BILL ANALYSIS
AB 354
Page 1
Date of Hearing: April 21, 2009
ASSEMBLY COMMITTEE ON HEALTH
Dave Jones, Chair
AB 354 (Arambula) - As Amended: April 13, 2009
SUBJECT : Health: immunizations.
SUMMARY : Allows the Department of Public Health (DPH) to
update vaccination requirements for children entering schools
and child care facilities and adds the American Academy of
Family Physicians (AAFP) to the list of entities whose
recommendations DPH must consider when updating the list of
required vaccinations. Specifically, this bill :
1)States the Legislature's intent to not relinquish its
responsibilities relating to immunization requirements.
2)Deletes the age, grade, and date exemptions from the following
vaccination requirements:
a) Haemophilus influenzae type b (Hib) immunization of
children who have reached the age of four years and six
months;
b) Mumps immunization of children who have reached the age
of seven years;
c) Pertussis immunization of children who have reached the
age of seven years;
d) Hepatitis B immunization of pupils who are above the
kindergarten level; and,
e) Varicella (chickenpox) immunization of pupils who were
admitted to California public or private schools at or
above the kindergarten level before July 1, 2001.
3)Makes changes to the list of entities whose recommendations
DPH must consider when developing new disease immunization
requirements, as follows: Corrects a reference to the federal
affiliation of Advisory Committee on Immunization Practices
(ACIP); replaces the American Academy of Pediatrics (AAP)
Committee on Infectious Diseases with AAP; and, adds AAFP.
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4)Deletes a provision authorizing DPH to adopt emergency
regulations to implement a varicella immunization requirement
which was enacted in 2000.
EXISTING LAW :
1)Prohibits the governing authority of a school or other
institution from unconditionally admitting any person as a
pupil of any private or public elementary or secondary school,
child care center, day nursery, nursery school, family day
care home, or development center, unless prior to his or her
first admission to that institution he or she has been fully
immunized against the following diseases: Diphtheria; Hib
(except for children who have reached the age of four years
and six months); measles; mumps (except for children who have
reached the age of seven years); pertussis (except for
children who have reached the age of seven years);
poliomyelitis; rubella; tetanus; hepatitis B (for all children
admitted at the kindergarten level or below, and for pupils
entering the seventh grade); varicella (chickenpox) (except
for children already admitted to California public or private
schools at the kindergarten level or above before July 1,
2001); and any other disease deemed appropriate by DPH, taking
into consideration the recommendations of ACIP and AAP.
2)Waives the requirement in 1) above for medical reasons or if
the parent or guardian or adult who has assumed responsibility
for the child files a letter or affidavit with the school
governing authority stating that the immunization is contrary
to his or her beliefs.
3)Permits a child who has had an immunization requirement
waived, whenever there is good cause to believe that the
person has been exposed to one of specified communicable
diseases, to be temporarily excluded from the school or
institution until the local health officer is satisfied that
the person is no longer at risk of developing the disease.
4)Requires county health officers to organize and maintain a
program to make immunizations available to all persons
required to be immunized as specified under 1) above and other
specified statutes, and specifies that counties shall pay
costs that are not recovered from persons immunized.
FISCAL EFFECT : This bill has not been analyzed by a fiscal
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committee.
COMMENTS :
1)PURPOSE OF THIS BILL . According to the author, this bill is
needed to allow DPH to require pertussis booster vaccines for
students prior to the start of the seventh grade. The author
states pertussis is the only vaccine-preventable disease that
remains widespread despite high levels of vaccination in early
childhood. Although childhood immunization against pertussis
does not provide lasting immunity needed to control the
disease and protect public health, current law limits the
requirement for pertussis vaccination to children seven years
old or younger. The author states that also vaccinating
children upon entry to the seventh grade will reduce infection
rates among adolescents and adults, which will also help
protect infants who are too young to receive their first
inoculations.
2)PERTUSSIS . Pertussis is a highly communicable disease that
lasts for many weeks and is typically manifested in children
with violent spasms of severe coughing that can cause
difficulty breathing, eating, and sleeping; as well as
vomiting. Sometimes a "whoop" sound occurs while gasping for
breath during a coughing spell, though adults rarely have the
"whoop." According to the U.S. Centers for Disease Control
(CDC), pertussis is highly contagious, with up to 90% of
susceptible household contacts developing clinical disease
following exposure. However, pertussis is distinct from other
childhood illnesses in that most children get the infection
from adults, rather than children. Adolescents and adults
become susceptible and can contract pertussis when immunity
from childhood vaccinations wanes. They can then easily
infect infants who are not fully vaccinated. In adults,
pertussis can appear to be an ordinary upper respiratory tract
infection, and is often not diagnosed. In infants, pertussis
can be fatal.
3)PERTUSSIS IN CALIFORNIA . DPH reports that in California,
since 1976, pertussis incidence has risen cyclically with
peaks every three to five years, mirroring national incidence.
Between 2001 and 2006, pertussis incidence rose from 644
cases reported in 2001 to 3,160 cases in 2005, dropping down
to 1,661 cases in 2006. CDC states that actual incidence may
be many times greater than the reported numbers. Other areas
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of the U.S. also experience the same trend of outbreaks every
three to five years. In March 2007, a pertussis outbreak in
Santa Cruz resulted in the temporary closure of one middle
school and treatment of over 80 students and staff of another
middle school.
The highest pertussis rates occur among infants, who are also at
highest risk of complications. In California from 2001
through 2006, 91% of infant cases occurred in the first six
months of life, before three doses of the vaccine were
administered, and 74% of such cases were hospitalized. During
the same period, 24 California infants under two months old
died from pertussis. DPH reports that the age distribution of
reported pertussis cases has been changing since the 1990s.
In 1990, 11% of all reported cases in California were children
over nine years old; by 2005, more than half of reported cases
were children over nine years old.
According to DPH, hospital charges for treating pertussis in
2005 exceeded $17 million, of which at least $12 million was
paid by the Medi-Cal Program. DPH further states that the
true costs are likely to be far higher, as most outpatient and
some hospitalized cases of pertussis are never diagnosed but
require services. DPH additionally notes that state funds
also pay for the state and local health department response to
pertussis cases and outbreaks. Contra Costa County Health
Department calculated that it required over $50,000 of staff
time to respond to a single pertussis outbreak in a school in
the spring of 2008. DPH contends that several pertussis
outbreaks are likely to occur in a given year, and that
requiring pertussis boosters would likely nearly eliminate
pertussis among adolescents.
4)PERTUSSIS VACCINE . Pertussis immunizations are given in
combination with tetanus and diphtheria immunizations (called
DTaP and DTP), at two, four, and six months of age. A fourth
dose is given at 15 to 18 months and a fifth dose is given at
four to six years of age. Because immunity from infection by
the vaccine only lasts for approximately five to ten years, a
booster shot is recommended in early adolescence. ACIP has
recommended vaccinating adolescents and adults, in part
because a newer vaccine called Tdap has greatly reduced the
incidence of adverse effects observed with the earlier
pertussis vaccine. Tdap is different from the DTaP vaccine
currently given to babies and young children: Tdap contains
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smaller quantities of diphtheria and pertussis proteins and is
therefore much less likely to cause side effects such as pain,
redness and tenderness in adolescents. ACIP, AAP, and AAFP
recommend Tdap booster vaccines at the age of eleven to twelve
years for those who have completed the recommended childhood
DTaP or DTP series and not received a tetanus diphtheria
booster dose, as well as for thirteen to eighteen year olds
who have not received the vaccine at the age of eleven to
twelve years.
According to a letter to the author from the Director of DPH, at
least 50% of 11-18 year old children who are insured by
Medi-Cal have received the pertussis booster vaccine through
the federally funded Vaccines for Children Program. DPH
estimates that requiring the Tdap booster would increase the
percentage of children who receive Tdap booster vaccines to
the point of nearly eliminating pertussis during adolescence
in California and would reduce transmission to other age
groups, including infants. DPH highlights the experience of
British Columbia, which since 2004 has achieved 75-86%
pertussis immunization rates of students entering the ninth
grade. DPH states British Columbia now enjoys low levels of
pertussis, without the expected fluctuations in incidence.
5)DPH Authority . DPH has not exercised its authority to change
the list of required immunizations. DPH states the reasons it
has not used this authority include the following:
a) The state has achieved high immunization rates for
diseases such as pneumococcal pneumonia and Hepatitis A
without changing requirements. These high rates are
attributed to high interest in a disease or vaccination, or
because requirements for existing vaccines given at the
same ages enhance uptake of vaccines;
b) Limited track record of use and insufficient
reimbursement mechanisms for recently introduced vaccines;
c) A disease for which there is a new vaccine, such as
human papilloma virus (HPV) infection, is not transmitted
in the school setting; and,
d) DPH lacks authority to change the existing statutory age
restrictions on requirements for diseases against which
children must be immunized.
6)ACIP . Federal law requires ACIP to provide advice and
guidance to the Secretary of the U.S. Department of Health and
Human Services, the Assistant Secretary for Health, and the
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CDC on the most effective means to prevent vaccine-preventable
diseases. Another goal of ACIP is to increase the safe usage
of vaccines and related biological products. ACIP consists of
15 experts in fields associated with immunization who have
been selected by the Secretary, and is the only entity in the
federal government which develops recommendations for the
routine administration of vaccines to children and adults,
along with schedules regarding the appropriate dosage, dosing
intervals, precautions, and contraindications applicable to
the vaccines.
ACIP recommends immunizations for the following diseases that
are not currently in state requirements for children entering
school or day care:
a) Rotavirus, which CDC states is the most common cause of
severe diarrhea among children, resulting in the
hospitalization of approximately 55,000 children each year
in the U.S. ACIP recommends rotavirus vaccine only for
infants;
b) Hepatitis A, for certain high-risk groups;
c) Polio; and,
d) Meningococcal meningitis for certain high-risk groups.
ACIP also recommends vaccines for the following diseases at
ages that are not consistent with existing state law:
a) Mumps: California currently requires mumps
immunizations until children reach age seven; however, ACIP
recommends catch-up vaccinations of the measles, mumps, and
rubella vaccine for children age seven through 18 years if
they have not had the recommended early childhood doses;
and,
b) Varicella (chickenpox): California requires varicella
vaccines except for children already admitted to California
public or private schools at the kindergarten level or
above before July 1, 2001. ACIP recommends a varicella
booster for children, adolescents, and adults who
previously received only one dose of varicella vaccine, and
routine vaccination of all persons age 13 years and older
without evidence of immunity.
1)SUPPORT . The California Academy of Family Physicians (CAFP)
writes in support that pediatric immunizations have proven to
be one of the most successful, safe, and cost-effective public
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health interventions of the 20th century, and removing
existing age and date restrictions on immunization
requirements is a positive step forward in improving access
and public safety. CAFP states unvaccinated children can
contract and spread dangerous diseases. AAP (California
District) writes in support that this bill will cost the state
nothing but ensures state public health officials are not
hindered by antiquated law in their efforts to stop pertussis
outbreaks. The California Medical Association and
GlaxoSmithKline (GSK) write in support that a pertussis
booster vaccine will protect public health, reduce infections
among adolescents and adults, and help protect California's
infants. The California School Nurses Association writes in
support that an extra immunization or booster is often
necessary and removing age guidelines facilitates requiring
these additional immunizations. GSK and the American
Federation of State, County, and Municipal Employees, AFL-CIO
write that this bill will make schools safer.
2)RELATED LEGISLATION .
a) AB 1021 (Emmerson), pending in the Assembly, is
sponsored by DPH and is nearly identical to this bill,
except that AB 1021 does not amend intent language.
b) AB 1201 (V. Manuel Perez), pending in the Assembly,
requires a health care service plan (health plan) or health
insurer that provides coverage for childhood and adolescent
immunizations to reimburse a physician or physician group
the entire cost of acquiring and administering the vaccine
and prohibits a health plan or insurer from requiring
cost-sharing for immunizations.
c) AB 977 (Skinner), pending in the Assembly, would, among
other things, authorize a pharmacist to initiate and
administer immunizations pursuant to a protocol with a
prescriber or the immunization schedules recommended by
CDC. In addition, AB 977 would require a pharmacist to
maintain a specified immunization administration record,
report any adverse event and administer epinephrine for
severe allergic reactions, and assure proper storage and
handling of vaccines.
d) SB 249 (Cox), pending in the Senate, would authorize DPH
to include children eleven years of age in the public
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awareness campaign about meningococcal disease that DPH is
already authorized to design and implement.
e) SB 158 (Wiggins), pending in the Senate, would require
specified health plan contracts and insurance policies to
provide coverage for the HPV vaccination, as specified.
3)PREVIOUS LEGISLATION .
a) AB 2580 (Arambula) of 2008 was similar to this bill, but
would also have required pupils entering the seventh grade
to be fully immunized against pertussis by receiving any
necessary adolescent booster immunization. AB 2580 was
held on the Senate Appropriations Committee suspense file.
b) SB 1179 (Aanestad) of 2008 would have removed from DPH
the authority to add immunizations to the current list that
is required for admission to school so that only the
Legislature could determine which immunizations are
necessary. SB 1179 was scheduled to be heard in the
Assembly Health Committee on April 10, 2008, but the
hearing was cancelled at the request of the author.
c) SB 676 (Ridley-Thomas) of 2007 was similar to AB 2580.
SB 676 was held on the suspense file in Assembly
Appropriations Committee.
d) SB 533 (Yee) of 2007 would have added pneumococcus
vaccination for children under 24 months of age to the list
of immunizations required prior to admission into schools,
child care centers, nursery schools, day care, and
development centers. The Governor vetoed SB 533, stating:
"The Department of Public Health can already require that
young children receive the pneumococcal vaccine.
California's vaccine experts have not established a mandate
as they believe it is not needed. Approximately 86 percent
of children are already being vaccinated under a voluntary
system."
e) AB 16 (Hernandez) of 2007 would have repealed and recast
immunization statutes relating to school children and would
have required children to be immunized in accordance with
recommendations of the CDC upon approval by the State
Public Health Officer. AB 16 (Hernandez) was subsequently
amended as AB 16 (Evans), which would have required health
plans and health insurers that currently provide coverage
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for cervical cancer to also cover the HPV vaccine. AB 16
(Evans) was vetoed by Governor Schwarzenegger, who stated
that the addition of a new mandate, no matter how small,
would only serve to increase the overall cost of health
care.
4)CHAPTERING ISSUE . This bill and AB 1021 amend the same code
section; if both bills pass this committee, this conflict will
need to be resolved.
REGISTERED SUPPORT / OPPOSITION :
Support
American Academy of Pediatrics (California District)
American Federation of State, County, and Municipal Employees,
AFL-CIO
California Academy of Family Physicians
California Medical Association
California School Nurses Association
GlaxoSmithKline
Opposition
None on file.
Analysis Prepared by : Allegra Kim / HEALTH / (916) 319-2097