BILL ANALYSIS                                                                                                                                                                                                    Ó






                             SENATE COMMITTEE ON HEALTH
                          Senator Ed Hernandez, O.D., Chair

          BILL NO:       AB 2109
          AUTHOR:        Pan
          AMENDED:       June 20, 2012
          HEARING DATE:  June 27, 2012
          CONSULTANT:    Moreno

           SUBJECT :  Communicable disease: immunization exemption.
           
          SUMMARY :  Requires, after July 1, 2014, a separate form 
          prescribed by the Department of Public Health (DPH) to accompany 
          a letter or affidavit to exempt a child from immunization 
          requirements under existing law on the basis that  immunization 
          is contrary to beliefs of the child's parent or guardian.

          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 diphtheria, haemophilus influenzae type b 
            (Hib), measles, mumps, pertussis, poliomyelitis, rubella, 
            tetanus, hepatitis b (except after 7th grade), and chickenpox, 
            as specified. 

          2.Permits DPH to add to this list any other disease deemed 
            appropriate, taking into consideration the recommendations of 
            the Centers for Disease Control and Prevention (CDC) Advisory 
            Committee on Immunization Practices (ACIP) and the American 
            Academy of Pediatrics (AAP) Committee on Infectious Diseases.  


          3.Waives the above requirements if the parent or guardian or 
            adult who has assumed responsibility for the child's care and 
            custody, or the person seeking admission, if an emancipated 
            minor, files a letter or affidavit with the governing 
            authority stating that the immunization is contrary to his or 
            her beliefs.  

          4.Permits a child for whom the requirement has been waived, 
            whenever there is good cause to believe that he or she has 
            been exposed to one of the specified communicable diseases, to 
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            be temporarily excluded from the school or institution until 
            the local health officer is satisfied that the child is no 
            longer at risk of developing the disease. 
          
          This bill:
          1.Requires, after July 1, 2014, a separate form prescribed by 
            DPH to accompany a letter or affidavit to exempt a child from 
            immunization requirements under existing law on the basis that 
            immunization is contrary to the beliefs of the child's parent 
            or guardian.

          2.Requires the form to include:
             a.   A signed attestation from a health care practitioner 
               that indicates that he or she provided the parent or 
               guardian of the person who is subject to the immunization 
               requirements in existing law, the adult who has assumed 
               responsibility for the care and custody of the person, or 
               to the person if he or she is a emancipated minor, with 
               information regarding the benefits and risks of the 
               immunization and the health risks of specified communicable 
               diseases to the person and to the community. 
             b.   A written statement signed by the parent or guardian of 
               the person who is subject to the immunization requirements 
               in existing law, the adult who has assumed responsibility 
               for the care and custody of the person, or the person if he 
               or she is an emancipated minor, that indicates that the 
               signer has received the information provided by the health 
               care practitioner. 

          3.Requires the form to be signed not more than 6 months prior to 
            the date when the person first becomes subject to the 
            immunization requirement for which exemption is being sought.

          4.Permits a photocopy of the signed form or a letter signed by a 
            health care practitioner that includes all information and 
            attestations included on the form to be accepted in lieu of 
            the original form.

          5.Defines, for the purposes of this bill, a "health care 
            practitioner" as a physician and surgeon, a nurse 
            practitioner, a physician assistant, an osteopathic physician 
            and surgeon, or a naturopathic doctor, as specified.

          6.Exempts issuance and revision of the form from rulemaking 
            requirements under the Administrative Procedure Act.





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           FISCAL EFFECT  :  According to the Assembly Appropriations 
          Committee, based on DPH experience with another recent change to 
          immunization requirements, one-time costs for notification 
          including printing, mailing, and development of informational 
          materials in the range of $80,000 federal funds. Issuing 
          regulations and developing the form would result in one-time 
          staff time costs of $50,000, distributed among a number of 
          existing federally funded staff.  

          a.Minor, absorbable one-time costs to Department of Social 
            Services (DSS) Child Care Licensing Division staff and K-12 
            school administrative staff for training on the new 
            requirement.
          b.Potential increase of $20,000 General Fund/98 annually in 
            state-reimbursable mandate costs to K-12 school administrative 
            staff to ensure compliance with the new form. DSS costs 
            related to ongoing enforcement are expected be minor and 
            absorbable.
          c.Any impact on Medi-Cal or Healthy Families Program from a 
            small number of increased office visits, to the extent any 
            program enrollees seek exemptions and require additional 
            office visits to do so, is likely to be negligible.  

           PRIOR VOTES :  
          Assembly Health:    13- 5
          Assembly Appropriations:12- 5
          Assembly Floor:     47- 26
           
          COMMENTS  :  
           1.Author's statement.  California is 1 of only 20 states that 
            allows for a personal beliefs, or philosophical exemption to 
            school or childcare immunization requirements.  Under existing 
            law, to exempt the child from the immunization requirements, a 
            parent or guardian must only provide a signed written 
            statement or sign their name to a two-sentence standard 
            exemption statement on the back of the School Immunization 
            Record. While parents do have a choice to exempt their 
            children, they are not required to document their concerns 
            about vaccines or affirm that they have reviewed fact-based, 
            accurate information regarding the risks and benefits of 
            vaccines and the risks of vaccine-preventable diseases. The 
            continued increase in personal belief exemptions and resultant 
            decreases in community immunization rates in California will 
            result in outbreaks of diseases such as measles, mumps, and 
            pertussis. Exposure to these preventable diseases not only 




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            places the individual child at risk, but the entire community, 
            including infants too young to be fully immunized and 
            individuals with compromised immune systems, who are 
            vulnerable to complications of vaccine-preventable diseases, 
            including death.  his measure would rectify this problem by 
            creating a process where parents would be able make an 
            informed decision for their children.
            
          2.Immunizations.  According to the CDC, vaccines contain the 
            same antigens or parts of antigens that cause diseases, but 
            the antigens in vaccines are either killed or greatly 
            weakened. Vaccine antigens are not strong enough to cause 
            disease but, they are strong enough to make the immune system 
            produce antibodies against them. Memory cells prevent 
            re-infection when they encounter that disease again in the 
            future. Vaccines are responsible for the control of many 
            infectious diseases that were once common around the world, 
            including polio, measles, diphtheria, pertussis (whooping 
            cough), rubella (German measles), mumps, tetanus, and Hib. 
            Vaccine eradicated smallpox, one of the most devastating 
            diseases in history. Over the years, vaccines have prevented 
            countless cases of infectious diseases and saved literally 
            millions of lives. Vaccine-preventable diseases have a costly 
            impact, resulting in doctor's visits, hospitalizations, and 
            premature deaths. Sick children can also cause parents to lose 
            time from work. CDC recommends routine vaccination to prevent 
            17 vaccine-preventable diseases that occur in infants, 
            children, adolescents, or adults. According to DPH, 
            implementation of statewide immunization requirements has been 
            effective in maintaining a 92 percent immunization coverage 
            rate among children in licensed child care facilities and 
            kindergartens.

          3.ACIP.  ACIP consists of 16 experts in fields associated with 
            immunization who have been selected by the Secretary of the 
            U.S. Department of Health and Human Services to provide advice 
            and guidance to the Secretary, the Assistant Secretary for 
            Health, and the CDC on the most effective means to prevent 
            vaccine-preventable diseases. ACIP develops written 
            recommendations for the routine administration of vaccines to 
            pediatric and adult populations, along with schedules 
            regarding the appropriate periodicity, dosage, and 
            contraindications applicable to the vaccines and is the only 
            entity within the federal government which makes such 
            recommendations. The overall goals of ACIP are to provide 
            advice to assist in reducing the incidence of 




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            vaccine-preventable diseases and to increase the safe usage of 
            vaccines and related biological products.  

            ACIP, along with AAP and the American Academy of Family 
            Physicians, approved the 2012 Recommended Immunization 
            Schedules for Persons Aged 0 Through 18 Years. Children under 
            six are recommended to receive vaccines for: hepatitis b; 
            rotavirus; diphtheria, tetanus, and pertussis (DTaP); Hib; 
            pneumococcal; polio; influenza; measles, mumps, rubella (MMR); 
            varicella; hepatitis a; and meningococcal.

          4.School vaccination requirements.  States enact laws or 
            regulations that require children to receive certain vaccines 
            before they enter childcare facilities and school, but with 
            some exceptions, including medical, religious, and 
            philosophical objections. School vaccination requirements are 
            thought to serve an important public health function, but can 
            also face resistance. An article published in the 2001-2002 
            Kentucky Law Journal reviewed historical and modern legal, 
            political, philosophical, and social struggles surrounding 
            vaccination requirements. The authors stated that though 
            school vaccination has been an important component of public 
            health practice for decades, it has had a controversial 
            history in the United States and abroad. Historical and modern 
            examples of the real, perceived, and potential harms of 
            vaccination, governmental abuses underlying its widespread 
            practice and strongly held religious beliefs have led to 
            fervent objections among parents and other persons who object 
            to vaccines on legal, ethical, social, and epidemiological 
            grounds. The article states that public health authorities 
            argue that school vaccination requirements have led to a 
            drastic decrease in the incidence of once common childhood 
            diseases. Those who object to vaccines tend to view the 
            consequences of mass vaccination on an individualistic basis, 
            focusing on alleged or actual harms to children from 
            vaccinations. 

          As part of their research, the authors compared childhood 
            immunization rates and rates of vaccine-preventable childhood 
            diseases before and after the introduction of school 
            vaccination requirements. The data suggest that school 
            vaccination requirements have succeeded in increasing 
            vaccination rates and reducing the incidence of childhood 
            disease. 





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          5.Exemptions to vaccine requirements. There are two types of 
            non-medical exemptions to the requirement that children be 
            vaccinated before entering school: religious exemption and 
            philosophical exemption.  Religious exemption means that there 
            is a provision in the statute that allows parents to exempt 
            their children from vaccination if it contradicts their 
            sincere religious beliefs.  Philosophical exemption means that 
            the statutory language does not restrict the exemption to 
            purely religious or spiritual beliefs.  For example, Maine 
            allows restrictions based on "moral, philosophical or other 
            personal beliefs," and California allows objections based on 
            simply the parent(s) beliefs.  According to the National 
            Conference of State Legislatures, as of February 2012, 48 
            states allow religious exemptions (all but Mississippi and 
            West Virginia), and 20 states (Arizona, California, Colorado, 
            Idaho, Louisiana, Maine, Michigan, Minnesota, Missouri 
            (limited to daycare, preschool and nursery school), New 
            Mexico, North Dakota, Ohio, Oklahoma, Pennsylvania, Texas, 
            Utah, Vermont, Washington, West Virginia and Wisconsin) permit 
            philosophic exemptions. The criteria for allowing these 
            exemptions vary greatly by state. Some states require 
            membership in a recognized religion, whereas other states, 
            merely require an affirmation of religious (or philosophic) 
            opposition.
                
           6.Author's briefing.  On February 29, 2012, the author hosted a 
            briefing, "Disease Prevention through Immunization: A 
            Community Responsibility," which included topics relating to 
            vaccines and preventable diseases, how immunization 
            recommendations are developed and vaccine safety, and the 
            increase in personal belief exemptions (PBEs). During the 
            briefing, it was pointed out that the number of parents or 
            guardians choosing to exempt their children from school 
            immunization requirements has increased. DPH demonstrated the 
            trend in PBE among kindergarten students over a 32-year span, 
            which has gone from below .5 percent in 1978 to almost 2.5 
            percent in 2010.  

            DPH also presented a map of the percentage of PBEs in each of 
            California's counties, which range significantly. In Del 
            Norte, Humboldt, Shasta, Mendocino, Sonoma, Marin, Santa Cruz, 
            Butte, Plumas, Nevada, El Dorado, and San Luis Obispo 
            counties, between 5 percent and 17.7 percent of children are 
            entering kindergarten with PBEs. Santa Barbara, Ventura, 
            Orange, and San Diego Counties have between 2.5 percent and 
            4.9 percent of children entering kindergarten with PBEs. 




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            Merced, Glen, Alpine, and Imperial counties have the least 
            percentage of kindergarteners with PBEs, with less than one 
            percent. DPH indicated that the reasons for non-vaccination 
            nationwide include perception that children had low 
            susceptibility to these diseases, severity of the diseases was 
            low, efficacy and safety of the vaccines was low, and the most 
            frequent reason (stated by 69 percent of the parents) was the 
            concern the vaccine might cause harm.

          7.Physician dismissing of patients.  In stressing that this bill 
            would have a negative impact on families, the opponents to 
            this bill submitted two studies to demonstrate the prevalence 
            of physicians dismissing families who delay and/or refuse 
            vaccination.  A 2011 article published in Public Health 
            Reports titled, "Physicians' Experience with and Response to 
            Parental Vaccine Safety Concerns and Vaccine Refusals: A 
            Survey of Connecticut Pediatricians" (2011 Article) examined 
            how frequently pediatricians in one New England state 
            encounter parental vaccine safety concerns and vaccine 
            refusals. According to the 2011 Article, the study consisted 
            of a quantitative survey of 133 pediatricians who completed a 
            questionnaire; the majority of responding pediatricians 
            reported an increase in parental vaccine safety concerns and 
            refusals. More than 30 percent indicated they have dismissed 
            families because of their refusal to immunize. Suburban 
            physicians caring for wealthier, better educated families 
            experience more vaccine concerns and/or refusals and are more 
            likely to dismiss families for vaccine refusal. According to 
            the 2011 Article, vaccine refusals have a negative personal 
            impact on one-third of physician respondents. The 2011 Article 
            also points out the AAP, American Medical Association, and CDC 
            all recommend against discharging families solely based on 
            vaccine refusal.  

          In a 2005 study entitled "Dismissing the Family Who Refuses 
            Vaccines" published in the Archives of Pediatrics & Adolescent 
            Medicine (2005 Study), the objective was to describe 
            pediatrician's responses to scenarios of vaccine refusal, 
            identify reasons pediatricians cite for both parent refusal 
            and family dismissal and to illustrate pediatrician attitudes 
            about well-established versus newer recommended vaccines. The 
            2005 Study conducted a nationwide survey mailed to 1,004 
            randomly selected members of AAP in Illinois. The study found: 
            54 percent faced total vaccine refusal during a 12-month 
            period; pediatricians cited safety concerns as a top reason 




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            for parent refusal; 39 percent said they would dismiss a 
            family for refusing all vaccinations; and 28 percent said they 
            would dismiss a family for refusing select vaccines.  

          8.Related legislation.  AB 2064 (V. Manuel Pérez) would have 
            required a health care service plan or health insurer that 
            provides coverage for childhood and adolescent immunizations 
            to reimburse a physician or physician group in an amount not 
            less than the actual cost of acquiring the vaccine plus the 
            cost of administration of the vaccine, as specified. AB 2064 
            was held on suspense in the Assembly Appropriations Committee.

          9.Prior legislation. SB 614 (Kehoe), Chapter 123, Statutes of 
            2011, allowed a pupil in grades seven through 12, to 
            conditionally attend school for up to 30 calendar days beyond 
            the pupil's first day of attendance for the 2011-12 school 
            year, if that pupil has not been fully immunized with all 
            pertussis boosters appropriate for the pupil's age if 
            specified conditions are met.

            AB 354 (Arambula), Chapter 434, Statutes of 2010, allows DPH 
            to update vaccination requirements for children entering 
            schools and child care facilities and adds the American 
            Academy of Family Physicians to the list of entities whose 
            recommendations DPH must consider when updating the list of 
            required vaccinations. Requires children entering grades 7 
            through 12 receive a TDaP booster prior to admittance to 
            school.

            AB 1201 (V. Manuel Pérez) of 2009 would have required a health 
            care service 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. AB 1201 
            was held on the Assembly Appropriations Committee suspense 
            file.

            SB 1179 (Aanestad) of  2008 would have deleted DPH's authority 
            to add diseases to the list of those requiring immunizations 
            prior to entry to any private or public elementary or 
            secondary school, child care center, day nursery, nursery 
            school, family day care home, or development center. SB 1179 
            died in Senate Health Committee.

            AB 2580 (Arambula) of 2008 would have required pupils entering 




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            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.

            SB 676 (Ridley-Thomas) of 2007 would have required pupils 
            entering the seventh grade to be fully immunized against 
            pertussis. SB 676 was held on suspense in Assembly 
            Appropriations Committee. 

            SB 533 (Yee) of 2007 would have added pneumococcus to the list 
            of diseases that pupils are required to be immunized against 
            before entry into any private or public elementary or 
            secondary school, child care center, day nursery, nursery 
            school, family day care home, or development center, except 
            for children who are 24 months of age or older.  SB 533 was 
            vetoed by the Governor, who stated that a mandate for this 
            vaccination was not necessary.
             
          10.Support. The AAP, California Medical Association, and the 
            Health Officers Association of California (HOAC), joint 
            sponsors of this bill, state that this bill would increase 
            protection for children and communities from 
            vaccine-preventable diseases, while still respecting and 
            preserving parent choice. They state that the continued 
            increase in PBEs and resultant decreases in community 
            immunization rates could have a significant impact on public 
            safety and because PBEs are relatively easy to obtain, parents 
            or schools may use them simply because they find vaccination 
            inconvenient, or because they have been misinformed about the 
            health effects of vaccines.

          The California Maternal, Child and Adolescent Health Directors, 
            the California School Health Centers Association, March of 
            Dimes, and the California Black Health Network state that this 
            bill will make certain that all parents are aware of the 
            individual and public health risks of exempting a child from 
            required immunizations. They also state that this bill 
            increases the protection of children and communities from 
            vaccine-preventable diseases while still respecting and 
            preserving parent choice.
          
          11.Opposition.  The Pacific Justice Institute states that 
            existing law provides a reasonable process for exemptions from 
            mandated student vaccinations. This bill changes the current 




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            approach and inserts more bureaucracy into intimate medical 
            decisions. Health Advocacy in the Public Interest indicates 
            that parents must have the freedom to make their own decisions 
            with respect to the vaccination of their children. Numerous 
            letters from individuals, parents, and practitioners state 
            that this bill is an intrusion into the personal freedom of 
            parents to make health care decisions for their children. They 
            state that this measure causes an undue burden on parents, 
            discriminates against families utilizing complementary and 
                                                  alternative medicine, and promotes more vaccine use and profit 
            from the pharmaceutical industry.

           SUPPORT AND OPPOSITION  :
          Support:  American Academy of Pediatrics (co-sponsor)
                    California Medical Association (co-sponsor)
                    Health Officers Association of California (co-sponsor)
                    Association of Northern California Oncologists
                    BayBio
                    California Black Health Network
                    California Hepatitis C Task Force
                    California Immunization Coalition
                    California Naturopathic Doctors Association
                    California Pharmacists Association
                    California Primary Care Association
                    California School Health Centers Association
                    California State Association of Counties
                    County Health Executives Association of California
                    Los Angeles County Board of Supervisors
                    Los Angeles Unified School District
                    March of Dimes California Chapter
                    San Francisco Immunization Coalition
                    Santa Clara County Board of Supervisors
                    Tracy Unified school District
                    Two individuals

          Oppose:   California Federation of Republican Women
                    California Right to Life Committee, Inc.
                    Canary Party
                    Child and Family Protection Association
                    CORE Sacramento
                    Health Advocacy in the Public Interest
                    Maher Insurance and Financial Services
                    National Vaccine Information Center
                    Pacific Justice Institute
                    ParentalRights.Org
                    Private School Advocacy Center




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                    Over 400 individuals

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