Report (MMWR) ....................................................................................................................................................................................._......................................................................................._.................................................................................. Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis (Tdap) Vaccine in Adults Aged 65 Years and Older — Advisory Committee on Immunization Practices (ACIP), 2012 .............................................................................................................................................................................................................................................................................................................................................. Weekly June 29, 2012/ 61(25);468-470 Since 2005,the Advisory Committee on Immunization Practices (ACIP)has recommended a tetanus toxoid,reduced diphtheria toxoid, and acellular pertussis (Tdap)vaccine booster dose for all adolescents aged 11 through 18 years (preferred at ii through 12 years) and for those adults aged 19 through 64 years who have not yet received a dose (1,2). In October 2010, despite the lack of an approved Tdap vaccine for adults aged 65 years and older,ACIP recommended that unvaccinated adults aged 65 years and older be vaccinated with Tdap if in •close contact with an infant, and that other adults aged 65 years and older may receive Tdap (3). In July 2011,the Food and Drug Administration(FDA) approved expanding the age indication for Boostrix (GlaxoSmithKline Biologicals, Rixensart, Belgium) to aged 65 years and older (4). In February 2012,ACIP recommended Tdap for all adults aged 65 years and older. This recommendation supersedes previous Tdap recommendations regarding adults aged 65 years and older. The Pertussis Vaccines Work Group of ACIP reviewed the epidemiology of pertussis in adults aged 65 years and older and two cost-effectiveness models to assess the epidemiologic and economic impact of pertussis vaccination in this population. The Work Group also considered safety and immunogenicity data from clinical trials and observational studies on the use of Tdap in adults aged 65 years and older( ). The two Tdap vaccines available in the United States, Boostrix and Adacel (Sanofi Pasteur, Toronto, Canada), differ in composition and approved age for use Table . Only Boostrix is approved for adults aged 65 years and older;however,ACIP discussed the use of Adacel in this age group. On February 22, 2012,ACIP approved use of Tdap for all adults aged 65 years and older.This report summarizes data considered and conclusions made by ACIP and provides guidance for implementing the recommendation. The Pertussis Vaccines Work Group of ACIP reviewed the epidemiology of pertussis in adults aged 65 years and older and two cost-effectiveness models to assess the epidemiologic and economic impact of pertussis vaccination in this population.The Work Group also considered osafety and immunogenicity data from clinical trials and observational studies on the use of Tdap in adults aged 65 years and older( ). The Work Group then presented policy options for consideration to the full ACIP. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6l25a4.htm 7/5/2012 Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and ... Page 2 of 5 Epidemiology of Pertussis in Older Adults • Because pertussis is underdiagnosed and underreported substantially in all age groups, the actual burden of disease in adults aged 65 years and older is unknown (5). During 2000-2010, an annual average of 318 pertussis cases (range: 71-719 cases) in adults aged 65 years and older were reported each year through the National Notifiable Diseases Surveillance System (CDC, unpublished data, 2011). Challenges to diagnosing and reporting pertussis in all adults include 1) underrecognition of pertussis as a cause for cough illness, 2) atypical presentation of symptoms in adults, and 3) a low index of suspicion among providers (6,7). Few studies are focused on the burden of pertussis in adults aged 65 years and older.Among reported prospective studies,the calculated pertussis incidence ranged from 66 to 590 cases per 100,00o persons per year (8-11). Reported pertussis incidence ranges from one to five cases per loo,000 in adults of similar age ranges (CDC,unpublished data, 2011);this 70-fold to loo- fold difference suggests that actual pertussis incidence in older adults is much higher than reported (CDC,unpublished data, 2011). ACIP supported the conclusion that the actual burden of pertussis in adults aged 65 years and older likely is at least loo times greater than that reported. Cost Effectiveness Analysis ACIP reviewed two unpublished cost-effectiveness models, developed'independently by G1axoSmithKline and CDC (12,13). Both models were developed to assess the epidemiologic and economic impact of Tdap vaccination in adults aged 65 years and older and demonstrated that a dose of Tdap for older adults resulted in a moderate decrease in the number of cases and outcomes (e.g., outpatient visits,hospitalizations, and deaths), which might represent a cost- effective intervention. Model results were most sensitive to incidence of pertussis; however, • sensitivity analyses showed that even with a range of underreporting of incidence,Tdap vaccination might be cost-effective in this population. Reassured by the concordance between the two cost-effectiveness models,ACIP's interpretations were that the cost per case averted and cost per quality-adjusted life-year saved were modest, and pertussis incidence estimates accounting for underreporting were reasonable based on limited data and expert opinion. Tdap Products in the United States Safety and immunogenicity data of Tdap administered to adults aged 65 years and older were reviewed by ACIP in October 2010 and in February 2012 (3). Published and unpublished data from clinical trials of Boostrix (N = 1,104) and Adacel (N = 1,170) on the safety and immunogenicity of Tdap in adults aged 65 years and older who received vaccine were provided by G1axoSmithKline and Sanofi Pasteur. Safety. For both Tdap products,the frequency and severity of adverse events in persons aged 65 years and older were comparable to those among persons aged less than 65 years. No increase in local or generalized reactions in Tdap recipients was observed,compared with persons who received Td. No serious adverse events were considered related to vaccination ( ). Postmarketing data from the Vaccine Adverse Event Reporting System (VAERS) suggest that the safety profile of Tdap vaccine in adults aged 65 years and older was comparable to that of Td vaccine (14). Boostrix immunogenicity. For diphtheria and tetanus, immune responses to Boostrix were • noninferior to the immune responses elicited by a comparator Td vaccine (15). Immune responses to pertussis antigens (i.e., pertussis toxin [PT],filamentous hemagglutinin [FHA], and pertactin [PRN])were noninferior to those observed following a 3-dose primary DTaP http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6l25a4.htm 7/5/2012 Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and ... Page 3 of 5 1 series with Infanrix (G1axoSmithICine), according to predefined criteria discussed with and agreed to by FDA before study initiation (16). Boostrix contains the same three pertussis antigens as Infanrix,but in reduced quantities. The geometric mean concentrations for • antibodies to PT, FHA, and PRN after Boostrix administration increased 7.4-fold to 13.7-fold over baseline levels (15). Adacel immunogenicity. Antibody responses to diphtheria and tetanus toxoids in Adacel were noninferior to a comparator Td vaccine. Because a limited quantity of sera remained from infant efficacy trials, immune responses to three of the four pertussis antigens (FHA, PRN, and fimbriae [FIM]) in Adacel were bridged to a 3-dose DTaP (Daptacel [Sanofi Pasteur])series, and PT was bridged to a 4-dose series. Immune responses were observed to all Adacel pertussis antigens but some did not meet predefined noninferiority criteria as agreed upon by FDA and Sanofi Pasteur (16); however, a 4.4-fold to 15.1-fold increase in anti-pertussis antibodies, depending on the antigen, was observed. Multiple other countries,including Canada Austra lia, > and European Union members have approved Adacel for use in persons aged 65 years and older.ACIP concluded that Adacel likely would provide protection in adults aged 65 years and older. Guidance for Use Tdap use in adults. ACIP recommends that all adults aged 19 years and older who have not yet received a dose of Tdap should receive a single dose. Tdap should be administered regardless of interval since last tetanus or diphtheria toxoid-containing vaccine. After receipt of Tdap, persons should continue to receive Td for routine booster immunization against tetanus and diphtheria, according to previously published guidelines (1,2 . Currently, Tdap is recommended only for a single dose across all age groups.ACIP will begin discussions on the • need for additional doses of Tdap and timing of revaccination of persons who have received Tdap previously. Tdap products in adults aged 65 years and older. Providers should not miss an opportunity to vaccinate persons aged 65 years and older with Tdap. Therefore, providers may administer the Tdap vaccine they have available. When feasible, Boostrix should be used for adults aged 65 years and older; however,ACIP concluded that either vaccine administered to a person 65 years or older is immunogenic and would provide protection. A dose of either vaccine may be considered valid. Tetanus prophylaxis in wound management for adults. As part of standard wound management care to prevent tetanus, a tetanus toxoid—containing vaccine might be recommended for wound management in adults aged 19 years and older if 5 years or more have elapsed since last receiving Td. If a tetanus booster is indicated,Tdap,is preferred over Td for wound management in adults aged 19 years and older who have not received Tdap previously. References 1. CDC. Preventing tetanus diphtheriaand pertussis among adolescents: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccines. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 20o6;55(No. RR-3). 2. CDC. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine. Recommendations of the • Advisory Committee on Immunization Practices (ACIP) and recommendation of ACIP, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6l25a4.htm 7/5/2012 Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and ... Page 3 of 5 i series with Infanrix (G1axoSmithKline), according to predefined criteria discussed with and agreed to by FDA before study initiation (16). Boostrix contains the same three pertussis • antigens as Infanrix,but in reduced quantities. The geometric mean concentrations for -� antibodies to PT, FHA, and PRN after Boostrix administration increased 7.4-fold to 13.7-fold over baseline levels (15). Adacel immunogenicity. Antibody responses to diphtheria and tetanus toxoids in Adacel were noninferior to a comparator Td vaccine. Because a limited quantity of sera remained from infant efficacy trials, immune responses to three of the four pertussis antigens (FHA, PRN, and fimbriae [FIM])in Adacel were bridged to a 3-dose DTaP (Daptacel [Sanofi Pasteur])series, and PT was bridged to a 4-dose series. Immune responses were observed to all Adacel pertussis antigens but some did not meet predefined noninferiority criteria as agreed upon by FDA and Sanofi Pasteur (16); however, a 4.4-fold to 15.1-fold increase in anti-pertussis antibodies, depending on the antigen,was observed. Multiple other countries,including Canada,Australia, and European Union members have approved Adacel for use in persons aged 65 years and older.ACIP concluded that Adacel likely would provide protection in adults aged 65 years and older. Guidance for Use Tdap use in adults.ACIP recommends that all adults aged 19 years and older who have not yet received a dose of Tdap should receive a single dose.Tdap should be administered regardless of interval since last tetanus or diphtheria toxoid-containing vaccine. After receipt of Tdap, persons should continue to receive Td for routine booster immunization against tetanus and diphtheria,according to previously published guidelines (1,2. Currently, Tdap is j • recommended only for a single dose across all age groups.ACIP will begin discussions on the need for additional doses of Tdap and timing of revaccination of persons who have received Tdap previously. Tdap products in adults aged 65 years and older. Providers should not miss an opportunity to vaccinate persons aged 65 years and older with Tdap. Therefore, providers may administer the Tdap vaccine they have available. When feasible, Boostrix should be used for adults aged 65 years and older; however,ACIP concluded that either vaccine administered to a person 65 years or older is immunogenic and would provide protection.A dose of either vaccine may be considered valid. Tetanus prophylaxis in wound management for adults. As part of standard wound management care to prevent tetanus, a tetanus toxoid—containing vaccine might be recommended for wound management in adults aged 19 years and older if 5 years or more have elapsed since last receiving Td. If a tetanus booster is indicated,Tdap is preferred over Td for wound management in adults aged 19 years and older who have not received Tdap, previously. References 1. CDC. Preventing tetanus, diphtheria,and pertussis among adolescents: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccines Recommendations of the Advisory Committee on Immunization Practices (ACIP) MMWR 20o6;55(No RR �) 2. CDC. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid. • reduced diphtheria toxoid and acellular pertussis vaccine Recommendations of the Advisory Committee on Immunization Practices (ACIP) and recommendation of ACIP http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6l25a4.htm 7/5/2012 Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and ... Page 4 of 5 supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among health-care personnel. MMWR 20o6,55(No RR-17) • 3. CDC. Updated recommendations for use of tetanus toxoid reduced diphtheria toxoid and acellular pertussis (Tdap)vaccine from the Advisory Committee on Immunization Practices,, 2010. MM"2011;60.13-5 4. CDC FDA approval of expanded age indication for a tetanus toxoid, reduced diphtheria toxoid, acellular pertussis vaccine MMWR 2011i6o•1279-8o 5. Cherry JD, Grim prel E, Guiso N, Heininger U, Mertsola J. Defining pertussis epidemiology: clinical, microbiologic and serologic perspectives. Pediatr Infect Dis J 2005;24(5 Suppl):S25-34. 6. Hoffait M, Hanlon D, Benninghoff B, Calcoen S. Pertussis knowledge, attitude and practices among European health care professionals in charge of adult vaccination. Hum Vaccin 2011;7:197-201. 7. Cornia PB, Hersh AL, Lipsky BA, Newman TB, Gonzales R. Does this coughing adolescent or adult patient have pertussis?JAMA 2010;304:89o-6. 8. Lasserre A, Laurent E, Turbelin C, Hanslik T, Blanchon T, Guiso N. Pertussis incidence among adolescents and adults surveyed in general practices in the Paris area, France, May 20o8 to March 20o9. Euro Surveill 2011;16. 9. Ward JI, Cherry JD, Chang SJ, et al. Efficacy of an acellular pertussis vaccine among adolescents and adults. N Engl J Med 2005;353:1555-63• 1o. Strebel P, Nordin J, Edwards K, et al. Population-based incidence of pertussis among adolescents and adults, Minnesota, 1995-1996. J Infect Dis 2001;183:1353-9• 11. Nennig ME, Shinefield HR, Edwards KM, Black SB, Fireman BH. Prevalence and incidence of adult pertussis in an urban population. JAMA 1996;275:1672-4. 12. Acosta A. Cost-effectiveness of Tdap substitution for Td in prevention of pertussis in adults 65 years and older. Presented to the Advisory Committee on Immunization • Practices (ACIP), February 22, 2012. Atlanta, GA: US Department of Health and Human Services, CDC; 2012. 13. Krishnarajah G. Cost-effectiveness analysis of Boostrix (tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine, adsorbed) among individuals >_65 years of age in prevention of pertussis. Presented to the Advisory Committee on Immunization Practices (ACIP), February 22, 2012. Atlanta, GA: US Department of Health and Human Services, CDC; 2012. 14. Moro PL,Yue X, Lewis P, Haber P, Broder K. Adverse events after tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap)vaccine administered to adults 65 years of age and older reported to the Vaccine Adverse Event Reporting System (VAERS), 2005-2010. Vaccine 2011;29:9404-8• 15. Weston WM, Friedland LR, Wu X, Howe B.Vaccination of adults 65 years of age and older with tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Boostrix): results of two randomized trials.Vaccine 2012;30:1721-8. 16. Center for Biologics Evaluation and Research, Food and Drug Administration. Vaccines and Related Biological Products Advisory Committee (day one). Bethesda, MD: US Department of Health and Human Services, CDC, Food and Drug Administration; 1997. Available athttp://www.fda.gov/ohrms/dockets/ac/97/transcpt/.13ootl.pdf V . Accessed June 26, 2012. TABLE. Composition and approved age for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap)vaccines,by trade name - United States, 2012 http://www.cdc.gov/mmwr/preview/mmwrhtnfl/mm6l25a4.htm 7/5/2012 Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and ... Page 5 of 5 Trade Manufacturer FDA- Pertussis antigens Diphtheria Tetanus name approved (µg) toxoid (Lf) toxoid age for (Lf) • use* (yrs) PT FHA PRN FIM Boostrix G1axoSmithKline 10 and 8 8 2.5 — 2.5 5 Biologicals older Adacel Sanofi Pasteur 11 through 2.5 5 3 5t 2 5 64 Abbreviations:FDA=Food and Drug Administration;PT=pertussis toxin;FHA=filamentous hemagglutinin;PRN= pertactin;FIM=fimbriae;Lf=limit of floccuation units. *Indicated as a single dose. t Types 2 and 3. Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services. References to non-CDC sites on the Internet are provided as a service to MMWR readers and do not constitute or imply endorsement of these organizations or their programs by CDC or the U.S.Department of Health and Human Services.CDC is not responsible for the content of pages found at these sites.URL addresses listed in MMWR were current as of the date of publication. All MMWR HTML versions of articles are electronic conversions from typeset documents.This conversion might • result in character translation or format errors in the HTML version.Users are referred to the electronic PDF version(http://www.cdc.gov/mmwr)and/or the original MMWR paper copy for printable versions of official text, figures, and tables.An original paper copy of this issue can be obtained from the Superintendent of Documents, U.S.Government Printing Office(GPO),Washington,DC 20402-9371;telephone: (202)512-1800.Contact GPO for current prices. "Questions or messages regarding errors in formatting should be addressed to mmwrq(&cdc.g_ov. .................................................................................................................................................................................................................................................................................................................................................................. Page last reviewed:June 29,2012 Page last updated:June 29,2012 Content source:Centers for Disease Control and Prevention .................................................................................................................................................................................................................................................................................................................................................................. Centers for Disease Control and Prevention 1600 Clifton Rd.Atlanta,GA 30333,USA 800-CDC-INFO(8o0-232-4636)TTY:(888) 232-6348-cdcinfo(@cdc.gov • http://www.cdc.gov/mmwr/preview/mmwrhtml/niin6l25a4.htm 7/5/2012 Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and ... Page 5 of 5 Trade Manufacturer FDA- Pertussis antigens Diphtheria Tetanus name approved (µg) toxoid (Lf) toxoid • age for (Lf) use* (yrs) PT FHA PRN FIM Boostrix G1axoSmithKline io and 8 8 2.5 — 2.5 5 Biologicals older Adacel Sanofi Pasteur li through 2.5 5 3 5t 2 5 64 Abbreviations:FDA=Food and Drug Administration;PT=pertussis toxin;FHA=filamentous hemagglutinin;PRN= pertactin;FIM=fimbriae;Lf=limit of floccuation units. *Indicated as a single dose. t Types 2 and 3. Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services. References to non-CDC sites on the Internet are provided as a service to MMWR readers and do not constitute or imply endorsement of these organizations or their programs by CDC or the U.S.Department of Health and Human Services.CDC is not responsible for the content of pages found at these sites.URL addresses listed in MMWR were current as of the date of publication. • All MMWR HTML versions of articles are electronic conversions from typeset documents.This conversion might result in character translation or format errors in the HTML version.Users are referred to the electronic PDF version(http//www.cdc.gov/mmwr)and/or the original MMWR paper copy for printable versions of official text, figures,and tables.An original paper copy of this issue can be obtained from the Superintendent of Documents, U.S.Government Printing Office(GPO),Washington,DC 20402-9371;telephone: (202)512-1800.Contact GPO for current prices. **Questions or messages regarding errors in formatting should be addressed to mmM Pcdc.gov. .................._....................................................................................._................................................................................................................................................................_............................_............................................. ....... Page last reviewed:June 29,2012 Page last updated:June 29,2012 Content source:Centers for Disease Control and Prevention ................................._................................................................................................................................................._.. _......................................................................................._................................................................... Centers for Disease Control and Prevention 1600 Clifton Rd.Atlanta,GA 30333,USA 800-CDC-INFO(8o0-232-4636)TTY:(888)232-6348-cdcinfona cdc.gov 1 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6125a4.htm 7/5/2012 Administration Monthly Report June-12 Burial Permits @ $25.00 $800.00 Permits $2,930.00 Certificate of Fitness@$50.00 $3,250.00 Fines Total Monies Collected = $6,980.00 Annual Budget Expended Available Balance Total Salary/Longevity $344,000.00 $314,827.79 $29,172.21 Annual Budget Expended Available Balance Non-Personnel $19,600.00 $19,600.00 $0.00 Regulation of the City of Salem Board of Health • Restricting the Sale and Use of Tobacco Products & Nicotine Delivery Products FINAL DRAFT A. Statement of Purpose: Whereas there exists conclusive evidence that tobacco smoke causes cancer,respiratory and cardiac diseases,negative birth outcomes, irritations to the eyes, nose and throat (Centers for Disease Control and Prevention(hereinafter "CDC'), Health Effects of Cigarette Smoking Fact Sheet, (January 2012)); whereas among the 15.7%of students nationwide who currently smoked cigarettes and were aged less than eighteen(18)years '14.1%usually obtained their own cigarettes by buying them in a store (i.e., convert enc--store, supermarket, or discount store) or gas station during the thirty(30)days before the survey(CDC, Youth Risk Behavior,Surveillance Summaries.2009, MMWR 2010:59(NO:SS-55)`at 11);whereas nationally in 2000, sixty-nine (69%)percent of middle school,ag6 children who smoke'at least once a month were not asked to show proof of age whei;purchasing cigarettes (CDC_Youth Tobacco,Surveillance Summaries. 2000, MMWR 2001 50 N—ISS-04)),whereas the U.S". Department of Health and Human Services has concided"that nicotine is as addictive as cocaine Or heroin(U.S. Department of Health and Human Services,How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for;Smoking-Attributable:Disease:A Report of the Surgeon General,Atlanta, GA: U.S.Department of Health and Human Services Centers.for Disease Control and Prevention, National Center for Chronic Disease Prevention-and Health Promotion, Office on Smoking • and Health, 2010.); whereas despite state laws prohibiting the sale of tobacco products to minors, access by minors;to-tobacco produets:ls a major—pro blem;whereas according to the CDC, cigarette price increases reduce the demand for cigarettes and thereby reduce smoking prevalence, cigarette consumption, and youth initiation of smoking (U.S. Department of Health and-Human Services.Reducing Tobacco Use:A Report of the Surgeon General. Atlanta, GA. U.S. Department of Health,and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease,Preveiition and=Flealth Promotion, Office on Smoking and Health, 2000 at 358) Whereasthe 2012 U.S. Surgeon General's Report on Preventing Tobacco Use Among Youth and Xoung Adults,reports that in 2005 Ringel,Wasserman, &Andreyeva(U.S. Department of Health andHumai,,Services,Nicotine Addiction,Atlanta, GA: U.S.Department of Health and Human Services,CDC,National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Healfh,=.1988) Conducted logistic regression analyses to examine whether increased cigar prices a d state tobacco control policies affected the rate of cigar use. (U.S.Department of Health and Human Services. Preventing Tobacco Use Among Youth and Young Adults,Atlanta, GA: U.S.Department of Health and Human Services, Centers for Disease Control and Prevention,National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2012 at 706). Using the 1999 and 2000 iterations of the National Youth Tobacco Survey, Ringel and colleagues analyzed data from 33,632 adolescent participants aged nine to seventeen. They found that increased cigar prices significantly decreased the probability of male adolescent cigar use and found that a 10%increase in cigar prices would reduce the sample's cigar use by 3.4%(Ringel JS, Wasserman J,Andreyeva T,Effects of Public Policy on Adolescents'Cigar Use:Evidence From the National Youth Tobacco Survey, 95 Am.J. • Pub. Health 995-8(June 1, 2005); whereas according to the CDC's youth risk behavior surveillance system,the percentage of high school students in Massachusetts who reported the use of cigars within the past 30 days went from 11.8% in 2003 to 14.9% in 2009 (CDC, Youth Risk Behavior. Surveillance Summaries, 2009. MMWR 2010;59(No. SS-55)at 72; CDC, Youth Risk Behavior. Surveillance Summaries,2003.MMWR 2004;53(No. SS-02)at 54);whereas • nicotine levels in cigars are generally much higher than nicotine levels in cigarettes. (Nat'l Cancer Institute at the Nat'1 Inst. of Health, Questions and Answers About Cigar Smoking and Cancer (Oct. 27, 2010)); Whereas commercial Roll Your Own(RYO)machines enable loose, unpackaged tobacco to be poured into a machine and placed into empty,unpackaged cigarette tubes to be inhaled by individuals who smoke them. This procedure provides risk of contamination of the tobacco and unsanitary conditions in the machine and is injurious to public health; whereas commercial Roll Your Own (RYO)machines located in retail stores enable retailers to sell cigarettes without paying the federal and state excise,taxes that are imposed on conventionally manufactured cigarettes (RYO FILLING STATION, www.wofllingstation.com (Feb. 27,2012). High excise taxes encourage adult smokers to quit and deter youth from starting (Kenneth E. Warner, Smoking and.-Health lmplications of a Change in the Federal Cigarettte Excise Tax,255 J.AM. MED.Ass 1028.(1980),Frank'J=Chaloupka&Rosalie Liccardo Pacula, The Impact of Price on Youth Tobacco Use,,irF=1s4 SMOKING AND-TOBACCO CONTROL MONOGRAPHS:CHANGING ADOLESCENT SMOKING PREVALENCE 1 Q3(U.S. Dep't Health and Human Services et al. eds., 2001)). Therefore, inexpensive cigarettes;-like those produced from RYO machines, promote the use of tobacco,resulting in a negative impact on public health and increased health care costs, and;sever_'ely undercut the evidence- based public health benefit of imposing high excise taxes on tobacco, Whereas the sale of tobacco products and nicotine delivery products are incompatible with the mission of healthcare institutions because_they are detrimental to the public health and undermine efforts to educate patients on the safe,and effective use of • medication; Whereas educational;institutions:-sell tobacco`products to a younger population,which is particularly at risk for becoming smokers and such sale of tobacco products and nicotine delivery products.are incompatible with the mission of educational institutions that educate a:;younger::population out social; environmental and health risks and harms; Now;therefore it is the rntention of the City of Salem Board of Health to regulate the access of tobacco productk.and nicotine delivery products. B. Authority: This regulation is promulgated pursuant to the authority granted to the City of Salem Board of Health by Massachusetts General Laws Chapter 111, Section 31 that 'Boards of Health may make reasonable health regulations". C. Definitions: For the purpose of this regulation, the following words shall have the following meanings: • 1 2009(CDC, Youth Risk Behavior. Surveillance Summaries, 2009. MMWR 2010;59(No. SS-55)at 72; • CDC, Youth Risk Behavior.Surveillance Summaries,2003. MAI"2004,53(No. SS-02)at 54);whereas nicotine levels in cigars are generally much higher than nicotine levels in cigarettes. (Nat'l Cancer Institute at the Nat 7Inst. of Health, Questions and Answers About Cigar Smoking and Cancer (Oct.27, 2010)); Whereas commercial Roll Your Own(RYO)machines enable loose,unpackaged tobacco to be poured into a machine and placed into empty,unpackaged cigarette tubes to be inhaled by,individuals who smoke them. This procedure provides risk of contamination of the tobacco and unsanitary conditions in the machine and is injurious to public health; whereas commercial Roll Your Own (RYO)machines located in retail stores enable retailers to sell cigarettes without paying the federal and state excise taxes that are imposed on conventionally manufactured cigarettes (RYO FILLING STATION, www.ryofillingstation.com(Feb. 27,2012). High excise taxes encourage adult smokers to quit and deter youth from starting(Kenneth E. Warner,Smoking and-Realfh Implications of a Change in the Federal Cigarettte Excise Tax,255 J.AM.MED.Ass 1028.(19*,Frank!X Chaloupka&Rosalie Liccardo Pacula, The Impact of Price on Youth Tobacco Use,itk=14:,S1 iOKING AND-TOBACCO CONTROL MONOGRAPHS:CHANGING ADOLESCENT.S1lOKING PREVALENCE 193(U.S.Dept Health and Human Services et al. eds.,2001)). Therefore, inexpensive cigarettes -i those produced from RYO machines,promote the use of�tobacco,;;resulting in a negative impact on public health and increased health care costs, and-isevezely undercut the evidence- based public health benefit of imposing high excise taxes on tobacco; Whereas the sale of tobacco products antl=niootine delivery pr-oducts are incompatible with the mission of health care institutio because they are.detrimental to the public • health and undermine efforts to educate patiients..on the,safe:and effective use of medication; Whereas educational institutions sell tobacco products to a younger population,which is particularly at risk for becoming smokers and sbh sale of tobacco products and nicotine delivery products__are incoiripatible with:the mission of educational institutions that educate a younger population about social, environmental and health risks and harms; Now,therefore it is the intention of the City of Salem Board of Health to regulate the access of tobbacco products-aiid nicotine delivery products.. B. Authority: This regulation is promulgated pursuant to the authority granted to the City of Salem Board of Health by Massachusetts General Laws Chapter 111, Section 31 that 'Boards of Health may make reasonable health regulations". C. Definitions: For the purpose of this regulation,the following words shall have the following meanings: 1 i Blunt Wrap: Any tobacco product manufactured or packaged as a wrap or as a hollow • tube made wholly or in part from tobacco that is designed or intended to be filled by the consumer with loose tobacco or other fillers. Business Agent: An individual who has been designated by the owner or operator of any establishment to be the manager or otherwise in charge of said establishment. Cigar: Any roll of tobacco that is wrapped in leaf tobacco or in any substance containing tobacco with or without a tip or mouthpiece not otherwise defined as a cigarette under Massachusetts General Law, Chapter 64C, Section 1, Paragraph 1. Commercial Roll-Your-Own(RYO)machine: A mechanical device, by whatever manufacturer made and by whatever name known, that is designed to roll and wrap tobacco into products. RYO machines located in a private home,used for personal consumption, are not Commercial Roll-Your-Own machines. E-Cigarette: Any electronic Nicotine Delivery Product composed of a mouthpiece, heating element,battery and/or electronic circuits that provides a vapor of liquid nicotine to the user, or relies on vaporization of solid nicotine or any-liquid. This term'shall include such devices whether they are manufactured' s e-cigarettes, e-cigars,e-pipes or under any other product name. Educational Institution: Any public or private college, schdoi;professional school, scientific or technical institution,university Or other institution famishing a program of • higher education. Employee: Any individual who performs services for an employer. Employer: Any individual,partnership, association; corporation, trust or other organized group of individuals that uses the services of one(1)or more employees. Health Care Institution: An individual,partnership, association, corporation or trust or any person or group of persons that provides health care services and employs health care providers licensed, or subject to licensing,by the Massachusetts Department of Public Health under M.G.L. c. 112 or a retail establishment that provides pharmaceutical goods and services and subject to the provisions of 247 CMR 6.00. Health care institution includes, but is not limited to,hospitals, clinics,health centers,pharmacies, drug stores, doctor offices and dentist offices. Minor: Any individual who is under the age of eighteen(18). Nicotine Delivery Product: Any manufactured article or product made wholly or in part of a tobacco substitute or containing nicotine that is expected or intended for human consumption,but not including a tobacco substitute prescribed by a licensed physician or a product that has been approved by the United States Food and Drug Administration for sale as a tobacco use cessation or harm reduction product or for other medical purposes and which is being marketed and sold solely for that approved purpose. Nicotine delivery • product includes, but is not limited to, e-cigarettes. 2 Permit Holder: Any person engaged in the sale or distribution of tobacco or nicotine delivery products directly to consumers who applies for and receives a tobacco and • nicotine delivery product sales permit or any person who is required to apply for a tobacco and nicotine delivery product sales permit pursuant to these regulations, or his or her business agent. Tobacco Product: Cigarettes, cigars, chewing tobacco,pipe tobacco, bidis, snuff or tobacco in any of its forms. Vending Machine: Any automated or mechanical self-service device, which upon insertion of money, tokens or any other form of payment, dispenses or makes cigarettes, any other tobacco product or Nicotine Delivery Product. D. Tobacco and Nicotine Delivery Product Sales to Minors Prohibited: 1.No person shall sell tobacco or nicotine delivery products or permit tobacco or nicotine delivery products to be sold to a minor; or not being the minor's parent or legal guardian, give tobacco or nicotine delivery products to a minor. 2. Required Signage a. In conformance with and in addition to Massachusetts General Law, Chapter 270, Section 7, a copy of Massachusetts General Laws, Chapter.270, Section 6, shall be posted conspicuously by the owner or=other person in charge thereof in the shop or other place used to sell tobacco products at retail. The notice shall be • provided by the Massachusetts Department of Public Health and made available from the City of-Salem Board of Health. The notice shall be at least 48 square inches and shall be posted conspicuously by the permit holder in the retail establishment or.other place in such a manner so that it may be readily seen by a person standing at or approaching the cash register. The notice shall directly face the purchaser and shall-not be obstructed from view or placed at a height of less than four(4)feet:or greater than nine(9) feet from the floor. The owner or other person in charge of a shop-or other place used to sell tobacco products at retail shall conspicuously'post any additional signs required by the Massachusetts Department of Public Health. b. The owner or other person in charge of a shop or other place used to sell tobacco products at retail'shall conspicuously post signage provided by the City of Salem board of health that discloses current referral information about smoking cessation. c. The owner or other person in charge of a shop or other place used to sell nicotine delivery products at retail shall conspicuously post a sign stating that"The sale of nicotine delivery products to minors under 18 years of age is prohibited."The owner or other person in charge of a shop or other place used to sell e-cigarettes at retail shall conspicuously post a sign stating that"The use of e-cigarettes at indoor establishments may be prohibited by local law."The notices shall be no smaller than 8.5"by 11"and shall be posted conspicuously in the retail establishment or • other place in such a manner so that they may be readily seen by a person standing at or approaching the cash register. These notices shall directly face the 3 Permit Holder: Any person engaged in the sale or distribution of tobacco or nicotine delivery products directly to consumers who applies for and receives a tobacco and nicotine delivery product sales permit or any person who is required to apply for a tobacco and nicotine delivery product sales permit pursuant to these regulations, or his or her business agent. Tobacco Product: Cigarettes, cigars, chewing tobacco,pipe tobacco, bidis, snuff or tobacco in any of its forms. Vending Machine: Any automated or mechanical self-service device,which upon insertion of money,tokens or any other form of payment, dispenses or makes cigarettes, any other tobacco product or Nicotine Delivery Product. D. Tobacco and Nicotine Delivery Product Sales to Minors Prohibited: 1.No person shall sell tobacco or nicotine delivery products or permit tobacco or nicotine delivery products to be sold to a minor; or not being the minor's parent or legal guardian, give tobacco or nicotine delivery products to a minor. 2. Required Signage a. In conformance with and in addition to Massachusetts General Law, Chapter 270, Section 7, a copy of Massachusetts_General Laws, Chap4er.270, Section 6, shall be posted conspicuously by the owner or other persontn.charge thereof in the • shop or other place used to sell tobacco products at retail. The notice shall be provided by the Massachusetts Department of Public Health and made available from the City of'Saleri Board of Health. The notice shall be at least 48 square inches and shall be posted conspicuously by the permit holder in the retail establishment or.other place in such a manner so that it may be readily seen by a person standing at or approaching the cash register. The notice shall directly face the.purchaser and shallmot be obstructed from view or placed at a height of less than four(4)Teet or greater,than nine(9) feet from the floor. The owner or other person in charge of a shop brother place used to sell tobacco products at retail shall conspicuously"post any additional signs required by the Massachusetts_ Department of Public Health. b. The owner or other person in charge of a shop or other place used to sell tobacco products at retail shall conspicuously post signage provided by the City of Salem board of health that discloses current referral information about smoking cessation. c. The owner or other person in charge of a shop or other place used to sell nicotine delivery products at retail shall conspicuously post a sign stating that"The sale of nicotine delivery products to minors under 18 years of age is prohibited."The owner or other person in charge of a shop or other place used to sell e-cigarettes at retail shall conspicuously post a sign stating that"The use of e-cigarettes at indoor establishments may be prohibited by.local law."The notices shall be no smaller • than-8.5"by 11"and shall be posted conspicuously in the retail establishment or other place in such a manner so that they may be readily seen by a person standing at or approaching the cash register. These notices shall directly face the 3 purchaser and shall not be obstructed from view or placed at a height of less than • four(4) feet or greater than nine (9) feet from the floor. 3. Identification: Each person selling or distributing tobacco or nicotine delivery products shall verify the age of the purchaser by means of valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 18 years old or older. Verification is required for any person under the age of 27. 4. All retail sales of tobacco or nicotine delivery products must be face-to-face between the seller and the buyer. E. Tobacco and Nicotine Delivery Product Sales Permit: 1.No person shall sell or otherwise distribute tobacco or nicotine delivery products at retail within the City of Salem without first obtaining a Tobacco and Nicotine Delivery Product Sales Permit issued annually by the City of Salem Board of Health. Only owners of establishments with a permanent, non-mobile location in Salem are eligible to apply for a permit and sell tobacco products or nicotine delivery products at the specified location in Salem. 2. As part of the Tobacco and Nicotine Delivery Product Sales Permit application process,the applicant will be provided with the City of Salem Board of Health regulation. Each applicant is required to sign a statement declaring that the applicant has read said regulation and that the applicant is responsible:for-instructing any and all employees who • will be responsible for tobacco and nicotine delivery product sales regarding both state laws regarding the sale of.tobacco and this regulation. 3. Each applicant who sells tobacco is requiredao provide proof of a current tobacco sales license issued by the Massachusetts Department of Revenue before a Tobacco and Nicotine Delivery Product Sales Permit can be-issued. 4. The fee for a Tobacco:and Nicotine Delivery Product Sales Permit shall be determined by the City of Salem Board of Health:annually. All such permits shall be renewed annually. 5. A separate permit is required for each retail establishment selling tobacco or nicotine delivery products. 6. Each Tobacco and Nicotine Delivery Product Sales Permit shall be displayed at the retail establishment in a conspicuous place. 7. No Tobacco and Nicotine Delivery Product Sales Permit holder shall allow any employee to sell tobacco products or nicotine delivery products until such employee reads this regulation and state laws regarding the sale of tobacco and signs a statement, a copy of which will be placed on file in the office of the employer, that he/she has read the regulation and applicable state laws. • 8.A Tobacco and Nicotine Delivery Product Sales Permit is non-transferable. A new owner of an establishment that sells tobacco or nicotine delivery products must apply for 4 a new permit.No new permit will be issued unless and until all outstanding penalties incurred by the previous permit holder are satisfied in full. • 9. Issuance of a Tobacco and Nicotine Delivery Product Sales Permit shall be conditioned on an applicant's consent to unannounced, periodic inspections of his/her retail establishment to ensure compliance with this regulation. 10. Issuance and holding of a Tobacco and Nicotine Delivery Product Sales Permit shall be conditioned on an applicant's on-going compliance with current Massachusetts Department of Revenue requirements and policies including, but not limited to, minimum retail prices of tobacco products. 11. A Tobacco and Nicotine Delivery Product Sales Permit will'not be renewed if the permit holder has failed to pay all fines issued and the time:perod to appeal the fines has expired and/or has not satisfied any outstanding permit suspensions. 12. Maximum Number of Tobacco and Nicotine Delivery Product Sales"Permits. At any given time, there shall be no more'than 60 Tobacco and Nicotine Delivery Product Sales Permits issued in City of Salem;No-permit renewal will be denied based on the requirements of this subsection except any permittee who has failed to renew their current permit within(30)days of expiration will be treated as a first-time permit applicant. Applicants who purchase_a business that holds a current Tobacco and Nicotine Delivery Product Sales Permit at the time of the sale of said business may apply, within sixty(60)days of such sale, for the permit • held by the Seller if..the Buyer intends.to sell tobacco products and/or Nicotine Delivery Products. New applicants for permits who are applying at a time when the maximuminumber of permits have been issued will be placed on a waiting list and will be eligible to apply for a permit_-on a"first-come, first-serve"basis as issued permits are either notrenewed or are returned to the Board. F. mar Sales Regulated: 1.No retailer, retail establishment, or other individual or entity shall sell or distribute or cause to be sold or distributed a cigar unless the cigar is contained in an original package of at least four(4).cigars. 2. This Section shall not apply to: a. The sale or distribution of any cigar having a retail price of more than two dollars and fifty cents ($2.50). b. A person or entity engaged in the business of selling or distributing cigars for commercial purposes to another person or entity engaged in the business of selling or distributing cigars for commercial purposes with the intent to sell or distribute outside the boundaries of City of Salem. 3. The Board of Health may adjust from time to time the amounts specified in this • Section to reflect changes in the applicable Consumer Price Index by amendment of this regulation. 5 • retail prices of tobacco pro*. • 11. A Tobacco and Nicotine Delivery Product Sales Permit will:not be renewed if the permit holder has failed to pay all fines issued and the time.per od to appeal the fines has expired and/or has not satisfied any outstanding permit suspensions. 12. Maximum Number of Tobacco and Nicotine Delivery Product Sales Permits. At any given time, there shall be no more.-:than 60 Tobacco and Nicotine Delivery Product Sales Permits issued in City of Salem: No:permit renewal will be denied based on the requirements of this subsection except any permittee who has failed to renew their current permit within(30) days of expiration will be treated as a first-time permit applicant. Applicants who purchase a:business that holds a current Tobacco and Nicotine Delivery Pro duct Sales Permit at the time of the sale of said business may apply, within sixty,(6U:)..days of such sale, for the permit held by the Seller if-the Buyer intends-40 sell tobacco products and/or Nicotine Delivery Products. New applicants for permits who are applying at a time when the maximumpumber of-permits have been issued will be placed on a waiting list and will be eligible to apply for a permit-on a"first-come, first-serve"basis as issued permits are either not'renewed or are returned to the Board. F. Cigar Sales Re lug_ated.- 1.No retailer,retail establishment,.'or other individual or entity shall sell or distribute or cause to be sold or distributed a cigar unless the cigar is contained in an original package of at least four`(4).cigars. 2. This Section shall not apply to: a. The sale or distribution of any cigar having a retail price of more than two dollars and fifty cents ($2.50). b. A person or entity engaged in the business of selling or distributing cigars for commercial purposes to another person or entity engaged in the business of selling or distributing cigars for commercial purposes with the intent to sell or distribute outside the boundaries of City of Salem. 3. The Board of Health may adjust from time-to time the amounts specified in this Section to reflect changes in the applicable Consumer Price Index by amendment of this regulation. 5 • G. Prohibition of the Sale of Blunt Wraps No person or entity shall sell or distribute blunt wraps within the City of Salem. H. Free Distribution and Coupon Redemption: No person shall distribute, or cause to be distributed, any free samples of tobacco products or nicotine delivery products. No means, instruments or devices that allow for the redemption of tobacco products for free or at a reduced price below the minimum retail price determined by the Massachusetts Department of Revenue shall be accepted by any permittee. I. Out-of-Package Sales: No person may sell or cause to be sold or distribute or cause to be distributed, any cigarette package that contains fewer than twenty(20)cigarettes, including single cigarettes. J. Self-Service Displays: All self-service displays of tobacco products and/or nicotine delivery products are prohibited. All humidors including, but-not limited to,walk*in must be locked. K. Vending?Machines: • All tobacco and/or nicotine delivery product vending machines are prohibited. L. Commercial Roll-Your-Own Machines All commercial Roll-Your-Own machines are prohibited. M. Prohibition of the Sale of Tobacco and Nicotine Delivery Products by Health Care Institutions: No health care institution located in City of Salem shall sell or cause to be sold tobacco or nicotine delivery products. No retail establishment that operates or has a health care institution within it,such as a pharmacy or drug store, shall sell or cause to be sold tobacco products or nicotine delivery products. N. Prohibition of the Sale of Tobacco and Nicotine Delivery Products by Educational Institutions: No educational institution located in City of Salem shall sell or cause to be sold tobacco or nicotine delivery products. This includes all educational institutions as well as any retail establishments that operate on the property of an educational institution. • O. E-Cigarette Use: 6 The use of e-cigarettes is prohibited wherever smoking is prohibited per M.G.L. Ch.270, §22 and the Salem Environmental Tobacco Smoke(ETS)regulation. • P. Violations: 1. It shall be the responsibility of the establishment,permit holder and/or his or her business agent to ensure compliance with all sections of this regulation pertaining to his or her distribution of tobacco and/or nicotine delivery products. The violator shall receive: a. In the case of a first violation, a fine of one hundred dollars ($100.00). b. In the case of a second violation within 36 months of the date of the current violation, a fine of two hundred dollars ($200.00) and.t'he Tobacco and Nicotine Delivery Product Sales Permit shall be suspended+for seven.(7)consecutive business days. c. In the case of three or more violations within a 36 month period, a fine of three hundred dollars ($300.00) and the Tobacco and Nicotine Delivery Product Sales Permit shall be suspended for thirty(30)consecutive business days. 2. Refusal to cooperate with inspections pursuant to this regulation shall result.in the suspension of the Tobacco and Nicotine.Delivery Product Sales Permit for thirty(30) consecutive business days. 3. In addition to the monetary fines set above, any permitholder who engages in the sale • or distribution of tobacco or nicotine delivery products directly to a consumer while his or her permit is suspended shall;be subject to the suspension of all board of health issued permits for thirty (30)consecutive business days. 4. The City of Salem Board of Health shall=provide notice of the intent to suspend a Tobacco:and Nicotine Delivery Product Sales Permit,which notice shall contain the reasons'therefor and establish a time.and date for a hearing which date shall be no earlier than seven(7)days after the date of said notice. The permit holder or its business agent shall have an opportunity to be heard at such hearing and shall be notified of the Board of Health's decision and the reasons therefore in writing. After a hearing, the City of Salem Board of Health shall suspend the Tobacco and Nicotine Delivery Product Sales Permit if the Board finds that a sale to a minor occurred. For purposes of such suspensions, the Board shall make the determination notwithstanding any separate criminal or non- criminal proceedings brought in court hereunder or under the Massachusetts General Laws for the same offense. All tobacco products and nicotine delivery products shall be removed from the retail establishment upon suspension of the Tobacco and Nicotine Delivery Product Sales Permit. Failure to remove all tobacco and nicotine delivery products shall constitute a separate violation of this regulation. Q.Non-Criminal Disposition: Whoever violates any provision of this regulation may be penalized by the non-criminal • method of disposition as provided in General Laws, Chapter 40, Section 21 D or by filing a criminal complaint at the appropriate venue. 7 r The use of e-cigarettes is prohibited wherever smoking is prohibited per M.G.L. Ch.270, • §22 and the Salem Environmental Tobacco Smoke(ETS)regulation. - P. Violations: 1. It shall be the responsibility of the establishment,permit holder and/or his or her business agent to ensure compliance with all sections of this regulation pertaining to his or her distribution of tobacco and/or nicotine delivery products. The violator shall receive: a. In the case of a first violation, a fine of one hundred dollars ($100.00). b. In the case of a second violation within 36 months of the date of the current violation, a fine of two hundred dollars ($200.00) and the Tobacco and Nicotine Delivery Product Sales Permit shall be suspended for seven.(7)consecutive business days. c. In the case of three or more violations within a 36 month period,a fine of three hundred dollars ($300.00)and the Tobacco and Nicotine Delivery Product Sales Permit shall be suspended for thirty(30)consecutive business days. 2. Refusal to cooperate with inspections;pursuant to this regulation shall result.in the sus`ension of the Tobacco and Nicotim Delivery Product Sales Permit for thirty(30) • consecutive business days. 3. In addition to the monetary fines set above, aiiy permit holder who engages in the sale or distribution of tobacco or nicotine delivery:products directly to a consumer while his or her permit is suspended shall be subject to the suspension of all board of health issued permits for thirty(30)consecutive business days: 4. The City of Salem Board of Health shallprovide notice of the intent to suspend a Tobacco:and Nicotine Delivery Product Sales Permit,which notice shall contain the reasons therefor and establish a tir e.:and date for a hearing which date shall be no earlier than seven(7)days after the date of-said notice. The permit holder or its business agent shall have an opportunity to be heard at such hearing and shall be notified of the Board of Health's decision and the reasons therefore in writing. After a hearing,the City of Salem Board of Health shall suspend the Tobacco and Nicotine Delivery Product Sales Permit if the Board finds that a:sale to a minor occurred. For purposes of such suspensions,the Board shall make the determination notwithstanding any separate criminal or non- criminal proceedings brought in court hereunder or under the Massachusetts General Laws for the same offense. All tobacco products and nicotine delivery products shall be removed from the retail establishment upon suspension of the Tobacco and Nicotine Delivery Product Sales Permit. Failure to remove all tobacco and nicotine delivery products shall constitute a separate violation of this regulation. Q.Non-Criminal Disposition: • Whoever violates any provision of this regulation may be penalized by the non-criminal -\ method of disposition as provided in General Laws, Chapter 40, Section 21 D or by filing a criminal complaint at the appropriate venue. 7 • Each day any violation exists shall be deemed to be a separate offense. R. Enforcement: Enforcement of this regulation shall be by the City of Salem Board of Health of or its designated agent(s). Any citizen who desires to register a complaint pursuant to the regulation may do so by contacting the City of Salem Board of Health or its designated agent(s) and the Board shall investigate. S. Severability: If any provision of these regulations is declared invalid oz`cuienfoeeable,the other provisions shall not be affected thereby but shall continue in full force-and effect. T. Effective Date: This regulation shall take effect on with the exception of Section F(Cigar Sales Regulated which shall take effect on February 4, 2013. • 8 • Regulation of the City of Salem Board of Health Restricting the Sale and Use of Tobacco Products & Nicotine Delivery Products FINAL DRAFT A. Statement of Purpose: Whereas there exists conclusive evidence that tobacco smoke causes cancer,respiratory and cardiac diseases, negative birth outcomes, irritations to the eyes,nose and throat (Centers for Disease Control and Prevention(hereinafter "CDC'), Health Effects of Cigarette Smoking Fact Sheet, (January 2012)); whereas among the 15.7%of students nationwide who currently smoked cigarettes and were aged less than eighteen(18) years4 j4.1%usually obtained their own cigarettes by buying them in a store (i.e., convenience:store, supermarket, or discount store)or gas station during the thirty(30)days before t6.a ey(CDC, Youth Risk Behavior, Surveillance Summaries. 2009, MMWR 2010:59(No"SS�55)`at 11); whereas nationally in 2000, sixty-nine(69%)percent of middle school,age children who smoke`at least once a month were not asked to show proof of age whentpurchasing cigarettes (CDC,-;Youth Tobacco,Surveillance Summaries. 2000, MMWR 2001 50YYo SS-04)),whereas the U.S Department of Health and Human Services has concludedthat nicotine is as addictive as cocaine Or heroin(U.S.Department of Health and Human Seivices.How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable-Disease:A Report of the Surgeon General, Atlanta, GA: U.S.Department of Health and Human Services Centers for Disease Control and Prevention,National Center for Chronic Disease',Preventii*and Health Promotion, Office on Smoking and Health, 2010.); whereas despite state lawk rohibi'tm the sale of tobacco products to minors, access by minors jo tobacco products is a major�.pro blem; whereas according to the CDC, cigarette price incrcas'as reduce the'Vemand for'cigarettes and thereby reduce smoking prevalence, cigarette consumption, and youth initiation of smoking (U.S. Department of Health and Haiman Services. Reducing Tobacco Use:A Report of the Surgeon General. Atlanta, GA. U.S.Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention an'd=Health Promotion, Office on Smoking and Health, 171, 2000 at 35,8) '..� Whereasthe 2012 U.S. Suigeon General's Report on Preventing Tobacco Use Among Youth and`:Young Adults,reports that in 2005 Ringel, Wasserman, &Andreyeva(U.S. Department of Health and Humd»:'Services,Nicotine Addiction,Atlanta, GA: U.S.Department of Health and Human Services;;CDC,National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health,;1988)conducted logistic regression analyses to examine whether increased cigar prices aid state tobacco control policies affected the rate of cigar use. (U.S.Department of Health and Human Services.Preventing Tobacco Use Among Youth and Young Adults,Atlanta, GA: U.S.Department of Health and Human Services, Centers for Disease Control and Prevention,National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2012 at 706). Using the 1999 and 2000 iterations of the National Youth Tobacco Survey, Ringel and colleagues analyzed data from 33,632 adolescent participants aged nine to seventeen. They found that increased cigar prices significantly decreased the probability of male adolescent cigar use and found that a 10% increase in cigar prices would reduce the sample's cigar use by 3.4%(Ringel JS, Wasserman J,Andreyeva T,Effects of Public Policy on Adolescents'Cigar Use:Evidence From the National Youth Tobacco Survey, 95 Am.J. Pub.Health 995-8(June 1, 2005); whereas according to the CDC's youth risk behavior • surveillance system, the percentage of high school students in Massachusetts who reported the use of cigars within the past 30 days went from 11.8% in 2003 to 14.9% in 2009 (CDC, Youth Risk Behavior. Surveillance Summaries,2009. MMWR 2010;59(No. SS-55)at 72; • CDC, Youth Risk Behavior. Surveillance Summaries, 2003. MMWR 2004;53(No. SS-02)at 54); whereas nicotine levels in cigars are generally much higher than nicotine levels in cigarettes. (Nat'l Cancer Institute at the Nat'l Inst. of Health, Questions and Answers About Cigar Smoking and Cancer (Oct. 27, 2010)); Whereas commercial Roll Your Own(RYO)machines enable loose, unpackaged tobacco to be poured into a machine and placed into empty,unpackaged cigarette tubes to be inhaled by individuals who smoke them. This procedure provides risk of contamination of the tobacco and unsanitary conditions in the machine and is injurious to public health; whereas commercial Roll Your Own (RYO)machines located in retail stores enable retailers to sell cigarettes without paying the federal and state excise taxes that are imposed on conventionally manufactured cigarettes(RYO FILLING'STATION, www.ryorllinzstation.com (Feb. 27,2012). High excise taxes encourage adult smokers to quit and deter youth from starting (Kenneth E. Warner, Smoking and.-ke lth.itnplications of a Change in the Federal Cigarettte Excise Tax, 255 J.AM. MED.Ass'N 1028,(1986),FranO Chaloupka&Rosalie Liccardo Pacula, The Impact of Price on Youth Tobacco Use, 11i4.SMOKING AND;TOBACCO CONTROL MONOGRAPHS: CHANGING ADOLESCENTySMOKING PRE VALENCE]93(U.S.Dep't Health and Human Services et al. eds., 2001)). Therefore, inexpensive cigarettes„like those produced from RYO machines,promote the use oftobacco resulting in a negative impact on public health and increased health care costs, andseverelyindercut the evidence- based public health benefit of imposing high excise taxes-on tobacco; Whereas the sale of tobacco products and ncotine delivery products are incompatible with the mission of health care institutions because-.they are detrimental to the public health and undermine efforts to educate patients on the,safe and effective use of medication; r= Whereas educational institution sell tobacco products to a younger population, which is particularly at risk for becoming smokers and such sale of tobacco products and nicotine delivery products are incompatible with the w-mission of educational institutions that educate ayouunger population=about social,'`environmental and health risks and harms; T. .#.....p # Now,therefore it is the intention ofthe City of Salem Board of Health to regulate the access of tobacco product's.and nicotine delivery products. B. Authority: =`' iJ= This regulation is promulgated pursuant to the authority granted to the City of Salem Board of Health by Massachusetts General Laws Chapter 111, Section 31 that 'Boards of Health may make reasonable health regulations". C. Definitions: For the purpose of this regulation, the following words shall have the following meanings: • 1 Blunt Wrap: Any tobacco product manufactured or packaged as a wrap or as a hollow • tube made wholly or in part from tobacco that is designed or intended to be filled by the consumer with loose tobacco or other fillers. Business Agent: An individual who has been designated by the owner or operator of any establishment to be the manager or otherwise in charge of said establishment. Cigar: Any roll of tobacco that is wrapped in leaf tobacco or in any substance containing tobacco with or without a tip or mouthpiece not otherwise defined as a cigarette under Massachusetts General Law, Chapter 64C, Section 1, Paragraph 1. Commercial Roll-Your-Own(RYO)machine: A mechanical device, by whatever manufacturer made and by whatever name known, that is designed to roll and wrap tobacco into products. RYO machines located in a private home, used for personal consumption, are not Commercial Roll-Your-Own machines. E-Cigarette: Any electronic Nicotine Delivery Product'composed of a mouthpiece, heating element, battery and/or electronic circuits that provides a vapor of liquid nicotine to the user, or relies on vaporization of solid nicotine or any liquid. This term shall include such devices whether they are manufactured as e-cigarettes, e-cigars, e-pipes or under any other product name. Educational Institution: Any public or'private.college, school,professional school, scientific or technical institution, university or other institution furnishing a program of • higher education. Employee: Any individual who performs services for air employer. Employer: Any individual, partnership, association, corporation, trust or other organized group of individuals that uses the services of one(1)or more employees. Health Care Institution: An individual, partnership, association, corporation or trust or any person or group of persons that provides health care services and employs health care providers licensed, or subject to licensing,by the Massachusetts Department of Public Health under M.G.L. c. 112 or a retail establishment that provides pharmaceutical goods and services and subject to the provisions of 247 CMR 6.00. Health care institution includes,but is not limited to, hospitals, clinics, health centers,pharmacies, drug stores, doctor offices and dentist offices. Minor: Any individual who is under the age of eighteen(18). Nicotine Delivery Product: Any manufactured article or product made wholly or in part of a tobacco substitute or containing nicotine that is expected or intended for human consumption,but not including a tobacco substitute prescribed by a licensed physician or a product that has been approved by the United States Food and Drug Administration for sale as a tobacco use cessation or harm reduction product or for other medical purposes and which is being marketed and sold solely for that approved purpose. Nicotine delivery • product includes,but is not limited to, e-cigarettes. 2 Permit Holder: Any person engaged in the sale or distribution of tobacco or nicotine • delivery products directly to consumers who applies for and receives a tobacco and nicotine delivery product sales permit or any person who is required to apply for a tobacco and nicotine delivery product sales permit pursuant to these regulations, or his or her business agent. Tobacco Product: Cigarettes, cigars, chewing tobacco, pipe tobacco,bidis, snuff or tobacco in any of its forms. Vending Machine: Any automated or mechanical self-service device,which upon insertion of money, tokens or any other form of payment, dispenses or makes cigarettes, any other tobacco product or Nicotine Delivery Product. D. Tobacco and Nicotine Delivery Product Sales to Minors.Prohibited: 1. No person shall sell tobacco or nicotine delivery products or permit tobacco or nicotine delivery products to be sold to a minor; or not being the minor's parent or.legal guardian, give tobacco or nicotine delivery products to a minor. 2. Required Signage a. In conformance with and in addition to Massachusetts General Law, Chapter 270, Section 7, a copy of Massachusetts General Laws, Chapter 270, Section 6, shall be posted conspicuously by the owner or other person in.charge thereof in the • shop or other place used to sell tobacco products at retail. The notice shall be provided by the Massachusetts Department of Public Health and made available from the City of Salem Board of Health. The notice shall be at least 48 square inches and shall be posted_conspicuously by the permit holder in the retail establishment or-other place in such a manner so that it may be readily seen by a person standing at or approaching the cash register. The notice shall directly face the_purchaser and shall'not be obstructed from view or placed at a height of less than four(4)-feet or greater than nine (9) feet from the floor. The owner or other person in charge'of a shop or other place used to sell tobacco products at retail shall conspicuously post any additional signs required by the Massachusetts Department of Public Health. b. The owner or other person in charge of a shop or other place used to sell tobacco products at retail shall conspicuously post signage provided by the City of Salem board of health that discloses current referral information about smoking cessation. c. The owner or other person in charge of a shop or other place used to sell nicotine delivery products at retail shall conspicuously post a sign stating that"The sale of nicotine delivery products to minors under 18 years of age is prohibited." The owner or other person in charge of a shop or other place used to sell e-cigarettes at retail shall conspicuously post a sign stating that"The use of e-cigarettes at indoor establishments may be prohibited by local law."The notices shall be no smaller • than 8.5"by I I"and shall be posted conspicuously in the retail establishment or other place in such a manner so that they may be readily seen by a person standing at or approaching the cash register. These notices shall directly face the 3 purchaser and shall not be obstructed from view or placed at a height of less than • four(4) feet or greater than nine (9) feet from the floor. 3. Identification: Each person selling or distributing tobacco or nicotine delivery products shall verify the age of the purchaser by means of valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 18 years old or older. Verification is required for any person under the age of 27. 4. All retail sales of tobacco or nicotine delivery products must be face-to-face between the seller and the buyer. E. Tobacco and Nicotine Delivery Product Sales Permit: 1. No person shall sell or otherwise distribute tobacco or nicotine delivery products at retail within the City of Salem without first obtaining a Tobacco and Nicotine Delivery Product Sales Permit issued annually by the City of Salem Board of Health. Only owners of establishments with a permanent,non-mobile location in Salem are eligible to apply for a permit and sell tobacco products or nicotine delivery products at the specified location in Salem. 2. As part of the Tobacco and Nicotine Delivery Product:Sales Permit application process, the applicant will be provided with the City of Salem Board of Health regulation. Each applicant is required to sign a statement.declaring that the applicant has read said regulation and that the applicant is responsible for-instructing any and all employees who • will be responsible for tobacco and nicotine delivery product.sales regarding both state laws regarding the sale of.tobacco and this regulation. 3. Each applicant who'sells tobacco is required to provide proof of a current tobacco sales license issued by the Massachusetts Department of Revenue before a Tobacco and Nicotine Delivery Product Sales-Permit can be issued. 4. The fee for a Tobacco and Nicotine Delivery Product Sales Permit shall be determined by the City of Salem Board of Health-annually. All such permits shall be renewed annually. 5. A separate permit is required for each retail establishment selling tobacco or nicotine delivery products. 6. Each Tobacco andNicotine Delivery Product Sales Permit shall be displayed at the retail establishment in a conspicuous place. 7. No Tobacco and Nicotine Delivery Product Sales Permit holder shall allow any employee to sell tobacco products or nicotine delivery products until such employee reads this regulation and state laws regarding the sale of tobacco and signs a statement, a copy of which will be placed on file in the office of the employer, that he/she has read the regulation and applicable state laws. • 8.A Tobacco and Nicotine Delivery Product Sales Permit is non-transferable. A new owner of an establishment that sells tobacco or nicotine delivery products must apply for 4 a new permit. No new permit will be issued unless and until all outstanding penalties • incurred by the previous permit holder are satisfied in full. 9. Issuance of a Tobacco and Nicotine Delivery Product Sales Permit shall be conditioned on an applicant's consent to unannounced, periodic inspections of his/her retail establishment to ensure compliance with this regulation. 10. Issuance and holding of a Tobacco and Nicotine Delivery Product Sales Permit shall be conditioned on an applicant's on-going compliance with current Massachusetts Department of Revenue requirements and policies including, but not limited to,minimum retail prices of tobacco products. 11. A Tobacco and Nicotine Delivery Product Sales Permit will not be renewed if the permit holder has failed to pay all fines issued and the time.period to appeal the fines has expired and/or has not satisfied any outstanding permit suspensions. 12. Maximum Number of Tobacco and Nicotine Delivery Product Sales;Permits. At any given time, there shall be no more.than 60 Tobacco and Nicotine Delivery Product Sales Permits issued in City of Salem >No;permit renewal will be denied based on the requirements of this subsection except any permittee who has failed to renew their current permit within(30)days of expiration will be treated as a first-time permit applicant. Applicants who purchase a business that holds a current Tobacco and Nicotine Delivery Product Sales Permit at the time of the • sale of said business may apply, within sixty(60)_days"of such sale, for the permit held by the Seller if-the Buyer intends,to sell tobacco products and/or Nicotine Delivery Products'. New applicants for permits who are applying at a time when the maximum number of permits have been issued will be placed on a waiting list and will be eligible to apply for a permit'on'a"first-come, first-serve"basis as issued permits are.either not renewed or are returned to the Board. F. Cigar Sales Regulated-. 1.No retailer, retail establishment,,or other individual or entity shall sell or distribute or cause to be sold or distributed a cigar unless the cigar is contained in an original package of at least four(4).cigars. 2. This Section shall not apply to: a. The sale or distribution of any cigar having a retail price of more than two dollars and fifty cents ($2.50). b. A person or entity engaged in the business of selling or distributing cigars for commercial purposes to another person or entity engaged in the business of selling or distributing cigars for commercial purposes with the intent to sell or distribute outside the boundaries of City of Salem. • 3. The Board of Health may adjust from time to time the amounts specified in this Section to reflect changes in the applicable Consumer Price Index by amendment of this regulation. 5 G. Prohibition of the Sale of Blunt Wraps • No person or entity shall sell or distribute blunt wraps within the City of Salem. H. Free Distribution and Coupon Redemption: No person shall distribute, or cause to be distributed, any free samples of tobacco products or nicotine delivery products. No means, instruments or devices that allow for the redemption of tobacco products for free or at a reduced price below the minimum retail price determined by the Massachusetts Department of Revenue shall be accepted by any permittee. I. Out-of-Package : No person may sell or cause to be sold or distribute or cause to be distributed, any cigarette package that contains fewer than twenty(20)'6garettes, including single cigarettes. J. Self-Service Displays: All self-service displays of tobacco products and/or nicotine delivery products are prohibited. All humidors including, but not limited to, walk-in humidors must be locked. • K. Vending Machines: All tobacco and/or nicotine delivery product vending machines are prohibited. L. Commercial Roll-Your-Own-Machines All commercial R611-Your=Own machines are prohibited. M. Prohibition of the Sale of Tobacco and Nicotine Delivery Products by Health Care Institutions: No health care institution located in City of Salem shall sell or cause to be sold tobacco or nicotine delivery products. No retail establishment that operates or has a health care institution within it such as a pharmacy or drug store, shall sell or cause to be sold tobacco products or nicotine delivery products. N. Prohibition of the Sale of Tobacco and Nicotine Delivery Products by Educational Institutions: No educational institution located in City of Salem shall sell or cause to be sold tobacco or nicotine delivery products. This includes all educational institutions as well as any retail establishments that operate on the property of an educational institution. • O. E-Cigarette Use: 6 The use of e-cigarettes is prohibited wherever smoking is prohibited per M.G.L. Ch.270, • §22 and the Salem Environmental Tobacco Smoke(ETS)regulation. P. Violations: 1. It shall be the responsibility of the establishment, permit holder and/or his or her business agent to ensure compliance with all sections of this regulation pertaining to his or her distribution of tobacco and/or nicotine delivery products. The violator shall receive: a. In the case of a first violation, a fine of one hundred dollars ($100.00). b. In the case of a second violation within 36 months of the date of the current violation, a fine of two hundred dollars ($200.00) and the Tobacco and Nicotine Delivery Product Sales Permit shall be suspended for seven,(7)consecutive business days. c. In the case of three or more violations within a 36 month period,a fine of three hundred dollars ($300.00) and the Tobacco and Nicotine Delivery Product Sales Permit shall be suspended for thirty(30)consecutive business days. 2. Refusal to cooperate with inspections pursuant to this regulation shall result in the suspension of the Tobacco and Nicotine Delivery Product Sales Permit for thirty(30) consecutive business days. • 3. In addition to the monetary.fines set above, any permit holder who engages in the sale or distribution of tobacco or nicotine delivery;products directly to a consumer while his or her permit is suspended shall be subject to the suspension of all board of health issued permits for thirty(30)consecutive business days. 4. The City,of Salem Board of Health shall provide notice of the intent to suspend a Tobacco and Nicotine Delivery Product Sales Permit,which notice shall contain the reasons therefor and establish a time and date for a hearing which date shall be no earlier than seven(7)days after the date of said notice. The permit holder or its business agent shall have an opportunity to be heard at such hearing and shall be notified of the Board of Health's decision and the reasons therefore in writing. After a hearing, the City of Salem Board of Health shall suspend the Tobacco and Nicotine Delivery Product Sales Permit if the Board finds that a'sale to a minor occurred. For purposes of such suspensions, the Board shall make the determination notwithstanding any separate criminal or non- criminal proceedings brought in court hereunder or under the Massachusetts General Laws for the same offense. All tobacco products and nicotine delivery products shall be removed from the retail establishment upon suspension of the Tobacco and Nicotine Delivery Product Sales Permit. Failure to remove all tobacco and nicotine delivery products shall constitute a separate violation of this regulation. Q. Non-Criminal Disposition: • Whoever violates any provision of this regulation may be penalized by the non-criminal method of disposition as provided in General Laws, Chapter 40, Section 21 D or by filing a criminal complaint at the appropriate venue. 7 • Each day any violation exists shall be deemed to be a separate offense. R. Enforcement: Enforcement of this regulation shall be by the City of Salem Board of Health of or its designated agent(s). Any citizen who desires to register a complaint pursuant to the regulation may do so by contacting the City of Salem Board of Health or its designated agent(s)and the Board shall investigate. -r S. Severability: Y .4b If any provision of these regulations is declared invalid or"_'t nenf&beable, the other provisions shall not be affected thereby but shall continue-in full feed-and effect. fF '' T. Effective Date: i} ry7k This regulation shall take effect on �, 2012, with the exception of Section F (Cigar Sales Regulated)which shall take effect on February 4, 2013. . �w. P: ti .oi .S: I • 8 4k Municipal Tobacco Control Technical Assistance Program Donald J. Wilson, Director c/o Massachusetts Municipal Association (617) 426-7272 One Winthrop Square FAX (617) 695-1314 Boston, Massachusetts 02110 djwilson@mma.org ---------------------------------------------------------------- ---------------------------------------------------------------- MEMORANDUM TO: Salem Board of Health FROM: D. J. Wilson RE: Concerns Raised at July 10 Public Hearing DATE: July 11, 2012 At the above-captioned public hearing a number of local business owners testified regarding concerns about three sections of the regulation: Section E.12—Permit Number Cap, Section F— • Cigar Sales Regulated and Section G—Prohibition of the Sale of Blunt Wraps. I'd like to answer concerns raised on each after first noting that the draft before the Board contains over a dozen components all in the effort to keep youth from smoking and to encourage current smokers to quit. There is no one"silver bullet"to do this and it is important to note that only these sections of the draft were raised at the hearing. Section E.12—Permit Number Cap The proposed language makes the permit more valuable in that there would be a finite number of permittees allowed to sell tobacco products and places those businesses in a privileged class. That privileged class means that not only do they hold a valuable commodity but that they need to be diligent in preventing this privilege taken away from them as a result of being repeat offenders to the regulation. The proposal mimics long-held theory by the Commonwealth and their liquor license local allotment formula that containing the number of outlets has reasonable public health and public welfare goals. The proposed language is intended to ensure that a current permit holder is not disadvantaged when selling their business to a buyer who is not a permit holder. Upon concerns from one trade association, that language was clarified to indicate that a bona fide buyer will get a permit and not be "shut out"by the permit cap. Section F—Cigar Sales Regulated In February of 2011,the City of Boston instituted a ban on the sale of cheap single cigars. The impetus for doing so was that evidence existed that youth were buying these cheap cigars. This effort mimics the ban on single cigarettes ("loosies") and"kiddie packs" (packs of 5 or 10 cigarettes)by controlling the price or size of cigar packs sold. No evidence exists in Massachusetts that the ban on"loosies"led to increased smoking because smokers were now compelled to buy a whole pack of cigarettes. Rather, impulse buys of single cigarettes,priced as low as 25 cents at the time of the state law ban,were reduced. To date, compliance has been high in the city of Boston and no lawsuits have been brought against the City. The delayed start date for this section of the proposed regulation is intended to allow for a year's worth of enforcement experience in Boston before other cities in towns in Massachusetts institute their own effort on cigar sales. Section G—Prohibition of the Sale of Blunt Wraps One retailer opposed the ban on blunt wraps. Boston has had this ban in place for three years. Lynn, Worcester and New Bedford also ban blunt wraps. Boston's ban survived a legal challenge when the Massachusetts Supreme Judicial Court siding with the city. After that decision, a federal lawsuit against Worcester's ban was dropped. Section H—Free Distribution and Coupon Redem tp ion Lastly, while no one testified on this subject at the hearing, the Board did receive written communications concerning the redemption of coupons. The language in this draft accomplishes two goals: (1) for all tobacco products, no coupon can be • redeemed that results in the product being free, which confirms the first sentence of this section that bans "any free samples of tobacco products" and(2) if it is a coupon for cigarettes,the amount of the coupon cannot drive the price below that listed in the Massachusetts Department of Revenue's minimum pricing list. The section is thusly worded in case the Mass. DoR decides in the'future to expand its minimum price list beyond cigarettes to other tobacco products. This provision will actually help retailers from violating the state law by permitting the acceptance of only those coupons that keep the then discounted price above the Commonwealth's legal minimum. There is in fact a federal court case involving a coupon redemption ban imposed by Providence, Rhode Island. Differentiating this lawsuit from the language in the draft is the important distinction that the Massachusetts Department of Revenue maintains a minimum price list for each and every brand of cigarette sold in the Commonwealth. No such list exists in Rhode Island. It is also important to note that nowhere in the draft regulation is there any regulation of flavored tobacco products. • ! • Sign in Sheet for Public Hearing for Tobacco Sales Regulation "Please print information' 7/10/2012 NAME (PRINT) STREET ADDRESS ESTABLISHMENT TT '01770 Uf,- O (� 1.► � � ITC,-4 � P C . 6, ,� 2W14AE� l 7 3, S 0 Sign in Sheet for Public Hearing for Tobacco Sales Regulation **Please print information*'k 7/10/2012 NE �a r�vc� rS 1 ca^aA ZZ, L-AA..-3 m nc 11 A ` A) �' /`� 6 L AN (� Co n v Cv1 i e n�. /\/�)k A r V2 -3Lck 4 4c, I - M JfJryjr F New England Convenience Store Association Dr. Barbara Poremba, Chairperson Salem Board of Health 120 Washington Street(4th floor) Salem, MA 01970 VIA electronic mail and regular mail July 9, 2012 Comments of the New England Convenience Store Association Regarding Proposed Regulation of the Salem Board of Health Restricting the Sale of Tobacco Products and Nicotine Delivery Products Dear Chairperson Poremba and Members of the Salem Board of Health: I am submitting this letter on behalf of the New England Convenience Store Association (NECSA). NECSA's membership consists of independent, family owned convenience stores, independently owned franchise stores as well as chain-operated convenience stores. According to the National Association of Convenience Stores [NACS] latest industry report, as of December 2010, there are approximately 2,800 convenience stores operating in Massachusetts. Passage of several of the proposed regulations-particularly 1) the cigar mandates that could ironically require consumers to buy more tobacco products than they choose to consume and 2) the provisions regarding limitations and potential elimination of retail sales permits for store owners - will directly and negatively affect the ability of small businesses in Salem to remain in business, grow, and create and maintain jobs in the community. We respectfully ask that you not adopt these provisions. 1) Requiring consumers to buy more tobacco products than they want seems inconsistent with a health regulation The proposed regulation stipulates that no cigar may be sold in packs of less than four- except cigars over a certain price point. With all due respect to the drafters of this proposal, how can a regulation requiring people to buy as much as four times more of a tobacco product than they want possibly be construed as a productive health ordinance? This question does not seem to have a clear answer to those who would be regulated under this proposal and will ultimately cause economic harm to store owners in the City of Salem. Unlike cigarettes, there are many adults who may want only one cigar of their particular brand and compelling them to purchase more than they want seem illogical. In fact, data shows that less than 1% of cigar smokers do soon a daily basis (see below). For Salem's convenience stores, a ban on single cigar sales with a retail price of$2.50 or less would have a significant financial impact on retail sales and a store's ability to maintain their bottom line. Regardless of an individual's feeling about tobacco, cigars are legal adult products and are important to your local convenience store's business. According to the National Association of Convenience Stores'(NACS)State of the Industry Report for 2010,`other tobacco Products including cigars' on average constitute 4%of sales at convenience stores which is the 5t highest in store sales product. Single cigar sales for the`under$2.50 retail class' represent a significant sales category and would severely impact their overall sales and a store's profit which impacts their ability to employ staff. This is 1044 Central Street Suite 203-Stoughton, MA 02072-Phone:781-297-9600- Fax: 781-297-9601 New England Convenience Store Association an industry in which every dollar counts and convenience stores should not be deprived of an opportunity to generate revenue from their fifth largest selling category in this competitive market. Here is relevant data that may be of interest to you about single cigar sales. • 60%of machine-made large cigars are sold in convenience stores(Volume By Trade Class) Source: STARS Geo Agg Database updated 9/3/11, data through week ending 7/2/11 • 70 %of machine-made large cigars are sold as single cigars(Transactions by Cigar Count) Source: Symphony IRI Group Info Scan Database updated to 9/4/11, data through week ending 7/3/11 • Less than 1%of adults who smoke cigars do so on a daily basis. See National Cancer Institute, Monograph 9: Cigars: Health Effects and Trends, Trends in Cigar Smoking and Smoking Prevalence,40-49(1998); CDC, Cigarette Smoking Among Adults—United States, 2004, 295 JAMA 749, 749-50(2006). This relates to our members'view that most adult consumers legitimately prefer to purchase cigars in smaller quantities-perhaps only a single cigar or a few cigars at a time. Also, our members'customers may travel to a neighboring town or order products over the Internet to the financial disadvantage of the local convenience store's business and the city's economy. 2) Arbitrary Limits on Sales Permits are Detrimental to Small Business Growth The proposed regulations seem to limit the number of retail sales permits to no more than sixty and then allow the Board of Health to, presumably at their sole discretion, to potentially lower that number even further. Sales of businesses would not ensure the transfer of the permit to subsequent owners. In fact, the proposal expressly states that the permit is non-transferrable. This could significantly impact the value of every existing retail store that currently sells tobacco in Salem since there is no guarantee that a subsequent owner would be able to continue the business. In addition, anyone seeking to start a new business in Salem could-and it seems would-be denied a permit if the limit set by the city is reached. Regardless of the intentions, this proposal seems to have no clear, legitimate basis as a health regulation but rather as a means of stopping the creation of job- generating businesses that sell legal products in a responsible manner. We respectfully urge you not to adopt it. For the foregoing reasons we ask that you not adopt these regulations referenced above. Thank you very much for your time and consideration of our request. 2teDphe yaA, Esq. Executive Director New England Convenience Store Association 1044 Central Street Suite 203^ Stoughton, MA 02072-Phone: 781-297-9600- Fax: 781-297-9601 - Lan Ramdin -- ------ From: Duffill, Raymond A <Raymond.Duffill@fda.hhs.gov> Sent: Tuesday,July 10, 2012 9:45 AM To: Larry Ramdin Cc: O'Malley, Elizabeth Subject: FW: Salem 2102 grant application.doc Attachments: Salem 2102 grant application.doc Good Morning Larry, Congratulations! Your Program Standards Funding proposal for the 2012-2013 year has been qpproved. A purchase order will be processed to award $2500.00 for the deliverables as described below: '(:''The City if Salem Board of Health will enroll in the FDA Voluntary Retail Food Regulatory Program Standards ('Program Standards)and submit the required National Registry and Permission to Publish forms to the FDA Regional Office Retail Food Specialist. 2.::-::The City of Salem Board of Health will complete a Food Protection Program self-assessment against the current ygo§ion of the Program Standards within 12 months of enrollment and submit the required National Registry and Eei mission to Publish forms to the FDA Regional Retail Food Specialist to report that accomplishment. 3. The City of Salem Board of Health will develop an action plan and submit a report and/or National Registry and Permission to Publish forms as applicable to the FDA Regional Retail Food Specialist on or before July 1, 2013. Please review and if acceptable to you, amend your proposal to reflect the deliverables as detailed above in items 1-3. If there are questions or there is a need to change anything, please do not hesitate to conteact me. Thank you and best regards. Ray From: Larry Ramdin [mailto:Iramdin(56alem.coml Sent: Tuesday, July 03, 2012 11:42 AM To:: Duffill, Raymond A Cc:,O'Malley, Elizabeth Subject: RE: Salem 2102 grant application.doc Ray, The application is attached,thanks for your assistance in completing it. Sincerely Larry Ramdin Health Agent Salem Board of Health 120 Washington Street, 4th floor Salem MA 01970 978-741-1800 (phone) 0 978-745-0343(fax) 1 1999 Food Code 6-501.115 Prohibiting Animals.* (A) Except as specified in 1111(B)and (C)of this section,live animals may not be allowed on the premises of a food establishment. (B) Live animals may be allowed in the following situations if the contamination of food; clean equipment, utensils,and linens;and unwrapped single-service and single-use articles can not result: (1) Edible fish or decorative fish in aquariums,shellfish or crustacea on ice or under refrigeration,and shellfish and crustacea in display tank systems; (2) Patrol dogs accompanying police or security officers in offices and dining,sales,and storage areas, and sentry dogs running loose in outside fenced areas; 3 In areas that are not used for food preparation and that• (. ) p pare usually open for customers,such as dining and sales areas,service animals that are controlled by the disabled employee or person if a health or safety hazard will not result from the presence or activities of the service animal; (4) Pets in the common dining areas of group residences at times other than during meals if: (a) Effective partitioning and self-closing doors separate the common dining areas from food storage or food preparation areas, (b) Condiments,equipment,and utensils are stored in enclosed cabinets or removed from the common dining areas when pets are present,and (c) Dining areas including tables,countertops,and similar surfaces are effectively cleaned before the next meal service;and (S) In areas that are not used for food preparation,storage,sales,display, or dining, in which there are caged animals or animals that are similarly restricted,such as in a variety store that sells pets or a tourist park that displays animals. (C) live or dead fish bait may be stored if contamination of food; clean equipment, utensils,and linens; and unwrapped single-service and single-use articles can not result. FDA Food Code Public Health rationale -6-501.115 Prohibiting Animals.* Animals carry disease-causing organisms and can transmit pathogens to humans through direct and/or indirect contamination of food and food-contact surfaces.The restrictions apply to live animals with limited access allowed only in specific situations and under controlled conditions and to the storage of live and dead fish bait. Employees with support animals are required under§ 2-301.14 to wash their hands after each contact with animals to remove bacteria and soil. Animals shed hair continuously and may deposit liquid or fecal waste, creating the need for vigilance and more frequent and rigorous cleaning efforts. The definition for"service animal" is adapted from 28 CFR 36.104 adopted pursuant to the Americans with Disabilities Act(ADA)of 1990(42 U.S.C. 12101 et seq.). A service animal performs some of the functions that persons with a disability cannot perform for themselves,such as those provided by "seeing eye dogs"; alerting persons with hearing impairments to sounds; pulling wheelchairs or carrying and picking up things for persons with mobility impairments; and assisting persons with mobility impairments with balance. A service animal is not considered to be a pet. Under Title III of the ADA, privately owned businesses that serve the public are prohibited from discriminating against individuals with diabilities.The ADA requires these businesses to allow people with disabilities to bring their service animals onto business premises in whatever areas customers are generally allowed.Some,but not all,service animals wear special collars or harnesses.Some, but not all, are licensed or certified and have identification papers. Decisions regarding a food employee or applicant with a disability who needs to use a service animal should be made on a case-by-case basis.An employer must comply with health and safety requirements,but is obligated to consider whether there is a reasonable accommodation that can be made. Guidance is available from the U.S. Department of Justice,Civil Rights Division, Disability Rights Section or the U.S. Equal Employment Opportunity Commission,the federal agency which has the lead in these matters, in documents such as, "Commonly Asked Questions About Service Animals in Places of Business"; "The Americans with Disabilities Act Questions and Answers"; "A Guide to Disability Rights Laws"; and "Americans with Disabilities Act Title III Technical Assistance Manual, 1994 Supplement."The ADA Information Line is 800-514-0301(voice)or 800-514-0383 (TDD) and the Internet Home Page address is http://www.usdoj.gov/crt/ada/adahoml.htm3. Larry Ramdin Frorn: dildar hussain <barkeleywater@hotmail.com> Sent: Monday,July 09, 2012 12:14 PM To: Larry Ramdin Subject: Tobacco Ordinance My Name is Dildar Hussain.i own 2 small businesses in the city of salem,Canal st gloabl ,200 canal st,and pump n pantry,10 paradise road. i am a resposible retailer,been selling the tobacco prodcuts to adult consumers of legal age never have issues of any kind. with the new purposal of cigar tobacco regulation it will certainly hurt the small retail business as is we are struggling to meet our.end needs. The,reason being our sales of tobacco product will go down drastically and it will hurt us financially. Consumer point of view struggling with econmy they prefer buying single units due to the price structure and convienence packing. Fair trade market,also if the can buy the same product crossing the town,salem retailers will loose the sales and the revenue also the taxes state and city collects on the merchandising. My humble request to the board is please review carefully with retailer point of view and then make decision on it Best Regards. Dildar Hussain. 08-327-8815. i 1 N A 11 T�w July 10,2012 officers Larry Ramdin,RS/REHS,CHO, CP-FS Chairman Health Agent Me Salem Board of Health ;- 120 Washington Street,40 Floor Salem,MA.01970 Vice Chairman Re: Proposed Tobacco Regulation Amendments Secretary Dear Agent Ramdin, The Retailers Association of Massachusetts (RAM), established in 1918, is a Treasurer statewide trade association of over 3,400 member companies. Our membership � �411"71'1'" ranges from independent, "mom and pop" owned stores to larger, national chains Executive Staff operating in the general retail, restaurant and service sectors of the retail industry. The industry's contributions to the Commonwealth include over $112 billion in President annual sales; over $5.7 billion in annual sales and use taxes collected; 17% of all .K!n 1`. ilul;,r Massachusetts jobs; and operations in over 38,000 locations across the state. Vice President V1`i1 i.;:1-;;-*. RAM wishes to be recorded in opposition to the proposal to be considered by the General Counsei Salem Board of Health during a public hearing on Tuesday, July 10, 2012, which, aims to ban on the sale of tobacco products in retail pharmacies and drug stores Membership Director located in your town. Finance Manager We find this proposal to be discriminatory in that it seeks to ban the sale of tobacco, a legal product, in certain types of stores. In taking this proposed course of action, your municipality is essentially picking winners and losers in a very competitive retail marketplace. Retail pharmacies will be placed at a competitive disadvantage with the loss of tobacco products from their shelves. Retailers should be allowed to decide for themselves whether or not to offer tobacco products to adult consumers. It is simply unfair to deprive a legitimate and licensed retail business the opportunity to sell a legal product. The proposed sales ban will not result in a decrease in tobacco usage. Yet, it will result in the loss of revenue for those retail locations that currently sell tobacco and seek to operate a pharmacy in the future. The elimination of products from their shelves will result in a decrease in customer traffic and will impact the sale of any number of other product lines. Depending on the current economic viability of a . particular retail location,the resulting revenue loss to a competitor across the street that does not have a pharmacy may translate into job loss and possibly store closings. Furthermore, any proposal that directly or indirectly hinders the sale of legal products is illogical in today's economic climate where the Commonwealth is hard pressed for revenue needed to fund local aid. Every sale that goes unrealized by a retailer translates into a loss of badly needed state revenue. It is also important for any Iocal government to be aware of the real possibility of costly legal action resulting from the adoption of such a law. Although no lawsuit has yet to be brought against any of the growing number of Massachusetts cities and towns which currently have a ban, we caution you that it is only a matter of time. Just last spring, a large grocery chain in San Francisco brought suit against that city challenging a similar ordinance adopted there. This most recent action follows a string of previous suits dating back to 2008 when the original ordinance was adopted. As more local tobacco bans are imposed and more retailers become aware of efforts, like those taken in San Francisco to protect retailers' Constitutional rights, the more likely it becomes that local businesses will follow suit. For the reasons detailed above, RAM is also opposed to those provisions of the proposal which. aim to prohibit the sale of cigars in packages of less than four and which restrict the sale of e- cigarettes. Again these prohibitions apply to legal products intended for consumption by adult consumers. To prohibit the sale of these products is competitively unfair, has a negative impact on state tax revenue and exposes the government to costly legal disputes. Today's consumer has a wide variety of choices available to them when deciding where to shop. Many consumers look for that one stop shopping experience and appreciate the availability of a wide variety of product offerings. We ask that consumers be allowed to continue to enjoy that current flexibility of choice in the marketplace. RAM respectfully requests that you oppose this proposal and we thank you for your consideration. Sincerely, Ryari'C. Kearney General Counsel cc: Salem Board of Health Members . DEPARTMENT OF HEALTH AND HUMAN SERVICES Food and Drug Administration 21 CFR Part 1140 [Docket No. FDA-1995-N-0259] (formerly Docket No. 1995N-0253) RIN 0910-AG33 Regulations Restricting the Sale and Distribution of Cigarettes and Smokeless Tobacco To Protect Children and Adolescents SUBCHAPTER K--TOBACCO PRODUCTS PART 1140--CIGARETTES AND SMOKELESS TOBACCO Subpart A--General Provisions Sec. 1140.1 Scope. 1140.2 Purpose. 1140.3 Definitions. Subpart B--Prohibition of Sale and Distribution to Persons Younger Than 18 Years of Age 1140.10 General responsibilities of manufacturers, distributors, and retailers. 1140.12 Additional responsibilities of manufacturers. 1140.14 Additional responsibilities of retailers. 1140.16 Conditions of manufacture, sale, and distribution. Subpart C--[Reserved] Subpart D--Labeling and Advertising 1140.30 Scope of permissible forms of labeling and advertising. 1140.32 Format and content requirements for labeling and advertising. 1140.34 Sale and distribution of nontobacco items and services, gifts, and sponsorship of events. Authority: 21 U.S.C. 301 et seq., Sec. 102, Pub. L. 111-31, 123 Stat. 1776. Subpart A--General Provisions Sec. 1140.1 Scope. (a) This part sets out the restrictions under the Federal Food, Drug, and Cosmetic Act (the act) on the sale, distribution, and use of cigarettes and smokeless tobacco that contain nicotine. (b) The failure to comply with any applicable provision in this part in the sale, distribution, and use of cigarettes and smokeless tobacco renders the product misbranded under the act. • (c) References in this part to regulatory sections of the Code of Federal Regulations are to chapter I of title 21, unless otherwise noted. Sec. 1140.2 Purpose. The purpose of this part is to establish restrictions on the sale, distribution, and use of cigarettes and smokeless tobacco in order to reduce the number of children and adolescents who use these products, and to reduce the life-threatening consequences associated with tobacco use. Sec. 1140.3 Definitions. (a) Cigarette. (1) Means a product that: (i) Is a tobacco product; and (ii) Meets the definition of the term ' 'cigarette' ' in section 3 (1) of the Federal Cigarette Labeling and Advertising Act; and (2) Includes tobacco, in any form, that is functional in the product, which, because of its appearance, the type of tobacco used in the filler, or its packaging and labeling, is likely to be offered to, or purchased by, consumers as a cigarette or as roll-your-own tobacco. (b) Cigarette tobacco means any product that consists of loose tobacco that is intended for use by consumers in a cigarette. unless otherwise stated, the requirements applicable to cigarettes under this chapter shall also apply to cigarette tobacco. (c) Distributor means any person who furthers the distribution of cigarettes or smokeless tobacco, whether domestic or imported, at any point from the original place of manufacture to the person who sells or distributes the product to individuals for personal consumption. Common carriers are not considered distributors for the purposes of this part. (d) Manufacturer means any person, including any repacker and/or relabeler, who manufactures, fabricates, assembles, processes, or labels a finished cigarette or smokeless tobacco product. (e) Nicotine means the chemical substance named 3-(1-Methyl-2- pyrrolidinyl)pyridine or C[10]H[14]N[2] , including any salt or complex of nicotine. (f) Package means a pack, box, carton, or container of any kind in which cigarettes or smokeless tobacco are offered for sale, sold, or otherwise distributed to consumers. (g) Point of sale means any location at which a consumer can purchase or otherwise obtain cigarettes or smokeless tobacco for personal consumption. (h) Retailer means any person who sells cigarettes or smokeless tobacco to individuals for personal consumption, or who operates a facility where vending machines or self-service displays are permitted under this part. (i) Smokeless tobacco means any tobacco product that consists of cut, ground, powdered, or leaf tobacco and that is intended to be placed in the oral or nasal cavity. Subpart B--Prohibition of Sale and Distribution to Persons Younger Than 18 Years of Age • Sec. 1140.10 General responsibilities of manufacturers, • distributors, and retailers. Each manufacturer, distributor, and retailer is responsible for ensuring that the cigarettes or smokeless tobacco it manufactures, labels, advertises, packages, distributes, sells, or otherwise holds for sale comply with all applicable requirements under this part. Sec. 1140 .12 Additional responsibilities of manufacturers. In addition to the other responsibilities under this part, each manufacturer shall remove from each point of sale all self-service displays, advertising, labeling, and other items that the manufacturer owns that do not comply with the requirements under this part. Sec. 1140.14 Additional responsibilities of retailers. In addition to the other requirements under this part, each retailer is responsible for ensuring that all sales of cigarettes or smokeless tobacco to any person comply with the following requirements: (a) No retailer may sell cigarettes or smokeless tobacco to any person younger than 18 years of age; (b) (1) Except as otherwise provided in Sec. 1140.16(c) (2) (i) and in paragraph (b) (2) of this section, each retailer shall verify by means of photographic identification containing the bearer's date of birth that no person purchasing the product is younger than 18 years of age; (2) No such verification is required for any person over the age of 26; (c) Except as otherwise provided in Sec. 1140.16(c) (2) (ii) , a retailer may sell cigarettes or smokeless tobacco only in a direct, face-to-face exchange without [ [Page 13231] ] the assistance of any electronic or mechanical device (such as a vending machine) ; (d) No retailer may break or otherwise open any cigarette or smokeless tobacco package to sell or distribute individual cigarettes or a number of unpackaged cigarettes that is smaller than the quantity in the minimum cigarette package size defined in Sec. 1140.16 (b) , or any quantity of cigarette tobacco or smokeless tobacco that is smaller than the smallest package distributed by the manufacturer for individual consumer use; and (e) Each retailer shall ensure that all self-service displays, advertising, labeling, and other items, that are located in the retailer's establishment and that do not comply with the requirements of this part, are removed or are brought into compliance with the requirements under this part. Sec. 1140.16 Conditions of manufacture, sale, and distribution. (a) Restriction on product names. A manufacturer shall not use a trade or brand name of a nontobacco product as the trade or brand name for a cigarette or smokeless tobacco product, except for a tobacco product whose trade or brand name was on both a tobacco product and a nontobacco product that were sold in the United States on January 1, 1995. (b) Minimum cigarette package size. Except as otherwise provided under this section, no manufacturer, distributor, or retailer may sell or cause to be sold, or distribute or cause to be distributed, any cigarette package that contains fewer than 20 cigarettes. (c) Vending machines, self-service displays, mail-order sales, and other ' 'impersonal' ' modes of sale. (1) Except as otherwise provided under this section, a retailer may sell cigarettes and smokeless tobacco only in a direct, face-to-face exchange between the retailer and the consumer. Examples of methods of sale that are not permitted include vending machines and self-service displays. (2) Exceptions. The following methods of sale are permitted: (i) Mail-order sales, excluding mail-order redemption of coupons and distribution of free samples through the mail; and (ii) Vending machines (including vending machines that sell packaged, single cigarettes) and self-service displays that are located in facilities where the retailer ensures that no person younger than 18 years of age is present, or permitted to enter, at any time. (d) (1) Except as provided in paragraph (d) (2) of this section, no manufacturer, distributor, or retailer may distribute or cause to be distributed any free samples of cigarettes, smokeless tobacco, or other tobacco products (as such term is defined in section 201 of the Federal Food, Drug, and Cosmetic Act) . (2) (i) Paragraph (d) (1) of this section does not prohibit a manufacturer, distributor, or retailer from distributing or causing to be distributed free samples of smokeless tobacco in a qualified adult- only facility. (ii) Paragraph (d) (2) of this section does not affect the authority of a State or local government to prohibit or otherwise restrict the distribution of free samples of smokeless tobacco. (iii) For purposes of paragraph (d) of this section, the term qualified adult-only facility' ' means a facility or restricted area that: (A) Requires each person present to provide to a law enforcement officer (whether on or off duty) or to a security guard licensed by a governmental entity government-issued identification showing a photograph and at least the minimum age established by applicable law for the purchase of smokeless tobacco; (B) Does not sell, serve, or distribute alcohol; (C) Is not located adjacent to or immediately across from (in any direction) a space that is used primarily for youth-oriented marketing, promotional, or other activities; (D) Is a temporary structure constructed, designated, and operated as a distinct enclosed area for the purpose of distributing free samples of smokeless tobacco in accordance with this paragraph (d) (2) of this section; (E) Is enclosed by a barrier that: (1) Is constructed of, or covered with, an opaque material (except for entrances and exits) ; (2) Extends from no more than 12 inches above the ground or floor (which area at the bottom of the barrier must be covered with material that restricts visibility but may allow airflow) to at least 8 feet above the ground or floor (or to the ceiling) ; and (3) Prevents persons outside the qualified adult-only facility from seeing into the qualified adult-only facility, unless they make unreasonable efforts to do so; and (F) Does not display on its exterior: (1) Any tobacco product advertising; (2) A brand name other than in conjunction with words for an area or enclosure to identify an adult-only facility; or (3) Any combination of words that would imply to a reasonable observer that the manufacturer, distributor, or retailer has a sponsorship that would violate Sec. 1140.34 (c) . (iv) Distribution of samples of smokeless tobacco under paragraph (d) (2) of this section permitted to be taken out of the qualified adult-only facility shall be limited to one package per adult consumer containing no more than 0.53 ounces (15 grams) of smokeless tobacco. If such package of smokeless tobacco contains individual portions of smokeless tobacco, the individual portions of smokeless tobacco shall not exceed eight individual portions, and the collective weight of such individual portions shall not exceed 0.53 ounces (15 grams) . Any manufacturer, distributor, or retailer who distributes or causes to be distributed free samples also shall take reasonable steps to ensure that the amounts in this paragraph (d) .(2) (iv) are limited to one such package per adult consumer per day. (3) Notwithstanding paragraph (d) (2) of this section, no manufacturer, distributor, or retailer may distribute or cause to be distributed any free samples of smokeless tobacco: (i) To a sports team or entertainment group; or (ii) At any football, basketball, baseball, soccer, or hockey event or any other sporting or entertainment event determined by the Secretary to be covered by paragraph (d) (3) of this section. (4) The Secretary shall implement a program to ensure compliance with paragraph (d) of this section and submit a report to the Congress on such compliance not later than 18 months after the date of enactment of the Family Smoking Prevention and Tobacco Control Act. (5) Nothing in paragraph (d) of this section shall be construed to authorize any person to distribute or cause to be distributed any sample of a tobacco product to any individual who has not attained the minimum age established by applicable law for the purchase of such product. (e) Restrictions on labels, labeling, and advertising. No manufacturer, distributor, or retailer may sell or distribute, or cause to be sold or distributed, cigarettes or smokeless tobacco with labels, labeling, or advertising not in compliance with subpart D of this part, and other applicable requirements. [ [Page 13232] ] Subpart C--[Reserved] Subpart D--Labeling and Advertising Sec. 1140.30 Scope of permissible forms of labeling and advertising. (a) (1) A manufacturer; distributor, or retailer may, in accordance with this subpart D, disseminate or cause to be disseminated advertising or labeling which bears a cigarette or smokeless tobacco brand name (alone or in conjunction with any other word) or any other indicia of tobacco product identification, in newspapers; in magazines; in periodicals or other publications (whether periodic or limited C distribution) ; on billboards, posters, and placards; in nonpoint-of- sale promotional material (including direct mail) ; in point-of-sale promotional material; and in audio or video formats delivered at a point-of-sale. (2) A manufacturer, distributor, or retailer intending to disseminate, or to cause to be disseminated, advertising or labeling for cigarettes or smokeless tobacco in a medium that is not listed in paragraph (a) (1) of this section, shall notify the agency 30 days prior to the use of such medium. The notice shall describe the medium and discuss the extent to which the advertising or labeling may be seen by persons younger than 18 years of age. The manufacturer, distributor, or retailer shall send this notice to the Office of Compliance, Center for Tobacco Products, Food and Drug Administration, 9200 Corporate Blvd., Rockville, MD, 20850-3229. (b) [Reserved] (c) This subpart D does not apply to cigarette or smokeless tobacco package labels. Sec. 1140.32 Format and content requirements for labeling and advertising. (a) Except as provided in paragraph (b) of this section, each manufacturer, distributor, and retailer advertising or causing to be advertised, disseminating or causing to be disseminated, any labeling or advertising for cigarettes or smokeless tobacco shall use only black text on a white background. This section does not apply to advertising: (1) In any facility where vending machines and self- service displays are permitted under this part, provided that the advertising is not visible from outside the facility and that it is affixed to a wall or fixture in the facility; or (2) Appearing in any publication (whether periodic or limited distribution) that the manufacturer, distributor, or retailer demonstrates is an adult publication. For the purposes of this section, an adult publication is a newspaper, magazine, periodical, or other publication: (i) Whose readers younger than 18 years of age constitute 15 percent or less of the total readership as measured by competent and reliable survey evidence; and (ii) That is read by fewer than 2 million persons younger than 18 years of age as measured by competent and reliable survey evidence. (b) Labeling and advertising in an audio or video format shall be limited as follows: (1) Audio format shall be limited to words only with no music or sound effects. (2) Video formats shall be limited to static black text only on a white background. Any audio with the video shall be limited to words only with no music or sound effects. Sec. 1140 .34 Sale and distribution of nontobacco items and services, gifts, and sponsorship of events. (a) No manufacturer and no distributor of imported cigarettes or smokeless tobacco may market, license, distribute, sell, or cause to be marketed, licensed, distributed, or sold any item (other than cigarettes or smokeless tobacco or roll-your-own paper) or service, f which bears the brand name (alone or in conjunction with any other word) , logo, symbol, motto, selling message, recognizable color or pattern of colors, or any other indicia of product identification identical or similar to, or identifiable with, those used for any brand of cigarettes or smokeless tobacco. (b) No manufacturer, distributor, or retailer may offer or cause to be offered any gift or item (other than cigarettes or smokeless tobacco) to any person purchasing cigarettes or smokeless tobacco in consideration of the purchase thereof, or to any person in consideration of furnishing evidence, such as credits, proofs-of- purchase, or coupons, of such a purchase. (c) No manufacturer, distributor, or retailer may sponsor or cause to be sponsored any athletic, musical, artistic, or other social or cultural event, or any entry or team in any event, in the brand name (alone or in conjunction with any other word) , logo, symbol, motto, selling message, recognizable color or pattern of colors, or any other indicia of product identification identical or similar to, or identifiable with, those used for any brand of cigarettes or smokeless tobacco. Nothing in this paragraph prevents a manufacturer, distributor, or retailer from sponsoring or causing to be sponsored any athletic, musical, artistic, or other social or cultural event, or team or entry, in the name of the corporation which manufactures the tobacco product, provided that both the corporate name and the corporation were registered and in use in the United States prior to January 1, 1995, and that the corporate name does not include any brand name (alone or in conjunction with any other word) , logo, symbol, motto, selling message, recognizable color or pattern of colors, or any other indicia of product identification identical or similar to, or identifiable • with, those used for any brand of cigarettes or smokeless tobacco. Dated: March 11, 2010. Margaret A. Hamburg, Commissioner of Food and Drugs. Dated: March 11, 2010. Kathleen Sebelius, Secretary of Health and Human Services. [FR Doc. 2010-6087 Filed 3-18-10; 8:45 am] BILLING CODE 4160-01-5 :.., gn A NEW ENGLAND SERVICE STATION& AUTO REPAIR ASSOCIATION.INC. July 9th,2012 Board of Health Salem City Hall 120 Washington St. Salem, MA 01970 Re:Comments on Proposed Minimum Cigar Pack Size Restriction Dear Board of Health members: The New England Service Station and Automotive Repair Association strongly opposes the Salem Board of Health's proposed amendment to the Tobacco Regulation that would ban the sale of loose cigars in Salem.The proposed regulation,which would ban the sale of cigars with a wholesale price of two dollars or less,except in packages of four or more,would adversely impact our adult customers who legally purchase tobacco products. Many of our retailers sell single cigars,and in fact 70% of machine-made large cigars are sold as single sticks.There is an adult market for this legal product.The proposed regulation would not only have a. negative economic impact on our members who responsibly sell tobacco, but would force adult consumers to purchase more tobacco than they choose to consume. NESSARA members adhere to strict policies for tobacco sales in Salem to deter and prevent sales to minors. For years our members have voluntarily trained their clerks to help them properly check IDs, spot fake ones and prevent the sale of tobacco to minors. And to mark our industry's progress,the most recent national Synar survey showed the lowest level of tobacco sales to minors in history. We are also concerned that people will circumvent a single cigar sale regulation, placing sales of individual cigars outside of the retailer environment and onto the streets where sellers will not check ID, refuse a sale to a minor, have the proper license or collect the appropriate tax revenue. We share the goals of the Salem Board of Health—keeping tobacco products out of minor's hands.The goals you seek to accomplish can be achieved through continued retailer enforcement and accountability and continued anti-tobacco youth education. The proposed amendment therefore is unnecessary, and redundant. Banning us from selling single cigars will do nothing more than cut off revenue from our loyal adult customers,and further burden us during these tough economic times. Please do not hesitate to contact me at 978-667-7706 or mattl@nessara.org if you need additional information. Sincerely, 461- _ Matthew LeLacheur Executive Director, NESSARA I , (city of ale , - (office of the Cetp Council • ��9� � Citp Jball COUNCILLORS-AT-LARGE JOAN B. LOVELY WARD COUNCILLORS PRESIDENT 2012 CHERYL A. LAPOINTE 2012 KEVIN R.CARR,JR. CITY CLERK ROBERT K.MCCARTHY THOMAS H.FUREY MICHAEL SOSNOWSKI JOAN B.LOVELY TODD A.SIEGEL ARTHUR C.SARGENT III p ('Z JERRY L.RYAN `) `rl�( ` JOSH H.TURIEL PAULC.PREVEY JOSEPH A.O'KEEFE,SR. La v- r Yj -5 U c:V%.. w v- c v. 5 LC G ra U � U J t h e d✓�. J ✓ t \C/"� a h Ct fn cL lUrn c � C e� w� a\c��no�c GR�. �� ��.N ! ea'a� £�5��ta�U �r o�5 wQtTQ ail G Qa � ��� uJe `a v\ y\GW 15 C_c ve- s -�� e`r c Q Irt t C a`� c�2 _I' �G� 6 4j'&C K )U N G S - � } ( l i `o rn )��'J1J� �� G � jcL ` C �G $ems es Y 4 0 U l � l " `M Sc—t�. V. G V i �/1/\�.l Vi o�e�� Sy Ckr 1 `� Q GAS v+ee� ( GA S G- kec- 1ov, �GsC ,�, �o � ,� aAj, -FtG�, rug- Y Gip � Lg � �YG�' e N l \�tJ t e af �%Gi b Pe W 0- C-CO >� U �/ (` r+1`ec� P `� pn ..(�. -{1,� e v w Se `t'" py Gl �. 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