BILL ANALYSIS                                                                                                                                                                                                    

                                                                  AB 354
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          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  

             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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           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  

           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  
             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;  
             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.  


             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.


             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  

             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  

           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. 


          American Academy of Pediatrics (California District)
          American Federation of State, County, and Municipal Employees,  
          California Academy of Family Physicians
          California Medical Association
          California School Nurses Association

          None on file. 
          Analysis Prepared by :    Allegra Kim / HEALTH / (916) 319-2097