BILL ANALYSIS Ó
SENATE HEALTH
COMMITTEE ANALYSIS
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 614
S
AUTHOR: Kehoe
B
AMENDED: July 12, 2011
HEARING DATE: July 14, 2011
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CONSULTANT:
1
Trueworthy
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PURSUANT TO S.R. 29.10
SUBJECT
Childhood immunization
SUMMARY
Allows a pupil in grades 7 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.
CHANGES TO EXISTING LAW
Existing law:
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:
Continued---
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diphtheria; haemophilus influenza type b; measles; mumps;
pertussis; poliomyelitis; rubella; tetanus; hepatitis B;
varicella (chickenpox); and any other disease deemed
appropriate by the Department of Public Health (DPH),
taking into consideration the recommendations of the
Advisory Committee on Immunization Practices of the United
States (US) Department of Health and Human Services, the
American Academy of Pediatrics, and the American Academy of
Family Physicians (AAFP).
Prohibits from July 1, 2011, until June 30, 2012, a
governing authority from unconditionally admitting or
advancing any pupil to the 7 through 12 grade levels of any
private or public elementary or secondary school unless the
pupil has been fully immunized against pertussis, including
all pertussis boosters appropriate for the pupil's age.
Waives the requirements described above for medical reasons
or if the parent, guardian, or adult who has assumed
responsibility for the pupil files a letter or affidavit
with the school governing authority stating that the
immunization is contrary to his or her beliefs.
Allows a pupil 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 pupil is no longer at risk of developing the
disease.
Requires county health officers to organize and maintain a
program to make immunizations available to all persons
required to be immunized and specifies that counties shall
pay costs that are not recovered from persons immunized.
This bill:
Allows a pupil, advancing to or enrolling in any of grades
7 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, and if all of the following conditions are
met:
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1) The pupil was enrolled in the county office of
education or school district in
the prior year, and is continuing in the same or
advancing to the next grade level.
2) The pupil's first day of attendance in 2011-12
school year for that county office of education or
school district occurs on or before the 6th Friday
following the first day on which classes are offered
at the school in which the pupil is enrolled.
3) The county office of education or school
district work with the pupil's parent or legal
guardian so that the pupil receives all
immunizations or boosters necessary for continued
attendance.
Contains an urgency clause to ensure that the provisions of
this bill go into immediate effect upon enactment.
Sunsets the provisions of this section on January 1, 2013.
FISCAL IMPACT
According to the Senate Appropriations Committee, although
this bill is keyed non-fiscal, there would be a
multi-million dollar fiscal effect associated with its
passage. Without this bill, children would not be able to
attend school until they were vaccinated, which would
result in a loss of average daily attendance (ADA)
Proposition 98 funds to local education agencies. Any loss
in ADA would revert to the Proposition 98 Reversion Account
for expenditure on general educational purposes.
BACKGROUND AND DISCUSSION
AB 354 (Arambula) Chapter 434, Statutes of 2010, among
other things, mandates that all 7 through 12 grade students
be vaccinated against pertussis (whooping cough) by July 1,
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2011. According to the author, schools across the state
have been working to get their existing middle and high
school students vaccinated. They have used a variety of
tools to notify parents, including the use of telephone and
mail alerts and sending notices home with students. With
the 2010-11 school year now over, contact with students and
their parents is lost entirely or severely diminished. The
author contends that without an extension of the July 1,
2011, pertussis vaccination deadline, pupils unable to show
proof of vaccination will be turned away from school at the
beginning of the coming school year and will remain out
until they provide proof of immunization. The author
states that these students will then lose valuable
classroom time, and their local schools will be penalized
financially for every day of lost student attendance.
The author states that districts from urban, suburban and
rural areas stand to lose substantial state funding because
high percentages of pupils in those districts have yet to
be immunized as required. The author contends that over 20
school districts will lose over $100,000 per day while San
Diego Unified School District (USD) will lose over $1
million per day. Los Angeles USD estimates that
approximately half of its 250,000 7th through 12th graders
still need the vaccination. The district forecasts that it
would lose $3.4 million daily if all of those students were
turned away. The author states that districts are also
concerned about unknown public health and public safety
impacts if students are not allowed to attend school and
must otherwise occupy their time.
Pertussis
According to the US Centers for Disease Control and
Prevention (CDC), pertussis (also known as whooping cough),
is a highly contagious respiratory disease that is known
for uncontrollable, violent coughing which often makes it
hard to breathe. After fits of many coughs, someone with
pertussis often needs to take deep breaths which result in
a "whooping" sound. Pertussis most commonly affects
infants and young children and can be fatal, especially in
babies less than one year of age. In infants younger than
one year of age who get pertussis, more than half must be
hospitalized. Of those infants who are hospitalized with
pertussis, about 1 in 5 get pneumonia, half will have apnea
(slowed or stopped breathing), 1 in 300 will have
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encephalopathy (disease of the brain); and 1 in 100 will
die.
According to the CDC, the incidence of pertussis is
cyclical, with peaks occurring every three to five years in
the US. The last peak was in 2005, when approximately
25,000 cases were reported nationally and approximately
3,000 cases in California, including 8 deaths in infants
under 3 months of age.
According to DPH, peak seasons for pertussis in California
and the US are typically summer and fall and it does not
know yet how severe the peak seasons will be in 2011.
California outbreak
In 2010, DPH saw a substantial increase in the number of
pertussis cases reported. According to a report from the
CDC, from January 1, 2010, to June 30, 2010, a total of
1,337 cases were reported in California, which was a 418
percent increase from the 258 cases reported during the
same period in 2009. From January to June of 2010, the
incidence of pertussis was 3.4 cases per 100,000 persons.
County rates ranged from 0 to 76.9 cases per 100,000. By
age group, incidence was highest (38.5 cases per 100,000)
among infants aged less than one year; 89 percent of cases
were among infants under 6 months, who are too young to be
fully immunized. Incidence among children aged 7 to 9
years was 10.1 cases per 100,000, and for children 10 to 18
years old it was 9.3 cases per 100,000. Incidence among
Latino infants (49.8 cases per 100,000) was higher than
among other racial/ethnic populations. According to DPH,
there were 10 deaths resulting from pertussis infection in
2010. According to DPH's June 2011 Pertussis Report,
disease activity in 2011 is still at relatively increased
levels throughout the state with 1,428 cases reported (7.8
cases per 100,000). This includes 326 new cases being
reported since the last update in May 2011.
Pertussis vaccine
According to the CDC, the best way to prevent pertussis is
to get vaccinated. In the US, the recommended pertussis
vaccine for infants and children is called DTaP, which is a
combination vaccine that protects against three diseases:
diphtheria; tetanus; and pertussis. For maximum protection
against pertussis, children need five DTaP shots. The first
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three shots are given at two, four, and six months of age.
The fourth shot is given between 15 and 18 months of age,
and a fifth shot is given before a child enters school, at
four to six years of age. Parents can also help protect
infants by keeping them away as much as possible from
anyone who has cold symptoms or is coughing. Vaccine
protection for pertussis, tetanus, and diphtheria fades
with time. Before 2005, the only booster available
contained protection against tetanus and diphtheria, and
was recommended for teens and adults once every 10 years.
There are currently boosters for pre-teens, teens and
adults that contain protection against tetanus, diphtheria,
and pertussis. Current guidelines recommend that pre-teens
going to the doctor for their regular check-up at age 11 or
12 years get a dose, and that teens who did not get this
vaccine at the 11- or 12-year-old check-up get vaccinated
at their next visit. Adults who did not get the booster as
a pre-teen or teen should get a dose. Pregnant women who
had not previously received the booster shot should get one
postpartum before leaving the hospital or birthing center.
Adults age 65 years and older, as well as parents,
grandparents, child care providers, and health care
providers who have close contact with infants should also
get vaccinated.
Compliance with July 1 requirement
According to a survey of 68 local education agencies
conducted by the California Association of School Business
Officials, compliance to the July 1 pertussis booster
requirement varies fairly significantly. Rates of
compliance range from as low as 20 percent in Las Virgenes
USD, 25 percent in Pajaro Valley USD, and 30 percent in
Central Union USD, to as high as 80 percent in Brentwood
Union USD, 85 percent in La Habra City School District, and
95 percent in CoronaNorco USD. Los Angeles USD has 250,000
pupils in 7th through 12th grades, half of whom have had
the TDaP booster.
Related bills
AB 1192 (Garrick) would require DPH to make available on
its internet website specified information related to the
pertussis vaccine for use by hospitals. Would permit
hospitals to distribute this information to the parents of
newborn children. This bill was heard, but not voted on,
in the Assembly Health Committee on April 29, 2011.
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Prior legislation
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 (AAFP) to the list of
entities whose recommendations DPH must consider when
updating the list of required vaccinations. Further
requires children entering grades 7 through 12 receive a
TDaP booster prior to admittance to school.
AB 1201 (V. Manuel Perez) of 2009 requires 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 was set for hearing in the
Senate Health Committee, but was pulled at the author's
request.
AB 2580 (Arambula) of 2008 would have required pupils
entering the 7th 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 7th grade to be fully immunized against
pertussis. Required the DPH to maintain a list of diseases
and conditions for which immunization is required prior to
entry into any private or public elementary or secondary
school, child care center, day nursery, nursery school,
family day care home, or development center. Permitted the
DPH to modify the list at any time and required the DPH to
annually review and modify immunization requirements for
pupils. Exempted modification of the list established by
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the DPH from administrative regulations and rulemaking
requirements under existing law. 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.
Arguments in support (based on the July 1, 2011, version of
the bill)
Numerous school districts write in support that despite
extensive district outreach over the past six months,
including public education campaigns, parent contacts, and
school -sponsored clinics, it is now clear that a
significant number of 2011-12 year's incoming grade 7
through 12 students are not yet immunized. These school
districts state that with summer vacation now underway,
their ability to reach families of non-immunized students
is severely diminished. The San Diego USD (SDUSD), the
sponsor of SB 614, write that since schools receive state
funding based on attendance, turning away students will
result in the loss of up to $1 million per day in funding
for SDUSD schools. SDUSD states that this loss of funds
would severely set back their ability to deliver
educational programs to students, and may result in serious
mid-year cuts. Further, SDUSD writes that the unattainable
current deadline may also have negative health impact as
some families who find it difficult to get their students
immunized quickly may sign personal belief waivers just to
keep their students in school - which could undermine the
very purpose of the pertussis immunization requirement.
Other supporters write that an extension is in the best
interest of students because a more realistic time frame
will allow schools, providers, and local public health
entities to work together to ensure complete immunization
and students will be less likely to be excluded from
school. Supporters are concerned that the current time
frame will cause parents to seek waivers and possibly never
have their children immunized.
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Arguments in opposition (based on the July 1, 2011, version
of the bill)
The American Academy of Pediatrics, California (AAP-CA)
writes that delaying the pertussis requirement until
January 1, 2012, is only likely to push the problem of
compliance back, rather than eliminate it. Further, during
these months of proposed delay infants would remain at
increased risk of hospitalization and death since pertussis
peaks in late summer and early fall. AAP-CA writes that it
supports an amendment that would provide a grace period of
30 days after the first day of school during which students
may attend school without providing evidence of their
booster vaccine for pertussis.
The Health Officers Association of California writes that
vaccinating children before or during the summer / fall is
of critical importance due to the seasonal nature of
pertussis. Extending the deadline to January 1, 2012, as
the July 1, 2011, version of SB 614 proposes to do, will
result in increased opportunity for transmission and will
not adequately protect California's children from this
potentially fatal disease.
PRIOR ACTIONS
Assembly Health:17- 0
Other votes not relevant to this version of the bill.
COMMENTS
1. Recent amendments. The Assembly Health Committee
adopted amendments to AB 614 when it was heard on July 11,
2011. These amendments deleted the prior version of the
bill which delayed, from July 1, 2011, to January 1, 2012,
the requirement that a pupil of any private or public
elementary or secondary school be fully immunized against
pertussis, including all pertussis boosters appropriate for
the pupil's age, before he or she can be admitted or
advanced in the 7th through 12th grades. To address the
opposition's concerns that a six month delay is too long,
the amendments instead allow a pupil in grades 7 through
12, to conditionally attend school for up to 30 calendar
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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.
POSITIONS
Support: American Academy of Pediatrics, California
California Academy of Family Physicians
California Immunization Coalition
California Medical Association
California State PTA
Kern County Superintendent of Schools
Riverside County School Superintendents'
Association
Oppose: None received
Support (based on the July 1, 2011, version of the bill):
San Diego Unified School District (sponsor)
Alvord Unified School District
Association of California School Administrators
Attendance Works
Beaumont Unified School District
California Adolescent Health Collaborative
California Association of School Business
Officials
California Association of Suburban School
Districts
California County Superintendents Educational
Services Association
California School Boards Association
California School Health Centers Association
California School Nurses Association
Central Valley Education Coalition
Children Now
Clovis Unified School District
Corona-Norco Unified School District
El Dorado County Superintendent of Schools
Elk Grove Unified School District
Elsie Allen Health Center
Fresno Unified School District
Hemet Unified School District
Irvine Unified School District
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Jurupa Unified School District
Long Beach Unified School District
Los Angeles County Office of Education
Los Angeles Unified School District
Monterey County Office of Education
Newport-Mesa Unified School District
Oakland Unified School District
Rialto Unified School District
Riverside County School Superintendents'
Association
Riverside Unified School District
Roseland Children's Health Center
Sacramento City Unified School District
San Bernardino County Superintendent of Schools
San Jacinto Unified School District
Santa Cruz City Schools
Small School Districts' Association
Temecula Valley Unified School District
Tulare City School District
Oppose (based on the July 1, 2011, version of the bill):
American Academy of Pediatrics, California
Health Officers Association of California
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